Samy A. Alsirafy

The Palliative Prognostic Index for the Prediction of Survival and In-Hospital Mortality of Patients with Advanced Cancer in Kuwait

INTRODUCTION Prognostic scoring systems are increasingly used in cancer care. One of these systems is the Palliative Prognostic Index (PPI) which is based on clinical findings. Few studies validated the PPI in different settings. Our aim was to test the predictive value of the PPI in an acute cancer care setting. METHODS Prospective study that included patients with advanced cancer admitted to a tertiary cancer center in Kuwait. Patients were divided according to the PPI score into three groups: A (PPI≤3), B (PPI>3- ≤6), and C (>6). RESULTS The study included 91 hospitalized patients. At the time of PPI assessment, the plan of treatment was best supportive care only in 70 (77%) patients. The majority (80%) of included patients died in-hospital. The in-hospital mortality rate for patients with a PPI>6 was significantly higher than those with ≤6 (93% versus 56%, p<0.001). Using a cutoff point of PPI>6, in-hospital mortality was predicted with a 73% sensitivity, 78% specificity, 93% positive predictive value, and 41% negative predictive value. The median survival was 61 days (95% confidence interval [CI]: 25.8-96.2) for group A, 20 days (95% CI: 4.5-35.5) for group B, and 6 days (95% CI: 4-8) for group C. The difference in survival was highly significant (p<0.001). CONCLUSION The results suggest that the PPI may be helpful for oncologists in predicting survival and in-hospital mortality of patients with advanced cancer in the acute care setting.

Symptom burden in hospitalized patients with cancer in kuwait and the need for palliative care.

We conducted this study to describe the symptom burden among hospitalized patients with cancer in a Kuwaiti cancer center. Twenty physical symptoms were assessed in 45 patients with cancer. The majority (82%) of patients had an advanced incurable cancer and 42% were receiving best supportive care only. The median number of symptoms per patient was 6.4 ± 2.8. The most common symptoms were pain (82%), weakness/fatigue (80%), anorexia (67%), weight loss (49%), and dyspnea (42%). Pain was the most distressing symptom in 31% of patients, followed by dyspnea (24%) and weakness/fatigue (11%). The high prevalence of advanced disease and the demonstrated high symptom burden mandate the initiation and development of culturally sensitive palliative care models, especially hospital-based ones, to relieve the suffering of patients with cancer in Kuwait.

Hospitalization pattern in a hospital-based palliative care program: an example from Saudi Arabia.

The few palliative care programs available to date in Saudi Arabia are largely hospital-based. Subacute palliative care models have not been developed yet. This retrospective review was conducted to assess the patterns and outcomes of hospital-based palliative care unit admissions in the absence of subacute palliative care models. We reviewed 759 eligible palliative care unit admissions related to 629 cancer patients during a 4-year period. Of all admissions, 66% were hospitalized through the emergency room. The average hospital stay was 24 days. The majority (86%) of patients died in-hospital. These results suggest that end-of-life quality indicators are unlikely to improve depending on hospital-based palliative care models only. To improve palliative care services in Saudi Arabia, other subacute models may need to be considered.

Opioid Needs of Patients with Advanced Cancer and the Morphine Dose-Limiting Law in Egypt

BACKGROUND Morphine is the drug of choice for moderate to severe cancer pain management. The Egyptian Narcotics Control Law limits the amount of morphine prescribed in a single prescription to a maximum of 420 mg for tablets and 60 mg for ampoules. The usual practice in Egypt is to provide that limited amount of morphine on a weekly basis. The aim of this study is to estimate the extent to which Egyptian patients may be undertreated because of this law. METHODS We reviewed the medical records of advanced cancer patients referred to the first palliative care unit in Egypt over a seven-month period. Cancer pain was managed following the WHO guidelines. After modifying the internal institutional policy, patients received adequate amounts of the available opioids without any violations of the law. RESULTS From 117 eligible advanced cancer patients, 58 (50%) patients required strong opioids, 32 (27%) required weak opioids, and 27 (23%) required no regular opioids. The mean last prescribed opioid dose for those who required strong opioids was 194 mg of oral morphine equivalent/24 h (± 180). For this group of patients, a single weekly prescription would supply enough oral morphine for only 26% of them. In the case of parenteral morphine, none of these patients would receive an adequate supply. CONCLUSIONS In view of the current morphine dose-limiting law and practices in Egypt, the majority of patients suffering severe cancer pain would not have access to adequate morphine doses. That dose-limiting law and other restrictive regulations represent an obstacle to cancer pain control in Egypt and should be revised urgently.

Where Do Egyptian Palliative Care Patients With Cancer Die

This report describes the death place of patients with advanced cancer referred to an Egyptian palliative care program over 1 year. Of 79 patients included, 73% died at home and 27% in hospital or ambulance. Patients who were visited by a palliative care physician at home were significantly more likely to die at home compared to those who did not (92% vs 64%, P = .008). The palliative care survival of those who died at home was significantly longer than those who died in hospital or ambulance (63 vs 39 days, P = .04). These results demonstrate the need for the integration of effective home care model in evolving Egyptian palliative care programs and suggest that physician home visits and earlier referral to palliative care help patients die at home.

Prevalence of methicillin-resistant Staphylococcus aureus colonization and infection in hospitalized palliative care patients with cancer.

Little is known about the pattern of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in hospitalized palliative care (PC) patients. We reviewed 854 admissions for 289 patients with advanced cancer managed by a PC service in a tertiary care hospital. The MRSA screening was performed at least once in 228 (79%) patients, and 21 (9%) of them were MRSA positive. Other cultures were done in 251 (86.8%) patients, and 8 (3%) patients were MRSA positive. The total number of MRSA-positive admissions was 28 (3%), with a median admission duration of 8 days. A substantial proportion of hospitalized PC patients with cancer are MRSA positive. Research is required to study the impact of infection control measures on the quality of PC delivered to MRSA-positive terminally ill patients in hospitals.

Predictive impact of electrolyte abnormalities on the admission outcome and survival of palliative care cancer referrals.

BACKGROUND AND AIM Electrolyte abnormalities are common among patients with advanced cancer. Our aim was to estimate the prognostic significance of such abnormalities in a palliative care setting. METHODS A retrospective review of the medical records of inpatients with cancer referred to palliative care over a 25-month period. The five electrolytes studied were potassium, sodium, calcium, magnesium, and phosphate. The prognostic impact of related abnormalities on admission outcome and overall survival was estimated in univariate analysis. RESULTS From 866 new cancer referrals, 259 (30%) were eligible for analysis. Abnormalities in sodium, calcium, and magnesium levels were associated with a significant difference in inpatient death rates (p = 0.004, 0.001 and 0.04, respectively) and overall survival (p = 0.0008 and 0.0008, and < 0.0001, respectively). The status of potassium and phosphate had no significant impact on admission outcome or overall survival. The three electrolyte abnormalities associated with the highest inpatient death rate were hypercalcemia, hypernatremia, and hypermagnesemia (69%, 68%, and 62%, respectively). Patients with these abnormalities had the shortest median survival as well (12, 8, and 12 days, respectively). CONCLUSION Some electrolyte abnormalities may be useful as prognostic indicators in the palliative care setting. However, their prognostic value needs to be investigated in prospective studies and adjusted against proven prognostic indicators.

Emergency Department Visits at the End of Life of Patients With Terminal Cancer: Pattern, Causes, and Avoidability.

Frequent emergency department visits (EDVs) by patients with terminal cancer indicates aggressive care. The pattern and causes of EDVs in 154 patients with terminal cancer were investigated. The EDVs that started during working hours and ended by home discharge were considered avoidable. During the last 3 months of life, 77% of patients had at least 1 EDV. In total, 309 EDVs were analyzed. The EDVs occurred out of hour in 67%, extended for an average of 3.6 hours, and ended by hospitalization in 52%. The most common chief complaints were pain (46%), dyspnea (13%), and vomiting (12%). The EDVs were considered avoidable in 19% of the visits. The majority of patients with terminal cancer visit the ED before death, mainly because of uncontrolled symptoms. A significant proportion of EDVs at the end of life is potentially avoidable.

Pattern of cancer deaths in a saudi tertiary care hospital.

The medical records of deceased patients were reviewed to describe the pattern of cancer deaths in a newly established Saudi tertiary care hospital. During eleven months, 87 patients died of cancer. The majority (80 patients, 92%) died of incurable cancer; among which 53% did not receive any systemic anti-cancer therapy (SAT) and 43% received SAT with palliative intent. Younger age (< 65 years), relatively chemosensitive tumours and initial presentation in a potentially curable stage were associated with higher prevalence of palliative SAT administration (p = 0.009, 0.019 and 0.001, respectively). The last palliative SAT was administered during the last two months of life in 66% and during the last two weeks in 14%. During the last admission, 54% of patients were admitted through emergency room, 50% stayed >14 days and 14% died in intensive care unit or emergency room. The results demonstrate that palliative care is a realistic treatment for the majority of patients in our setting and that a significant proportion of these patients receive aggressive care at the end-of-life. There is a need to establish an integrative palliative care program to improve the quality-of-life of dying cancer patients in our region and to minimize the aggressiveness of end-of-life care.

Pattern of referral of noncancer patients to palliative care in the Eastern province of Saudi Arabia

Aim: The palliative care (PC) needs of patients with noncancer life-threatening illnesses are comparable to that of cancer patients. This report describes the contribution of noncancer patients to the population of PC patients in a tertiary care hospital in the Eastern Province of Saudi Arabia. Materials and Methods: This is a retrospective review of the “palliative care inpatient database” of 21 months. Results: From 474 patients, 20 (4.2%) had a noncancer diagnosis. The main reason for the referral of noncancer patients was pain control. The most prevalent diagnoses were sickle cell disease (SCD) in 6 (30%) patients and peripheral arterial disease (PAD) in 5 (25%). Conclusions: These findings suggest that the PC needs of noncancer patients are largely unmet in our region. Further efforts are necessary to advance noncancer PC in Saudi Arabia. The PC needs of patients with SCD and PAD need to be addressed in future research.