Outcome as a measure of quality of care in oncology: experience at sultan qaboos university hospital, oman

OBJECTIVES

Measurement of outcomes is increasingly employed as an indicator of the quality of clinical care. The most commonly measured outcome in many clinical studies, especially in oncology, still remains the overall survival rate. Sultan Qaboos University Hospital (SQUH), Oman, is striving for excellence through quality management. In seeking continual improvement, quality measurement exercises have been initiated throughout the Hospital. We present the overall survival rate of four of the ten most common cancers diagnosed in Oman.

METHODS

The cancers included non-Hodgkin's lymphoma (NHL), Hodgkin's lymphoma (HL), breast cancer, and stomach cancer. The studies were all retrospective and had been conducted previously. For present purposes, only the overall survival was compared with studies both from the region, and with bench-mark studies.

RESULTS

For NHL, with a median follow-up of 8 months, the 2-year overall survival rate was 64%; 90% for low risk, 55% for intermediate risk, and 15% for high risk groups. For HL, the 5-year overall survival rate was 64%; 76% for low risk and 42% for high risk. For breast cancer, the 5-year survival rate was 67%; percentages were 88%, 75% and 59% for Groups I, II, and III respectively. For gastric cancer, the 5-year survival rate was 16.5 %; 24% for the non-metastatic group.

CONCLUSION

The outcome of patients with early stages and fewer adverse prognostic factors is comparable to what has been reported in the international literature; however, the outcome is inferior for patients presenting with advanced stage disease and several adverse prognostic factors.

Some Risk Factors for Coronary Heart Disease among Omani Males: A matched case-control study

OBJECTIVES

Evaluation of some of the leading risk factors for coronary heart disease (CHD) among males in Oman.

METHODS

We conducted a hospital-based pair-wise matched case-control study among Omani CHD patients admitted in the Sultan Qaboos University Hospital and the Royal Hospital located in Muscat, Oman. The cases were matched with an equal number of controls in respect of age and hospital. The information was collected from the cases and controls based on an interview and review of the medical records of the admitted CHD patients. The odds ratios (ORs) were estimated under univariate as well as multivariate situations using conditional multiple binary logistic regression model.

RESULTS

The analysis revealed that 74 percent of the cases were of angina pectoris. The majority of the cases (96%) were above 40 years of age. The prevalence of sedentary life style was predominant (88.0%). Hypertension, diabetes, family history of CHD and a sedentary occupation were the most significant risk factors for the development of the disease. The estimated values of the adjusted ORs were found to be 9.98, 2.74, 28.19 and 3.00 respectively (p<0.05).

CONCLUSION

Individuals with hypertension, diabetes mellitus, a family history of CHD and with sedentary occupations are to be considered at high risk of developing CHD. Such individuals should be provided with appropriate health education along with close monitoring for symptoms and signs of CHD.

Reference ranges for lymphocyte subsets in healthy adult male Omanis

OBJECTIVE

To determine the reference ranges of lymphocyte subsets in serologically HIV-seronegative healthy male adults in Oman.

METHODS

A cohort, of 118 healthy male blood donors ranging in age from 18-51 years, was included in the study. The average age was 25 years. Blood samples collected into tubes containing ethylene-diamine-tetra acetic acid were investigated for lymphocyte subsets using flow cytometer. This study was conducted in the Immunology Laboratory of the Sultan Qaboos University, College of Medicine and Health Sciences, Muscat, Oman during the year 2006.

RESULTS

For the 118 males investigated, the mean percentage and absolute values of the lymphocyte subsets were as follows: CD3: 68.53 +/- 7.5%, 1701 +/- 489 cells/microliter; CD4: 40.4 +/- 6.5%, 1006 +/- 319 cells/microliter; CD8: 25.8 +/- 5.9%, 638 +/- 225 cells/microliter; CD19: 13.7 +/- 4.7%, 349 +/- 158 cells/microliter, and CD56: 12.2 +/- 6.7%, 308 +/- 204 cells/microliter. The ratio of CD4/CD8 was 1.6.

CONCLUSION

Immunophenotyping has been used to establish reference values of lymphocyte subsets in normal healthy adult males in Oman. The Omani male reference values obtained in this study show wide variations compared with kits values previously used as a reference.

Clinical and genetic study of spinal muscular atrophies in Oman

This article presents a retrospective study and a prospective study on spinal muscular atrophy in Oman. For the retrospective study, data were collected from neurophysiology records, from both inpatient and outpatient files. The prospective study was conducted on children as they presented to the hospital and was funded by Sultan Qaboos University. The patients of spinal muscular atrophy were classified into types I, II, and III based on their clinical features as per the International Spinal Muscular Atrophy Consortium classification. The incidence of spinal muscular atrophy was about 1 per 6000 live births. Spinal muscular atrophy type I formed 65% of the cases. Survival motor neuron deletion was seen in 70% of cases of all types of spinal muscular atrophy. The deletion was 83% in spinal muscular atrophy type I. A further study to look into the nondeletional cases is in progress.

NAT2 polymorphism in Omani gastric cancer patients-risk predisposition and clinicopathological associations

AIM: To study whether N-acetyltransferase 2 (NAT2) genotypes and phenotypes are associated with increased risk factor for gastric cancer in Omani patients and to study the clinico-pathological correlations and the prognostic significance of NAT2.

METHODS: Genomic DNA was extracted from peripheral blood of 100 gastric cancer patients and 100 control subjects. NAT2 genotyping was performed using DNA sequencing. The prognostic significance of NAT2 and other clinicopathological features was assessed by univariate and multivariate analyses.

RESULTS: We observed no significant association between NAT2 genotypes and phenotypes and gastric cancer risk. The NAT2 phenotype polymorphisms and gastric cancer risk predisposition were not modified by concomitant H pylori infection and smoking. There was no significant association between NAT2 and clinicopathological features, and NAT2 had no independent prognostic significance.

CONCLUSION: In the current study, NAT2 genotypes and phenotypes are not associated with gastric cancer risk predisposition. Moreover NAT2 phenotypes had no clinicopathological associations or prognostic significance.

[Conceiving and implementing an ISO 9001:2000 quality management system: quality improvement and efficiency increase over 3 years at the Dept. of Ophthalmology, Sultan Qaboos University in Oman]

BACKGROUND

Oman is a developing country of the Middle East with a University Hospital in a national health system. Problems related to documentation, structure, and procedure prevailing in a multicultural environment result in a lack of productivity. The aim of this study was to test the feasibility of introducing a quality management system according to ISO 9001:2000 into a university department of ophthalmology with special reference to quality and efficiency data over 3 years.

MATERIALS AND METHODS

Standardized types of documentation (35 documents, 183 forms and formats, and 453 registers) under a formal roof (booklets for work instructions, quality management, procedures) were conceived in 2001 and implemented, and were evaluated by descriptive statistics over the years 2002-2005 with respect to quality and efficiency. In 2005, the departmental QMS was merged into the QMS of the whole hospital.

RESULTS

Establishment of "responsibility clusters" with structured surveillance tasks, procedural improvements, and continuous audits resulted in a significant quality improvement already during the implementation until ISO 9001:2000 certification in 2002, and over the following 3 years. The data were assessed by non-conformities documented monthly (total inpatients: -50%, outpatients: -20%, operating theater: -100%, teaching: -10%; p <0.05) and increased efficiency assessed by the most important performance indicators (before QMS vs a median of 3 years with QMS): major surgery: +459%, inpatient stay: -49.7%, occupancy rate: +63.9%, technical diagnostics: +292.9%, postgraduate teaching total: +740%, research output total: +330% (p <0.05).

CONCLUSIONS

It is feasible to introduce the quality management system according to ISO 9001:2000 into a developing country in the Middle East. It has an immediate effect on the increase of efficiency (measured by performance indicators) and quality in all systems providing the possibility for regional benchmarking.

Perception of stroke and knowledge of potential risk factors among Omani patients at increased risk for stroke

Background

Previous studies have demonstrated poor knowledge of stroke among patients with established risk factors. This study aims to assess the baseline knowledge, among patients with increased risk for stroke in Oman, of warning symptoms of stroke, impending risk factors, treatment, and sources of information.

Methods

In April 2005, trained family practice residents at Sultan Qaboos University Hospital Clinics (cardiology, neurology, diabetic, and lipid clinics), using a standardised, structured, pre-tested questionnaire, conducted a survey of 400 Omani patients. These patients all demonstrated potential risk factors for stroke.

Results

Only 35% of the subjects stated that the brain is the organ affected by a stroke, 68% correctly identified at least one symptom/sign of a stroke, and 43% correctly identified at least one stroke risk factor. The majority (62%) did not believe they were at increased risk for stroke, and 98% had not been advised by their attending physician that their clinical conditions were risk factors for stroke. In the multivariable logistic regression analysis, lower age and higher levels of education were associated with better knowledge regarding the organ involved in stroke, stroke symptoms, and risk factors.

Conclusion

Because their knowledge about stroke risk factors was poor, the subjects in this study were largely unaware of their increased risk for stroke. Intensive health education is needed to improve awareness of stroke, especially among the most vulnerable groups.

The prognostic determinants of gastric cancer treatment outcome in Omani Arab patients

BACKGROUND

Gastric cancer is the most common cancer in Oman and a leading cause of cancer death. The variation in survival rates between countries and ethnic groups has been attributed to early detection policies, differences in clinicopathological features, treatment approaches, and biological characteristics. There were no previous reports on gastric cancer from Oman and very few studies on Asian Arabs.

AIM

To evaluate the impact of clinicopathological and treatment variables on the survival prospects of Omani Arab patients diagnosed with gastric cancer.

METHODS

The medical records of 339 Omani Arab patients diagnosed with invasive gastric adenocarcinoma during the period 1993-2004 were retrospectively reviewed. The relative importance of clinicopathological features and surgical and medical treatments were assessed using univariate and multivariate analyses.

RESULTS

Most patients had distal ulcerating-type gastric cancer and presented at advanced stages. The median survival time for the entire cohort was 12 months (95% CI 9.7-14.4) with a 5-year overall survival rate of 16.7%. On univariate analysis of 237 patients who underwent surgical resection, the following positive prognostic factors emerged as significant: early overall TNM stage, early T stage, negative lymph nodes, tumor size <5 cm, ulcerating macroscopic appearance, and curative surgical attempt. The independent prognostic factors on multivariate analysis were T stage and lymph node involvement.

CONCLUSION

The overall T and N stages are the most important determining factor for survival in Omani Arab patients. More efforts need to be made for the early detection of gastric cancer in developing countries such as Oman, while continuing to employ the standard surgical and medical treatments.

The prognostic significance of p53, p27 kip1, p21 waf1, HER-2/neu, and Ki67 proteins expression in gastric cancer: a clinicopathological and immunohistochemical study of 121 Arab patients

BACKGROUND

The variability of prognosis within a pathological stage of gastric cancer (GC) at presentation, underscores the need for specific biological markers to identify subgroups of patients with aggressive course for intensive treatment. To our knowledge, this is the first study from an Arab population reporting on the relationship of p53, p27 kip1, p21 waf1, HER-2/neu, and Ki67 expression, and clinicopathological features and their prognostic significance.

METHODS

Formalin-fixed paraffin-embedded tumors were studied by immunohistochemistry, using monoclonal antibodies to p53, p27 kip1, p21 waf1, HER-2/neu, and Ki67. The results were correlated with clinicopathological features and survival.

RESULTS

M:F = 80:41; median age = 60 years; stage III and IV = 71%; and median follow-up = 34.4 months. Positive expression rates of p53, p27 kip1, p21 waf1, Ki67, and HER-2/neu were 54%, 40%, 8.3%, 70%, and 12% respectively. p53 expression correlated with age <60 years (P = 0.03), tumor size >5 cm (P = 0.01), p27 kip1 and Ki67 expression (P = 0.0001), and HER-2/neu (P = 0.04). p21 waf1 correlated inversely with T-stage (P = 0.008) and Her-2/neu expression correlated with histological grade (P = 0.04) and T-stage (P = 0.008). Univariate analysis showed that p53 overexpression (P = 0.01), fungating and infiltrative macroscopic appearance (P = 0.02), size >5 cm (P = 0.0001), lymph node metastasis (P = 0.0001), p T3 and T4 disease (P = 0.01), and overall stage III and IV (P = 0.0001) disease were adverse prognostic factors. Patients with tumor profiles p53 (-)/p27 (+) had better survival than those with p53 (+)/p27 kip1 (-)(P = 0.02). On multivariate analysis by Cox regression model, the expression of p53 (P = 0.03) and lymph node involvement (P = 0.01) were significant adverse prognostic factors for overall survival.

CONCLUSIONS

The expression of p53 in Arab patients with GC correlates with aggressive tumor characteristics and is an independent prognostic factor. The combined analysis of p53 and p27 kip1 is of added prognostic value.

Association of the risk allele of dopamine transporter gene (DAT1*10) in Omani male children with attention-deficit hyperactivity disorder

OBJECTIVES

To determine the frequency of the VNTR alleles in the human dopamine transporter gene (DAT1) in the Omani population and to investigate association of the VNTR alleles with attention-deficit hyperactivity disorder (ADHD).

DESIGN AND METHODS

92 Omani children with ADHD and 110 healthy Omani subjects were genotyped for the DAT1-VNTR polymorphism in a case-control study using two independent PCR tests (one developed in our laboratory) followed by agarose gel electrophoresis.

RESULTS AND CONCLUSIONS

We determined the DAT1-VNTR alleles in 202 Omani subjects. There were two common alleles (DAT1*9 and *10) and five rare ones. The DAT1*10 allele distribution was essentially the same both in the control (60.9%) and the patient group (64.6%). There was, however, a relatively higher occurrence of the DAT1*10 allele in ADHD males (69.4%) than females (55%), but this gender difference was not present in the control group (males 60%, females 62%).

The outcome of treatment of breast cancer in a developing country--Oman

The aim of the present study was to evaluate the outcome of treatment of breast cancer in Oman with an analysis of clinico-pathological features, treatment modalities utilized, and prognostic factors. One hundred fifty-two breast cancer patients diagnosed between January 1996 and June 2002 were evaluated retrospectively. Their mean age was 48.5 (S.D. +/- 10.8) years, and 48% of the female patients were premenopausal. The mean tumor size according to pathology was 4.6 (S.D. 3.29)cm, and 34.9% and 15.8% of patients had stage III or IV disease, respectively. Only 26.3% of the patients had breast-conserving surgery, and neoadjuvant chemotherapy was underutilized. The overall 5-year relapse-free survival (RFS) and overall (OS) survival rates were 62% and 64%, respectively. On multivariate analysis, axillary lymph node involvement and tumor differentiation were predictive of RFS and OS, respectively. Thus, breast cancer patients in Oman present with advanced stages of the disease at younger ages than their counterparts in the West and have lower survival rates. Increasing awareness and the introduction of screening programs and of a multidisciplinary approach are essential in Oman and other developing countries to improve the outcome of treatment.

Retinopathy of prematurity in VLBW and extreme LBW babies

OBJECTIVE

This is a hospital-based, prospective clinical study to determine the incidence, risk factors, and outcome of extreme low birth weight and very low birth weight pre-term babies with retinopathy of prematurity (ROP) at the Sultan Qaboos University Hospital, Oman.

METHODS

All babies with a birth weight =/< 1500 g and gestational age =/< 32 weeks admitted in the Neonatal Unit, were screened for ROP between 4 to 6 weeks of age and staged according to the international classification and were followed up until complete vascularization of the retina. Fifty nine babies formed the study group.

RESULTS

The overall incidence of ROP was 25.4% (15 out of 59), of which 6 babies had severe ROP and underwent cryotherapy/laser. All babies with ROP had a birth weight < 1250 g and were born before 31 weeks of gestation.

CONCLUSION

ROP is a multifactorial disease, the immature retina of the pre-term baby being the primary factor. Incidence and severity was inversely proportional to birth weight and gestational age. Multiple logistic regression analysis showed that sepsis and total parenteral nutrition to be highly significant risk factors. Repeated blood transfusions, hypotension and congenital heart disease with left to right shunt were seen to be considerably associated with the development of ROP. A decrease in overall incidence and severity of ROP was observed in this study.

MATERNAL RISK FACTORS AS DETERMINANTS OF LOW BIRTH WEIGHT AMONG ARMED FORCES FAMILIES

Low birth weight (LBW) is responsible for a significant proportion of child morbidity and mortality apart from its possible role in the occurrence of chronic disease in adult life. This study highlights the overall low incidence of LBWs at 13.6% among the Armed Forces families. The Other Ranks had a proportionally higher incidence of LBW at 24.14%. 82.14% of the LBWs occurred in the age group of 20-29 yrs, with only 6.93% of the births being teenage pregnancies. Primiparous women accounted for 54.95% of births but 75% of the LBWs. Smoking was not a significant factor. The findings underscore the need for special attention to other rank families and primiparas. A continued effort at updating the health care facilities provided to the Armed Forces families, and a concerted health and dietary advice by the authorised medical attendants, directed at the primiparous women, will further help lower the incidence of LBWs. The National LBW target of less than 10% by 2000 AD is definitely achievable by the Armed Forces.

Evaluation of some risk factors for ischaemic heart disease under a matched pairs case-control design

A pair-wise matched case-control study was carried out in 200 male patients of ischaemic heart disease (IHD). The cases were matched with an equal number of controls in respect of the variables viz., age and socio-economic status. The objective was to quantify the risk of developing IHD for some of the leading risk factors under the univariate and multivariate situations. The analysis revealed that of the factors (smoking, overweight, hypertension, diabetes, serum cholesterol and family history) considered, the smoking habit of the individual, presence of family history of the disease and overweight were the significant risk factors responsible for the development of the disease. The estimated odds ratios were found to be 3.29, 2.60 and 2.00 respectively.

Analysis of ordinal data in a study of endometrial cancer under a matched pairs case-control design

While estimating odds ratios (ORs) in the context of dose levels of conjugated oestrogen exposure and development of endometrial cancer, the categories formed by the levels of the exposure are ordinal in nature. In the literature, the binary logistic model is used for estimating OR for each category relative to the baseline category. We describe the use of two ordinal logistic models, the cumulative logit and continuation-ratio logit models, to estimate the ORs for the matched pairs case-control data set of the Los Angeles endometrial cancer study. A test for equality of the cumulative ORs across the exposure levels is proposed. The test statistic follows asymptotically the chi-square distribution.

Evaluation of susceptibility status of Culex quinquefasciatus larvae to few organophosphorus insecticides based on logistic regression analysis

A laboratory trial was carried out at Pune to evaluate the effectiveness of five types of larvicides viz. Malathion, Temephos, Fenthion, Dichlorvos and Fenitrothion against Culex quinquesfasciatus larvae. The expected number of mortality at various dose levels for the five types of insecticides were estimated separately using logistic regression model. Based on the fitted model, the estimated dose level corresponding to the 90 percent mortality (LC90) was obtained for each insecticide. Approximate 95 percent confidence intervals for the LC90 dose, in each case, has been provided. The analysis revealed that out of all the five types of insecticides included in the study, fenthion was the most effective. The estimated value of LC90 in this case was the lowest and is equal to 0.007 mg/L. The effectiveness of temephos, dichlorvos and fenitrothion was found to be approximately same and malathion was the least effective. The results were found to be comparable with that obtained under probit method.

Calcium channel blockers and the CVS reflex responses during lower body suction

Nine normal men (mean age 27.6 yr) were exposed to continuous lower-body suction pressure (LBSP) of -20 to -50 mmHg (for 5 min at each level) on four different occasions after having consumed a single oral therapeutic dose of either diltiazem, nifedipine, verapamil, or a placebo, randomly, in a single blind manner. The suction was applied at 12.30 pm in all experiments, while the medications were administered in such a manner so that their expected peak plasma levels would have been achieved at the time of suction application. The cardiovascular reflex effects commenced at a pressure of -30 mmHg, and peaked at -50 mmHg. The increases in the heart rate for all treatments at -50 mmHg was statistically similar (about 16-20 beats/min). The systolic BP fell by about 9 mmHg for the placebo experiments, and this change was not different from the changes produced by the 3 Calcium channel blocker treatments. The diastolic BP increase was about 3 mmHg. The Cardiac index did not vary significantly. Our results suggest that the commonly used Ca++ channel blockers do not adversely affect orthostatic tolerance.

Laboratory evaluation of some larvicidal agents against Anopheles culicifacies in Pune

A laboratory study to evaluate some larvicidal agents against Anopheles culcifacies was carried out. The findings of this study brought out that the larvae of this species were highly susceptible to temephos, fenthion, Paris green and Mosquito Larvicidal Oil (MLO) in that order. The LC50 values in respect of these larvicides were 0.0009 ppm, 0.0081 ppm, 0.029 ppm and 0.015 ml respectively and LC90 values were 0.0018 ppm, 0.022 ppm, 0.11 ppm and 0.046 ml respectively.

A case control study of cancer cervix patients attending Command Hospital, Pune

A case control study was undertaken with the objective to determine the association of certain host factors like marital status, age at first marriage, duration of married life, parity, literary status and genital hygiene, in the subsequent development of cancer cervix. A total number of ninety-two cases and an equal number of control subjects, under matched case control design, were studied at Command Hospital, Pune over a period of nine months. Salient findings of this epidemiological study have been highlighted in this communication. Few of the risk factors viz early age at first marriage, longer duration of married life, increased and early parity, low educational status and poor genital hygiene were found to have played significant role in the subsequent development of carcinoma cervix.

Medico-social profile of male teenager STD patients attending a clinic in Pune

A study of 250 male teenager STD cases was carried out to determine the association between certain medicosocial factors e.g. age, type of infection, educational status, source of infection, knowledge about mode of acquiring infection and prophylaxis etc. Salient findings of the study such as gonorrhoea being the commonest type of STD, curiosity being the main reason for first sexual exposure and prostitutes being the major source of infection have been highlighted in this communication.

A study of morbidity pattern among prostitutes attending a municipal clinic in Pune

The findings of the present study revealed that out of 200 prostitutes attending a clinic for various ailments, 81.50% were suffering from sexually transmitted diseases (STD) thus posing a potential risk of transmitting these diseases to their clients. Syphilis was found to be the commonest STD afflicting 36.80% of the respondents, the next common being the chancroid (31.28%); 5.52% of the respondents were found to be suffering from concomitant venereal infections. The other important communicable diseases with which some respondents were found to be afflicted, included--tinea infection (3 cases), scabies (2 cases), leprosy (2 cases), pulmonary tuberculosis (4 cases) and upper respiratory tract infection [3 cases). Thus, the prostitutes remain an undisputed potential source of infection not only of STDs but also several other communicable diseases. Therefore, their continuous surveillance, early diagnosis, appropriate treatment and subsequent follow-up should be meticulously carried out. On the other hand the public, particularly the sexually promiscuous individuals must be imparted vigorous health education to avoid exposure to this source.