Indian Journal of Palliative Care
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   2012| January-April  | Volume 18 | Issue 1  
    Online since June 18, 2012

 
 
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ORIGINAL ARTICLES
Breast self-examination: Knowledge, attitude, and practice among female dental students in Hyderabad city, India
Dolar Doshi, B Srikanth Reddy, Suhas Kulkarni, P Karunakar
January-April 2012, 18(1):68-73
DOI:10.4103/0973-1075.97476  
Aim: The aim was to assess the knowledge, attitude, and practice (KAP) regarding breast self-examination (BSE) in a cohort of Indian female dental students. Materials and Methods: A cross-sectional descriptive questionnaire study was conducted on dental students at Panineeya Institute of Dental Sciences, Hyderabad, Andhra Pradesh, India. Data were analyzed using SPSS software (version 12). Chi-square test was used for analysis of categorical variables. Correlation was analyzed using Karl Pearson's correlation coefficient. The total scores for KAP were categorized into good and poor scores based on 70% cut-off point out of the total expected score for each. P-value of <0.05 was considered statistically significant. Results: This study involved a cohort of 203 female dental students. Overall, the total mean knowledge score was 14.22 ± 8.04 with the fourth year students having the maximum mean score (19.98 ± 3.68). The mean attitude score was 26.45 ± 5.97. For the practice score, the overall mean score was 12.64 ± 5.92 with the highest mean score noted for third year 13.94 ± 5.31 students. KAP scores upon correlation revealed a significant correlation between knowledge and attitude scores only (P<0.05). Conclusion: The study highlights the need for educational programs to create awareness regarding regular breast cancer screening behavior.
  15,258 546 4
REVIEW ARTICLES
Oral health in children with leukemia
Vijay Prakash Mathur, Jatinder Kaur Dhillon, Gauri Kalra
January-April 2012, 18(1):12-18
DOI:10.4103/0973-1075.97343  
Leukemia is one of the most common malignancies affecting children in India. These children usually suffer from various oral complications, which may be due to the leukemia or due to the chemotherapeutic agents and/or radiotherapy. The complications may include some of the opportunistic infections like candidiasis, herpes simplex; hemorrhage, mucositis, taste alterations and increased incidence of dental caries etc. These complications can cause significant morbidity and mortality in the patients. The aim of this review is to summarize the various oral complications in these children and the methods of prevention and management.
  12,158 477 2
Palliative care for patients with chronic obstructive pulmonary disease: Current perspectives
Anirban Hom Choudhuri
January-April 2012, 18(1):6-11
DOI:10.4103/0973-1075.97342  
Chronic obstructive pulmonary disease (COPD) is a chronic respiratory illness with a myriad of disabling symptoms and a decline in the functional parameters that affect the quality of life. The mortality and morbidity associated with severe COPD is high and the patients are mostly housebound and in need of continuous care and support. The uncertain nature of its prognosis makes the commencement of palliative care and discussion of end-of-life issues difficult even in the advanced stage of the disease. This is often compounded by inadequate communication and counseling with patients and their relatives. The areas that may improve the quality of care include the management of dyspnea, oxygen therapy, nutritional support, antianxiety, and antidepressant treatment, and advance care planning. Hence, it is necessary to pursue a holistic care approach for palliative care services along with disease-specific medical management in all such patients to improve the quality of life in end-stage COPD.
  7,273 224 2
ORIGINAL ARTICLES
Should patients and family be involved in "Do not resuscitate" decisions? Views of oncology and palliative care doctors and nurses
Grace M Yang, Ann K Kwee, Lalit Krishna
January-April 2012, 18(1):52-58
DOI:10.4103/0973-1075.97474  
Background: "Do not resuscitate" (DNR) orders are put in place where cardiopulmonary resuscitation is inappropriate. However, it is unclear who should be involved in discussions and decisions around DNR orders. Aim: The aim was to determine the views of oncology and palliative care doctors and nurses on DNR orders. Materials and Methods: A questionnaire survey was conducted on 146 doctors and nurses in oncology and palliative care working within a tertiary specialist cancer center in Singapore. Results: Perceived care differences as a result of DNR determinations led to 50.7% of respondents reporting concerns that a DNR order would mean that the patient received a substandard level of care. On the matter of DNR discussions, majority thought that patients (78.8%) and the next of kin (78.1%) should be involved though with whom the ultimate decision lay differed. There was also a wide range of views on the most appropriate time to have a DNR discussion. Conclusions: From the viewpoint of oncology and palliative care healthcare professionals, patients should be involved at least in discussing if not in the determination of DNR orders, challenging the norm of familial determination in the Asian context. The varied responses highlight the complexity of decision making on issues relating to the end of life. Thus, it is important to take into account the innumerable bio-psychosocial, practical, and ethical factors that are involved within such deliberations.
  7,293 178 1
Reporting of "Quality of life": A systematic review and quantitative analysis of research publications in palliative care journals
Senthil P Kumar
January-April 2012, 18(1):59-67
DOI:10.4103/0973-1075.97475  
Context: Palliative care clinical practice depends upon an evidence-based decision-making process which in turn is based upon current research evidence. One of the most important goals in clinical palliative care is to improve patients' quality of life (QoL). Aim: This study aimed to perform a quantitative analysis of research publications in palliative care journals for reporting characteristics of articles on QoL. Settings and Design: This was a systematic review of palliative care journals. Materials and Methods: Twelve palliative care journals were searched for articles with "QoL" in the title of the articles published from 2006 to 2010. The reporting rates of all journals were compared. The selected articles were categorized into assessment and treatment, 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 article 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 1.95% (71/3634), and Indian Journal of Palliative Care (IJPC) had the highest reporting rate of 5.08% (3/59), followed by Palliative Medicine (PM) with 3.71% (20/538), and Palliative and Supportive Care (PSC) with 3.64% (9/247) reporting. Conclusions: The overall reporting rate for QoL articles in palliative care journals was 1.95% and there were very few randomized clinical trials and systematic reviews found. The study findings indicate further high-quality research to establish an adequate evidence base for QoL.
  6,374 265 2
Feeding tube-related complications and problems in patients receiving long-term home enteral nutrition
Vasileios Alivizatos, Vasiliki Gavala, Panagiotis Alexopoulos, Alexandros Apostolopoulos, Slaja Bajrucevic
January-April 2012, 18(1):31-33
DOI:10.4103/0973-1075.97346  
Aim: The aim of this study was to evaluate the long-term complications and problems related to gastrostomy and jejunostomy feeding tubes used for home enteral nutrition support and the effect these have on health care use. Materials and Methods: The medical records of 31 patients having gastrostomy (27 patients) and jejunostomy (4) feeding tubes inserted in our Department were retrospectively studied. All were discharged on long-term (>3 months) enteral nutrition and followed up at regular intervals by a dedicated nurse. Any problem or complication associated with tube feeding as well as the intervention, if any, that occurred, was recorded. Data were collected and analyzed. Results: All the patients were followed up for a mean of 17.5 months (4-78). The most frequent tube-related complications included inadvertent removal of the tube (broken tube, plugged tube; 45.1%), tube leakage (6.4%), dermatitis of the stoma (6.4%), and diarrhea (6.4%). There were 92 unscheduled health care contacts, with an average rate of such 2.9 contacts over the mean follow-up time of 17.5 months. Conclusion: In patients receiving long-term home enteral nutrition, feeding tube-related complications and problems are frequent and result in significant health care use. Further studies are needed to address their optimal prevention modalities and management.
  5,609 173 4
Effect of the perioperative infusion of dexmedetomidine on chronic pain after breast surgery
Gaurav Jain, Pranav Bansal, Bashir Ahmad, Dinesh K Singh, Ghanshyam Yadav
January-April 2012, 18(1):45-51
DOI:10.4103/0973-1075.97354  
Background: This prospective double-blind trial was undertaken to analyze the role of perioperatively administered dexmedetomidine on the occurrence of chronic pain in cases undergoing surgery for breast cancer. Subjects and Methods: Eighty-six cases were randomly assigned to two groups to receive either dexmedetomidine (2 μg/ml) in group D or saline in group C, in a loading dose of 0.5 ml/kg, intravenous (IV), 30 min prior to induction, followed by a continuous infusion of 0.25 ml/kg/h IV till the completion of surgery, and then the dose tapered to 0.1 ml/kg/h for up to 24 h. The standardized questionnaires that measured chronic pain (Brief Pain Inventory, BPI; Short Form McGill Pain Questionnaire, SF-MPQ2) and quality of life (Quality of Life Scale, QOLS) were gathered after 3 months of surgery as a primary outcome. Pain (verbal numerical score, VNS), sedation scores (Ramsay scoring), and analgesic requirements were also assessed for 72 h postoperatively. Results: In total, 84 cases (n=42) were analyzed for acute pain and 69 (34 in group D and 35 in group C) for chronic pain. The consumption of isoflurane/fentanyl intra-operatively and paracetamol postoperatively was significantly lower in Group D. The sedation scores were non-significant between the groups. The VNS at rest and after movement was significantly lower in group D at corresponding times (except at 60 min) throughout the assessment period. The BPI and SF-MPQ2 scores were significantly lower in group D in most of the factors. The QOLS score was significantly better in group D in all items except for relationships, friends, and learning. Conclusion: The perioperative infusion of dexmedetomidine has a pivotal role in attenuating the incidence and severity of chronic pain and improving the quality of life in cases undergoing breast cancer surgery.
  4,768 178 3
REVIEW ARTICLES
Oral health care needs in the dependant elderly in India
Arati S Panchbhai
January-April 2012, 18(1):19-26
DOI:10.4103/0973-1075.97344  
There is a sudden blast of the "65 plus" population in the last decade, and India is no exception to that. A continuing progress in the medical field has raised the longevity of life. This changing face of population offers the oral professionals to observe unique challenges to treat the rapidly growing segment of the elderly and the dependant overage population- the Homebound residents and the Nursing homebound residents. The old age of the residents is compounded with chronic medical problems they are suffering from and the medications they are taking. This cohort is characteristically different from other elderly due to their dependency to carry even the routine activities such as tooth cleaning which results in increased risk towards the oral ailments. As very few surveys are done regarding the oral health status among this section, the prevalence of oral and dental problems in them is under a cloud. "Dental care at home or at destinations of residents" is yet a novel concept in India, hence not only there is a need to reach to the residents but also to treat them in the holistic manner. The purpose of this paper is to review the existing oral health conditions in the elderly in India.
  4,433 261 2
CASE REPORTS
Custom ocular prosthesis: A palliative approach
Prachi Thakkar, JR Patel, Rajesh Sethuraman, Narendra Nirmal
January-April 2012, 18(1):78-83
DOI:10.4103/0973-1075.97480  
The goal of palliative care is the achievement of the best quality of life for patients and their families. Eyes are generally the first features of the face to be noticed. Loss of an eye is a traumatic event which has a crippling effect on the psychology of the patient. Several ocular and orbital disorders require surgical intervention that may result in ocular defects. An ocular prosthesis is fabricated to restore the structure, function, and cosmetics of the defects created by such conditions. Although an implant eye prosthesis has a superior outcome, due to economic factors it may not be a feasible option for all patients. Therefore, a custom-made ocular prosthesis is a good alternative. This case report presents a palliative treatment for a patient with an enucleated eye by fabricating a custom ocular prosthesis which improved his psychological, physical, social, functional, emotional and spiritual needs.
  4,160 161 -
REVIEW ARTICLES
Pseudomonas bronchopulmonary infections in a palliative care setting
Naveen Salins, Nandini Vallath, VV Prince
January-April 2012, 18(1):1-5
DOI:10.4103/0973-1075.97341  
Blood stream infections and pneumonia caused by Pseudomonas aeruginosa is associated with high mortality, especially in an immunocompromised host. A large section of the palliative care patient population has varied forms of compromised immunity due to advanced cancer or cancer treatment, organ failures, chronic autoimmune disorders, degenerative conditions, and acquired immunodeficiency syndrome. The lung is one of the most frequently involved organs in a variety of complications in an immunocompromised host and infection is the most common complication. P. aeruginosa is one of the most common pathogens associated with bronchopulmonary infections in an immunocompromised host. Routine radiological tests like chest X-ray may often be unyielding and an early and a prompt initiation of treatment reduces mortality and morbidity risk.
  3,650 146 -
ORIGINAL ARTICLES
Should blood cultures be performed in terminally Ill cancer patients?
Nobuhiro Asai, Masahiro Aoshima, Yoshihiro Ohkuni, Yoshihito Otsuka, Norihiro Kaneko
January-April 2012, 18(1):40-44
DOI:10.4103/0973-1075.97348  
Background: No evidence-based guidelines or protocols to treat the infection-related symptoms in cancer patients with terminal stages have been established. Materials and Methods: We retrospectively analyzed all the patients with terminal stage cancer who died between April 2009 and March 2010. The patients' background, the prevalence of infection and clinical outcomes, pathogens isolated, antibiotics used, and whether blood cultures and some of examinations were performed or not were evaluated. Results: A total of 62 (44 males and 18 females) patients were included in this study. The median age was 73 years (35-98 years). The most common cancer was that of the lung (n =59, 95.2%). A total of 32 patients were diagnosed with the following infections: Infection of respiratory tract in 27 (84.4%), of urinary tract in 4 (12.5%), and cholangitis in 1 (3.1%). Two cases (6.3%) had pneumonia complicated with urinary tract infection. Blood cultures and antibiotic therapies were performed in 28 and 30 cases, respectively. Four (14.3%) positive cultures were isolated from the blood obtained from 28 individual patients. As for clinical course, 3 (10%) of them experienced improved symptoms after antibiotic therapy. Twenty-seven (90%) patients were not confirmed as having any symptom improvement. Conclusions: Blood cultures and antibiotic therapy were limited, and might not be effective in terminally ill cancer patients with lung cancer. We suggest that administering an antibiotic therapy without performing a blood culture would be one of choices in those with respiratory tract infections if patients' life expectancy is short.
  3,457 94 2
Effectiveness of two high-dose-rate intraluminal brachytherapy schedules for symptom palliation in carcinoma esophagus: A tertiary care center experience
Rakesh Kapoor, Anshuma Bansal, Rakesh Kochhar, Pankaj Kumar, Suresh C Sharma
January-April 2012, 18(1):34-39
DOI:10.4103/0973-1075.97347  
Aim: The aim was to analyze different radiation schedules with high-dose-rate (HDR) brachytherapy in patients with unresectable carcinoma esophagus in terms of dysphagia-free survival (DyFS), local control (LC), disease-free survival (DFS), and complications. Materials and Methods: Eighty-six patients were studied under three different radiation schedules: Schedule A - radiation 35 Gy/15# followed by HDR brachytherapy 6 Gy each in two sessions; schedule B - chemoradiation 35 Gy/15# with weekly injection cisplatin 30 mg/m 2 infusion and 5-fluorouracil 325 mg/m 2 bolus followed by HDR brachytherapy 6 Gy each in two sessions; and schedule C - same chemoradiation dose followed by HDR brachytherapy three sessions of 4.68 Gy each. The median follow-up was 12.1 months. Results: Treatment compliance was good. There were no significant differences in the incidence of acute toxicities across the three schedules. No grade III toxicities were noted. At 1 month, 27 patients had dysphagia improvement, which was not different across the three schedules. At 6 months, schedule C showed a trend toward better symptom control of dysphagia (dysphagia free=55%). The 2-year DyFS reached 49.5% in schedule C. Two-year LC rates were approximating 89% in both chemoradiation schedules versus 67.6% in schedule A. The 2-year DFS was also high in chemoradiation schedules. Major complications like ulceration and tracheoesophageal fistulas were more often seen with schedule B with a higher dose per fraction of the brachytherapy schedule. Conclusion: In unresectable carcinoma esophagus, radiation-only schedules are associated with lower LC and DFS rates. Concurrent chemoradiation followed by a brachytherapy boost is feasible in suitable patients with a good Karnofsky performance score and are associated with higher DyFS, LC, and DFS with acceptable toxicities. Still there is a need for the standardization of HDR brachytherapy schedules with chemoradiation protocols.
  3,348 100 -
CASE REPORTS
Palliative sedation at home
B Barathi
January-April 2012, 18(1):74-77
DOI:10.4103/0973-1075.97477  
Patients with advanced cancer often suffer from multiple intractable physical symptoms. Though majority of the symptoms can be controlled, in some of the patients these symptoms remain refractory and uncontrolled till the end. Palliative sedation (PS) is one of the ways to relieve intractable suffering of the dying cancer patients. The main concern while using PS is its life-shortening effect. This case report describes the feasibility of administering PS in Indian home settings.
  3,151 159 1
ORIGINAL ARTICLES
A prospective survey of patient drop-outs in a palliative care setting
Kumudam Unni, Divakaran Edasseri
January-April 2012, 18(1):27-30
DOI:10.4103/0973-1075.97345  
Aim: A prospective survey of patient drop-outs was carried out in a palliative care setting to understand the background of patients in the drop-out category. This was to understand the background of patients who drop out and why they drop out. Materials and Methods: The survey was conducted on 425 patients who had registered in the clinic in 2009 and subsequently persistently dropped out. Patients were classified on the basis of age, gender, education, disease, socioeconomic class, distance from clinic to home, family size, general health on the basis of symptoms on first arrival, reasons subsequently found for missing the appointment, primary caregiver details, and social support. The data were collected, and analyzed statistically using chi-square tests and percentages. Results: Majority of patients presented in the 41- to 60-year age group had secondary level education, with a family size of four. The drop-out rate was 25.06%. There was a significant association (P = 0.026) between reasons for dropping out and social support. A P-value < 0.05 shows that these are two related attributes. Yule's coefficient of association shows a negative correlation. When social support increases, the drop-out rate decreases. Majority of patients discontinued because a similar facility became available nearer their residence. Conclusion: A number of palliative care clinics have been created in the district and this has resulted in the significant drop-out rate.
  2,917 102 1
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