Indian Journal of Palliative Care
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   2011| September-December  | Volume 17 | Issue 3  
    Online since January 28, 2012

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Reporting of pediatric palliative care: A systematic review and quantitative analysis of research publications in palliative care journals
Senthil P Kumar
September-December 2011, 17(3):202-209
DOI:10.4103/0973-1075.92337  PMID:22347775
Context: Pediatric palliative care clinical practice depends upon an evidence-based decision-making process which in turn is based upon current research evidence. Aims: This study aimed to perform a quantitative analysis of research publications in palliative care journals for reporting characteristics of articles on pediatric palliative care. Settings and Design: This was a systematic review of palliative care journals. Materials and Methods: Twelve palliative care journals were searched for articles with "paediatric" or "children" in titles of the articles published from 2006 to 2010. The reporting rates of all journals were compared. The selected articles were categorized into practice, education, research, and administration, and subsequently grouped into original and review articles. The original articles were subgrouped into qualitative and quantitative studies, and the review articles were grouped into narrative and systematic reviews. Each subgroup of original articles' category was further classified according to study designs. Statistical Analysis Used: Descriptive analysis using frequencies and percentiles was done using SPSS for Windows, version 11.5. Results: The overall reporting rate among all journals was 2.66% (97/3634), and Journal of Hospice and Palliative Nursing (JHPN) had the highest reporting rate of 12.5% (1/8), followed by Journal of Social Work in End-of-Life and Palliative Care (JSWELPC) with a rate of 7.5% (5/66), and Journal of Palliative Care (JPC) with a rate of 5.33% (11/206). Conclusions: The overall reporting rate for pediatric palliative care articles in palliative care journals was very low and there were no randomized clinical trials and systematic reviews found. The study findings indicate a lack of adequate evidence base for pediatric palliative care.
  4 6,629 222
Opioid-prescribing practices in chronic cancer pain in a tertiary care pain clinic
Raghu S Thota, PN Jain, Sumitra G Bakshi, Chhaya N Dhanve
September-December 2011, 17(3):222-226
DOI:10.4103/0973-1075.92340  PMID:22346047
Introduction: Under treatment of pain is a recognized global issue. Opioid analgesic medication is the mainstay of treatment in cancer patients as per the World Health Organization (WHO) pain relief ladder, yet 50% of cancer patients worldwide do not receive adequate pain relief or are undertreated. Aim: The aim of this study was to audit the ongoing opioid-prescribing practices in our tertiary cancer pain clinic during January-June 2010. Materials& Methods: The prescribed type of opioid, dose, dosing interval, and laxatives details were analyzed. Results: Five hundred pain files were reviewed and 435 were found complete for audit. Three hundred forty-eight (80%) patients were prescribed opioids. Two hundred fifty-nine (74.4%) received weak opioids while 118 (33.9%) received strong opioids. A total of 195 (45%) patients had moderate and 184 (42%) had severe pain. Ninety-three (26.7%) patients received morphine; however, only 31.5% (58 of 184) in severe pain received morphine as per the WHO pain ladder. Only 73 of 93 (78.4%) patients received an adequate dose of morphine with an adequate dosing interval and only 27 (29%) were prescribed laxatives with morphine. Conclusion: This study shows that the under treatment of pain and under dosing of opioids coupled with improper side effect management are major issues.
  4 4,738 168
Quality of life in cancer patients with disfigurement due to cancer and its treatments
Duraipandi Arunachalam, Ammapattian Thirumoorthy, Saraswathi Devi, Thennarasu
September-December 2011, 17(3):184-190
DOI:10.4103/0973-1075.92334  PMID:22346042
Aim: The aim of this study was to evaluate the effect of disfigurement due to cancer and its treatments on quality of life. Materials andMethods: A total of 120 patients from the inpatient/outpatient department of oncology who had undergone various forms of treatment for cancer were included in this study. The WHOQuality of Life BREF (WHOQL-BREF) version was administered to the patients to assess their quality of life. Results: Patients' overall quality of life score ranged from 34 to 79 with an average of 53.18 (SD 11.94) and a large number of patients had scored from 40 to 54 on the WHOQOL-BREF.The study showed a significant difference between gender groups (t = 3.899, P< 0.05), with a significant difference in the mean quality of life between different categories of the prominent stigma (f = 4.018, P< 0.05) and the nature of stigma. Disfigurement clearly was a stressful experience for both sexes, but substantially more distressing for women. Majority of the patients experienced poor quality of life in all dimensions, namely, physical health, psychological health, social relationships, environmental health, and other sociodemographic variables. Conclusion: Living with a disfiguring body which is visibly different is not always easy. A sudden change either due to cancer or its treatment or due to side effects leads to significant social maladjustment, elevated anxiety, depression, and poor quality of life among the cancer survivors with body disfigurement which calls for multiprofessional involvement in addressing various psychosocial issues.
  3 4,122 229
Pain in blood cancers
Pasquale Niscola, Andrea Tendas, Laura Scaramucci, Marco Giovannini, Vitaliana De Sanctis
September-December 2011, 17(3):175-183
DOI:10.4103/0973-1075.92333  PMID:22346041
Patients with blood-related cancers (BRC) suffer from a substantial symptom burden, including several pain syndromes sustained by different causes and pathogenetic mechanisms. So, with regard to pain, a multifaceted clinical scenario may be observed in this setting. Indeed, pain may be correlated to disease itself, to disease-associated complications, to iatrogenic causes or may be due to unrelated clinical conditions. A close diagnostic procedure for the assessment of the underlying causes of the pain and of its pathogenetic mechanisms may direct the treatment approach which should be based on a multidisciplinary management and requires the integration of etiology-targeted interventions and painkilling drugs. The World Health Organization's three-step analgesic ladder for cancer pain relief can provide adequate pain control using oral drugs in most patients with BRC on pain, although more complex interventions may be necessary for many difficult-to-treat pain syndromes which are not infrequently encountered in this setting.
  3 5,320 220
Dexmedetomidine infusion to facilitate opioid detoxification and withdrawal in a patient with chronic opioid abuse
Surjya Prasad Upadhyay, Piyush Narayan Mallick, Waleed Mohamed Elmatite, Manish Jagia, Salah Taqi
September-December 2011, 17(3):251-254
DOI:10.4103/0973-1075.92353  PMID:22346054
Many patients are admitted to the intensive care unit (ICU) for acute intoxication, serious complication of overdose, or withdrawal symptoms of illicit drugs. An acute withdrawal of drugs with addiction potential is associated with a sympathetic overactivity leading to marked psychomimetic disturbances. Acute intoxication or withdrawal of such drugs is often associated with life-threatening complications which require ICU admission and necessitate prolonged sedative analgesic medications, weaning from which is often complicated by withdrawal and other psychomimetic symptoms. Dexmedetomidine, an alpha-2 (α2 ) agonist, has been used successfully to facilitate withdrawal and detoxification of various drugs and also to control delirium in ICU patients. Herein, we report a case of a chronic opioid abuse (heroin) patient admitted with acute overdose complications leading to a prolonged ICU course requiring sedative-analgesic medication; the drug withdrawal-related symptoms further complicated the weaning process. Dexmedetomidine infusion was successfully used as a sedative-analgesic to control the withdrawal-related psychomimetic symptoms and to facilitate smooth detoxification and weaning from opioid and other sedatives.
  2 5,772 119
Attitudes toward euthanasia among doctors in a tertiary care hospital in South India: A cross sectional study
Sneha Kamath, Priya Bhate, Ginu Mathew, Srijith Sashidharan, Anjali B Daniel
September-December 2011, 17(3):197-201
DOI:10.4103/0973-1075.92336  PMID:22346044
Context: Advances in expertise and equipment have enabled the medical profession to exercise more control over the processes of life and death, creating a number of moral and ethical dilemmas. People may live for extended periods with chronic painful or debilitating conditions that may be incurable. Aim: This study attempts to study the attitudes of doctors toward euthanasia and the possible factors responsible for these attitudes. Settings and Design: A cross-sectional survey of 213 doctors working at a tertiary care hospital was conducted to determine their attitudes toward euthanasia. Materials and Methods: A self-administered questionnaire was used to assess attitudes and personal perceptions about euthanasia. Statistical Analysis Used: The Chi square test was used to assess factors influencing attitudes toward euthanasia. Results: A majority of the respondents (69.3%) supported the concept of euthanasia. Relief from unbearable pain and suffering was the most commonly (80.3%) cited reason for being willing to consider the option of euthanasia. Majority of those who were against euthanasia (66.2%) felt that the freedom to perform euthanasia could easily be misused. Disapproval of euthanasia was associated with religious affiliation (P<0.001) and speciality (P<0.001). Conclusions: A majority of the doctors in this study supported euthanasia for the relief of unbearable pain and suffering. Religion and speciality appear to be significant in determining attitudes toward euthanasia.
  2 5,530 200
Attitudes and beliefs about chronic pain among nurses- biomedical or behavioral? A cross-sectional survey
Venkatesan Prem, Harikesavan Karvannan, RD Chakravarthy, B Binukumar, Saroja Jaykumar, Senthil P Kumar
September-December 2011, 17(3):227-234
DOI:10.4103/0973-1075.92341  PMID:22346048
Context: Studies have documented that nurses and other health care professionals are inadequately prepared to care for patients in chronic pain. Several reasons have been identified including inadequacies in nursing education, absence of curriculum content related to pain management, and attitudes and beliefs related to chronic pain. Aims: The objective of this paper was to assess the chronic pain-related attitudes and beliefs among nursing professionals in order to evaluate the biomedical and behavioral dimensions of their perceptions on pain. Settings and Design: Cross-sectional survey of 363 nurses in a multispecialty hospital. Materials and Methods: The study utilized a self-report questionnaire - pain attitudes and beliefs scale (PABS) - which had 31 items (statements about pain) for each of which the person had to indicate the level at which he or she agreed or disagreed with each statement. Factor 1 score indicated a biomedical dimension while factor 2 score indicated a behavioral dimension to pain. Statistical Analysis Used: Comparisons across individual and professional variables for both dimensions were done using one-way ANOVA and correlations were done using the Karl-Pearson co-efficient using SPSS version 11.5 for Windows. Results: The overall factor 1 score was 52.95 ± 10.23 and factor 2 score was 20.93 ± 4.72 (P = 0.00). The female nurses had a higher behavioral dimension score (21.1 ± 4.81) than their male counterparts (19.55 ± 3.67) which was significant at P< 0.05 level. Conclusions: Nurses had a greater orientation toward the biomedical dimension of chronic pain than the behavioral dimension. This difference was more pronounced in female nurses and those nurses who reported "very good" general health had higher behavioral dimension scores than those who had "good" general health. The study findings have important curricular implications for nurses and practical implications in palliative care.
  2 6,373 171
Palliative and Supportive Care in Acrometastasis to the Hand: Case Series
Narendra Kumar, Ritesh Kumar, Anjan Bera, Pankaj Kumar, Shabab L Angurana, Sushmita Ghosal, Radhika Srinivasan, Suresh Chander Sharma
September-December 2011, 17(3):241-244
DOI:10.4103/0973-1075.92347  PMID:22346051
Acrometastasis to the hand is an unusual presentation which might mimic an infectious, inflammatory, or a metabolic pathology. We herein describe a case series of three patients of acrometastasis to the hand. We encountered three cases of acrometastasis to the hand attending the departmental clinics from 2007 to 2010. The median age at presentation was noted to be 55 years. All were males. The primaries included squamous cell carcinoma of the skin, larynx, and esophagus. In two patients, acrometastasis was detected at presentation and in one it was detected 2 years postcompletion of radical therapy. Two patients were offered palliative radiation to acrometastasis, and best supportive care was given to one. Palliation achieved after radiation was noted to be modest to good. The brief report highlights the importance of the clinical awareness of metastatic dissemination to unusual sites in the face of increasing cancer survivorship. Acrometastasis portends a poor prognosis with limited survival, and optimal integration of the best supportive care is mandatory. A short course of hypofractionated palliative radiation therapy results in modest to good palliation.
  1 11,641 96
Anticoagulants and anti-platelet agents in palliative home healthcare
Viroj Wiwanitkit
September-December 2011, 17(3):260-260
DOI:10.4103/0973-1075.92355  PMID:22346056
  1 1,700 82
Authors' reply
Andrea Tendas, Luca Cupelli, Laura Scaramucci, Massimiliano Palombi, Malgorzata Monika Trawinska, Marco Giovannini, Gregorio Antonio Brunetti, Claudio Cartoni, Francesco Bondanini, Paolo de Fabritiis, Pasquale Niscola
September-December 2011, 17(3):260-260
  1 2,168 59
A randomized controlled trial to compare the efficacy of bisphosphonates in the management of painful bone metastasis
Krishnangshu Bhanja Choudhury, Chandrani Mallik, Shyam Sharma, Debangshu Bhanja Choudhury, Sumana Maiti, Chhaya Roy
September-December 2011, 17(3):210-218
DOI:10.4103/0973-1075.92338  PMID:22346045
Introduction: The prospective interventional single-institution randomized control study was carried out to compare the pain relieving efficacy among different bisphosphonates at the cost of incidence of skeletal-related events (SRE). Materials and Methods: During June 2008 and May 2011, 256 patients with painful bone metastasis in solid tumors with a pain score of at least 5 were randomized into three arms: zoledronic acid (4 mg, i.v.), ibandronate (6 mg, i.v.) and pamidronate (90 mg, i.v.). Radiation was given to all patients, either 800 cGy single fraction or 20 Gy in five fractions. The ANOVA test was used for analysis. The Pearson test was used to correlate pain scores with proportions of responders as statistical estimation of pain relief. Results: With a mean baseline pain score of 6.5 ± 1.2, there was no difference in pain scores among the three treatment arms, assessed at 3 months and at the end of the study. However, the pain scores at 6 months were statistically reduced in zoledronic acid-receiving patients (1.5 ± 0.4) unlike the scores in patients receiving ibandronate (3.1 ± 0.5) and pamidronate (2.3 ± 0.4), with a P-value of 0.024. The response was statistically significant at 6 months (0.039) and at the end of the study (0.023), in favor of zoledronic acid. Pearson's correlation demonstrated a statistically significant positive correlation between pain scores and response rates. There were no statistical differences in the narcotic scores among the treatment arms during the study period. The overall duration of pain relief was not different in any of treatment arms. The time of detection of hypercalcemia was no different; however, the incidence of hypercalcemia was significantly less in the zoledronic acid arm (28.3%) against 44.6% and 50% in ibandronate and pamidronate arms, respectively, with a P-value of 0.041. Conclusion: The use of bisphosphonates for 6 months or more results in a statistical significant improvement in bone pain, more so with zoledronic acid. Hypercalcemia, an SRE, was significantly less in the zoledronic acid arm.
  1 4,141 166
What does the informal caregiver of a terminally ill cancer patient need? A study from a cancer centre
Anjum S Khan Joad, TC Mayamol, Mohita Chaturvedi
September-December 2011, 17(3):191-196
DOI:10.4103/0973-1075.92335  PMID:22346043
Aims: To assess the needs of informal caregivers of terminally ill cancer patients. Materials and Methods: Fifty four informal caregivers of patients registered in our palliative care service were interviewed 3-6 months after the death of the patient with the help of a semistructured questionnaire covering the physical, medical, psychological, social, and information domains. Results: Most of the caregivers were middle aged and had no prior experience of care giving. The caregivers were satisfied by the information and medical support provided to them by their treatment team. Most had an "emergency plan." Caregivers had unmet needs including homecare, psychological support, and financial help. Conclusions: informal caregivers provide most of the nursing and psychological support to the patient. However, palliative care services need to recognize that the caregiver too may need psychological and technical support.
  1 4,726 187
Managing pressures ulcers in a resource constrained situation: A holistic approach
Abhijit Dam, Nivedita Datta, Usha Rani Mohanty, Chandreyi Bandhopadhyay
September-December 2011, 17(3):255-259
DOI:10.4103/0973-1075.92354  PMID:22346055
Managing pressure ulcers remain a challenge and call for a multidisciplinary team approach to care. Even more daunting is the management of such patients in remote locations and in resource constrained situations. The management of pressure sores in a patient with progressive muscular atrophy has been discussed using resources that were locally available, accessible, and affordable. Community participation was encouraged. A holistic approach to care was adopted.
  - 10,010 129
Neuropathic pain due to fibromatosis: Does anticancer treatment help?
David Mathew, Reena Mary George, Jenifer Jeba, Sunita Susan Varghese
September-December 2011, 17(3):245-247
DOI:10.4103/0973-1075.92349  PMID:22346052
Desmoid fibromatosis, although histologically benign, infiltrates local structures. The involvement of neural structures can lead to difficult neuropathic pain and the escalating use of analgesics. We report a patient with desmoid fibromatosis of the chest wall causing brachial plexus infiltration. As the tumor was locally invasive and unresectable, he was treated with radiation therapy and oral tamoxifen. On follow-up, there was significant pain relief, sustained reduction in the tumor size, and reduced analgesic requirement. Antineoplastic treatments like local radiation therapy and targeted systemic therapy with hormones or other agents can be considered in the management of selected unresectable desmoid fibromatosis to improve symptom control and reduce polypharmacy.
  - 3,597 92
Providing Palliative Care for a dying teen at home: Perspectives and challenges
Malathi Nayak, Naveen Salins
September-December 2011, 17(3):248-250
DOI:10.4103/0973-1075.92351  PMID:22346053
Adolescents and young adults with cancer are a heterogeneous group. Management of this special group requires a broad-based interdisciplinary clinical team, which should include palliative care (PC), psychology, social work, oncology, and nursing representatives. The function of PC is to provide impeccable pain and other symptom control and to coordinate care as the disease progresses. The cure rate of cancer in adolescents is high but between 10% and 40% of them will develop incurable disease depending on tumor type and prognostic factors. PC in adolescents should also take care of the specific physical and psychosocial developmental changes in this age group. A 16-year old boy suffered with incurable disease and team has provided the PC at the door step taken as a case study.
  - 3,024 105
Speech and swallowing outcomes in buccal mucosa carcinoma
Sunila John, Rashida M Hassuji, B Rajashekhar
September-December 2011, 17(3):238-240
DOI:10.4103/0973-1075.92344  PMID:22346050
Buccal carcinoma is one of the most common malignant neoplasms among all oral cancers in India. Understanding the role of speech language pathologists (SLPs) in the domains of evaluation and management strategies of this condition is limited, especially in the Indian context. This is a case report of a young adult with recurrent squamous cell carcinoma of the buccal mucosa with no deleterious habits usually associated with buccal mucosa carcinoma. Following composite resection, pectoralis major myocutaneous flap reconstruction, he developed severe oral dysphagia and demonstrated unintelligible speech. This case report focuses on the issues of swallowing and speech deficits in buccal mucosa carcinoma that need to be addressed by SLPs, and the outcomes of speech and swallowing rehabilitation and prognostic issues.
  - 3,269 111
Palliative care of young adults: An issue which needs higher and better awareness
Sushma Bhatnagar, Saurabh Joshi
September-December 2011, 17(3):173-174
DOI:10.4103/0973-1075.92332  PMID:22346040
  - 5,181 201
Hypofractionated radiotherapy as local hemostatic agent in advanced cancer
Malik Tariq Rasool, Najmi Arshad Manzoor, Syed Arshad Mustafa, Lone Mohammad Maqbool, Fir Afroz
September-December 2011, 17(3):219-221
DOI:10.4103/0973-1075.92339  PMID:22346046
Purpose : Tumor bleeding continues to remain a challenge in an oncological setting, and radiotherapy has been studied as a local hemostatic agent. We studied the role of local radiotherapy in controlling bleeding at our center. Materials and Methods : We reviewed 25 treated cases (cancer urinary bladder: 12, lung cancer: 5, cervical cancer: 4, uterine cancer: 1, rectal cancer: 2, schwanoma: 1) at our center from March 2008 to December 2010. All patients had either an advanced or recurrent disease. Radiotherapy schedule was either 20 Gray in 5 fractions or 15 Gray in 5 fractions and was delivered with Cobalt 60. Results and Conclusion : Of 25 patients, 22 (88%) responded, and there was complete cessation of bleeding. Both 15 Gray and 20 Gray dose schedule had equal efficacy. Treatment was well tolerated without any intermission. Radiotherapy is a safe and effective option in controlling tumor bleeding.
  - 4,044 146
Pattern of referral of noncancer patients to palliative care in the Eastern province of Saudi Arabia
Hafez M Ghanem, Rawabi M Shaikh, Ahmad M Abou Alia, Amani S Al-Zayir, Samy A Alsirafy
September-December 2011, 17(3):235-237
DOI:10.4103/0973-1075.92342  PMID:22346049
Aim : The palliative care (PC) needs of patients with noncancer life-threatening illnesses are comparable to that of cancer patients. This report describes the contribution of noncancer patients to the population of PC patients in a tertiary care hospital in the Eastern Province of Saudi Arabia. Materials andMethods : This is a retrospective review of the "palliative care inpatient database" of 21 months. Results : From 474 patients, 20 (4.2%) had a noncancer diagnosis. The main reason for the referral of noncancer patients was pain control. The most prevalent diagnoses were sickle cell disease (SCD) in 6 (30%) patients and peripheral arterial disease (PAD) in 5 (25%). Conclusions : These findings suggest that the PC needs of noncancer patients are largely unmet in our region. Further efforts are necessary to advance noncancer PC in Saudi Arabia. The PC needs of patients with SCD and PAD need to be addressed in future research.
  - 2,910 105
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