The high incidence of fatal diseases, inequitable access to health care, and socioeconomic disparities in India generate plentiful clinical bad news including diagnosis of a life-limiting disease, poor prognosis, treatment failure, and impending death. These contexts compel health care professionals to become the messengers of bad news to patients and their families. In global literature on breaking bad news, there is very little about such complex clinical interactions occurring in India or guiding health care providers to do it well. The purpose of this article is to identify the issues for future research that would contribute to the volume, comprehensiveness, and quality of empirical literature on breaking bad news in clinical settings across India. Towards this end, we have synthesized the studies done across the globe on breaking bad news, under four themes: (a) deciding the amount of bad news to deliver; (b) attending to cultural and ethical issues; (c) managing psychological distress; and (d) producing competent messengers of bad news. We believe that robust research is inevitable to build an indigenous knowledge base, enhance communicative competence among health care professionals, and thereby to improve the quality of clinical interactions in India.

The field of pain medicine that once began as a supportive and compassionate care, adding value to the management of acute and chronic ailments, has now transformed into a vital and essential specialty with structured training programs and service units with professionals dedicating their careers to it. The expansion of understanding of the direct relationship of pain relief to the quality of life, uncovering of neuronal pathways, and technological advances in imaging as well as in interventional techniques have all contributed to this phenomenal growth. However, there is a growing concern whether the training programs and the specialized practitioners are gradually limiting their skilled inputs primarily within the sensory realm of the pain experience with sophisticated interventional techniques and relegating its subjective and emotional dimensions to perfunctory realms within the schema of service provision. While the specialty is still young, if we can understand the inherent aspect of these dimensions within the pain experience and acknowledge the gaps in service provision, it may be possible to champion development of truly comprehensive pain relief programs that responds effectively and ethically to a patient's felt needs. This article attempts to position the subjectivity of pain experience in context and surface the need to design complete systems of pain relief services inclusive of this dimension. It presents authors' review of literature on perspectives of 'unpleasant subjective emotional experiencing of the pain" to elucidate possible clinical implications based on the evidences presented on neuro-biology and neuro-psychology of the pain experience; the aim being to inspire systems of care where this dimension is sufficiently evaluated and managed.

Development of palliative care (PC) culture spur the need of proper and formal training. Palliative medicine is not fully recognized as an academic medical discipline due to its humanistic influences, and studies show that physicians declare to be not prepared to provide care and pain management to dying patients. Nowadays, despite leading countries in PC being considered more innovative than other countries,such as Italy, facts show that the achievement of acknowledged discipline went through a long process. In Italy,professionals from about 450 PC units and organizations need to receive a proper and homogeneous training. In Italy, palliative medicine official certification is an undergoing process advocated by a few organizations and in Bologna the Academy of the Sciences of Palliative Medicine operates since 2007 with the defined mission of developing PC culture, also within the University. In order to be as much effective in pursuing its mission, the Academy has strengthened several international cooperation programs and today is leader in PC professional training and research in Italy. The recent law and its feasibility is fastening the process of development of Palliative Care Culture in Italy even if training is not properly regulated and official certification for physician is under evaluation. In Europe, the European Association of Palliative Care is stressing the need for training programs in palliative medicine and the outcomes of the dedicated task force on official certification and specialty in Palliative Medicine will remarkably force policy makers and national councils to officially recognize the discipline.

Context: Mechanism-based classification (MBC) was established with current evidence and physical therapy (PT) management methods for both cancer and for noncancer pain. Aims: This study aims to describe the efficacy of MBC-based PT in persons with primary complaints of cancer pain. Settings and Design: A prospective case series of patients who attended the physiotherapy department of a multispecialty university-affiliated teaching hospital. Material and Methods: A total of 24 adults (18 female, 6 male) aged 47.5 ± 10.6 years, with primary diagnosis of heterogeneous group of cancer, chief complaints of chronic disabling pain were included in the study on their consent for participation The patients were evaluated and classified on the basis of five predominant mechanisms for pain. Physical therapy interventions were recommended based on mechanisms identified and home program was prescribed with a patient log to ensure compliance. Treatments were given in five consecutive weekly sessions for five weeks each of 30 min duration. Statistical Analysis Used: Pre-post comparisons for pain severity (PS) and pain interference (PI) subscales of Brief pain inventory-Cancer pain (BPI-CP) and, European organization for research and treatment in cancer-quality of life questionnaire (EORTC-QLQ-C30) were done using Wilcoxon signed-rank test at 95% confidence interval using SPSS for Windows version 16.0 (SPSS Inc, Chicago, IL). Results: There were statistically significant ( P < 0.05) reduction in pain severity, pain interference and total BPI-CP scores, and the EORTC-QLQ-C30. Conclusion: MBC-PT was effective for improving BPI-CP and EORTC-QLQ-C30 scores in people with cancer pain.

Background: The psychological stress after diagnosis of breast cancer is often severe. Most of the women with breast cancer and their families suffer from emotional, social, financial and psychological disturbances. Materials and Methods: A cluster non-randomized trial was conducted at a Cancer Society in Melaka, Malaysia to assess the effectiveness of psycho-education on well-being status and depression among breast cancer patients. The study period was for one month (11 ^th June 2011 and 16 ^th July 2011). Participants in this study were 34 adult women suffering from non-metastatic breast cancer and on appropriate allopathic medication. The WHO-five Well-being Index (1998 version) was used as the screening instrument for the assessment of well-being and depression. The data collected were tabulated and analyzed by using the Statistical Package for Social Sciences (SPSS) version 11.0. Wilcoxon Signed-rank Test was applied for comparison between pre-test and post-test scores. A P value <0.05 was considered as statistically significant. Results: This study revealed that majority of the participants was in the state of adequate well-being after the psycho-education 33 (97.1%). The proportion of depressed individuals had also reduced from 8 (23.5%) to 1 (2.9%) after the psychological intervention. The post-test results significantly improved after the intervention for the items related to "I have felt calm and relaxed", "I woke up feeling fresh and rested" and "my daily life has been filled with things that interest me" along with the "overall impression" in the WHO-5 Well-being Index. Conclusion: Group psycho-education played a significant role in improving the well-being status and reducing depression of breast cancer survivors.

Background: Patients with advanced cancer often suffer from multiple refractory symptoms in the terminal phase of their life. Palliative sedation is one of the few ways to relieve this refractory suffering. Objectives: This systematic review investigated the effect of palliative sedation on survival time in terminally ill cancer patients. Materials and Methods: Six electronic databases were searched for both prospective and retrospective studies which evaluated the effect of palliative sedation on survival time. Only those studies which had a comparison group that did not receive palliative sedation were selected for the review. Abstracts of all retrieved studies were screened to include the most relevant studies and only studies which met inclusion criteria were selected. References of all retrieved studies were also screened for relevant studies. Selected studies were assessed for quality and data extraction was done using the structured data extraction form. Results: Eleven studies including four prospective and seven retrospective studies were identified. Mean survival time (MST) was measured as the time from last admission until death. A careful analysis of the results of all the 11 studies indicated that MST of sedated and non-sedated group was not statistically different in any of the studies. Conclusion: This systematic review supports the fact that palliative sedation does not shorten survival in terminally ill cancer patients. However, this conclusion needs to be taken with consideration of the methodology, study design, and the population studied of the included studies in this review.

Background: Gefitinib, an epidermal growth factor receptor-tyrosine kinase inhibitor, represents a new treatment option for patients with advanced non-small-cell lung cancer (NSCLC). We analyzed the data of patients who received Gefitinib for NSCLC in a tertiary care center in South India. Materials and Methods: Sixty-three patients with advanced NSCLC who had received Gefitinib either after failure of conventional chemotherapy or were previously not treated as they were unfit or unwilling for conventional treatment were included in the analysis. Results: The median follow-up for the cohort was 311 days (range 11-1544 days). Median time to progression was 161 (range 9-883) days. Complete and partial remission was seen in 1 (2%) and 6 (9%) patients, respectively, with overall response rate of 11%. Twenty-four (38%) patients had stable disease. Gefitinib was well tolerated with no significant side effects. Conclusion: Gefitinib shows anti-tumor activity in pretreated or previously untreated patients with advanced NSCLC. It has a favorable toxicity profile and is well tolerated. Gefitinib should be considered as a viable therapy in patients with NSCLC.

Introduction: A way to assess compliance with analgesics in an outpatient palliative care clinic is essential since often the patient is too ill or weak to come to hospital for weekly follow-ups. A pilot study was conducted using Short Messaging Service via mobile phone as a follow-up tool. Context: A predominantly outpatient palliative care clinic of a 300 bedded multidisciplinary hospital. Materials and Methods: Sixty patients attending the palliative care clinic were enrolled in the study. Analgesic drugs, co-analgesics, and adjuvants were prescribed on an outpatient basis. If possible, patients were admitted for 1 or 2 days. A simple scoring system was devised and taught to the patients and their attenders. A short message service had to be sent to the author's mobile number. The period was fixed at 2 weeks by which the patients and attenders were familiar with the drugs and pain relief as well. Drowsiness was a worrisome complaint. The mobile number of the patient was called and attender instructed to skip one or two doses of morphine and reassurance given. If required, attender was asked to bring patient to the hospital or come to the hospital for a different prescription as the situation warranted. Results: Out of 60 patients, 22 were admitted initially for dose titration and all others were outpatients. Three patients were lost to follow-up and one patient died after 7 days. 93% of patients responded promptly. Random survey was done in 10 patients to confirm their SMS response and the results were analyzed. Conclusion: Mobile phones are available with all strata of people. It is easy to train patients to send an SMS.This technology can be used to follow- up palliative care patients and help them comply with their treatment regimen.

Aims: In this paper, we have reported a previously undescribed risk factor of deterioration of renal function in zoledronic acid treatment of skeletal metastasis - high serum calcium level. Based on this consideration, a modified method of treatment of hypercalcemia (HCM) with zoledronic acid is suggested in this paper. Material and Methods: Bone scan findings of 1090 cancer patients were analyzed, of which 26 had intense renal parenchymal uptake as a result of HCM or bone metastases. Subsequently, a total of 56 bone metastases patients with zoledronic acid treatment were divided into three groups: HCM group who were pre-treated to normal serum calcium level (13 patients), HCM group (19 patients), and normal serum calcium group (24 patients). Results: More patients with intense renal parenchymal uptake were hyperglycemic, statistically significantly (18/26 versus 19/1064, P = 2.1, E-78). No more patients with intense renal parenchymal uptake were associated with bone metastases (14/26 versus 438/1064, P = 0.20). Subsequently, more HCM patients receiving zoledronic acid treatment showed renal injury compared to patients with normal serum calcium level (5/15 versus 2/24, P < 0.05) and HCM patients with pre-treatment to normal serum calcium level (5/15 versus 1/17, P < 0.05). Conclusions: Intense renal parenchymal uptake of bisphosphonates is closely related to HCM rather than to bone metastases in cancer patients. The serum calcium should be measured and reduced to normal level before zoledronic acid is used in managements of adverse skeletal events in order to decrease the risk of renal injury.

Simultaneous double cancers in the biliary system are rare. Most are associated with pancreaticobiliary maljunction (PBM). However, it can occur in patients without PBM. Differentiation between these events is important since these two mechanistic origins imply different stages of disease, as well as different subsequent treatments and prognoses. Herein, we report a case of ampullary carcinoma associated with gall bladder carcinoma diagnosed nonoperatively and palliated with biliary metal stenting.

Retinoblastoma is a highly malignant neoplasm. Most of the cases are usually far advanced at the time of detection, requiring enucleation to salvage the child's life. However, the cosmetic rehabilitation of these patients should always be an integral part of their treatment, which helps in their re-integration in the society. This paper presents a case of 5-year-old patient who had undergone enucleation of her left eye due to retinoblastoma. A multidisciplinary approach, including ophthalmologist, psychotherapist, and a prosthodontist, was adopted to meet her physical, psychological, functional, emotional, social, and cosmetic demands. The patient was rehabilitated cosmetically with precisely fabricated ocular prosthesis. An ocular prosthesis is a highly positive and non-invasive approach to improve the cosmetic appearance and psychological well-being of patient.

In this single case study, we attempt to outline the possible effect of low-level laser therapy (LLLT) on delayed wound healing and pain in chronic dehiscent sternotomy of a diabetic individual. The methods that were employed to evaluate changes pre and post irradiation were wound photography, wound area measurement, pressure ulcer scale of healing (PUSH), and visual analogue scale (VAS) for pain. After irradiation, proliferation of healthy granulation tissue was observed with decrease in scores of PUSH for sternal dehiscence and VAS for bilateral shoulders and sternal dehiscence. We found that LLLT irradiation could be a novel method of treatment for chronic sternal dehiscence following coronary artery bypass grafting, as it augments wound healing with an early closure of the wound deficit. Hence, this might be translated into an early functional rehabilitation and decreased pain perception of an individual following surgical complication.