Does hematology rotation impact the interest of internal medicine residents in considering hematology as a career?

BACKGROUND: The ongoing need for hematologists is not met in many parts of the world. The hematology rotation during internal medicine residency is an opportunity to attract more physicians to the hematology field. This study aimed to assess the impact of a hematology rotation on internal medicine residents' interest in considering a hematology career. METHODS: Internal medicine residents were invited to complete an anonymous questionnaire before and after a mandatory hematology rotation. Their interest in pursuing a hematology career was assessed by asking them to rate "Consider hematology as a career" on a 0 to 10 scale (0 = never, 10 = strongly agree). In addition, viewing the hematology workload as manageable, comfort in dealing with cancer and satisfaction with the hematologist lifestyle were assessed before and after the rotation. RESULTS: Sixty out of 62 IM residents completed the pre- and post-hematology rotation questionnaire (response rate 97%). 80% were in the age range of 25-29 years and 73% were males. Two-thirds were in the senior level (3rd and 4th year) of their residency program and 40% had a prior rotation in a hematology unit. Rating considering hematology as a career increased significantly from a median of 7 (IQR: 5-9) pre-rotation to 8.5 (IQR: 7-10) post-rotation (p = 0.0018). Subgroup analysis showed a significant increase in interest among subgroups except residents > 29 years of age, those with prior hematology rotation and junior residents (1st and 2nd year residency). The change in viewing hematology workload as manageable, comfort in dealing with cancer patients and perceiving the hematologist lifestyle as satisfactory were strongly positively correlated with the change in considering hematology as a career (p = 0.0014, < 0.0001 and < 0.0001; respectively). CONCLUSIONS: A hematology rotation is associated with an increase in the interest of internal medicine residents in considering hematology as a career. Further research is needed to Identify factors that may make hematology rotations an effective tool in attracting residents to the hematology field.

Burden, Depression and Quality of Life in Carers of Newly Diagnosed Advanced Cancer Patients in Egypt.

CONTEXT: The goal of palliative care (PC) is to improve the quality of life (QoL) of patients with life-limiting illnesses as well as their families. Ideally, PC is integrated early in the course of life-limiting illnesses. Less attention has been paid to the need for early PC for family caregivers (FCs) in lower-income settings. OBJECTIVES: This observational cross-sectional study was conducted to explore the burden experienced by FCs of newly diagnosed incurable cancer patients in Egypt and characterize its relation to depression and QoL. METHODS: Ninety-five adult FCs of adult patients with newly diagnosed incurable cancer completed the 22-item Zarit Burden Interview (ZBI-22), Patient Health Questionnaire (PHQ-9), and Short Form 12 (SF-12) to assess caregiving burden, depression, and QoL among FCs, respectively. RESULTS: The median (IQR) ZBI-22 score was 17(11-24) and 34% of FCs had significant burden (ZBI-22 score > 20). Assistance with late loss activities of daily living and availability for longer caregiving duration were associated significantly with higher caregiving burdens (P = 0.004 and 0.047, respectively). FCs with significant burden had significantly higher PHQ-9 scores (P = 0.0003). There was a significant negative correlation between ZBI-22 scores and the bodily pain, general health, mental health, physical function, role emotional, and social function subscales/items of SF-12. CONCLUSIONS: A substantial proportion of Egyptian FCs of incurable cancer patients experience significant burden early in the course of the disease. This burden is associated with depressive symptoms and worse QoL dimensions, physical, psychological, and social. In a lower-income setting, early PC interventions for FCs of incurable cancer patients are needed.

Palliative care journal publications by country as a metric for palliative care development level.

OBJECTIVE: There is a growing interest in developing a scientific research metric to assess the level of palliative care (PC) development in countries. This study assesses a metric based on publishing in specialised PC journals as an indicator for the level of PC development. METHODS: A 3-year average articles per million population per year (3y-AAMY) metric was calculated using documents published in 19 specialised PC journals indexed in Scopus database. Countries were categorised into six levels starting with level '0' with no publications then levels Q1 to Q5 according to the 3y-AAMY quintiles (Q5=best performance). The relationship between the 3y-AAMY and the level of PC development in countries and opioid consumption figures was tested. RESULTS: During 2016-2018, 6610 eligible documents were published in the selected 19 journals. The median (IQR) 3y-AAMY of 191 countries was 0.0123 (0-0.237). The 3y-AAMY differed significantly among the levels of PC development, being 0 (IQR:0-0) for category 1 (no known activity) countries and 1.129 (IQR:0.286-4.625) for category 4B (advanced integration) countries (Kruskal-Wallis test p<0.000001 and Jonckheere-Terpstra trend test p<0.00001). The correlation between the 3y-AAMY and average opioid consumption was a highly significant positive one (Spearman's ρ=0.681, p<0.0001). Furthermore, opioid consumption differed significantly between the 3y-AAMY categories being highest for Q5 countries (Kruskal-Wallis test p<0.000001 and Jonckheere-Terpstra trend test p<0.00001). CONCLUSION: A metric based on publishing in specialised PC journals correlates significantly with the levels of PC development and opioid consumption in countries and may be used alongside other indicators for the assessment of PC development.

Contribution of Eastern Mediterranean Region countries to palliative care journals from 1991 to 2020 and its relationship to the development of palliative care.

BACKGROUND: Palliative care (PC) is in an early stage of development in the Eastern Mediterranean Region (EMR) of the World Health Organization. A metric based on publishing in specialized PC journals may be useful in assessing PC development. This study was conducted to describe the contribution of EMR countries to PC research and to study the relationship between this contribution and the levels of PC development. METHODS: The Scopus database was used to search 21 PC journals (1991-2020) for articles with at least one EMR-affiliated author independently of his/her position in the article. As an indicator, the 3-year average articles per million population per year (AAMY) was calculated. Changes over time were calculated through a regression analysis. The relationship between the AAMY and the level of PC development and opioid consumption were assessed through Mann-Witney test using the worldmap PC development categories as a proxy, and Spearman analysis, respectively. RESULTS: The number of articles published during the 30-year period was 31,108 of which 402 (1.3%) were EMR-affiliated. There was a steady rise in the AAMY of the EMR (R2 = 0.894). The number of EMR-affiliated articles increased from 3 in the period 1991-1995 to 191 in 2016-2020. The 2018-2020 AAMY was significantly higher in countries with greater PC development than in those without (median [IQR] = 0.0975 [0.0254-0.1802] and 0.0098 [0-0.0256], p = 0.042). Also, it was significantly higher in countries that progressed to a higher level of PC development between 2006 and 2017 (p = 0.0159). There was a significant positive correlation between the average opioid consumption for the years 2017-2019 and the AAMY for the same period (p = 0.0043). CONCLUSIONS: There is a slow steady progress in the contribution of EMR countries to PC journals, which corresponds to the level of PC development and its progress in the region. A metric based on the contribution to specialized PC journals may be a useful indicator of PC development.

Not Telling Patients Their Cancer Diagnosis in Egypt: Is It Associated With Less Anxiety and Depression and Better Quality of Life?

PURPOSE: In many countries, including Egypt, it is still believed that not telling patients their cancer diagnosis is associated with less psychological morbidity. This study was conducted to explore whether not telling Egyptian patients their cancer diagnosis is associated with less anxiety and depression and better quality-of-life (QoL) or not. METHODS: A cross-sectional observational study was conducted in two Egyptian cancer care facilities and included 292 adult patients with cancer of whom 197 (67%) were aware of their diagnosis and 95 (33%) were unaware. The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression and the Functional Assessment of Cancer Therapy-General 7 questionnaire to assess QoL. RESULTS: Patients unaware of their cancer diagnosis were significantly more likely to be less educated, with no family history of cancer, interviewed within 6 months of cancer diagnosis, diagnosed with a cancer other than breast and colorectal cancer, in a poorer performance status, and with no history of anticancer treatment. There was no significant difference between unaware and aware patients in the scores of HADS-Anxiety (median [interquartile range (IQR)] = 6 [3-11] and 7 [4-11], P = .203), HADS-Depression (median [IQR] = 8 [4-12] and 8 [4-11], P = .64), and Functional Assessment of Cancer Therapy-General 7 (median [IQR] = 16 [12-20] and 16 [11-21], P = .754). In multiple regression analysis with adjustment, diagnosis unawareness did not associate significantly with anxiety, depression, and QoL (P = .394, .662, and .845, respectively). CONCLUSION: The results of the current study confirm that not telling adult patients their cancer diagnosis is not associated with less anxiety and depression nor better QoL.

Diagnosis Disclosure Preferences of Cancer Patients in Egypt: A Multi-Institutional Cross-Sectional Study.

BACKGROUND: Although diagnosis disclosure to cancer patients has important roles in cancer care, it is not a routine practice in countries like Egypt. Respecting patients' autonomy and responding to their preferences are among the factors that should guide the practice of cancer diagnosis disclosure. OBJECTIVES: To assess the preferences of Egyptian cancer patients regarding the disclosure of cancer diagnosis and to determine factors that may affect their preferences. METHODS: The study included 295 patients aware of their cancer diagnosis from 3 cancer care facilities in Egypt. Patients were asked if they would have preferred to be informed of the diagnosis or not, whom they would have preferred to receive the diagnosis information from, and if they would have preferred to tell their families or not. RESULTS: The vast majority (91%) of the included patients preferred to be informed about their diagnosis, 59% preferred to disclose the diagnosis to their families and 66% preferred to receive the diagnosis information from a physician. In univariate analysis, male gender, higher education level and employment were significantly associated with the preference for disclosure. None of the studied variables associated significantly with the preferences in multivariate analysis. CONCLUSION: The majority of Egyptian cancer patients in our study preferred to be informed about their diagnosis, which should be respected. The results may help in changing the diagnosis disclosure practice of health care professionals and refuting the misconception of family caregivers about cancer diagnosis disclosure in Egypt and countries with similar culture.

Transdermal fentanyl to parenteral morphine route switch and drug rotation in refractory cancer cachexia.

It is recommended not to use transdermal fentanyl (Fe) patches (TFP) in cancer cachexia but TFP may be the only available option for pain. Limited evidence suggests lower Fe absorption from TFP in cachexia. We describe a case of metastatic breast cancer with refractory cachexia. Her pain was uncontrolled on TFP and was route switched and drug rotated to intravenous morphine (M). We were conservative and did not use the 1:100 TFP to oral M conversion ratio. Assuming opioid needs were similar before and after switch/rotation, the suitable conversion ratio in this case was about 1:25. Absent clear guidelines on converting from TFP in cachexia, it is better to avoid TFP. When essential to use TFP in cachexia, caution should be taken when switching from TFP to avoid overdose.

Caregiver burden among family caregivers of incurable cancer patients in two eastern Mediterranean countries.

BACKGROUND: Although family caregivers (FCs) play an important role in the care provided to incurable cancer patients in our region, little is known about the burden they experience. This study was conducted to determine the prevalence of caregiver burden (CB) among FCs of incurable cancer patients in two Eastern Mediterranean countries and to identify factors that may be associated with significant CB. METHODS: The study included 218 FCs, 165 from Egypt and 53 from Saudi Arabia. The 22-item Zarit Burden Interview (ZBI-22) was used to assess caregiver burden CB. Significant CB was defined as a ZBI-22 score ≥ 21. The assistance with basic ADLs was classified into 3 levels according to FCs' assistance with early/middle/late-loss basic ADLs. The relationship between CB and the assistance with ADLs and other factors was studied. RESULTS: The mean (SD) ZBI-22 score among FCs was 23.4 (9.3) and the majority (128/218, 59%) had significant CB. Eighty-nine percent of FCs assisted with at least one basic ADL. Assistance with late-loss basic ADLs, best supportive care treatment plan and poorer performance status were associated with higher CB (p < 0.0001, =0.018 and = 0.005). However, in logistic regression analysis, only assistance with late-loss ADLs was independently associated with significant CB (OR = 3.4 [95%CI:1.2-9.7], p = 0.024). CONCLUSION: A substantial proportion of FCs of incurable cancer patients in our region experience significant CB. Family caregivers assisting with late-loss basic ADLs are at risk of significant CB and should be routinely screened for CB.

Mirtazapine in Cancer-Associated Anorexia and Cachexia: A Double-Blind Placebo-Controlled Randomized Trial.

CONTEXT: Few pharmacological interventions are available for cancer-associated anorexia and cachexia. Mirtazapine has been suggested for use in cancer-associated anorexia and cachexia. OBJECTIVES: This study was conducted to assess the efficacy and tolerability of mirtazapine in cancer-associated anorexia and cachexia. METHODS: A double-blind placebo-controlled randomized trial. The study included 120 incurable solid tumour patients with anorexia (appetite loss ≥4 on 0 - 10 scale, 10 = maximum appetite loss), cachexia (>5% body weight loss over 6 months or >2% plus body mass index <20) and depression score ≤3 on 0-6 scale (6 = extreme feelings of depression). Patients were 1:1 randomized to receive mirtazapine 15mg daily at night for 8 weeks or placebo. The primary endpoint was change in appetite from baseline to day 28. Other outcomes included changes in quality-of-life, fatigue, depressive symptoms, body weight, lean body mass, handgrip strength, inflammatory markers, adverse events and survival. RESULTS: 48 (80%) patients in the mirtazapine arm and 52 (87%) in the placebo were assessable for the 1ry endpoint. Appetite score increased significantly with mirtazapine as well as with placebo (P < 0.0001 each). The increase in appetite score did not differ significantly between the two arms in the per-protocol and intention-to-treat analysis (P = 0.472 and 0.462, respectively). Mirtazapine was associated with significantly less increase in depressive symptoms and higher prevalence of somnolence. The change in other outcomes did not differ significantly between mirtazapine and placebo. CONCLUSION: Mirtazapine 15mg at night for 28 days is no better than placebo in improving the appetite of incurable solid tumor patients with cancer-associated anorexia and cachexia.

Reliability and validity of the Arabic translation of the palliative performance scale.

OBJECTIVE: The aim of this study was to translate the Palliative Performance Scale (PPSv2) into Arabic and to test the reliability and validity of the PPS Arabic translation (PPS-Arabic). METHOD: The PPSv2 was translated into Modern Standard Arabic using a forward-backward method. Inter-rater and intra-rater reliabilities were tested in a pilot study that included 20 patients. The validation study included 150 cancer patients. Patients were divided according to their treatment plan into three groups (in-remission, palliative chemotherapy, and best supportive care) to perform hypothesis-testing construct validity. Validity was further evaluated by correlating PPS-Arabic with the Karnofsky Performance Scale (KPS), the Eastern Cooperative Oncology Group (ECOG) scale, and Physical Functioning (PF2) and Role Functioning (RF2) scales of the European Organization for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ-C30). RESULTS: The intraclass correlation coefficients for the intra-rater and inter-rater reliability were 0.935 (95% CI: 0.88-0.965; p < 0.001) and 0.965 (95% CI: 0.934-0.981; p < 0.001), respectively. The PPS-Arabic internal consistency Cronbach's alpha was 0.986. The average PPS-Arabic score differed significantly (p < 0.001) between the three groups of patients being 89 for in-remission, 58 for palliative chemotherapy, and 38 for best supportive care. The PPS-Arabic score correlated significantly (p < 0.001) with the KPS, ECOG performance scale, and the EORTC QLQ-C30 PF2 and RF2 scales. CONCLUSION: The PPS-Arabic is a reliable and valid tool for the assessment of performance status of cancer patients.

Effect of Low-Level Laser Therapy in Treatment of Chemotherapy Induced Oral Mucositis.

Introduction: Oral mucositis (OM) is an unavoidable condition of the oral cavity that accompanies chemotherapy for various malignant cases. Chemotherapy-induced oral Mucositis (COM) is a frequent complication due to mucotoxic drugs and is known to deteriorate the general health significantly, while negatively affecting the quality of life (QOL). Studies have reported that low-level laser therapy (LLLT) promotes the tissue healing. The objective of the present study was to explore the efficacy of gallium-arsenide (GaAs) laser in treating COM and its impact on inflammatory cytokine levels in patients receiving chemotherapy for various malignancies. Methods: A total of 80 patients with COM received LLLT 6 days/week. OM was graded according to the World Health Organization (WHO) grading scale. The outcome parameters were the serum levels of tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) measured before, during and after administration of LLLT. Results: After LLLT, a significant decrease was found in the mean values of mucositis grade from 2.35 ± 0.695 to 1.13 ± 0.333 after (P < 0.001). A significant reduction in the level of TNF-α was found after LLLT among breast cancer patients (P = 0.0045), but not in head and neck cancer and lymphoma patients. A significant reduction was also found in IL-6 level after treatment among head and neck and breast cancer patients (P = 0.0307 and 0.019, respectively). Conclusion: The use of GaAs LLLT in treating COM in patients with various malignancies is well tolerated by patients, it results in improvement of mucositis, however; mechanism of action does not seem to be completely linked to the change of pro or anti-inflammatory cytokines.

Preferred Place of Death for Patients With Incurable Cancer and Their Family Caregivers in Egypt.

BACKGROUND:: Little is known about the place of death of patients with cancer in Eastern Mediterranean countries including Egypt, where palliative care is underdeveloped. Identifying the preferred place of death (PPoD) is important for the development of appropriate palliative care models in these countries. OBJECTIVES:: To know the PPoD of Egyptian patients with incurable cancer and their family caregivers (FCGs) and to determine the factors that may impact their preferences. METHODS:: An observational cross-sectional study that included 301 dyads of patients with incurable cancer and one of their FCGs. A questionnaire was designed to collect data about the characteristics of patients and FCGs as well as their preferences. RESULTS:: The majority of dyads (272/301, 90.4%) answered the PPoD question. Home was the PPoD in 93% of patients and 90.1% of FCGs ( P = .218). The congruence between patients' and FCGs' PPoD was 92.7% (κ = 0.526). In multivariate analysis, poorer performance status (Eastern Cooperative Oncology Group 3 or 4) and full employment of FCGs associated significantly with patients' preference to die in hospital (odds ratio [OR] = 3.015 [95% confidence interval [CI]: 1.004-9.054], P = .049 and OR = 4.402 [95% CI: 1.561-12.417], P = .005, respectively), while poorer performance status and nonreferral to the palliative medicine unit were associated with FCGs' preference of hospital death (OR = 2.705 [95% CI: 1.105-6.626], P = .029 and OR = 2.537 [95% CI: 1.082-5.948], P = .032, respectively). CONCLUSIONS:: The results of the current study suggest that home is the PPoD for the vast majority of Egyptian patients with incurable cancer and their FCGs. Palliative care interventions that promote home death of patients with incurable cancer are needed in Egypt.

Timing and Outcome of Referral to the First Stand-Alone Palliative Care Center in the Eastern Mediterranean Region, the Palliative Care Center of Kuwait.

BACKGROUND: Compared to other regions of the world, palliative care (PC) in the Eastern Mediterranean region is at an earlier stage of development. The Palliative Care Center of Kuwait (PCC-K) was established a few years ago as the first stand-alone PC center in the region. This study was conducted to investigate the timing of referral to the PCC-K and its outcome. METHODS: Retrospective review of referrals to the PCC-K during its first 3 years of action. Late referral was defined as referral during the last 30 days of life. RESULTS: During the 3-year period, 498 patients with cancer were referred to the PCC-K of whom 467 were eligible for analysis. Referral was considered late in 58% of patients. Nononcology facilities were more likely to refer patients late when compared to oncology facilities ( P = .033). The palliative performance scale (PPS) was ≤30 in 59% of late referrals and 21% in earlier referrals ( P < .001). Among 467 referred patients, 342 (73%) were eligible for transfer to the PCC-K, 102 (22%) were ineligible, and 23 (5%) died before assessment by the PCC-K consultation team. From the 342 eligible patients, the family caregivers refused the transfer of 64 (19%) patients to the PCC-K. CONCLUSION: Patients are frequently referred late to the PCC-K. Further research to identify barriers to PC and its early integration in Kuwait is required. The PPS may be useful in identifying late referrals.

Cancer diagnosis disclosure preferences of family caregivers of cancer patients in Egypt.

OBJECTIVE: Family caregivers (FCs) of cancer patients are frequently seen as a barrier to honest communication with patients in Egypt. This study was conducted to investigate the attitude of FCs of cancer patients toward cancer diagnosis disclosure (CDD) and its determinants. METHODS: A structured interview was used to assess the preferences of 288 FCs regarding CDD. RESULTS: According to the FCs, 85% of patients were aware of their diagnosis. The majority (81%) of FCs preferred CDD to patients. In case they developed cancer, 92% of FCs wanted to know their diagnosis and 88% wanted to inform their families. In a univariate analysis, factors associated with FCs' negative attitude toward CDD to patients were as follows: patient's lower level of education (P = .001), patient's rural residence (P < .001), hematological malignancies (P < .001), FC's belief that the patient is unaware of diagnosis (P < .001), FC's unwillingness to know his/her own cancer diagnosis (P < .001), and FC's unwillingness to inform his/her family about his/her cancer diagnosis (P < .001). Only 2 factors predicted independently the negative attitude of FCs toward CDD, the FC's belief that the patient is unaware of diagnosis (P < .001), and the FC's unwillingness to know his/her own cancer diagnosis (P = .049). CONCLUSIONS: The results suggest that the majority of FCs of Egyptian cancer patients prefer CDD to patients. The finding that the vast majority of FCs of aware patients preferred CDD suggests that the reaction of Egyptian patients to CDD is acceptable by FCs. Family caregivers with a negative attitude toward CDD may be reflecting their own fears.

The Use of the Chuang's Prognostic Scale to Predict the Survival of Metastatic Colorectal Cancer Patients Receiving Palliative Systemic Anticancer Therapy.

BACKGROUND: With the increasing number of agents active against cancer, advanced cancer patients including metastatic colorectal cancer (mCRC) patients may continue receiving palliative systemic anticancer therapy (PSAT) near the end-of-life. Validated palliative prognostic models, such as the Chuang's prognostic scale (CPS), may be helpful in identifying mCRC patients with limited survival who are unlikely to benefit from PSAT. AIM: To test the ability of the CPS to predict the survival of mCRC under treatment with PSAT. METHODS: CPS was prospectively assessed in 36 mCRC patients who were receiving PSAT. The scale is based on eight items: ascites, edema, cognitive impairment, liver and lung metastases, performance status, tiredness, and weight loss. The total CPS score ranges from 0 to 8.5 with the higher score indicating worse prognosis. RESULTS: Patients were divided into two groups using a CPS cutoff score of 5, Group 1 with a CPS score ≤5 and Group 2 with a CPS score >5. Using this cutoff value, 3-month mortality was predicted with a positive predictive value of 71%, a negative predictive value of 77%, a sensitivity of 67%, a specificity of 81% and an overall accuracy of 75%. Group 1 patients had a longer median survival of 149 days (95% confidence interval [CI]: 82-216) in comparison to Group 2 patients who had a median survival of 61 days (95% CI: 35-87). The difference in survival was statistically significant (P = 0.01). CONCLUSION: CPS may be useful in identifying mCRC patients with limited survival who are unlikely to benefit from PSAT.

Voluntary reporting to assess symptom burden among Yemeni cancer patients: common symptoms are frequently missed.

BACKGROUND: Adequate symptom assessment is necessary to relieve the high symptom burden experienced by cancer patients. However, health care professionals may depend only on patient's voluntary reporting (VR) to assess symptoms and therefore some symptoms may be missed. OBJECTIVE: To assess the symptom burden experienced by Yemeni cancer patients by using VR and systematic assessment (SA). METHODS: 50 cancer patients were asked an open question to voluntarily report their symptoms. This was followed by an SA of a list of 20 common physical symptoms that was drawn up based on the literature. RESULTS: From 375 symptom entries related to the 20 symptoms, VR accounted for 66 entries (18%) and SA for 309 (82%). The mean number of VR symptoms/patient was 1.3, and the mean number of VR plus SA symptoms was 7.5 (𝑃 < .001). In all, 74% of VR symptoms and 57% of SA symptoms were moderate or severe. For each symptom, the percentage of patients who experienced it and did not report it voluntarily (missed) was 100% for bleeding, constipation, early satiety, hoarseness, taste changes, and weight loss. These were followed by anorexia (97%), skin symptoms (92%), dry mouth (91%), edema (89%), dyspnea (88%), sore mouth (88%), fatigue/weakness (85%), diarrhea (80%), dysphagia (80%), nausea (76%), cough (75%), urinary symptoms (75%), vomiting (62%), and pain (18%). Pain was the most common voluntarily reported symptom (56% of patients), the most commonly distressing (42%), and the least under-reported (18%). LIMITATIONS: Relatively small sample size; the SA included only 20 symptoms. CONCLUSIONS: SA of symptoms yields a more accurate estimation of symptom burden than does VR. As with many developing countries where the majority of cancer patients present at an incurable disease stage, Yemeni cancer patients suffer a high symptom burden, especially pain.

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.