Indian Journal of Palliative Care
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   Table of Contents - Current issue
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July-September 2020
Volume 26 | Issue 3
Page Nos. 269-397

Online since Saturday, August 29, 2020

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EDITORIAL  

Legislation for end-of-life care in India: Reflections on 5 years of the end-of-life care in India taskforce journey Highly accessed article p. 269
Roop Gursahani, Srinagesh Simha, Raj K Mani
DOI:10.4103/0973-1075.293879  
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ORIGINAL ARTICLES Top

Effectiveness of a breathing training program on quality of life in patients with predialysis chronic kidney disease: A randomized controlled trial Highly accessed article p. 271
Lasara Kharbteng, Monaliza, Vivek Kumar, Sukhpal Kaur, Sandhya Ghai
DOI:10.4103/IJPC.IJPC_118_19  
Context: Chronic kidney disease (CKD) patients have suboptimal quality of life (QOL). Various studies/researches have revealed that breathing exercises have a positive and favorable impact on different systems of the body. Aims: This study aims to assess the effect of a breathing training program on QOL in patients with predialysis CKD. Settings: The study was a single-center study conducted at PGIMER, Chandigarh. Design: Randomized controlled trial. Methods: Sixty individuals were enrolled and randomized using lottery method. QOL was assessed or evaluated by Kidney Disease and QOL questionnaire (KDQOL™-36). Breathing exercises were taught to the intervention group. Patients included in control group continued with the routine care. Assessment of QOL was done after 4 weeks in both the groups. Results: Change in KDQOL™-36 scores showed significant difference between control and the intervention group. The mean scores of control group in the subscale effects of kidney disease, SF-12 Physical functioning (Physical Health Composite) and SF-12 Mental functioning (Mental Health Composite) were 84.79, 39.16 and 37.40, respectively, whereas in intervention group, the respective mean scores were 91.88, 43.92, and 44.16. The difference was statistically significant (P = 0.04, P = 0.01, and P = 0.003, respectively). Conclusions: Breathing training program improves QOL in patients with predialysis CKD.
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The Relationship between “Self-Care Ability” and Psychological Changes among Hemodialysis Patients p. 276
Fatemeh Sadeghpour, Mehdi Heidarzadeh, Farzad Kohi, Reza Asadi, Masoomeh Aghamohammadi-Kalkhoran, Faeze Abbasi
DOI:10.4103/IJPC.IJPC_129_19  
Aim: The study investigates and analyzes the relationship among the concepts of demoralization, posttraumatic growth, and self-care ability in patients undergoing hemodialysis. Methods: The cross-sectional descriptive correlational study was conducted in 2017 on 150 hemodialysis patients selected through census in Buali Hospital, Ardabil, Iran. Demoralization scale, the posttraumatic growth inventory, and self-care questionnaire were used for cross-sectional data collection. Data were analyzed using descriptive statistics, Pearson and Spearman correlation coefficient. Results: The mean and standard deviation of demoralization, posttraumatic growth, and self-care were 36.25 ± 18.84, 63.17 ± 17.71, and 33.89 ± 6.40, respectively. Self-care ability was positively associated with posttraumatic growth (r = 0.287) and negatively related to demoralization (r = −0.168). Self-care ability was also found to be desirable in 84.7% of the patients. Conclusions: Hemodialysis patients can experience both positive and negative psychological changes. Self-care ability is associated with reductions in negative psychological problems and increases in positive psychological changes. Health-care providers can, therefore, help hemodialysis patients to improve their psychological conditions by making plans for improving self-care abilities.
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Comparison of safety and efficacy of pregabalin versus gabapentin for the treatment of uremic pruritus in patients with chronic kidney disease on maintenance haemodialysis p. 281
Ashima Ravindran, Rajesh Peringanazhi Kunnath, Anjali Sunny, Binoo Vimal
DOI:10.4103/IJPC.IJPC_212_19  
Background: Uremic pruritus (UP) affects many patients suffering from chronic kidney disease (CKD) and has a negative impact on the quality of life. The severity of UP ranges from sporadic discomfort to complete restlessness during both day and night time. It has become increasingly evident that central transmission and sensitization processes similar to those observed in chronic pain are important mechanisms of pruritus. Methodology: This was a randomized single-blind prospective-interventional study carried out for 6 weeks. Male and female patients aged between 20 and 85 years with end-stage renal disease undergoing maintenance hemodialysis and who had substantial pruritus defined as persistent were included in our study. Informed consent was obtained from each patient before enrolling in the study. Patients were randomly divided into two groups (Group A and B), with Group A receiving pregabalin 25 mg and Group B receiving gabapentin 100 mg. The efficacy and safety of drugs were assessed after 6 weeks using visual analog scale and 5D itch scale. Results: We used gabapentin 100 mg or pregabalin 25 mg for 42 consecutive patients with CKD on maintenance hemodialysis with a mean age of patients in Group A (pregabalin 25 mg) 55.29 ± 14.58 and B (gabapentin 100 mg) 58.10 ± 11.09. Both gabapentin and pregabalin produced a significant difference in itching intensity with P < 0.001; however, there was no statistically significant difference between the effectiveness of two drugs in reducing itch. While receiving gabapentin, 11 of 21 patients (52.38%) reported fatigue, dizziness, somnolescence, which was statistically significant (P ≤ 0.001) and 4 of these patients discontinued use of the drug due to excessive somnolence, all after the first dose. A statistically significant difference was found in each domain of 5D-Pruritus scale after gabapentin and pregabalin therapy.
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Death attitudes as possible predictors of death preparedness across lifespan among nonclinical populations in Nairobi County, Kenya p. 287
Stephen Asatsa
DOI:10.4103/IJPC.IJPC_127_19  
Context: Death is an important part of lifespan development, yet it remains trivialized or feared across many cultures. The perpetuation of death as a taboo subject continues to negatively affect the society. Death anxiety inhibits death preparedness which could affect the quality of dying. The pool of unclaimed assets held by different organizations continues to increase, intestate deaths remain high, and post death conflicts continue to affect many families. Aims: This study intended to examine death attitudes as possible predictors of death preparedness and explore the rationale for various death attitudes across lifespan in Nairobi, Kenya. Methods: The study adopted the mixed-methods explanatory sequential research design combining cross-sectional and phenomenological designs. The study targeted young adults, middle-aged adults, and seniors with a sample of 335 participants selected using multistage, stratified, and extreme case sampling designs. Data were collected using the Death Attitude Profile-Revised and interview guides. Analysis: Data were analyzed using univariate and thematic analyses. Results: The findings indicated that negative death attitudes declined with increase in age, whereas positive death attitudes increased with increase in age. Some of the reasons for negative death attitudes included threatening dying process, unfulfilled life goals, fear of hell, unresolved past deaths, and families with young children among others. The reasons for positive death attitude included reuniting with deceased loved ones and peers, meeting the creator, and end to a prolonged miserable life and fulfilled past life. Conclusion: This study implies that mental health practitioners need to target younger adults with death education programs to promote death preparedness and quality dying. For the older adults, addressing life regrets, family conflicts, and past unresolved deaths would significantly improve the quality of dying.
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Validation of Malayalam translation of the European organization for the research and treatment of cancer quality of life instrument OG25 for esophagogastric junction cancers p. 295
Mira Sudam Wagh, Arun Peter Mathew, Bharat Veerabhadran, Madhu Muralee, Sajeed Abdul Rahuman, Preethi Sarah George, K Chandramohan
DOI:10.4103/IJPC.IJPC_135_19  
Background: Quality of life questionnaire (QLQ) OG25 is the questionnaire used for measuring quality of life (QOL) of patients with esophago-gastric junction (OG) cancers. QLQ-OG 25 is a disease-specific tool to capture the QOL parameters of patients with OG junction cancers. OG 25 was developed by the European Organization for the Research and Treatment of Cancer (EORTC) using inspiration from their questionnaires for carcinoma stomach (STO22) and carcinoma esophagus (OES18). It is usually used along with QLQ-C30, which is a general tool applicable for all cancers. This questionnaire is in the English language. In order to use this questionnaire in a non-English speaking population, the English questionnaire has to be initially translated to the local languages. Malayalam is the language spoken by 38.5 million people residing in the South Indian state, Kerala, India. We have translated and validated the QLQ-OG 25 to Malayalam language in an attempt of enabling it to be used for future studies at this geographic region. Methods: The translation was done by the standard protocol adopted by EORTC. QLQ-C30 and QLQ-OG25 questionnaires were then filled in by patients with OG junction cancers. These patients had cancers of various subsites of the OG junction and were at different stages of treatment, at the time of interview. The interview was done twice, at an interval ranging from 48 h to 1 week between the two interviews. Results: A total of 46 patients with OG junction tumors at varying stages of treatment completed the questionnaire. There were no missing data. The average time to finish the interview was 12.12 min. The Cronbach's alpha, which signifies the internal consistency of the questionnaire, was found to be >0.7 in all the domains studied, except in cognitive function. The intraclass correlation coefficients varied from 0.63 to 0.93. Conclusion: The Malayalam translation of the QOL tool QLQ-OG25 has been found to be an acceptable and valid tool in assessing the QOL parameters of patients with OG junction cancers.
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Assessment of psychosocial distress among the palliative care patients in Wardha District of Maharashtra p. 302
Nikhil Dhande, Sunil Kumar, Ashwini Bolane
DOI:10.4103/IJPC.IJPC_114_19  
Aim: Palliative Care Outcome Scale (POS) is one of the various tools, available for the evaluation of the effectiveness of palliative services, having 10item multidimensional questionnaire, designed to assess the physical, psychosocial, spiritual, and practical aspects of patients with various sufferings. In this study, we had assessed psychosocial distress among the patients of a palliative care clinic of a rural teaching hospital at Wardha district. Methods: In this cross-sectional study, a total of 118 patients attending the palliative care clinic under the medicine department were enrolled between July 2018 and March 2019. POS has 10 questions in Likert type of scale with a scoring of 0–4, 0 for no effect to 4 for overwhelming effect. Each question provides the information regarding how the patient feels in the past 3 days. Results: In the first assessment for anxiety about illness or treatment, 32% of the participants reply that they occasionally feel the anxiety, whereas the same reply has been given in follow-up assessment by 34% of the participants, with an average mean score of 1.59 and 1.31, respectively. Approximately 48% of the participants feel that their family or friends were occasionally anxious and worried for them in the first assessment of POS compared to follow-up assessment where the feeling has been changed with approximately 46% for not at all anxious or worried followed by 39% occasionally. Conclusion: Participants were satisfied and accepted the palliative care treatment provided by the team with frequent visits, and also, the level of improvement fastens.
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Experiences of caregivers in a home-based palliative care model – A qualitative study p. 306
Aneka Paul, Elaine Fernandes
DOI:10.4103/IJPC.IJPC_154_19  
Background: Family caregivers are of vital support to patients receiving home-based palliative care. Aims and Objectives: This study sought to identify and comprehend the challenges that caregivers face while taking care of a terminally ill patient in a home-based palliative care setting and the mechanisms that facilitated their coping. Materials and Methods: A qualitative approach was employed to understand the perceptions of primary caregivers through 3 focus group discussions and 4 in-depth interviews, across 3 socioeconomic categories and 3 geographic zones of Mumbai. Results: Caregivers expressed that they wished they had been introduced to palliative care earlier. Being trained on minor clinical procedures and managing symptoms, and receiving emotional support through counselling were found beneficial. Caregivers did not perceive the need for self-care as the period of active caregiving was often short. Bereavement counselling was felt to be of much help. Conclusion: The study helped understand the caregivers' perceptions about the factors that would help them in patient as well as self-care. Recommendations for designing interventions for future caregivers and recipients were also made.
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Effectiveness of high-fidelity simulation in nursing education for end-of-life care: A quasi-experimental design p. 312
Salma Amin Rattani, Zohra Kurji, Amina Aijaz Khowaja, Jacqueline Maria Dias, Anila Naz AliSher
DOI:10.4103/IJPC.IJPC_157_19  
Background: Providing end of life (EOL) care is a component of palliative care but dealing with dying patients and their family members is stressful for the healthcare providers. To prepare them for providing EOL care, the high-fidelity simulation could be used as a pedagogy in which real-life scenarios are used on the computerized manikins mimicking the real patients. Aims: The aim of this study was to measure the effectiveness of high-fidelity simulation to teach EOL care in the palliative nursing course in the undergraduate nursing education program at the School of Nursing and Midwifery at Aga Khan University which is private university in Karachi, Pakistan. Methods: This study was approved by the ethics review committee of Aga Khan University. It was hypothesized that exposure to high-fidelity simulation will lead to an increased positive attitude in participants towards the care of dying. A quasi-experimental design was used. In line with the design, there was no control group. The same group of students (n = 42) were assessed through Frommelt Attitudes Toward Care of the Dying (FATCOD) Part B assessment tool. Permission for using this tool was obtained from Dr. Katherine Frommelt, the author of this tool. Research participants filled this tool before and after the intervention, i.e., providing EOL care to a patient in a high-fidelity simulation lab. Results: Out of 30-FATCOD items, significant attitude change was detected on 11-items of which 8 were positively worded statements and 3 were negatively worded statements. As per the hypothesis, it was expected for the positively worded statements that the mean score for the posttest would be significantly greater than the pretest mean score (pretest score < posttest score). The hypothesis was proved for items 1, 4, 10, 18, 22, 25, 27, and 30 as their t-value was significant at 0.05 alpha value (one-tailed). For the negatively worded statements, it was expected that the mean score for the posttest would be significantly lower than the pretest (pretest score > posttest score). The hypothesis was proved for items 5, 6, and 11 as their t-value was significant at 0.05 alpha value (one-tailed). Conclusion: In this research teaching, EOL care through high-fidelity simulation had improved the attitudes of students toward providing care. This pedagogy also provided the participants with a learning opportunity to deal with their own emotions. These findings provide a way forward for teaching EOL and other complex skills of clinical practice.
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Developing evidence-based clinical guidelines in palliative care for home care setting in India p. 319
Jenifer Jeba, Jayarajan Ponissery, Akhileswaran Ramaswamy, Jeremy Richard Johnson, Anu Savio Thelly, Pheroza J Bilimoria
DOI:10.4103/IJPC.IJPC_161_19  
Background: Clinical guidelines can improve care and reduce variations in practice. With the growth of The Jimmy S Bilimoria Foundation's PALCARE, a home-based palliative care service launched in December 2015, the foundation felt a need for locally relevant, clinical guidelines to ensure consistency and reliabilty of its service. A Clinical Consultative Committee (CCC) comprising of experienced palliative care professionals, from within and outside India, was constituted to help with the development of robust, evidence-based multidisciplinary clinical guidelines relevant to the delivery of palliative care for adults in a home care setting in Mumbai, India, which could be applied to other similar settings in India and elsewhere. Methodology and Development: The CCC developed 39 guidelines under eight categories; using a structured process from the initial draft to its finalization. The CCC vetted each of the guidelines over monthly Skype meetings for validity, relevance, local applicability and reproducibility. Feedback from the PALCARE team was also incorporated. Thirty-nine clinical guidelines relevant to adult palliative care services in home care setting were developed. These have been discussed and found useful by the PALCARE team. The guidelines are available on the PALCARE website for use by wider professional audience. Conclusion: Development of clinical guidelines locally for palliative care in a home care setting in response to a felt need to ensure quality care and reduce variation in practice has been beneficial in clinical care. It has proved to be a good teaching resource too. Regular audits to measure practice against these guidelines will ensure better patient outcomes.
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Effectiveness of yoga on quality of life of breast cancer patients undergoing chemotherapy: A randomized clinical controlled study p. 323
Kamli Prakash, Sunil K Saini, Sanchita Pugazhendi
DOI:10.4103/IJPC.IJPC_192_19  
Background: Cancer of breast is most common cancer among women in India and vast majority of countries worldwide. While undergoing chemotherapy for carcinoma management, women encounter side effects, which affects their quality of life (QOL). A randomized controlled study with quantitative research approach and time series design was conducted, to study the effectiveness of yoga on QOL of breast cancer patients undergoing chemotherapy. Methodology: One hundred breast cancer patients scheduled for 3-weekly, day-care adjuvant chemotherapy (CEF regimen) were enrolled with consecutive sampling technique, into control (n = 52) and experiment (n = 48) groups, by concealed randomization following written informed consent. Baseline data on QOL were collected before first-cycle chemotherapy using the European Organization for Research and Treatment of Cancer QLQ C30. Patients in the experimental group were taught diaphragmatic breathing techniques, systematic relaxation, and alternate nostril breathing, and Joints and Glands neck and shoulder exercises were instructed to practice twice daily at home. They were supervised in practicing these techniques while they received second, third, fourth, fifth, and sixth cycles of chemotherapy in the day-care facility. Participants in the control group received only routine care. All participants received standard post chemotherapy prescription. Data on QOL were collected from all patients during the second, third, fourth, fifth, and sixth cycles of chemotherapy. Results: The analysis revealed that at the baseline ( first chemotherapy cycle), breast cancer patients in control and experimental groups were homogeneous in terms of their sociodemographic and clinical variables and QOL score. Yoga practices were effective in improving the QOL of breast cancer patients in the experimental group in the areas of global health status, physical function, role function, and emotional function and decreasing the symptoms of fatigue, insomnia, loss of appetite, and constipation, during the period of chemotherapy. Conclusion: Yoga practices comprising of relaxation techniques reduce many side effects and improve the QOL of women undergoing chemotherapy for breast cancer.
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Impact of applying palliative care on symptoms and survival of patients with advanced chronic disease admitted to the emergency department p. 332
Jose P Amado, Rolando Vasquez, Roberto Huari, Liliana Rimache, Rosa Lizonde
DOI:10.4103/IJPC.IJPC_195_19  
Introduction: In the emergency department, there is a need to provide palliative care; however, they are not usually administered. The present study evaluates the evolution of the intensity of the symptoms when applying palliative care, in adult patients with advanced chronic disease admitted to the emergency room, and compares survival between those who receive this care and those who do not. Materials and Methods: A clinical intervention study was conducted including patients older than 18 years with advanced chronic disease admitted to the emergency room with an indication of palliative support according to the Supportive and Palliative Care Indicators Tool 2015. Three hundred and seven patients were studied (74 in the intervention group and 233 in the group not intervened). In the intervention group, the intensity of pre- and postintervention symptoms was compared (Wilcoxon test). The survival of both the groups were then compared (logrank test). Results: There was a significant decrease in pain and dyspnea at 24 and 48 h postintervention (P < 0.01), respectively, while drowsiness increased significantly at 24 h (P < 0.01) but did not change at 48 h (P = 0.38). Excluding patients with better functional status, there was less survival at 3 months in the intervention group (P = 0.01). Conclusions: Dyspnea and pain decreased with the application of palliative care but not drowsiness. Survival in the intervention group was lower than in the nonintervention group. However, the reason for providing palliative care is to relieve suffering at the end of life.
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Correlation of pediatric palliative screening scale and quality of life in pediatric cancer patients p. 338
Murti Andriastuti, Pricilia Gunawan Halim, Eny Kusrini, Meidiana Bangun
DOI:10.4103/IJPC.IJPC_197_19  
Context: Palliative care in children is used to be only intended for those in near end-of-life phase. Ideally, palliative intervention should be given since the first time of cancer diagnosis. Palliative care is introduced from the beginning of the treatment by acknowledging that it helps to ensure an ongoing focus on the quality of life (QOL) so that children still can enjoy their life. Several approaches have been used to identify children with the need of palliative care. Aims: The aim was to describe the use of Paediatric Palliative Screening Scale (PaPaS Scale) and its depiction to the QOL of children with malignancies. Settings and Design: A cross-sectional study was conducted in sixty children age 2–18 years with malignancies, who were consulted to the palliative team. Subjects and Methods: Sixty participants were recruited randomly during the study. PaPaS Scale and QOL (using PedsQLTM cancer module 3.0) were assessed at the same time. Cutoff points of 67 for parent–proxy report and 68.9 for self-report were used, those who have scores <67 and <68.9 were grouped as low QOL group. PaPaS scale was divided into three groups: (1) no palliative care needs (score 10–14), (2) considered palliative care (15–24), and (3) need for palliative (≥25). Statistical Analysis: Differences between palliative score and QOL were analyzed using Chi-square and Fisher test. Results: Children who have lower QOL based on parent–proxy report (<67) included 25 children; they consist of 16 children (64%) with score 10–14, four children (16%) with score 15–24, and five children (20%) with score ≥25. Children with higher QOL (16 children) consist of ten children (62.5%) with score 10–14, four children (25%) scores 15–24, and two children (12.5%) with score ≥25. In the self-report, children with low QOL (eight children) consist of four children (50%) with score 10–14, four children (50%) with score 15–24, and no children with score ≥ 25. Children with higher QOL (11 children) consist of eight children (72.2%) with score 10–14, two children (18.2%) with scores 15–24, and one child (9.1%) with score ≥25. Statistical analysis showed no correlation between PaPaS score and QOL of children with malignancies in parent–proxy report (P = 0.89) and self-report (P = 0.37). Conclusions: This study showed that children with malignancies already had lower QOL despite the low PaPaS scale they had. The results of this study support the provision of early palliative intervention, starting with a small proportion of intervention to improve the QOL of cancer child.
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Efficacy of chronomodulated chemotherapy for palliation of hematemesis in inoperable gastric cancer: A single-institutional retrospective study p. 342
Satadru Biswas, Santanu Acharyya, Pritha Roy, Debdeep Samaddar, Chandan Dasgupta, Debarshi Jana
DOI:10.4103/IJPC.IJPC_201_19  
Context: Aside abdominal discomfort and pain, upper gastrointestinal bleeding (UGIB) significantly disgraces the quality of life (QoL), especially in inoperable gastric cancer patients. Although, in early stages, it is infrequent and often ignored, but in advanced stages, its aggressiveness often deteriorates patient's hemoglobin (Hb) level and performing status. Aim: The aim of this study is to correlate the change in (1) the frequency of episodes of UGIB, (2) its severity in terms of Common Terminology Criteria for Adverse Events (CTCAE) grade for UGIB, and (3) Hb level with the successful completion of successive cycles of palliative chemotherapy where it becomes invariably the only modality to palliate the cancer disease. Setting and Design: This single-institutional retrospective observational study included seventy gastric carcinoma patients with a chief complaint of frequent hematemesis. They were divided according to the cause behind inoperability or irresectability: (1) Metastatic disease, (2) locally advanced irresectable disease, (3) uncontrolled comorbidities, (4) poor GC (PGC), and (5) refused to give surgical consent. Subjects and Methods: Following baseline evaluation and prechemotherapy workups, patients were subjected to three-weekly chronomodulated modified EOX regimen. Relevant parameters, i.e., (1) average episodes per-week (AEP) score, (2) Hb, and (3) average CTCAE grade value for UGIB were recorded after every cycle. Results: At 12-week follow-up, there was a significant decrease in mean AEP score from baseline (from 2.6691 ± 0.7047 to 1.5033 ± 0.6272) for the entire cohort (P < 0.001). Maximum benefit in terms of mean Hb (increase by 1.0737% above baseline) took place for PGC group (P < 0.001). Mean CTCAE grade value for the entire cohort decreased from baseline by 0.6428, which was statistically significant with a P < 0.001. Conclusions: PGC group was maximally benefited considering all three parameters. Though surgery defines the mainstay of treatment for gastric carcinoma, yet in inoperable cases, only chronomodulated chemotherapy significantly affects the severity of UGIB and thus may improve QoL.
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Impact of radiation therapy on pain relief of cancer patients affected by on malignant psoas syndrome: 26 years of experience p. 348
Alexandros Gerontopoulos, Eftychia Mosa, Filippo Alongi, Ioannis Kokakis, Haytham Hamed Saraireh, Nikolaos Tsoukalas, Nikolaos Charalampakis, Konstantinos Tsanadis, Konstantinos Tsapakidis, Maragkouli Eleni, Christos Christopoulos, Maria Tolia
DOI:10.4103/IJPC.IJPC_205_19  
Aim: The malignant psoas syndrome (MPS) is a rare and complex cancer-related clinical entity, with a significant impact on cancer patients' quality of life. The literature describing malignant infiltration of the psoas muscle as well as its management is limited. The primary endpoint of the study was the assessment of pain relief in symptomatic terminal-stage MPS patients. Materials and Methods: Patients underwent hypofractionated (two- or three-dimensional conformal) radiotherapy as palliative treatment. A dose of 42.5 Gy in 17 daily fractions (2.5 Gy/fraction) was prescribed. Pain response was measured before 3 and 6 months after radiation delivery. Results: Between May 1992 and April 2019, eight patients were treated. The median age was 75 years (range: 59–87 years). All patients had distant metastatic disease at the time of treatment. We found a significant pain relief (median duration of response of 105 days) and an improvement in health-related quality of life. Conclusions: Radiotherapy had a favorable outcome and can be considered an effective analgesic treatment in case of painful MPS.
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Deaths in the emergency department: An assessment of patient's end-of-life trajectory and quality of care p. 352
Kim Sadler, Gassan Abudari, Deena Aljawi, David Snelling
DOI:10.4103/IJPC.IJPC_206_19  
Background: A considerable proportion of deaths occur in the emergency department (ED), and yet a palliative care approach is not well integrated. End-of-life patients often either receive invasive care, or their care is neglected due to being perceived as not being “acutely” ill. While a small proportion of these deaths are of an unpredictable nature, most have identifiable dying trajectories: (a) advanced cancer, (b) organ failure, (c) chronic frailty, and (d) sudden death. Aims: This study aims (1) to determine the incidence, nature and illness trajectory of deaths in the ED; (2) to examine to which extent end of life discussions took place; (3) to analyze the aggressiveness of the care; and (4) to determine if palliative care services were being consulted. Methods: This retrospective study was conducted in a large tertiary hospital and cancer center in Saudi Arabia over a 1 year period. Data collection included demographics, clinical presentation, end-of-life care, and palliative care involvement. Results: Our study included 103 patients. Cancer was the main diagnosis (45.7%). Deaths were related to advanced cancer (45.6%), followed by organ failure (29.1%), sudden death (13.6%), and chronic frailty (11.7%,). 35.9% had a documented Do-Not-Attempt-Resuscitation (DNAR) status prior to admission. 51.5% received aggressive treatments. Palliative care was consulted for 19.4% of patients, among which 50% of referrals occurred 1 day prior to death. Conclusions: End-of-life care discussions tend to occur late in the disease trajectory; a number of patients are subjected to aggressive treatments, and palliative care services remain underutilized. An early, integrated and collaborative approach is warranted to address the challenges of end of life care.
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Exploring organizational culture regarding provision and utilization of palliative care in a Nigerian context: An interpretive descriptive study p. 358
David A Agom, Jude Ominyi, Tonia C Onyeka, Chukwuma N Anyigor
DOI:10.4103/IJPC.IJPC_39_20  
Background: Palliative care (PC) continues to be underutilized in Nigeria, but there is a lack of studies that explore organizational cultural dynamics regarding PC in Nigeria. The study aimed to understand the organizational culture in order to identify organizational enablers and inhibitors of the provision and utilization of PC in a Nigerian context. Methods: Identification of the organizational culture was developed using a qualitative interpretive descriptive design. Cultural enablers and inhibitors were mapped out using semi-structured interviews with 38 participants, consisting of medical staff, patients, and their relatives. Thematic analysis was used to identify and analyze patterns within the collected data. Results: Three themes were identified: cross-departmental collaborative practice, financial support practice, and continuity of care. The findings suggest that fundamental cultural changes, such as a policy for intradepartmental referral practices, telemedicine, and a welfare support system, are typically required as remedies for the failure to use PC in Nigeria and other similar contexts. Conclusions: This study offered a new understanding that not revealing deeper shared assumptions, and a shared way of thinking that underpins the PC practice within an organization, will have a negative bearing on organizational PC outcomes.
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Is C-reactive protein/albumin ratio of advanced-stage non-small cell lung cancer patients able to predict mortality in the admission for palliative care? p. 365
Irfan Karahan, Selim Yalçin
DOI:10.4103/IJPC.IJPC_218_19  
Context: Lung cancer is frequent and mortal cancer. The predicting mortality may be helpful for cancer management. Aim: The purpose of the study was to evaluate the role of baseline C-reactive protein (CRP)/albumin ratio (CAR) in relation to hospital mortality, the setting of advanced stage non-small cell lung cancer (NSCLC). Materials and Methods: The present study is a retrospective analysis and included 77 adult patients with Stage IV NSCLC who were hospitalized for supportive care. All patients are divided into two groups as survivors and nonsurvivors. CAR on the admission was compared between groups. The correlation between CAR and the death time was investigated. The cutoff level of CAR was calculated, and patients with a high level were described in two groups. Results: For all participants, the mean age was 63.0 ± 9.9 years, and the median values of CRP and albumin levels were 15.3 mg/dl (1–51.5) and 5.7 g/dl (0.02–22.7), respectively. CAR was significantly lower in the survivor group. By receiver operation curve analysis, the cutoff levels of CRP and CAR were determined as 10.8 and 3.5, respectively. The odds ratio of mortality was 3.85 (1.49–9.94 95% confidence interval [CI], P = 0.006) for higher than cutoff levels of CAR. The odds ratio was 3.38 (1.32–8.65 95% CI, P = 0.01) for higher CRP levels. There was a significant but weak negative correlation between the time of death and both CRP and CAR in the nonsurvivor group (r = −0.46, P = 0.002; r = −0.48, P = 0.001, respectively). Conclusion: The present study showed that CAR was significantly increased in nonsurvivors. CAR may be a cheap, easy, and effective tool for predicting the death and its time of hospitalized NSCLC patients.
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PERSPECTIVES Top

Review of medicinal use of Cannabis derivatives and the societal impact of legalization p. 369
Akshat Malik, Khuzema Saifuddin Fatehi, Nandini N Menon, Pankaj Chaturvedi
DOI:10.4103/IJPC.IJPC_19_20  
Background: In recent past, there has been a rush to legalize marijuana along with a lot of support for its medicinal uses. This review intends to discuss the medicinal uses of marijuana and its adverse effects based on the current available evidence. Furthermore, it discusses the impact of legalization of marijuana. Methodology: This was a narrative review for which a thorough literature search was conducted on the Medline and PubMed databases. A detailed search of the Internet to find relevant information on webpages was also performed. Results: High-quality evidence for the majority of medical indications of marijuana remains investigational. Most of the available literature compares it against placebos. Postlegalization usage of marijuana has increased. Conclusion: It would be prudent to wait for studies which prove beyond doubt the advantages of marijuana over the existing drugs and also outweigh its side effects and addiction potential. Moreover, further legalization of marijuana should only be considered after evaluating its effects at places where it is already legally available.
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CASE REPORTS Top

Effectiveness of gabapentinoids for cancer-related rectal and vesical tenesmus: Report of four cases p. 381
Keita Tagami, Masaru Yoshizumi, Akira Inoue, Motohiro Matoba
DOI:10.4103/IJPC.IJPC_203_19  
Gabapentinoids could be assumed to relieve cancer-related rectal/vesical tenesmus based on their pharmacological mechanism. Four patients were refractory for cancer-related rectal/vesical tenesmus although their opioid doses were titrated up. Symptom intensity difference (SID) between initiation and follow-up after 24, 48, and 72 h and daily changes in the frequency of urination, defecation, opioid rescue doses, presence of sleep disruption, and dose of regular opioid medication were evaluated. The median reductions in daily discomfort measured as SID between baseline and follow-up after 24, 48, and 72 h were 87.5%, 70.0%, and 80.0%, respectively, while those in daily pain intensity were 75%, 66.7%, and 66.7%, respectively. The initiation dose of gabapentin was 200 or 400 mg/day and that of pregabalin was 75 mg/day in one patient. Gabapentinoids were effective at low doses administered over a short duration to patients with refractory cancer-related rectal/vesical tenesmus.
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Respiratory muscle function and exercise capacity in a stage 4 head and neck cancer patient receiving chemoradiotherapy p. 385
Macrina D Souza, Stephen Rajan Samuel, Santosh PV Rai, P U Prakash Saxena, Gopala Krishna Alaparthi
DOI:10.4103/IJPC.IJPC_210_19  
Background: Reduced physical and functional capacity is one of the main treatment-related side effects of chemoradiation therapy in head-and-neck cancer patients. We evaluated a case of a head-and-neck cancer patient who was undergoing chemoradiation and was assessed for various components of cardiopulmonary function that plays a vital role in the treatment prognosis. The aim of this case report was to evaluate the respiratory muscle function and exercise capacity of a head-and-neck cancer patient receiving chemoradiation therapy. Settings and Design: From among the newly diagnosed admitted to the hospital care, a 60-year-old male with supraglottic carcinoma, who was undergoing concomitant chemoradiation for 7 weeks, was evaluated for various components of cardiopulmonary function. Subjects and Methods: Outcomes assessed were diaphragm function (mobility and thickness), maximal inspiratory pressure and maximal expiratory pressure, and 6-min walk test at baseline (pre), after 3 weeks, and after 7 weeks of chemoradiation therapy. The data were quantitatively analyzed to interpret the difference of respiratory muscle function and exercise capacity. Results: Evaluation of these outcomes showed a significant decrease from the baseline till the end of the 7th week. Conclusions: Therefore, concomitant chemoradiation therapy substantially decreased the respiratory muscle function and exercise capacity in the head-and-neck cancer patient.
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Peaceful end of life in an unviable newborn: A case report Highly accessed article p. 388
Gabriela Saldana Agudelo, Angel Flaminio Guiza Romero, Lucy Marcela Vesga Gualdrón
DOI:10.4103/IJPC.IJPC_215_19  
The limit of viability is a period of uncertainty regarding the prognosis and treatment, where palliative care (PC) is important to dignify death, although, in several countries, they are not implemented as in Colombia. The peculiarities of newborns make PC differ from care at other stages of life and which are rarely accepted by professionals who consider them overwhelming. The case of a newborn of 23 weeks of gestation is exposed where nursing care is revealed to the newborn and his family according to the theory of the peaceful end of life (PEL). The theory of the PEL is useful in the development of neonatal PC, which must be differentiated, improving well-being, and family support. Furthermore, health systems must recognize emotional risks for professionals.
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LETTERS TO EDITOR Top

To be there p. 392
Sujith Kumar Mullapally
DOI:10.4103/IJPC.IJPC_193_19  
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ActiPatch: Can it be a tool to empower chronic pain patients? p. 392
Abhijit Nair, Rajendra Sahoo
DOI:10.4103/IJPC.IJPC_194_19  
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Innovative method to deal with pericatheter leak in home-based management of malignant ascites p. 394
Praneeth Suvvari, Abhijit Nair, Poornachand Anne, Basanth Kumar Rayani
DOI:10.4103/IJPC.IJPC_199_19  
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The case for palliative medicine in the emergency medicine department – The time is now! p. 395
William Wilson
DOI:10.4103/IJPC.IJPC_49_20  
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ERRATUM Top

Erratum: IAPCON 2020 abstracts-oral presentations p. 397

DOI:10.4103/0973-1075.293880  
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