Indian Journal of Palliative Care
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   Table of Contents - Current issue
Coverpage
July-September 2017
Volume 23 | Issue 3
Page Nos. 219-352

Online since Monday, July 17, 2017

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EDITORIALS  

Integrating AYUSH into palliative care p. 219
Naveen Salins
DOI:10.4103/IJPC.IJPC_101_17  PMID:28827920
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Balancing improved opioid supply and safe use of opioids for cancer pain by using “Circle of safety” p. 221
Sushma Bhatnagar, Wasimul Hoda
DOI:10.4103/IJPC.IJPC_94_17  PMID:28827921
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SPECIAL SECTION: YOGA IN CANCER AND PALLIATIVE CARE - SPECIAL EDITORIAL Top

Integrating yoga in cancer care: Scope and challenges p. 223
HR Nagendra
DOI:10.4103/IJPC.IJPC_103_17  PMID:28827922
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SPECIAL SECTION: YOGA IN CANCER AND PALLIATIVE CARE - REVIEW ARTICLE Top

Role of yoga in cancer patients: Expectations, benefits, and risks: A review p. 225
Raghavendra Mohan Rao, Ram Amritanshu, HT Vinutha, Shanmugaraj Vaishnaruby, Shashidhara Deepashree, Murthy Megha, Rajendra Geetha, BS Ajaikumar
DOI:10.4103/IJPC.IJPC_107_17  PMID:28827923
Background: The diagnosis and treatment of cancer poses severe psychologic distress that impacts functional quality of life. While cancer directed treatments are directed purely against tumor killing, interventions that reduce treatment related distress and improve quality of life are the need of the hour. Yoga is one such mind body intervention that is gaining popularity among cancer patients. Method: Several research studies in the last two decades unravel the benefits of yoga in terms of improved mood states, symptom reduction, stress reduction and improved quality of life apart from improving host factors that are known to affect survival in cancer patients. However, several metaanalysis and reviews show equivocal benefits for yoga. In this review, we will study the Yoga interventions in cancer patients with respect to expectations, benefits and risks and analyse the principles behind tailoring yoga interventions in cancer patients. Results: The studies on Yoga show heterogeneity with varied types of Yoga Interventions, duration, exposure, practices and indications. It also elucidates the situational context for reaping benefits and cautions against its use in several others. However, there are several reviews and bibliometric analysis of effects of yoga; most of them have not enlarged the scope of their review to cover the basic principles behind use of these practices in cancer patients. Conclusion: This review offers insight into the principles and practice of yoga in cancer patients.
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SPECIAL SECTION: YOGA IN CANCER AND PALLIATIVE CARE - ORIGINAL ARTICLES Top

Effect of long-term yoga practice on psychological outcomes in breast cancer survivors p. 231
Ram R Amritanshu, Raghavendra Mohan Rao, Raghuram Nagaratna, Vidya Harini Veldore, MR Usha Rani, Kodaganur S Gopinath, BS Ajaikumar
DOI:10.4103/IJPC.IJPC_93_17  PMID:28827924
Aim: Breast cancer has become a pandemic with an ever-increasing incidence. Although better diagnostics and treatment modalities have reduced mortality, a large number of survivors face cancer and treatment-related long-term symptoms. Many survivors are taking up yoga for improving the quality of life (QoL). The present study attempts to evaluate predictors of psychological states in breast cancer survivors with long-term yoga experience. Materials and Methods: A case–control study recruited early breast cancer survivors, 30–65 years, completing treatment > 6 months before recruitment, and grouped them based on prior yoga experience (BCY, n = 27) or naïve (BCN, n = 25). Demography, cancer history, diet, exercise habits, and yoga schedule were collected and tools to assess stress, anxiety, depression, general health, and QoL were administered. Multivariate linear regression was done to identify predictors of psychological variables. Results: BCY had significantly lower stress, anxiety, depression, better general health, and QoL (P < 0.001). Global QoL and trait anxiety were significantly predicted by Yoga practice; depression was predicted by yoga practice, annual income, and sleep quality; state anxiety was predicted by Yoga practice and income; and stress was predicted by Yoga practice and sleep quality. Conclusion: Results indicate that breast cancer survivors, doing yoga, have better psychological profiles and are able to deal with demanding situations better. The psycho-oncogenic model of cancer etiology suggests that a better psychological state in survival has the potential to improve prognosis and survival outcomes and Yoga may be a suitable practice for staying cancer-free for a longer time.
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Effects of a yoga program on mood states, quality of life, and toxicity in breast cancer patients receiving conventional treatment: A randomized controlled trial p. 237
Raghavendra Mohan Rao, Nagaratna Raghuram, Hongasandra Ramarao Nagendra, Gopinath S Kodaganur, Ramesh S Bilimagga, HP Shashidhara, Ravi B Diwakar, Shekhar Patil, Nalini Rao
DOI:10.4103/IJPC.IJPC_92_17  PMID:28827925
Aims: The aim of this study is to compare the effects of yoga program with supportive therapy counseling on mood states, treatment-related symptoms, toxicity, and quality of life in Stage II and III breast cancer patients on conventional treatment. Methods: Ninety-eight Stage II and III breast cancer patients underwent surgery followed by adjuvant radiotherapy (RT) or chemotherapy (CT) or both at a cancer center were randomly assigned to receive yoga (n = 45) and supportive therapy counseling (n = 53) over a 24-week period. Intervention consisted of 60-min yoga sessions, daily while the control group was imparted supportive therapy during their hospital visits. Assessments included state-trait anxiety inventory, Beck's depression inventory, symptom checklist, common toxicity criteria, and functional living index-cancer. Assessments were done at baseline, after surgery, before, during, and after RT and six cycles of CT. Results: Both groups had similar baseline scores. There were 29 dropouts 12 (yoga) and 17 (controls) following surgery. Sixty-nine participants contributed data to the current analysis (33 in yoga, and 36 in controls). An ANCOVA, adjusting for baseline differences, showed a significant decrease for the yoga intervention as compared to the control group during RT ( first result) and CT (second result), in (i) anxiety state by 4.72 and 7.7 points, (ii) depression by 5.74 and 7.25 points, (iii) treatment-related symptoms by 2.34 and 2.97 points, (iv) severity of symptoms by 6.43 and 8.83 points, (v) distress by 7.19 and 13.11 points, and (vi) and improved overall quality of life by 23.9 and 31.2 points as compared to controls. Toxicity was significantly less in the yoga group (P = 0.01) during CT. Conclusion: The results suggest a possible use for yoga as a psychotherapeutic intervention in breast cancer patients undergoing conventional treatment.
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Effects of yoga in managing fatigue in breast cancer patients: A randomized controlled trial p. 247
HS Vadiraja, Raghavendra Mohan Rao, R Nagarathna, HR Nagendra, Shekhar Patil, Ravi B Diwakar, HP Shashidhara, KS Gopinath, BS Ajaikumar
DOI:10.4103/IJPC.IJPC_95_17  PMID:28827926
Background: Cancer-related fatigue is widely prevalent in cancer patients and affects quality of life in advanced cancer patients. Fatigue is caused due to both psychologic distress and physiological sequel following cancer progression and its treatment. In this study, we evaluate the effects of yogic intervention in managing fatigue in metastatic breast cancer patients. Methods: Ninety-one patients with metastatic breast cancer were randomized to receive integrated yoga program (n = 46) or supportive therapy and education (n = 45) over a 3-month period. Assessments such as perceived stress, fatigue symptom inventory, diurnal salivary cortisol, and natural killer cell counts were carried out before and after intervention. Analysis was done using an intention-to-treat approach. Postmeasures for the above outcomes were assessed using ANCOVA with respective baseline measure as a covariate. Results: The results suggest that yoga reduces perceived stress (P = 0.001), fatigue frequency (P < 0.001), fatigue severity (P < 0.001), interference (P < 0.001), and diurnal variation (P < 0.001) when compared to supportive therapy. There was a positive correlation of change in fatigue severity with 9 a.m. salivary cortisol levels. Conclusion: The results suggest that yoga reduces fatigue in advanced breast cancer patients.
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Effect of yoga on sleep quality and neuroendocrine immune response in metastatic breast cancer patients p. 253
Raghavendra Mohan Rao, HS Vadiraja, R Nagaratna, KS Gopinath, Shekhar Patil, Ravi B Diwakar, HP Shahsidhara, BS Ajaikumar, HR Nagendra
DOI:10.4103/IJPC.IJPC_102_17  PMID:28827927
Background: Studies have shown that distress and accompanying neuroendocrine stress responses as important predictor of survival in advanced breast cancer patients. Some psychotherapeutic intervention studies have shown have modulation of neuroendocrine-immune responses in advanced breast cancer patients. In this study, we evaluate the effects of yoga on perceived stress, sleep, diurnal cortisol, and natural killer (NK) cell counts in patients with metastatic cancer. Methods: In this study, 91 patients with metastatic breast cancer who satisfied selection criteria and consented to participate were recruited and randomized to receive “integrated yoga based stress reduction program” (n = 45) or standard “education and supportive therapy sessions” (n = 46) over a 3 month period. Psychometric assessments for sleep quality were done before and after intervention. Blood draws for NK cell counts were collected before and after the intervention. Saliva samples were collected for three consecutive days before and after intervention. Data were analyzed using the analysis of covariance on postmeasures using respective baseline measure as a covariate. Results: There was a significant decrease in scales of symptom distress (P < 0.001), sleep parameters (P = 0.02), and improvement in quality of sleep (P = 0.001) and Insomnia Rating Scale sleep score (P = 0.001) following intervention. There was a decrease in morning waking cortisol in yoga group (P = 0.003) alone following intervention. There was a significant improvement in NK cell percent (P = 0.03) following intervention in yoga group compared to control group. Conclusion: The results suggest modulation of neuroendocrine responses and improvement in sleep in patients with advanced breast cancer following yoga intervention.
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ORIGINAL ARTICLES Top

A study to assess the feasibility of introducing early palliative care in ambulatory patients with advanced lung cancer p. 261
Jayita Kedar Deodhar, Vanita Noronha, Mary Ann Muckaden, Shrikant Atreya, Amit Joshi, Sandeep P Tandon, Arunangshu Ghoshal, Naveen S Salins, Vijay M Patil, Kumar Prabhash
DOI:10.4103/IJPC.IJPC_19_17  PMID:28827928
Purpose: Early palliative care is beneficial in advanced lung cancer patients. We aimed to assess the feasibility of introducing early palliative care in ambulatory advanced lung cancer patients in an Indian tertiary cancer center. Methodology: In a longitudinal, single–arm, and single-center study, fifty patients were recruited and followed up every 3–4 weeks for 6 months, measuring the symptom burden using Edmonton Symptom Assessment Scale (ESAS) and quality of life (QoL) with European Organization for Research and Treatment of Cancer-QoL tools. The primary end point of feasibility was that at least 60% of the patients should complete 50% of the planned palliative care visits and over 50% of the patients should complete QoL questionnaires. Analysis was done using Statistical Package for the Social Sciences version 20. Results: Twenty-four of fifty patients (48%) completed the planned follow-up visits. All patients completed the questionnaires at baseline and 31 (62%) at their follow-up visits. The patients' main reasons for not following up in the hospital palliative care clinic were logistics and fatigue. Tiredness, pain, and appetite loss were the highest rated symptoms at baseline (ESAS scores 3, 2.2, and 2.1, respectively). Improvement in pain and anxiety scores at follow-up visits 1 and 2 was significant (P < 0.05). Scores on QoL functioning scales improved during the follow-up period. Conclusions: We did not meet the feasibility criteria for the introduction of early palliative care in our advanced lung cancer patients in a resource-limited country.
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Prevalence of depression in breast cancer patients and its association with their quality of life: A cross-sectional observational study p. 268
Debasweta Purkayastha, Chitra Venkateswaran, Kesavankutty Nayar, UG Unnikrishnan
DOI:10.4103/IJPC.IJPC_6_17  PMID:28827929
Background: Breast cancer is the leading cause of cancer death among women worldwide. In India, the incidence rate of breast cancer is found to be 25.8/10,000 females. The statistics for Kerala, India, is 30.5 in urban areas and 19.8 in rural areas. Cancer and treatment-related symptoms are major stressors in patients with breast cancer undergoing treatment for the disease. Depression is a prevalent psychological symptom perceived by breast cancer patients, and it also impacts the quality of life (QOL) in these patients. We aimed to assess the prevalence of depression and its association with QOL of patients with breast cancer undergoing treatment for breast cancer. Materials and Methods: This cross-sectional study enrolled 270 patients diagnosed with breast cancer (>18 years) and undergoing active treatment in a tertiary care center in Kerala, India. Depression was assessed using the Patient Health Questionnaire 9 and International Classification of Diseases, Tenth Edition Research guidelines. We measured the QOL and its domains using the WHOQOL-BREF. Results: The average age of women in research was 53.56 years. Of the 270 patients, 21.5% had depression. Among patients with depression, 22% had moderately severe to severe depression. Patients with depression experienced overall a poor QOL. Twenty-two patients reported their overall QOL was “poor” and 34 patients reported to be dissatisfied with their health. There was an association between depression and domains of QOL. Patients with depression had lower scores in all domains when compared to those without depression. Conclusion: Depression and poor QOL is common among breast cancer patients.
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Fluoroscopy-guided neurolytic splanchnic nerve block for intractable pain from upper abdominal malignancies in patients with distorted celiac axis anatomy: An effective alternative to celiac plexus neurolysis - A retrospective study Highly accessed article p. 274
Arif Ahmed, Divesh Arora
DOI:10.4103/IJPC.IJPC_28_17  PMID:28827930
Introduction: The pain from upper gastrointestinal malignancy leads to considerable morbidity. The celiac plexus and splanchnic nerve neurolysis are good therapeutic options. Although splanchnic nerve neurolysis less frequently performed, but it has an edge over celiac plexus as it can be performed in patients with altered celiac plexus anatomy by enlarged lymph nodes. Methods: The fluoroscopy-guided splanchnic nerve neurolysis was done in about 21 patients with intractable upper abdominal pain with pain intensity of ≥7 in numerical rating scale (NRS) from upper gastrointestinal cancers with distorted celiac plexus anatomy from enlarged celiac lymph nodes as seen by computed tomography scan after positive diagnostic splanchnic nerve neurolysis. The demographic features, pain intensity, daily opioid dose, functional status and quality of life was measured at baseline and 1 week, 1 and 3 months after the procedure. Results: There was a significant improvement in pain intensity, opioid requirement, functional status, and physical components quality of life after the neurolysis (P < 0.05) and this improvement had continued till 3 months. There were also more than 50% reduction in pain intensity and significant decrease in opioid requirement in all the patients after neurolysis. Conclusion: The fluoroscopy-guided splanchnic nerve neurolysis results significant pain relief, decrease in opioid intake, improvement in functional status, and quality of life for up to 3 months in upper abdominal pain from gastrointestinal cancers in patients with distorted celiac lymph node anatomy not amenable to celiac plexus neurolysis.
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Home-based application of sphenopalatine ganglion block for head and neck cancer pain management p. 282
Priti R Sanghavi, Bhavna C Shah, Geeta M Joshi
DOI:10.4103/IJPC.IJPC_39_17  PMID:28827931
Background: Head and neck cancer pain is intractable and difficult to manage. Many a times it is difficult to treat with oral opioids and adjuvants. Aim: This study aims to study the effects of transnasal sphenopalatine ganglion block (SPGB), administered using cotton swab/ear bud by patients' caretaker, at home, for pain management. Study Design: This is a prospective, single-arm observational study conducted on 100 head and neck cancer patients, from January 2014 to December 2015. Patients and caretaker were given a demonstration of the procedure using sterile cotton swab/ear buds. They were advised to repeat the procedure when their visual analog score (VAS) was more than 5. They continued with the oral analgesics. They kept the records of pre- and post-procedure pain score (VAS), the frequency of repetition, ease of performance of procedure, and morphine requirement. A paired t-test (SPSS software) was used for statistical analysis. Results: A significant reduction in pain was noted by a decrease in mean VAS from 8.57 ± 1.31 to 2.46 ± 1.23 (P < 0.0001), immediately on first administration. The mean duration of analgesia was 4.95 ± 3.43 days. Pre- and post-procedure mean morphine requirement were 128.2 ± 84.64 and 133.8 ± 81.93 (P > 0.05) mg per day, at the end of 2 months. Ease of performance was observed in 88 patients. Conclusion: The home-based application of SPGB is an easy, safe, and cost-effective method to manage cancer pain. It provides excellent immediate pain relief with a minimum side effect. It can be performed bilaterally, repeatedly and even with a feeding tube in place.
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Comparison of Neonatal Pain, Agitation, and Sedation Scale with Premature Infant Pain Profile for the assessment of acute prolonged pain in neonates on assisted ventilation: A prospective observational study p. 287
Saumil Ashvin Desai, Ruchi Nimish Nanavati, Bonny Bipin Jasani, Nandkishor Kabra
DOI:10.4103/IJPC.IJPC_42_17  PMID:28827932
Aim: This study aimed to compare Neonatal Pain, Agitation, and Sedation Scale (N-PASS) with Premature Infant Pain Profile (PIPP) for the assessment of acute prolonged pain in ventilated neonates. Methods: This study was conducted in two phases. In phase 1 of the study, we assessed whether neonates on assisted ventilation experienced acute prolonged pain. In phase 2, the aim was to compare N-PASS with PIPP for the assessment of acute prolonged pain in neonates on assisted ventilation.. Design: This is a prospective observational study. Study Setting and Duration: This study was conducted at a tertiary care neonatal intensive care unit for 6 months. Inclusion Criteria: Neonates on assisted ventilation for >48 h were selected for this study. Exclusion Criteria: Neonates with lethal congenital anomalies and severe encephalopathy were excluded from the study. N-PASS and PIPP tools were used to assess acute prolonged pain in ventilated neonates. Taking PIPP as gold standard and N-PASS as a new test, the correlation coefficient was calculated. The sensitivity, specificity, positive predictive value, and negative predictive value were also computed. The time taken to administer the tools was also computed. Results: The average PIPP score for ventilated neonates was 8.33. The correlation coefficient of N-PASS when compared to PIPP was 0.62. The average time taken to apply the N-PASS scale was 4.42 min as compared to 8.20 min for PIPP scale. In term neonates, the sensitivity, specificity, positive predictive value, and negative predictive value of N-PASS were 75%, 100%, 100%, and 60%, respectively. The corresponding values in preterm neonates were lesser. Conclusions: The study proves that neonates on assisted ventilation experience acute prolonged pain. N-PASS is clinically reliable and valid to assess acute prolonged pain in ventilated term neonates. The N-PASS is quicker than PIPP in assessing acute prolonged pain in ventilated neonates. Future Directions: The modified N-PASS tool (including the gestational age) should be developed.
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Validation of the Malayalam version of Leeds assessment of neuropathic symptoms and signs pain scale in cancer patients in the Regional Cancer Centre, Thiruvananthapuram, Kerala, India p. 293
Shoukkathali Anzar, Cherian Koshy, Kurian Mathew Abraham
DOI:10.4103/IJPC.IJPC_119_16  PMID:28827933
Objective: The Self-administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) is a 7-item self-report scale developed to identify pain which is of predominantly neuropathic origin. The aim of this study was to develop a Malayalam version of the LANSS and to test its validity and reliability in chronic pain patients. Methodology: We enrolled 101 Malayalam-speaking chronic pain patients who visited the Division of Palliative Medicine, Regional Cancer Centre, Thiruvananthapuram, Kerala, India. The translated version of S- LANSS was constructed by standard means. Fifty-one neuropathic pain and fifty nociceptive pain patients were identified by an independent pain physician and were subjected to the new pain scale by a palliative care nurse who was blinded to the diagnosis. The “gold standard diagnosis” is what the physician makes after clinical examination. Its validation, sensitivity, specificity, and positive and negative predictive values were determined. Results: Fifty-one neuropathic pain and fifty nociceptive pain patients were subjected to the Malayalam version of S-LANSS pain scale for validity testing. The agreement by Cohen's Kappa 0.743, Chi-square test P < 0.001, sensitivity 89.58, specificity 84.91, positive predictive value 84.31, negative predictive value 90.00, accuracy by 87.13, and likelihood ratio 5.94. Conclusion: The Malayalam version of S-LANSS pain scale is a validated screening tool for identifying neuropathic pain in chronic pain patients in Malayalam-speaking regions.
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The process of translation and linguistic validation of the Functional Assessment of Cancer Therapy-Brain quality of life instrument from English to Malayalam: The challenges faced p. 300
Durgapoorna Menon, Chitra Venkateswaran
DOI:10.4103/IJPC.IJPC_36_17  PMID:28827934
Aim: Both brain tumors and their treatments have a major negative impact on the quality of life (QoL). EORTC BN20 and Functional Assessment of Cancer Therapy-Brain (FACT-BR) are the most commonly used tools to assess QoL. The FACT-BR is a 23-item questionnaire, especially about the psychosocial aspects of QoL. This paper describes the challenges we faced during the process of translation and validation of the FACT-BR into Malayalam. Methods: We first screened the patients to ensure their mental status was satisfactory and that they could communicate well in both languages. According to the Functional Assessment of Chronic Illness Therapy methodology, there were two forward translations from English to Malayalam by two independent translators, a reconciliation of the two forward translations, a back-translation into English, a review/finalization by a fifth translator, proofreading, and then testing on a small cohort of patients. Results: The whole process of translation was fraught with small and large hurdles – from small technical issues to the gaps in sociocultural norms. The sub item BR 7, due to the lack of an exact equivalent word, had issues that persisted up to the validation phase. The postquestionnaire debriefing interviews confirmed that the translations were well understood and conceptually equivalent to the original English one. Conclusions: Translation of the FACT-BR into Malayalam nearly completely reproduced the concepts of the original English questionnaire, as proved in the subsequent validation process.
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Signs of spiritual distress and its implications for practice in Indian Palliative Care p. 306
Sushma Bhatnagar, Joris Gielen, Aanchal Satija, Suraj Pal Singh, Simon Noble, Santosh K Chaturvedi
DOI:10.4103/IJPC.IJPC_24_17  PMID:28827935
Introduction: Given the particularity of spirituality in the Indian context, models and tools for spiritual care that have been developed in Western countries may not be applicable to Indian palliative care patients. Therefore, we intended to describe the most common signs of spiritual distress in Indian palliative care patients, assess differences between male and female participants, and formulate contextually appropriate recommendations for spiritual care based on this data. Methods: Data from 300 adult cancer patients who had completed a questionnaire with 36 spirituality items were analyzed. We calculated frequencies and percentages, and we compared responses of male and female participants using Chi-squared tests. Results: Most participants believed in God or a higher power who somehow supports them. Signs of potential spiritual distress were evident in the participants' strong agreement with existential explanations of suffering that directly or indirectly put the blame for the illness on the patient, the persistence of the “Why meY” question, and feelings of unfairness and anger. Women were more likely to consider illness their fate, be worried about the future of their children or spouse and be angry about what was happening to them. They were less likely than men to blame themselves for their illness. The observations on spirituality enabled us to formulate recommendations for spiritual history taking in Indian palliative care. Conclusion: Our recommendations may help clinicians to provide appropriate spiritual care based on the latest evidence on spirituality in Indian palliative care. Unfortunately, this evidence is limited and more research is required.
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COMMENTARY Top

Commentary p. 311
Jayita Kedar Deodhar
DOI:10.4103/IJPC.IJPC_86_17  PMID:28827936
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ORIGINAL ARTICLES Top

Hypofractionated radiotherapy for palliation in locally advanced head and neck cancer p. 313
RK Spartacus, Rohitashwa Dana, Kartick Rastogi, Aseem Rai Bhatnagar, Dhiraj Daga, Kampra Gupta
DOI:10.4103/IJPC.IJPC_9_17  PMID:28827937
Context: In India, a considerable proportion of patients with head and neck cancer present with locoregionally advanced disease. Symptom palliation becomes a major objective in these cases when they could not be considered for a curative approach. Aims: The aim of this study is to assess the role of palliative radiotherapy for symptom control in patients with locally advanced head and neck cancer. Settings and Design: This was a retrospective study. Subjects and Methods: Between July 2015 and June 2016, 98 patients with stage IV head and neck cancer were treated with palliative radiotherapy 25 Gray (Gy)/4 fractions (fr)/1 fraction (6.25 Gy)/week. Presenting symptoms were noted. The primary end point was relief of symptoms in the 4th week after radiotherapy. Percentage symptom relief was quantified by the patient using a rupee scale. Treatment response was noted using the WHO criteria. Acute toxicity was graded as per the Radiation Therapy Oncology Group (RTOG) criteria. Results: The most common presenting symptom was pain. At 4 weeks after radiotherapy completion, all patients had >50% pain relief. Dysphagia was improved in 82% of patients. Respiratory distress was improved in all the symptomatic patients. Tumor complete response (CR) was seen in 2 patients, partial response in 89, stable disease in 3, and progressive disease in 4. RTOG Grade 2 and 3 acute skin and mucosal toxicities were seen in 29% and 27% cases, respectively. No patient had Grade 4 adverse effect. Conclusions: Hypofractionated radiation could provide effective symptom palliation in advanced head and neck cancers. The weekly schedule was well tolerated and found convenient by the patients.
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The effect of honey on radiation-induced oral mucositis in head and neck cancer patients p. 317
Amna Amanat, Asrar Ahmed, Abbas Kazmi, Bushra Aziz
DOI:10.4103/IJPC.IJPC_146_16  PMID:28827938
Aim: The aim of this study is to evaluate the effect of honey on clinically scoring grades of oral mucositis. Materials and Methods: This interventional study was carried out in Radiation Oncology Department of Mayo Hospital, Lahore. In this study, 82 patients of both genders, of head and neck cancer, planned for radiotherapy, were divided into two groups by random sampling numbers. Patients in both groups were treated with a total dose of 60–78 Grays in 4–6 weeks. In treatment group, patients were instructed to take 20 mL of honey. In control group, they were advised to rinse with 0.9% of saline. Patients were evaluated every week to assess the grades of oral mucositis up to 6 weeks. The assessment tool was Radiation Therapy Oncology Group Grading System. The statistical analysis was done by Chi-square test. Results: In honey-treated group, the proportion of mucositis (Grades 3 and 4) was lower and statistically significant as compared to control group at the end of 6 weeks of radiation. Conclusion: This study showed that oral intake of honey during radiotherapy is valuable in the reduction of severity of oral mucositis.
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Prognostic factors of 30-day survival of patients with malignant pleural effusion p. 321
Zulkifli Amin, Stephen Diah Iskandar, Sibli
DOI:10.4103/IJPC.IJPC_2_17  PMID:28827939
Background: Treatment of malignant pleural effusion (MPE) depends on the 1 month prognosis of patients. Until now, there is no study evaluate factors affecting 1 month survival. Aims: This study aims to determine the predictors of survival within 1 month. Methods: Prospective study of 102 patients with MPE. Biochemistry data of pleural fluid, characteristics of tumor, and massiveness of the effusion were analyzed to determine their effect on 30-day survival of the patients. Univariate analysis was performed using Chi-square. All prognostic factors that had P < 0.25 were included in multivariate analysis using Cox regression. Results: Median age of patients was 51 years, most of them were female (56%). Common primary sites of tumor were lung (31%), breast (19%), and lymphatic tissue (11%). In univariate analysis, factors that have P < 0.25 were low glucose concentration in pleural fluid (P = 0.01), high lactate dehydrogenase concentration in pleural fluid (P = 0.25), and high risk tumor (P = 0.24). In multivariate analysis, only low glucose concentration was significantly related to poor survival within 1 month (hazard ratio 2.85 [1.10–7.61], P = 0.03). Conclusions: Low level of glucose in pleural fluid is an important factor related to 30-day survival in patients with MPE. It can be used to determine prognosis-based treatment objectively.
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Assessment of private homes as spaces for the dying elderly p. 325
Tulika Bhattacharyya, Suhita Chopra Chatterjee, Dipannita Chand, Debolina Chatterjee, Jaydeep Sengupta
DOI:10.4103/IJPC.IJPC_148_16  PMID:28827940
Aim: This study makes an assessment of end-of-life care of the elderly in private homes in Kolkata, West Bengal, India. Participants and Methods: Primary data were collected from private homes which supported elder care through observation and semi-structured interviews with primary family caregivers of the elderly. Results: The study finds that the major factors preventing private homes from providing adequate care to the elderly were architecturally inadequate housing conditions, paucity of financial support, and scarcity of skilled caregivers. Besides, considerable neglect and domestic abuse of the elderly was also found in some private homes. In addition, the peripheral location of private homes within public health framework and inadequate state palliative policy, including stringent narcotic regulations, accentuated the problems of home care. Conclusion: The study concludes by questioning the rhetoric of private homes as spaces for the dying elderly in Kolkata and suggests remedial measures to improve their capacity to deliver care.
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Analytical study of short- and long-term results of home-based palliative care services to cancer patients p. 331
Dhritiman Datta, Gautam Majumdar, Shiromani Debbarma, Badan Janapati, Amit Kumar Datta
DOI:10.4103/IJPC.IJPC_46_17  PMID:28827941
Aims and Object: Identification and selection of patients suffering from terminal stage in bed ridden condition upto village level and to determine the type of palliative care need. Also to asses the effectiveness of the palliative care provided at the bed side. Materials: All registered patients under palliative care of Regional Cancer Centre, Agartala from 2014 April to 2016 March. Methods: A retrospective study. Ten teams comprising of doctors, nurses, pharmacists & Social Workers were trained and engaged in this study for symptom assessment and pain relief of palliative patients. Results: It is highly beneficial for the bed ridden & home bound cancer patients with improved quality of life due to regular home visits and medicine distribution by trained medical personnel. Short term benefits in symptom like pain, nausea & vomiting, retention of urine, constipation, bloating, fever etc. was dramatic after medication by palliative team. Patients also get relief as a result of repeated visit of palliative care team. Conclusion: Home based palliative care is beneficial for the bed ridden and home bound chronically ill patients including cancer patients. Bed ridden patients should be cared by palliative care team at least in every week.
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Effect of mirtazapine on gastric emptying in patients with cancer-associated anorexia p. 335
N Kumar, Sukanta Barai, S Gambhir, N Rastogi
DOI:10.4103/IJPC.IJPC_17_17  PMID:28827942
Background/Aims: The tetracyclic antidepressant mirtazapine is widely used in cancer patients suffering from anorexia. Although it is known to restore appetite, the exact mechanism remains unknown. The aim of the study was to evaluate if mirtazapine has any effect on gastric emptying in patients suffering from cancer-related anorexia. Materials and Methods: Solid-meal gastric-emptying study using radiolabeled meal was performed in 28 patients suffering from cancer anorexia once at baseline and repeated after 15 days of mirtazapine therapy. Results: At baseline, only 7 (25%) patients had normal gastric motility (emptying >70% at 3 h postingestion) whereas after treatment, 18 (64.2%) patients achieved this limit. Mean % gastric emptying increased from 55.2% ±21.0% to 68.9% ±21.3% (P < 0.001). Mean gastric emptying time (t1/2) before intervention was 314.7 ± 421.0 min which decreased to 116.0 ± 106.7 min after intervention. Results were further analyzed by dividing the patients into two groups based on baseline gastric-emptying study. Group A (normal gastric emptying) consisted of seven patients, mean % gastric emptying at baseline and postintervention was 75.0% ±5.25% and 87.57% ±5.94%, respectively (P < 0.018). Group B (delayed gastric emptying) consisted of 21 patients, mean % gastric emptying at baseline and postintervention was 48.71% ±18.82% and 62.76% ±16.86%, respectively (P < 0.001). Conclusion: Mirtazapine significantly improves gastric emptying in patients of prostate and breast cancer suffering from cancer-associated anorexia.
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PERSPECTIVES Top

The philosophical and cultural situatedness of spirituality at the end of life in India p. 338
Hamilton Inbadas
DOI:10.4103/IJPC.IJPC_61_17  PMID:28827943
The sustained interest in exploring the spiritual domain at end of life in the Indian context reflects the recognition of its significance as an integral part of palliative care. A key aspect of findings from studies so far is the identification of challenges, inadequacies, limitations and ethical dilemmas in relation to spirituality at the end of life. India is known for its rich spiritual heritage and has unique ways of understanding, experiencing and expressing spirituality. The philosophical and cultural frames of reference, with which communities in India make sense of life, death and dying, determine the characteristics of Indian spirituality at the end of life. Exploring the concepts of the human person, the purpose of human life, the meaning of death and caring for the dying using Indian philosophical and cultural resources can help address some of the identified limitations and challenges in the Indian context. A cross-disciplinary approach, drawing together expertise from clinical palliative care, philosophy, theology and sociology, will enrich the understanding of spirituality at the end of life and can contribute to effective spiritual care in palliative care in specific contexts around the world.
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Palliative care for patients with nonmalignant respiratory disease p. 341
Nishkarsh Gupta, Rakesh Garg, Vinod Kumar, Sachidanand Jee Bharati, Seema Mishra, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_14_17  PMID:28827944
Nonmalignant respiratory diseases are chronic and life-limiting conditions that need holistic palliative care. Such patients not only have a variety of physical symptoms such as dyspnea, pain, cough, depression, and anxiety, but also have a number of psychosocial and spiritual issues, which are not addressed to by us. This leads to a poor quality of life. Hence, these patients require supportive palliative care to relieve their sufferings, but unfortunately such care is not available to them in our country. In this article, we have tried to discuss the barriers to the provision of palliative care to such patients and suggested some measures to overcome them.
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Narrative: The fear of disfigurement in cancer patients p. 347
Aruna Deshpande, Ravindra Ghooi
DOI:10.4103/IJPC.IJPC_33_17  PMID:28827945
Fear of disfigurement affects patients with cancer, in whom the disease or its treatment leaves them permanently marked. Contrary to our thought, disfigurement is equally distressing to male patients, and it causes severe dislocation in their lives. We describe two cases in which disfigurement caused tremendous change in our patients; these cases underline the need for psychotherapy in patients suffering from cancer.
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CASE REPORT Top

Topical menthol for treatment of chemotherapy-induced peripheral neuropathy p. 350
Alessio Cortellini, Lucilla Verna, Katia Cannita, Luca Napoleoni, Alessandro Parisi, Corrado Ficorella, Giampiero Porzio
DOI:10.4103/IJPC.IJPC_23_17  PMID:28827946
Chemotherapy-induced peripheral neuropathy is a frequent treatment-limiting factor that significantly impairs patients' everyday life, also because of a lack of valid palliative options. Here, we report a case of a male patient with a history of metastatic colon cancer and previous chemotherapies. He came to our attention with a peripheral neuropathy that impaired his quality of life and could limit the further line of chemotherapy. We treated the neuropathy with menthol aqueous cream with benefit.
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