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Table of Contents 
ORIGINAL ARTICLE
Year : 2013  |  Volume : 19  |  Issue : 3  |  Page : 170-179

An exploratory analysis of levels of evidence for articles published in Indian journal of palliative care in the years 2010-2011


Srinivas College of Physiotherapy, Pandeshwar, Mangalore, India

Date of Web Publication18-Nov-2013

Correspondence Address:
Senthil Paramasivam Kumar
Srinivas College of Physiotherapy, Pandeshwar, Mangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1075.121535

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 » Abstract 

Context: Indian Journal of Palliative Care (IJPC) provides a comprehensive multidisciplinary evidence base for an evidence-informed clinical decision making.
Aims: To analyze the levels of evidence of articles published in IJPC in the years 2010-2011.
Settings and Design: Systematic review of palliative care journals.
Materials and Methods: Systematic review of articles was done and was scored according to Center for Evidence-Based Medicine levels of evidence into any of the five grades. The articles were categorized based upon article type, number of authors, study approach, age focus, population focus, disease focus, goals of care, domains of care, models of care, and year of publication.
Statistical Analysis Used: All descriptive analysis was done using frequencies and percentiles, and association between all categorical variables was done using Chi-square test at 95% confidence interval (CI) using Statistical Package for Social Sciences (SPSS) version 16 for Windows (SPSS Inc, Chicago, IL).
Results: There was a greater prevalence of low level evidence (level 4: n = 46, 51%; level 5: n = 35, 39%) among the 90 selected articles, and article type (original articles with higher level of evidence, P = 0.000), article approach (analytical studies with higher level of evidence, P = 0.000), domains of palliative care (practice-related studies with higher level of evidence, P = 0.000) and models of care (biological or psychosocial model with higher level of evidence, P = 0.044) had a significant association with the grade of levels of evidence. Association with other factors was not statistically significant (P > 0.05).
Conclusions: The levels of research evidence for palliative care provided by articles published in IJPC were predominantly level 4 and level 5, and there is scope for more high quality evidence to inform palliative care decisions in the developing countries.


Keywords: Evidence analysis, Evidence-based palliative care, Evidence hierarchy, Journal analysis, Levels of evidence


How to cite this article:
Kumar SP, Sisodia V. An exploratory analysis of levels of evidence for articles published in Indian journal of palliative care in the years 2010-2011. Indian J Palliat Care 2013;19:170-9

How to cite this URL:
Kumar SP, Sisodia V. An exploratory analysis of levels of evidence for articles published in Indian journal of palliative care in the years 2010-2011. Indian J Palliat Care [serial online] 2013 [cited 2020 Sep 28];19:170-9. Available from: http://www.jpalliativecare.com/text.asp?2013/19/3/170/121535


It is a well-known fact that there are barriers and difficulties to conduct research in the area of palliative care due to reservation and concerns about ethics and clinical trials on patients nearing the end of their life. This constraint makes research in this niche area more challenging and despite all reservations it is highly desirable to contribute authentic evidence-based treatment developments to the scientific knowledge pool. - Bhatnagar [1]


 » Introduction Top


Research in palliative care has grown leaps and bounds which is reflected in both quality and quantity of articles published in peer-reviewed journals. [2] Amongst many other specialties of professional journals such as medical, nursing, and anesthesiology; palliative care journals are reinforcing their responsibility by playing a leadership role in disseminating evidence for palliative and end of life care interventions.

Evidence for palliative care interventions through published articles enables clinicians and healthcare providers to understand, evaluate, interpret, and implement current findings into practice situations. Application of such evidence integrated with professional expertise and patient/caregiver preferences is termed as evidence-based practice (EBP). [3] Knowledge of palliative care research and evidence-base is indicated for an effective multidisciplinary collaborative shared informed decision making. [4]

Evidence-based palliative care relies on four aspects: Existing research evidence in palliative care; access to research evidence and dissemination of evidence; knowledge and skills in critical appraisal of evidence; and, in implementing evidence-based information into palliative care practice. [5] Due to the inability of many systematic reviews of health care interventions to provide conclusive answers, and also because the relevant RCTs simply do not exist or are of poor quality; clinician's wealth of experience-based knowledge is extended to provide an evidence-informed palliative care [6] rather than an evidence-based care.

Levels of evidence are a qualitative method of critical appraisal in which each type of published evidence is graded by its study design. It is commonly used for quality appraisal for inclusion in systematic reviews and evidence-based clinical practice guidelines. [7] Levels of evidence are a simple and an effective tool for critical appraisal which can be used for staffs and care providers in palliative care setting in developing countries. Previous reports on analysis of levels of evidence in journals were either on multiple journals or a single journal. [8]

The evidence for palliative care in developing countries depends upon the role played by Indian Journal of Palliative Care (IJPC) in dissemination of quality evidence to guide practice. IJPC got included in PubMed and its abstracts were indexed from January 2010 onwards. Ever since then, the leader's role in evidence-based palliative care in developing countries is played by IJPC with its motto, "no therapeutic activity should be prescribed unless supported by researched activity". [9]

The objective of this present study was to perform an exploratory analysis of articles published in IJPC and assess them according to levels of evidence, and to associate studies' characteristics and content with the attributed level of evidence.


 » Materials and Methods Top


Study design

A systematic review and quantitative analysis of articles published in IJPC.

Search methods

Two reviewers independently searched PubMed using specific search strategy and they independently extracted and synthesized the data from selected studies using a structured checklist. At all stages of the review process, disagreements were solved by mutual consensus before proceeding to the subsequent stages of review.

Search strategy and selection criteria

A thorough literature search of PubMed using keywords "Indian Journal of Palliative Care [Journal]" were used in the search tab, for obtaining all types of articles, published and indexed from 1 st January 2010 to 31 st December 2011. The articles from main issues of the journal would be considered and not the supplement(s).

Data extraction and synthesis

The full-text content of selected citations was examined for their attributes for analysis, as per the structured checklist.

Levels of evidence

The Center for Evidence-Based Medicine (CEBM) [10] levels of evidence grading was utilized for our analysis which constitutes as shown in [Table 1].
Table 1: Center for evidence‑based medicine
levels of evidence


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Levels of evidence was associated/correlated/compared with/between number of authors, country of author, article type (original article, other), article approach (descriptive, analytical), population age (adult, pediatric), study focus (patient/caregiver, professional, student), disease focus (cancer, HIV/AIDS, other, mixed), goal of care (diagnosis, prevention, treatment, prognosis, mixed), palliative care domain (practice, education, research, administration), model of care (biological, psychosocial, biopsychosocial), and year of publication (2010, 2011).

Data analysis

All descriptive analysis was done using frequencies and percentiles, and association between all categorical variables was done using Chi-square test at 95% confidence interval (CI) using Statistical Packages for Social Sciences (SPSS) version 16 for Windows (SPSS Inc Chicago, IL).


 » Results Top


Our initial search yielded 111 citations and we excluded 21 articles which were published in a supplement issue in January 2011 as a conference proceeding. Thus we had a final list of 90 articles for our analysis. [11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84],[85],[86],[87],[88],[89],[90],[91],[92],[93],[94],[95],[96],[97],[98],[99],[100]

The overall descriptive characteristics of the 90 articles with respect to number of authors per article [Figure 1], nationality of corresponding author [Figure 2], type of articles [Figure 3], type of study approach [Figure 4], study designs [Figure 5], target population [Figure 6], population focus [Figure 7], disease focus [Figure 8], goals of care [Figure 9], domains of palliative care [Figure 10], models of care [Figure 11], years of publication [Figure 12], and levels of evidence [Figure 13] are schematically shown.
Figure 1: Comparison of number of articles based upon number of authors per article

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Figure 2: Comparison of number of articles based upon the nationality of corresponding authors

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Figure 3: Comparison of number of articles based upon type of articles

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Figure 4: Comparison of number of articles based upon type of study approach

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Figure 5: Comparison of number of articles based upon study designs

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Figure 6: Comparison of number of articles based upon study target population

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Figure 7: Comparison of number of articles based upon study population focus

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Figure 8: Comparison of number of articles based upon disease focus

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Figure 9: Comparison of number of articles based upon goals of care

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Figure 10: Comparison of number of articles based upon domains of palliative care

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Figure 11: Comparison of number of articles based upon models of care

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Figure 12: Comparison of number of articles based upon years of publication

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Figure 13: Comparison of number of articles based upon levels of evidence

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Levels of evidence and number of authors per article

There was no significant association between levels of evidence and number of authors per article (P = 0.293). The comparison is shown in [Figure 14].
Figure 14: Comparison of number of articles based upon levels of evidence and number of authors per article

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Levels of evidence and country of author

There was no significant association between levels of evidence and the corresponding author's country (P = 0.987). The comparison is shown in [Figure 15].
Figure 15: Comparison of number of articles based upon levels of evidence and nationality of corresponding author

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Levels of evidence and article type

There was a statistically significant association between type of article and level of evidence (P = 0.000), that is, original articles were likely to be level 4 evidence (45/56) and other articles were likely to be level 5 evidence (33/34). The comparison is shown in [Figure 16].
Figure 16: Comparison of number of articles based upon levels of evidence and article type

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Levels of evidence and article approach

There was a significant association between levels of evidence and article approach (P = 0.000), that is, descriptive studies were likely to be levels 4 and 5 evidence (37/71 and 34/71, respectively) and analytical studies were likely to be levels 2 and 4 evidence (6/19 and 9/19, respectively). The comparison is shown in [Figure 17].
Figure 17: Comparison of number of articles based upon levels of evidence and study approach

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Levels of evidence and population age

There was no significant association between levels of evidence and study population's age focus (P = 0.156). The comparison is shown in [Figure 18].
Figure 18: Comparison of number of articles based upon levels of evidence and study population's age

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Levels of evidence and target population focus

There was no statistically significant association between level of evidence and target population focus (P = 0.103). The comparison is shown in [Figure 19].
Figure 19: Comparison of number of articles based upon levels of evidence and population focus

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Levels of evidence and disease focus

There was no significant association between levels of evidence and disease focus in the articles (P = 0.914). The comparison is shown in [Figure 20].
Figure 20: Comparison of number of articles based upon levels of evidence and disease focus

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Levels of evidence and goal of care

There was no significant association between levels of evidence and goals of care (P = 0.439). The comparison is shown in [Figure 21].
Figure 21: Comparison of number of articles based upon levels of evidence and goals of care

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Levels of evidence and palliative care domain

There was a significant association between levels of evidence and four domains of palliative care (P = 0.000), that is, articles on practice were more likely to be levels 4 and 5 evidence (37/65 and 27/65, respectively) and articles on administration were likely to be level 5 evidence (10/15). The comparison is shown in [Figure 22].
Figure 22: Comparison of number of articles based upon levels of evidence and domains of palliative care

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Levels of evidence and model of care

There was a significant association between levels of evidence and models of care (P = 0.044), that is, articles on biological model were likely to be level 4 evidence (23/38), articles on psychosocial model were likely to be level 4 evidence (16/24), and articles on biopsychosocial model were likely to be level 5 evidence (17/28). The comparison is shown in [Figure 23].
Figure 23: Comparison of number of articles based upon levels of evidence and models of care

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Levels of evidence and year of publication

There was no significant association between levels of evidence and year of publication (P = 0.331), and although articles at level 4 evidence increased from 17 in 2010 to 29 in 2011, their reporting rates had not (17/37 in 2010 and 29/53 in 2011). The comparison is shown in [Figure 24].
Figure 24: Comparison of number of articles based upon levels of evidence and years of publication

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Study designs and years of publication

There was no significant association between types of study design and years of publication (P = 0.470). There is an increase in number of systematic reviews and randomized controlled trials in 2011 compared to 2010. The comparison is shown in [Figure 25].
Figure 25: Comparison of number of articles based upon study designs and years of publication

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 » Discussion Top


This study aimed at exploring the levels of evidence for articles published in IJPC in a 2-year period and found that there was a greater prevalence of low level evidence among the articles, article type, article approach, domains of palliative care, and models of care had a significant association with the grade of levels of evidence; with rejection of null hypothesis. This is imperative because systematic reviews and randomized controlled studies were published as original articles, since they adopted an analytical approach.

The individual journals previously analyzed for levels of evidence were Journal of Bone and Joint Surgery-American (JBJS-A) and International Journal of Oral and Maxillofacial Surgery (IJOMFS; Kumar and Sisodia, 2012). [8] In the study by Hanzlik et al., (2009) [101] the authors reviewed JBJS-A articles across a 30-year period from 1975-2005 at four time-points of 10 year intervals and they found a trend towards increase in combined reporting rate of levels 1-3 evidence.

This present study found 3, 7, 0, 31, and 59% reporting for levels 1, 2, 3, 4, and 5; respectively. Lau and Samman's [102] (2007) findings were similar to this study in their analysis of IJOMFS where they found 0, 2, 8, 40, and 50% reporting for levels 1, 2, 3, 4, and 5; respectively. Bhandari et al., [103] (2004) found that the majority (69%) articles published in a 6-month period from January-June 2003 were studies of therapy, and 57% of the studies constituted level 6 evidence, which was again very much in agreement with our study's findings.

Influence of practice-related articles on levels of evidence is also not unexpected considering the overall higher prevalence of such articles in IJPC. Another influencing factor was the model of care and it was indeed surprising to note that articles along either biological or psychosocial model scored a higher level than biopsychosocial model. This could be explained in terms of relatively recent development of concept of behavioral model of chronic pain (Prem et al., 2012), [21] which the authors and experts had emphasized in their narrative reviews and editorials, and the trend is likely to be reversed with more randomized controlled trials along the biopsychosocial model in the near future.

The study had interesting observations; the four papers from Italy had ten authors or more per article, which questions further details on the role of contributors in those studies. International Committee of Medical Journal Editors (ICMJE) had listed a requirement of not more than six authors in a single-center study. This throws a suggestion on development of research co-operative groups and also a question on haunted authorship which should be appropriately addressed by including a 'role of contributors' section in articles (Leblanc et al., 2012). [104]

This study did not specifically aim to explore authorship characteristics, referencing and citation, or statistics used in the articles; and there is much scope for such research in the future.

The null hypothesis was substantially accepted in case of other factors by the lack of significant association of levels of evidence with other factors related to the articles. We initially presumed that Indian authors would have had published more level-specific evidence due to higher reporting of articles from this subcontinent. Interestingly, both systematic reviews and one randomized controlled trial were from India, although it did not reach statistical significance. There was greater number of studies with less than three authors, and earlier studies reported higher quality of published articles with greater number of authors, and this warrants future research on interprofessional training and educational interventions in this part of the globe.

This study was performed in articles on IJPC and future studies could be indicated along these lines, in other journals where active palliative care researchers publish their work (San-Miguel et al., 2011). [105]

Evidence-based medicine (EBM) is not an old hat, a "cookbook" medicine perpetrated by arrogant to serve cost cutters to suppress clinical freedom, a mandatory, deterministic, totalitarian practice of medicine, a way to control cost and to ignore patient preferences, a limit to personal/humanistic/individual medicine. EBM is a reference of excellence to guide clinical decisions, the integration of own expertise with others' expertise and patient preferences, a way to improve medical practice and limit the variability and errors created when there is no evidence to identify the gold standard and differentiate among alternatives available.- Freddi and Roman-Pumar [106]


 » Conclusion Top


There is a positive trend towards increase in number of published articles with high level of evidence in IJPC. The overall level of research evidence for palliative care provided by IJPC is low, and there is an urgent need for more high quality evidence to inform clinical palliative care practice in the developing countries.

 
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50.Kiran K, Kamala B. Palliative care in children: The role of a pediatric dentist in the Indian scenario. Indian J Palliat Care 2011;17:77-8.  Back to cited text no. 50
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51.Yadav P, Manjunath N, Deo S, Shukla N, Durgapal P, Muduly DK. Role of surgery in breast metastasis from carcinoma of the cervix. Indian J Palliat Care 2011;17:74-6.  Back to cited text no. 51
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52.Bhasin AS, Singh V, Mantri SS. Rehabilitation of patient with acquired maxillary defect, using a closed hollow bulb obturator. Indian J Palliat Care 2011;17:70-3.  Back to cited text no. 52
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53.Kumar S, Joshi MK. Emergency total thyroidectomy for bleeding anaplastic thyroid carcinoma: A viable option for palliation. Indian J Palliat Care 2011;17:67-9.  Back to cited text no. 53
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54.Kumar SP. Reporting characteristics of cancer pain: A systematic review and quantitative analysis of research publications in palliative care journals. Indian J Palliat Care 2011;17:57-66.  Back to cited text no. 54
    
55.Tendas A, Cupelli L, Scaramucci L, Palombi M, Trawinska MM, Giovannini M, et al. Anticoagulant and anti-thrombotic treatments in the management of hematological malignancies in a home care program. Indian J Palliat Care 2011;17:54-6.  Back to cited text no. 55
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56.Kumar SP, Jim A, Sisodia V. Effects of palliative care training program on knowledge, attitudes, beliefs and experiences among student physiotherapists: A preliminary quasi-experimental study. Indian J Palliat Care 2011;17:47-53.  Back to cited text no. 56
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57.Salins NS, Jansen W. Clinical audit on documentation of anticipatory "not for resuscitation" orders in a tertiary Australian teaching hospital. Indian J Palliat Care 2011;17:42-6.  Back to cited text no. 57
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58.Gielen J, Gupta H, Rajvanshi A, Bhatnagar S, Mishra S, Chaturvedi AK, et al. The attitudes of Indian palliative-care nurses and physicians to pain control and palliative sedation. Indian J Palliat Care 2011;17:33-41.  Back to cited text no. 58
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59.Santha S. Impact of pain and palliative care services on patients. Indian J Palliat Care 2011;17:24-32.  Back to cited text no. 59
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60.Karkada S, Nayak BS, Malathi. Awareness of palliative care among diploma nursing students. Indian J Palliat Care 2011;17:20-3.  Back to cited text no. 60
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61.Kang'ethe S. Evaluating the role of support group structures as vehicles of palliative care: Giving productivity in the Kanye care program in Botswana. Indian J Palliat Care 2011;17:11-9.  Back to cited text no. 61
    
62.Valsangkar S, Bodhare TN, Pande SB, Bele SD, Rao BS. Evaluation of knowledge among interns in a medical college regarding palliative care in people living with HIV/AIDS and the impact of a structured intervention. Indian J Palliat Care 2011;17:6-10.  Back to cited text no. 62
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63.Kaur J, Mohanti BK. Transition from curative to palliative care in cancer. Indian J Palliat Care 2011;17:1-5.  Back to cited text no. 63
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64.Wiwanitkit V. Care of terminally ill cancer patients: Resource allocation. Indian J Palliat Care 2010;16:184.  Back to cited text no. 64
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65.Bajwa SJ, Bajwa SK, Kaur J. Care of terminally ill cancer patients: An intensivist's dilemma. Indian J Palliat Care 2010;16:183.  Back to cited text no. 65
    
66.Koshy RC, Padmakumar G, Rajasree O. Low cost continuous femoral nerve block for relief of acute severe cancer related pain due to pathological fracture femur. Indian J Palliat Care 2010;16:180-2.  Back to cited text no. 66
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67.Kangethe S. The perfidious experiences of men as palliative caregivers of people living with HIV/AIDS and other terminal illnesses in Botswana. Eclectic data sources. Indian J Palliat Care 2010;16:174-9.  Back to cited text no. 67
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68.Krishna LK, Poulose JV, Goh C. Artificial hydration at the end of life in an oncology ward in Singapore. Indian J Palliat Care 2010;16:168-73.  Back to cited text no. 68
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69.David A, Banerjee S. Effectiveness of "palliative care information booklet" in enhancing nurses' knowledge. Indian J Palliat Care 2010;16:164-7.  Back to cited text no. 69
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70.Singh PK, Sakale H, Shrivastva S, Dulani R. Palliative surgical approach to rehabilitate spinal injury patient in Indian rural setup. Indian J Palliat Care 2010;16:160-3.  Back to cited text no. 70
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71.Sadhu S, Salins NS, Kamath A. Palliative care awareness among indian undergraduate health care students: A needs-assessment study to determine incorporation of palliative care education in undergraduate medical, nursing and allied health education. Indian J Palliat Care 2010;16:154-9.  Back to cited text no. 71
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72.Iranmanesh S, Axelsson K, Häggström T, Sävenstedt S. Caring for dying people: Attitudes among Iranian and Swedish nursing students. Indian J Palliat Care 2010;16:147-53.  Back to cited text no. 72
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73.Kumar SP, Jim A. Physical therapy in palliative care: From symptom control to quality of life: A critical review. Indian J Palliat Care 2010;16:138-46.  Back to cited text no. 73
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74.Tazi E, Errihani H. Treatment of cachexia in oncology. Indian J Palliat Care 2010;16:129-37.  Back to cited text no. 74
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75.Onyeka TC. Psychosocial issues in palliative care: A review of five cases. Indian J Palliat Care 2010;16:123-8.  Back to cited text no. 75
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76.Kangethe S. The dangers of involving children as family caregivers of palliative home-based-care to advanced HIV/AIDS patients. Indian J Palliat Care 2010;16:117-22.  Back to cited text no. 76
    
77.Jeyaraman S, Kathiresan G, Gopalsamy K. Hospice: Rehabilitation in reverse. Indian J Palliat Care 2010;16:111-6.  Back to cited text no. 77
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78.Mudigonda T, Mudigonda P. Palliative cancer care ethics: Principles and challenges in the Indian setting. Indian J Palliat Care 2010;16:107-10.  Back to cited text no. 78
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79.Saroja G, Devi PS, Namrata R. Oral morphine solution as an oral rinse or mouth gargle for mucositis pain. Indian J Palliat Care 2010;16:54-5.  Back to cited text no. 79
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80.Viroj W. Pain in HIV patients. Indian J Palliat Care 2010;16:54.  Back to cited text no. 80
    
81.Janaki M, Mukesh S, Arul Ponni T, Nirmala S. Aggressive approach in a case of cancer cervix with uremia. Indian J Palliat Care 2010;16:52-3.  Back to cited text no. 81
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82.Yadav N, Philip FA, Gogia V, Choudhary P, Rana SP, Mishra S, et al. Radio frequency ablation in drug resistant chemotherapy-induced peripheral neuropathy: A case report and review of literature. Indian J Palliat Care 2010;16:48-51.  Back to cited text no. 82
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83.Salins NS, Crawford GB. Intrathecal analgesia and palliative care: A case study. Indian J Palliat Care 2010;16:44-7.  Back to cited text no. 83
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84.Singh DP. Quality of life in cancer patients receiving palliative care. Indian J Palliat Care 2010;16:36-43.  Back to cited text no. 84
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85.Kangethe S. The perfidy of stigma experienced by the palliative CHBC of Kanye in Botswana. Indian J Palliat Care 2010;16:30-5.  Back to cited text no. 85
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86.Seth T. Communication to pediatric cancer patients and their families: A cultural perspective. Indian J Palliat Care 2010;16:26-9.  Back to cited text no. 86
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87.Dam A, Datta N, Mohanty UR. Evaluation of the "kosish cocktail" in treating severe pain in "home care" in morphine-naïve communities. Indian J Palliat Care 2010;16:23-5.  Back to cited text no. 87
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88.Kangethe S. Exploring states of panacea and perfidy of family and community volunteerism in palliative care giving in Kanye CHBC Program, Botswana. Indian J Palliat Care 2010;16:16-22.  Back to cited text no. 88
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89.Selman L, Harding R. How can we improve outcomes for patients and families under palliative care? Implementing clinical audit for quality improvement in resource limited settings. Indian J Palliat Care 2010;16:8-15.  Back to cited text no. 89
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90.Vallath N. Perspectives on yoga inputs in the management of chronic pain. Indian J Palliat Care 2010;16:1-7.  Back to cited text no. 90
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91.Kapali AS, Singh M, Deo S, Shukla NK, Muduly DK. Aggressive palliative surgery in metastatic phyllodes tumor: Impact on quality of life. Indian J Palliat Care 2010;16:101-4.  Back to cited text no. 91
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92.Thaker DA, Stafford BC, Gaffney LS. Palliative management of malignant bowel obstruction in terminally ill patient. Indian J Palliat Care 2010;16:97-100.  Back to cited text no. 92
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93.Iranmanesh S, Axelsson K, Sävenstedt S, Häggström T. Caring for dying and meeting death: Experiences of Iranian and Swedish nurses. Indian J Palliat Care 2010;16:90-6.  Back to cited text no. 93
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94.Bajwa SJ, Bajwa SK, Kaur J. Care of terminally ill cancer patients: An intensivist's dilemma. Indian J Palliat Care 2010;16:83-9.  Back to cited text no. 94
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95.Kangethe S. Occupational care giving conditions and human rights: A study of elderly caregivers in botswana. Indian J Palliat Care 2010;16:79-82.  Back to cited text no. 95
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96.Mol RP. The role of dentist in palliative care team. Indian J Palliat Care 2010;16:74-8.  Back to cited text no. 96
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97.Dam A, Datta N, Mohanty UR, Karn R, Singh D, Kumar S. Preventive palliation in the elderly-organizing health camps for the rural aged. Indian J Palliat Care 2010;16:70-3.  Back to cited text no. 97
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98.Salins NS, Pai SG, Vidyasagar M, Sobhana M. Ethics and medico legal aspects of "not for resuscitation". Indian J Palliat Care 2010;16:66-9.  Back to cited text no. 98
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99.Narayanan V, Bista B, Koshy C. 'BREAKS' Protocol for breaking bad news. Indian J Palliat Care 2010;16:61-5.  Back to cited text no. 99
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100.Rajagopal M. Disease, dignity and palliative care. Indian J Palliat Care 2010;16:59-60.  Back to cited text no. 100
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101.Hanzlik S, Mahabir RC, Baynosa RC, Khiabani KT. Levels of evidence in research published in The Journal of Bone and Joint Surgery (American Volume) over the last thirty years. J Bone Joint Surg Am 2009;91:425-8.  Back to cited text no. 101
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102.Lau SL, Samman N. Levels of evidence and journal impact factor in oral and maxillofacial surgery. Int J Oral Maxillofac Surg 2007;36:1-5.  Back to cited text no. 102
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103.Bhandari M, Swiontkowski MF, Einhorn TA, Tornetta P 3 rd , Schemitsch EH, Leece P, et al. Interobserver agreement in the application of levels of evidence to scientific papers in the American volume of the Journal of Bone and Joint Surgery. J Bone Joint Surg Am 2004;86-A:1717-20.  Back to cited text no. 103
    
104.Leblanc TW, Abernethy AP, Currow DC, Kutner JS. Considerations in reporting palliative care clinical trials: Standardizing information reported and authorship practices. Curr Opin Support Palliat Care 2012;6:494-9.  Back to cited text no. 104
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105.San-Miguel MT, Centeno C, Carvajal A, Ponz M. In which journals do active researchers of palliative care publish their articles? J Palliat Med 2011;14:4-5.  Back to cited text no. 105
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106.Freddi G, Romàn-Pumar JL. Evidence-based medicine: What it can and cannot do. Ann Ist Super Sanita 2011;47:22-5.  Back to cited text no. 106
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25]
 
 
    Tables

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