Vincent Maida

Use of the Palliative Performance Scale (PPS) for End-of-Life Prognostication in a Palliative Medicine Consultation Service

This study examines the use of the Palliative Performance Scale (PPS) in end-of-life prognostication within a regional palliative care program in a Canadian province. The analysis was done on a prospective cohort of 513 patients assessed by a palliative care consult team as part of an initial community/hospital-based consult. The variables used were initial PPS score, age, gender, diagnosis, cancer type, and survival time. The findings revealed initial PPS to be a significant predictor of survival, along with age, diagnosis, cancer type and site, but not gender. The survival curves were distinct for PPS 10%, 20%, and 30% individually, and for 40%-60% and > or =70% as bands. This is consistent with earlier findings of the ambiguity and difficulty when assessing patients at higher PPS levels because of the subjective nature of the tool. We advocate the use of median survival and survival rates based on a local cohort where feasible, when reporting individual survival estimates.

Wounds in advanced illness: a prevalence and incidence study based on a prospective case series

A prospective observational sequential case series was studied in order to ascertain an accurate inventory of the various wound types, their point prevalence and incidence rates and their anatomic locations in patients with advanced illness. Five hundred and ninety‐three patients were serially assessed until their deaths. Forty‐three individual wound types were identified and grouped into nine distinct classes. Data were stratified between patients suffering from malignant and non malignant disorders. One thousand and thirty‐six individual wounds (average 1·8 wounds per patient) were identified at baseline. Eight hundred and ninety‐one individual wounds (average 1·5 wounds per patient) were identified between baseline and their date of death. Pressure ulcers constituted the most commonly occurring wound class affecting more than 50% of all patients. Malignant wounds were observed only in cancer patients. Baseline point prevalence for pressure ulcers, traumatic wounds, venous ulcers and arterial ulcers in non cancer patients exceeded that in cancer patients. At baseline, iatrogenic wounds were more prevalent in cancer patients than in non cancer patients. Incidence rates for pressure ulcers, traumatic wounds, diabetic ulcers, arterial ulcers and ostomies in non cancer patients exceeded those in cancer patients. The broad range of wounds along with high rates of prevalence and incidence, identified in this study, reflects that wounds represent a significant management issue for patients with advanced illness. Therefore, there exists a need for advancement in modalities and measures aimed at risk assessment, prevention and appropriate goal‐oriented management.

A review of nabilone in the treatment of chemotherapy-induced nausea and vomiting

Chemotherapy-induced nausea and vomiting (CINV) in cancer patients places a significant burden on patients’ function and quality of life, their families and caregivers, and healthcare providers. Despite the advances in preventing CINV, a substantial proportion of patients experience persistent nausea and vomiting. Nabilone, a cannabinoid, recently received Food and Drug Administration approval for the treatment of the nausea and vomiting in patients receiving cancer chemotherapy who fail to achieve adequate relief from conventional treatments. The cannabinoids exert antiemetic effects via agonism of cannabinoid receptors (CB1 and CB2). Clinical trials have demonstrated the benefits of nabilone in cancer chemotherapy patients. Use of the agent is optimized with judicious dosing and selection of patients.

The emerging role of cannabinoid neuromodulators in symptom management

IntroductionThe cannabinoids nabilone (Cesamet) and dronabinol (Marinol) are indicated for the management of chemotherapy-induced nausea and vomiting (CINV) in cancer patients who have failed to respond adequately to conventional antiemetic therapy.DiscussionThe endocannabinoid (CB) system interacts with numerous other systems and pharmaceutical cannabinoids target ubiquitous CB1 and CB2 receptors in the central nervous system and periphery, relieving nausea and vomiting and pain.SummaryThe benefits of this novel class of medications in cancer may extend beyond CINV, as indicated by data from preclinical studies and animal models.

The Toronto Symptom Assessment System for Wounds: a new clinical and research tool.

OBJECTIVE: To formulate a patient-rated assessment tool that facilitates the measurement of pain and polysymptom distress directly related to all classes of wounds. DESIGN: A prospective observational study derived from a sequential case series of patients with advanced illness was carried out to determine the most common symptoms associated with wounds from 9 distinct classes (malignant, pressure ulcers, iatrogenic, traumatic, diabetic foot ulcers, venous ulcers, arterial ulcers, infections/inflammatory lesions, and ostomies). Ten wound-related symptoms were identified and used to create a patient-scored assessment tool. The Toronto Symptom Assessment System for Wounds (TSAS-W) was then developed and used in a pilot trial during which patients completed TSAS-W at baseline and 7 days later. PARTICIPANTS: Five hundred thirty-one patients either presented with wounds at baseline or developed them during the 24-month follow-up period. Patients affected by any type of wound were asked to report on the top 3 symptoms directly attributable to their wounds. The pilot trial of TSAS-W involved 103 wounds afflicting 83 sequential patients. MAIN RESULTS: The most prevalent wound-related symptoms included pain, exudation, odor, itching, bleeding, aesthetic concern, swelling, and mass and bulk effects from the wound and associated dressings; 78.6% of the TSAS-W assessments were carried out by the patient alone, 14.6% were carried out by the patient assisted by a caregiver, and 6.8% were carried out entirely by a caregiver. The summation of all 10 TSAS-W parameters, the global wound symptom distress score (GWSDS), resulted in a mean for all wounds of 34.47 at baseline and decreased to a mean of 28.40 at 7 days later. Cosmetic or aesthetic concern and/or distress was associated with the highest mean scores of all symptoms. Malignant wounds and wounds involving the perineum and genitalia were associated with the highest GWSDSs. CONCLUSION: The TSAS-W is a new tool for systematically assessing the degree of pain and polysymptom distress associated with all classes of wounds. It is modeled after the Edmonton Symptom Assessment System that is widely used and validated in the palliative care arena. TSAS-W is composed of 10 symptom parameters that are individually assessed on 11-point numeric rating scales (0-10). The summation of all of the element symptom scores equates to a GWSDS. It may be used in the clinical setting to guide wound-related pain and polysymptom management. In addition, TSAS-W may be useful as a tool in facilitating clinical audit and future wound care research.

Correlation between Braden Scale and Palliative Performance Scale in advanced illness

This study describes the significant correlation between the Braden Scale (BS) and the Palliative Performance Scale (PPS) in patients with advanced illness that has not been previously reported. The analysis was based on a prospective sequential case series of 664 patients suffering from advanced illness who were referred to a regional palliative medicine programme in Toronto, Canada. Baseline BS and PPS scores assessed within 24 hours of referral were considered for analysis. After controlling for age, gender, consult site and diagnosis (cancer versus non cancer), we observed a significant positive correlation between baseline PPS and BS scores (r = 0·885, P < 0·001). These findings suggest that for patients with advanced illness where BS is not routinely used, PPS could be considered as a proxy for pressure ulcer risk assessment.

Clinical parameters associated with pressure ulcer healing in patients with advanced illness.

CONTEXT Pressure ulcers are the most prevalent wounds affecting patients with advanced illness. Although complete wound healing is the most desired outcome, it remains unlikely in the setting of patients with limited life expectancy. Realistic goal setting may be enabled using objective clinical parameters. OBJECTIVES To identify clinical parameters associated with complete healing of Stage II pressure ulcers. METHODS Univariable and multivariable competing risk analyses were used to assess the association of complete healing with the following six clinical parameters, namely gender, age, total number of pressure ulcers, total number of other wounds, number of failing organ systems, and Palliative Performance Scale (PPS) scores. RESULTS A total of 147 patients with 245 Stage II pressure ulcers were followed until death; 9.4% of Stage II pressure ulcers achieved complete healing. Univariable analyses showed hazard ratios (HRs) for complete healing in favor of higher levels of PPS scores (HR 1.82-5.99, P<0.001) and age younger than 80 years (HR 3.28, P=0.031). Multivariable analyses showed HRs for complete healing in favor of higher levels of PPS scores (HR 1.49-3.34, P=0.003). CONCLUSION Higher levels of PPS scores are associated with complete healing of Stage II pressure ulcers in patients with advanced illness.

Topical Medical Cannabis: A New Treatment for Wound Pain—Three Cases of Pyoderma Gangrenosum

Pain associated with integumentary wounds is highly prevalent, yet it remains an area of significant unmet need within health care. Currently, systemically administered opioids are the mainstay of treatment. However, recent publications are casting opioids in a negative light given their high side effect profile, inhibition of wound healing, and association with accidental overdose, incidents that are frequently fatal. Thus, novel analgesic strategies for wound-related pain need to be investigated. The ideal methods of pain relief for wound patients are modalities that are topical, lack systemic side effects, noninvasive, self-administered, and display rapid onset of analgesia. Extracts derived from the cannabis plant have been applied to wounds for thousands of years. The discovery of the human endocannabinoid system and its dominant presence throughout the integumentary system provides a valid and logical scientific platform to consider the use of topical cannabinoids for wounds. We are reporting a prospective case series of three patients with pyoderma gangrenosum that were treated with topical medical cannabis compounded in nongenetically modified organic sunflower oil. Clinically significant analgesia that was associated with reduced opioid utilization was noted in all three cases. Topical medical cannabis has the potential to improve pain management in patients suffering from wounds of all classes.

Restoring prognosis as a core competency in medical practice.

During the era of Hippocrates (460–370 BC), the lack of effective diagnostic and therapeutic modalities made prognosis the most important physician competency. Conceptually, Hippocrates described prognosis as a two-dimensional construct: quoad vitam (predictions about survival and life expectancy) and quaod sanantionem (predictions about healing and restoration of function) (Christakis 1999). The Hippocratic prognostic process consists of two basic components, namely, foreseeing (formulating the prognosis) and foretelling (communicating the prognosis). Thus, a complete and comprehensive approach to prognosis must involve both components. Major advances in diagnostics and therapeutics have relegated this once highly valued core competency to an almost negligible role in modern medical practice. Not surprisingly, medical curricula are devoid of teaching opportunities focused on prognosis. This void is driven by a corresponding relative dearth within physician competency frameworks. In order to assess the level of content related to prognosis within CanMEDS, a foundational and prototypical physician competency framework, we conducted a quantitative content analysis using Foxit Reader 5.1 (Foxit Corporation, http:// www.foxitsoftware.com/company/press.php?action1⁄4 view&page1⁄4 201110265722.html), a keyword scanning software (Foxit Corporation). The complete compilation of CanMEDS 2005 framework documents of 29 physician specialties and 37 subspecialties across the seven physician roles (medical expert, communicator, collaborator, manager, health advocate, scholar and professional) were scanned. The keywords used in the search included prognosis, prognostic, prognosticate, and prognostication. Of the combined 66 specialties and subspecialties only 22 (33.3%) contained at least one citation of the keyword ‘‘prognosis’’, and 4 (6.1%) contained at least one citation of the keyword ‘‘prognostic’’. The terms ‘‘prognosticate’’ and ‘‘prognostication’’ were completely absent from all CanMEDS 2005 documents. Overall, the combined citations for ‘‘prognosis’’ and ‘‘prognostic’’ were linked with the following competency roles: Medical Expert (80.3%), Scholar (11.5%), and Communicator (8.2%). Prognosis is both an imperative and an enabler for truly patient-centered care. The formulation and communication of prognosis also intrinsic for the delivery of healthcare that is ethically, morally and legally sound. Therefore, given the fundamental importance of prognosis within medical practice, it is recommended that physicians develop appropriate attitudes, skills and knowledge related to the formulation and communication of prognosis. Reforming competency frameworks that build more content for outcomes involving prognosis has the potential to drive medical curricular reform. Thus, the content of objectives related to prognosis within CanMEDS should be addressed in advance of its planned update in 2015. Moreover, it is recommended that foreseeing and foretelling be emphasized within the scholar role and communicator role respectfully.

Prognosis: the "missing link" within the CanMEDS competency framework.

BackgroundThe concept of prognosis dates back to antiquity. Quantum advances in diagnostics and therapeutics have relegated this once highly valued core competency to an almost negligible role in modern medical practice. Medical curricula are devoid of teaching opportunities focused on prognosis. This void is driven by a corresponding relative dearth within physician competency frameworks. This study aims to assess the level of content related to prognosis within CanMEDS (Canadian Medical Education Directives for Specialists), a leading and prototypical physician competency framework.MethodsA quantitative content analysis of CanMEDS competency framework was carried out to measure the extent of this deficiency. Foxit Reader 5.1 (Foxit Corporation), a keyword scanning software, was used to assess the CanMEDS 2005 framework documents of 29 physician specialties and 37 subspecialties across the seven physician roles (medical expert, communicator, collaborator, manager, health advocate, scholar, and professional). The keywords used in the search included prognosis, prognostic, prognosticate, and prognostication.ResultsOf the 29 specialties six (20.7%) contained at least one citation of the keyword “prognosis”, and one (3.4%) contained one citation of the keyword “prognostic”. Of the 37 subspecialties, sixteen (43.2%) contained at least one citation of the keyword “prognosis”, and three (8.1%) contained at least one citation of the keyword “prognostic”. The terms “prognosticate” and “prognostication” were completely absent from all CanMEDS 2005 documents. Overall, the combined citations for “prognosis” and “prognostic” were linked with the following competency roles: Medical Expert (80.3%), Scholar (11.5%), and Communicator (8.2%).ConclusionsGiven the fundamental and foundational importance of prognosis within medical practice, it is recommended that physicians develop appropriate attitudes, skills and knowledge related to the formulation and communication of prognosis. The deficiencies within CanMEDS, demonstrated by this study, should be addressed in advance of the launch of its updated version in 2015.