Indian Journal of Palliative Care
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   2009| July-December  | Volume 15 | Issue 2  
    Online since December 21, 2009

 
 
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REVIEW ARTICLES
Radiation induced oral mucositis
PS Satheesh Kumar, Anita Balan, Arun Sankar, Tinky Bose
July-December 2009, 15(2):95-102
DOI:10.4103/0973-1075.58452  PMID:20668585
Patients receiving radiotherapy or chemotherapy will receive some degree of oral mucositis The incidence of oral mucositis was especially high in patients: (i) With primary tumors in the oral cavity, oropharynx, or nasopharynx; (ii) who also received concomitant chemotherapy; (iii) who received a total dose over 5,000 cGy; and (iv) who were treated with altered fractionation radiation schedules. Radiation-induced oral mucositis affects the quality of life of the patients and the family concerned. The present day management of oral mucositis is mostly palliative and or supportive care. The newer guidelines are suggesting Palifermin, which is the first active mucositis drug as well as Amifostine, for radiation protection and cryotherapy. The current management should focus more on palliative measures, such as pain management, nutritional support, and maintenance, of good oral hygiene
  10,461 582 11
EDITORIAL
Ethics in Palliative Care
Bidhu K Mohanti
July-December 2009, 15(2):89-92
DOI:10.4103/0973-1075.58450  PMID:20668583
  8,434 420 2
ORIGINAL ARTICLES
Caring for people at the end of life: Iranian oncology nurses' experiences
Sedigheh Iranmanesh, Abbas Abbaszadeh, Helen Dargahi, Mohammad Ali Cheraghi
July-December 2009, 15(2):141-147
DOI:10.4103/0973-1075.58461  PMID:20668594
Aim: To explore the meaning of Iranian oncology nurses' experiences of caring for people at the end of life. Materials and Methods: A phenomenological hermeneutic approach was applied. Fifteen nurses working in oncology units were interviewed in 2007 regarding their experiences of caring for people at the end of life. Results: Participants experienced caring for people at the end of life as sharing space and time to be lost within an organizational context. This main theme was divided into three subthemes including being attentive to the dying persons and their families, being cared for by the dying persons and their families, and being faced with barriers. Conclusion: The study suggests that the nurses' success in caring for people at the end of life is reliant on their interpersonal caring relationship. Facilitating such relationship requires the establishment of palliative care unit, incorporation of palliative care into undergraduate nursing studies, and cultural preparation through public education.
  5,427 210 2
Pattern of palliative care, pain management and referral trends in patients receiving radiotherapy at a tertiary cancer center
Kuldeep Sharma, Bidhu K Mohanti, Gaura K Rath, Sushma Bhatnagar
July-December 2009, 15(2):148-154
DOI:10.4103/0973-1075.58462  PMID:20668595
Background: Pain is a common primary symptom of advanced cancer and metastatic disease, occurring in 50-75% of all patients. Although palliative care and pain management are essential components in oncology practice, studies show that these areas are often inadequately addressed. Materials and Methods: We randomly selected 152 patients receiving palliative radiotherapy (PRT) from October 2006 to August 2008, excluding metastatic bone lesions. Patients' records were studied retrospectively. Results: A median follow-up of 21 weeks was available for 119 males and 33 females with a median age of 55 years. Maximum (60%) patients were of head and neck cancers followed by esophagus (14%), lung (10%) and others. Dysphagia, growth/ulcer and pain were the chief indications for PRT. Pain was present in 93 (61%) cases out of which, 56 (60%) were referred to pain clinic. All except one consulted pain clinic with a median pain score of 8 (0-10 point scale). Fifty-three of these 56 patients (96%) received opioid-based treatment with adequate pain relief in 33% cases and loss of follow-up in 40% cases. Only five (3%) cases were referred to a hospice. Twenty-two (14%) cases were considered for radical treatment following excellent response to PRT. Conclusion: In this selective sample, the standard of analgesic treatment was found to be satisfactory. However, there is a lot of scope for improvement regarding referral to pain clinic and later to the hospice. Patients' follow-up needs to be improved along with future studies evaluating those patients who were considered for further RT till radical dose. Programs to change the patients' attitude towards palliative care, physicians' (residents') training to improve communication skills, and institutional policies may be promising strategies.
  5,024 240 7
Critical coping challenges facing caregivers of persons living with HIV/AIDS and other terminally ill persons: The case of Kanye care program, Botswana
Simon Kangethe
July-December 2009, 15(2):115-121
DOI:10.4103/0973-1075.58456  PMID:20668589
Aim: This article aims to identify and explore the needs, gaps, and coping challenges faced by the Kanye CHBC caregivers. Objective: To provide the Kanye primary caregivers with an opportunity to explore, discuss, and brainstorm the care giving challenges that impede their coping process. Materials and Methods: The study was exploratory in nature and attracted qualitative design. Eighty-two primary caregivers aged between 18 and 85 years were involved in 10 focus group discussions steered by an interview guide; while five CHBC nurses were subjected to one-to-one in-depth interviews still guided by an interview guide that differed only slightly with the one for the caregivers. Results: The following aspects were found detrimental and affecting the productivity and coping capacities of the primary caregivers inadequate counseling and debriefings; lack of motivation and incentives; inadequate supervision visits; and lack of support groups to facilitate information sharing and encouraging one another. Conclusion: This article recommends counseling and debriefings; formation of caregivers support groups; motivation strategies to be put in place; and provisions of adequate care package and food basket.
  4,732 184 2
Quad shot: A short but effective schedule for palliative radiation for head and neck carcinoma
Sushmita Ghoshal, Santam Chakraborty, Neeru Moudgil, Manreet Kaur, Firuza D Patel
July-December 2009, 15(2):137-140
DOI:10.4103/0973-1075.58460  PMID:20668593
Background: To evaluate a 2-day course of palliative radiation in patients diagnosed to have inoperable or metastatic head and neck carcinoma. Aim: To evaluate the symptom relief and quality of life in these patients after this short course of radiation. Settings and Design: A pilot study was conducted in a tertiary care institute in India. Materia l s and Methods: Fifteen patients with stage IV B/C disease, KPS 50-70, were inducted after informed consent. External radiation was given in 2 days, two fractions per day, 6 h apart to a total dose of 14 Gy. Washington University quality of life questionnaire (QOL) was used for assessing QOL before and after radiation. Patients who had more than 50% regression of disease received a second course of similar radiation. All patients were followed up for a mean duration of 6 months. Statistical Analysis: The Wilcoxon signed rank test was used to evaluate the difference between the QOL scores before and after treatment. Results and Conclusions: Out of these 15 patients, majority (13) were males and the mean age of the patients was 62 years. After the first course, all patients had good symptom relief, improvement in the QOL, and 13 out of 15 had more than 50% objective response. The short duration of the treatment was favored by the outstation patients and their attendants. It may be concluded that this short course of radiation is an effective tool for palliative radiation and merits a larger randomized trial.
  4,688 186 3
REVIEW ARTICLES
Phantom breast syndrome
Ramesh , Nootan K Shukla, Sushma Bhatnagar
July-December 2009, 15(2):103-107
DOI:10.4103/0973-1075.58453  PMID:20668586
Phantom breast syndrome is a type of condition in which patients have a sensation of residual breast tissue and can include both non-painful sensations as well as phantom breast pain. The incidence varies in different studies, ranging from approximately 30% to as high as 80% of patients after mastectomy. It seriously affects quality of life through the combined impact of physical disability and emotional distress. The breast cancer incidence rate in India as well as Western countries has risen in recent years while survival rates have improved; this has effectively increased the number of women for whom post-treatment quality of life is important. In this context, chronic pain following treatment for breast cancer surgery is a significantly under-recognized and under-treated problem. Various types of chronic neuropathic pain may arise following breast cancer surgery due to surgical trauma. The cause of these syndromes is damage to various nerves during surgery. There are a number of assumed factors causing or perpetuating persistent neuropathic pain after breast cancer surgery. Most well-established risk factors for developing phantom breast pain and other related neuropathic pain syndromes are severe acute postoperative pain and greater postoperative use of analgesics. Based upon current evidence, the goals of prophylactic strategies could first target optimal peri-operative pain control and minimizing damage to nerves during surgery. There is some evidence that chronic pain and sensory abnormalities do decrease over time. The main group of oral medications studied includes anti-depressants, anticonvulsants, opioids, N-methyl-D-asparate receptor antagonists, mexilitine, topical lidocaine, cannabinoids, topical capsaicin and glysine antagonists. Neuromodulation techniques such as motor cortex stimulation, spinal cord stimulation, and intrathecal drug therapies have been used to treat various neuropathic pain syndromes.
  4,484 322 7
ORIGINAL ARTICLES
Oral morphine prescribing practices in severe cancer pain
B Barathi
July-December 2009, 15(2):127-131
DOI:10.4103/0973-1075.58458  PMID:20668591
Background: Nearly one million cancer patients in India need oral morphine for pain relief. Despite doctors prescribing oral morphine in our center, many cancer patients with severe pain found to be not facilitated with adequate pain relief. Aim: This audit was conducted to look at the "oral morphine prescribing practices for severe cancer pain" at a tertiary care hospital. Materials and Methods: Twenty case files of patients, who were admitted with severe cancer pain, and receiving oral morphine were analyzed in pre- and posteducational session. Local standards were set to assess the adequacy of pain relief. Deficiency in achieving analgesia was found in preinterventional audit. A clinical audit was conducted before and after the educational session on oral morphine prescribing. The education for doctors and nurses focused on starting patients on morphine, titration, and administering rescue dose. Then local guidelines on oral morphine prescribing were circulated. And analysis of following factors were done following pre- and posteducational session: Pain intensity at the beginning of treatment, starting dose of morphine, increments in morphine dose, number of rescue doses given, and fall in pain intensity at the end of 1 week. The outcomes were compared with the standards. Results: Preintervention audit showed that only 50% of patients achieved adequate pain relief. Rescue dose was administered in only 20% of patients. While reaudit following the educational session showed that 80% of patients achieved adequate pain relief and 100% received rescue doses. Conclusion: Educational sessions have significant impact on improving oral morphine prescribing practice among doctors and nurses. It was found failing to administer regular as well as rescue doses resulted in inadequate pain relief in patients receiving oral morphine.
  4,446 258 1
A comparative study to assess the awareness of palliative care between urban and rural areas of Ernakulum district, Kerala, India
Nitin Joseph, S Jayarama, Shashidhar Kotian
July-December 2009, 15(2):122-126
DOI:10.4103/0973-1075.58457  PMID:20668590
Aim: To assess the knowledge and attitude toward palliative care among people residing in urban and rural areas. Materials and Methods: This cross-sectional study was conducted among 185 urban and 165 rural households. Senior-most member of the household present was interviewed using a questionnaire. Only those people who have heard about palliative care were included in the study. Results: Out of 350 people, 47 (13.4%) have heard about palliative care. Of these 38 (20.5%) belonged to urban and 9 (5.4%) belonged to rural areas ( P< 0.0001).Twenty-nine (15.7%) participants in urban and 7 (4.2%) in rural areas had some knowledge about palliative care ( P= 0.0002). Source of information for 25 (53.2%) participants was newspapers followed by television 17 (36.2%). Thirty-three (86.8%) participants in urban and 7 (77.8%) in rural areas felt that palliative care helps in improving quality of life. Twenty (52.6%) participants in urban and 4 (44.4%) participants in rural areas felt that palliative care can be better provided at homes than hospitals. Thirty (78.9%) urban participants felt that bad news about the patient's condition needs to be told to the patient first and then to their family members. In case of rural participants majority 7 (77.8%) said vice versa ( P = 0.0039). Conclusion: Overall awareness of palliative care was poor. This calls for large-scale awareness campaigns. As home-based palliative care was preferred by many, home visits by care providers and training of family members of patient's needing palliative care needs to be practiced widely.
  4,200 244 7
Eyelid closure at death
AD Macleod
July-December 2009, 15(2):108-110
DOI:10.4103/0973-1075.58454  PMID:20668587
Aim: To observe the incidence of full or partial eyelid closure at death. Materials and Methods: The presence of ptosis was recorded in 100 consecutive hospice patient deaths. Results: Majority (63%) of the patients died with their eyes fully closed, however, 37% had bilateral ptosis at death, with incomplete eye closure. In this study, central nervous system tumor involvement and/or acute hepatic encephalopathy appeared to be pre-mortem risk factors of bilateral ptosis at death. Conclusion: Organicity and not psychogenicity is, therefore, the likely etiology of failure of full eyelid closure at death.
  4,120 145 -
Quality of life of ostomates with the selected factors in a selected hospital of Delhi with a view to develop guidelines for the health professionals
Aditi Sinha, Harinderjeet Goyal, Shailja Singh, Shiv Pratap Singh Rana
July-December 2009, 15(2):111-114
DOI:10.4103/0973-1075.58455  PMID:20668588
Background: A correlational survey to assess the quality of life (QoL) of ostomates with selected factors in a selected hospital of Delhi and to develop guidelines for the health professionals to improve QoL of ostomates was undertaken during the year 2005-2007. The objectives of the study were as follows: (1) To assess QoL of ostomates (2) To identify the factors associated with QoL of ostomates (3) To seek relationship between selected factors and QoL of ostomates (4) To develop guidelines for the health professionals to improve QoL of ostomates. Materials and Methods: The corelational survey was conducted on 50 ostomates from Surgical Oncology OPD of B.R.A. Institute Rotary Cancer Hospital, AIIMS, Delhi. Purposive sampling technique was employed to select the sample subjects. Structured interview schedule was prepared. Guidelines were prepared for health professionals to improve the quality of life of ostomates. Result: Majority of the ostomates possessed best quality of life. There was a significant association between QoL score of ostomates with age, sex, duration of surgery, education, income, and occupation. There was no significant association between QoL scores of ostomates and marital status and type of ostomy. Conclusion: This study conclude that nurses have a great role to play in the physical, psychological, economical, social, familial, and sexual aspects in the care of ostomates and to offer psychological support and empathy, to reinforce coping skills to promote an optimal QoL.also she has a great role to influence and educate all the aspects of care to the patients and their relatives. Their is a need to develop staff development program for nursing personnel in the clinical area in healthcare system.
  3,919 178 3
EDITORIAL COMMENTARY
Interventional pain management: Need of the hour for cancer pain patients
Sushma Bhatnagar
July-December 2009, 15(2):93-94
DOI:10.4103/0973-1075.58451  PMID:20668584
  3,315 265 5
ORIGINAL ARTICLES
α2δ Modulators for management of compression neuropathic pain: A review of three case series
Tariq A Tramboo, Showket Gurkhoo
July-December 2009, 15(2):132-136
DOI:10.4103/0973-1075.58459  PMID:20668592
Context: The α2δ modulators gabapentin and pregabalin are effective against neuropathic pain. Numerous brands of α2δ modulators are available in India, and are expected to have equivalent clinical effects. They are routinely used for management of neuropathic pain associated with radiculopathy. Aim: To describe clinical outcomes in three series of cases of neuropathic pain treated with three available brands of a2d modulators. Settings and Design: Retrospective analysis of clinical outcomes in patients attending an interventional pain clinic Patients and Methods: One hundred and ninety-four consecutive patients with neuropathic pain secondary to Magnetic Resonance Imaging (MRI)-documented compression radiculopathy received either LYRICA (LYR), a locally available generic brand of pregabalin (PGN), or a locally available generic brand of gabapentin (GBN), respectively. Drug treatment was continued till adequate pain relief was achieved. In each of the three groups, mean pain scores were analyzed at Days 0, 15, 60 and 90, and daytime sedation scores at Days 1, 15, 60 and 90. Statistical Analysis u0 sed: Analysis of variance (ANOVA) followed by pair-wise comparison using two-tailed unpaired t-test (if P value was significant). Results: Mean pain score was significantly lower in the LYR series as compared to the PGN and GBN series at Days 15, 60 and 90. As compared to the PGN and GBN series, a greater proportion of patients in the LYR series could discontinue drug therapy following adequate pain relief, by Day 90. Daytime sedation scores were significantly lower in the LYR series as compared to the PGN and GBN series at Days 1, 15 and 60, and as compared to the PGN series at Day 90. Conclusion: These results indicate the effectiveness of a2d modulators for management of neuropathic pain secondary to compression radiculopathy. The results also suggest a possible therapeutic superiority of LYRICA over locally available generic brands of pregabalin and gabapentin. These findings need to be further examined in randomized, controlled trials.
  3,213 199 -
LETTER TO EDITOR
Palliative care - Need of awareness in general population
Harshal T Pandve, Kevin Fernandez, Parvinder Singh Chawla, Samir A Singru
July-December 2009, 15(2):162-163
DOI:10.4103/0973-1075.58465  PMID:20668598
  3,036 188 -
ORIGINAL ARTICLES
The effect of homecare team visits in terminal cancer patients: Role of health teams reaching patients homes
Pratik Banerjee
July-December 2009, 15(2):155-158
DOI:10.4103/0973-1075.58463  PMID:20668596
Aim: The study has been conducted to see the effectiveness of homecare teams visit in terminal cancer patients (palliative care). Materials and Methods: The study basically utilized the effectiveness of the Cansupport's functioning. Cansupport is unique in its organization and function. It is the first organization in India that started the homecare visits for the terminal cancer patients. It has its headquarter with the administrative staff and a helpline that is officially active for about 8 hours a day for 5 days a week. The organization also has 10 homecare teams who are involved in the home visit. They have recently had an added support of community network officials. Each homecare team has a doctor, a nurse, and a counselor. Result: The total number of patients visited by the homecare teams of Cansupport in the year 2008-2009 was 1025. Total 104 patients were discharged. Out of 798 admissions last year, 384 patients were from IRCH (AIIMS). The helpline had 333 patients and others were just 81. Generally the team had to travel about 50-150 km a day. The number of visits range from four to seven per day. Generally the first visit of the team usually takes 90-120 min as the team takes time to understand the patient. The subsequent visits usually take 30-45 min. Usually, such patients stay with the team for a period of 1-2 months and then expire. Some patients stay with the team for 1-7 days. Conclusion: The eagerness of patients wanting the teams to reach their residence may be judged by the given figures. The total number of patients visited by the homecare teams of Cansupport in the year 2008-2009 was 1025. Out of them, there were about 104 patients who were discharged. The term discharge means that the patients were not interested in our visit or were not available in our subsequent visit. It has to be mentioned here that the service is a definite demand by society provided that the cost may be catered too.
  2,784 189 -
CASE REPORT
Palliative benefits of the multimodality approach in the re-treatment of recurrent malignant glioma: Two case reports
TR Arulponni, MG Janaki, S Nirmala
July-December 2009, 15(2):159-161
DOI:10.4103/0973-1075.58464  PMID:20668597
Two young male patients treated seven and four years back, for malignant glioma, returned with recurrence at the same site, with a World Health Organization (WHO) Performance Score of four and two. Both underwent resurgery and received postoperative reirradiation of 5040 cGy in 28 fractions and concurrent Temozolomide 75 mg/m 2 body surface area (BSA) daily, and one patient received additional adjuvant Temozolomide 250 mg (150 mg/m 2 BSA). Both patients tolerated the treatment well with 16 and 14 months follow-up from the time of recurrence. They were symptom-free, with normal physical function and good mental state, and resumed their respective jobs.
  2,702 115 -
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