Institute-based sustainable palliative care program: A unique initiative of “cancer treatment center program” Sushma Bhatnagar Indian Journal of Palliative Care 2019 25(4):485-486

The psychosocial and spiritual experiences of patients with advanced incurable illness in Bangladesh: A cross-sectional observational study Megan E Doherty, Liam Power, Rubayet Rahman, Lailatul Ferdous, Kazi M Akter, Sayeda Sharmin Quadir, Sadia Sharmin, Emily Evans, Farzana Khan Indian Journal of Palliative Care 2019 25(4):487-493 Context: The psychosocial and spiritual needs of individuals with life-limiting conditions in low- or middle-income countries have not been well described. Understanding these needs is important to providing holistic palliative care. Aim: This study aims to better understand the psychosocial and spiritual needs and supports of patients with advanced, incurable illness in Bangladesh. Subjects and Methods: Individuals with advanced incurable illnesses (advanced cancer and HIV/AIDS) from a wide geographical distribution across Bangladesh were interviewed about their health status, emotional and spiritual experiences with their illness, coping and support systems, and greatest needs and fears. Results: We interviewed 221 individuals with incurable cancer (82%) or HIV/AIDS (18%). Self-reported health status was poor or very poor for 48%, and 44% reported feeling unhappy all of the time. The majority (61%) rated their current level of unhappiness as 10/10. Spouses (50%), children (15%), and parents (13%) were the most common caregivers. Money and medical care were equally the most common needs (46%). Participants' greatest fears were for the future of their children (38%), being in pain (29%), and dying (28%). Conclusions: There is a significant burden of psychosocial and spiritual concerns among patients with advanced incurable illness in Bangladesh, with sadness being very frequent and of high intensity. Family and friends provide significant emotional and practical support to patients who are seriously ill, but very few patients access any professional support for these concerns.

Pain severity and adequacy of pain management in terminally ill patients with cancer: An experience from North Palestine Haneen Mallah, Raghda Mousa, Nisreen Bani Fadl, Samar Musmar, Somedeb Ball, Kenneth Nugent Indian Journal of Palliative Care 2019 25(4):494-500 Aim: Chronic pain is common in terminally ill patients with cancer and affects their quality of life. In this study, we wanted to evaluate pain severity and the adequacy of prescribed analgesics in terminally ill patients with cancer in North Palestine. Methods: We conducted a cross-sectional descriptive study in North Palestine on 77 terminally ill patients with cancer. Pain experience was evaluated with Brief Pain Inventory-Short Form (BPI-SF). Pain management index (PMI) was calculated to determine the adequacy of interventions. The relationships between adequacy of pain management and socioeconomic and clinical factors were analyzed by the covariance method. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS version 15.0 [SPSS Inc., Chicago, USA]). Results: Fifty-nine patients (76.6%) reported moderate-to-severe pain. According to the PMI, only 64.9% of the patients received adequate pain management. Thirty-five patients (45%) wanted additional treatment or an increase in the dose of pain medications. Although men and women reported similar pain severities, women were more likely to be inadequately treated (P = 0.027). Pain severity was significantly less in patients who received health-care services at least once in the last month before the interview, compared to those without recent access to health care (P = 0.024). Conclusion: There is substantial inadequacy in pain management in patients with cancer. The BPI-SF should be routinely used to evaluate pain severity, and analgesics should be prescribed equitably without discrimination with regard to gender and socioeconomic status of patients.

Low-dose oral ketamine as a procedural analgesia in pediatric cancer patients undergoing bone marrow aspirations at a resource-limited cancer hospital in India Spandana Rayala, Melker Kyander, Vikranth Haridass, Gayatri Palat, Axel Ström, Thomas Wiebe, Eva Brun, Mikael Segerlantz Indian Journal of Palliative Care 2019 25(4):501-507 Aim: Many pediatric cancer patients undergo repeated bone marrow aspirations (BMAs) for diagnostic and treatment evaluation purposes. Full anesthesia is the standard of care during this procedure in high-income countries. At hospitals with low resources in low/middle-income countries many children undergo these painful procedures without sufficient pain relief. This study aimed to evaluate the usefulness of low-dose oral ketamine as a procedural analgesic in a low-resource pediatric cancer care department. Materials and Methods: Pediatric patients, 4–15 years of age, who underwent BMAs between September 31 and November 30, 2018, were invited to participate. The study was designed as a placebo-controlled, single-blinded trial with three trial groups. Group K received 1.0 mg/kg of ketamine and Group KM received 1.0 mg/kg ketamine with an addition of 0.2 mg/kg midazolam, mixed in juice 30 min before procedures. Group P received placebo consisting of plain juice. All three groups also received the hospital's current standard treatment for procedural pain in BMAs. Patients and caregivers assessed the procedural pain, as did the performing doctors. For the patients, Faces Pain Scale – Revised was used and the Numeric Rating Scale-11 for caregivers and doctors. Results: A total of 87 patients were included in the study distributed with 29 in Group K, 29 in Group KM, and 29 in Group P. Seven patients were excluded, one patient denied participation and the remaining did not meet the inclusion criteria. There was no significant difference between the pain reported by the groups. A total of 69% patients in Group KM and 35% in Group K had somnolence reported as a side effect compared to 14% in Group P. Conclusion: We found no significant effects on the procedural pain in any of the treatment groups compared to placebo. There were only mild side effects. The doses of ketamine might be insufficient for this painful and stressful procedure.

Effect of perioperative pregabalin on incidence of chronic postmastectomy pain syndrome: A prospective randomized placebo-controlled pilot study Saurabh Vig, Vinod Kumar, Surayanarayana Deo, Swati Bhan, Seema Mishra, Sushma Bhatnagar Indian Journal of Palliative Care 2019 25(4):508-513 Background: Breast cancer is the most common malignancy among women. Chronic pain after breast surgeries is a well-known entity and is mainly neuropathic in nature. The primary aim of this study was to assess the effect of pregabalin given as preventive analgesic on the incidence of chronic postmastectomy pain. Methods: A randomized control trial (RCT) was performed on 80 patients. Patients were allocated into two groups. Group 1 received pregabalin (Lyrica, Pfizer) 75 mg. BD starting from the morning of surgery and continued for 1 week. Group 2 received placebo capsules at identical time intervals. Patients were followed up for 3 months postoperatively. Incidence, severity, and location of chronic pain were recorded. The primary objective was to evaluate the effect of perioperative oral pregabalin on the incidence of chronic postmastectomy pain (at 3 months postoperatively). Results: Of the 80 patients enrolled, 71 patients completed the study and were assessed for final outcomes. Incidence of chronic pain was comparable in both groups, with 16 out of 35 patients in Group 1 (44.7%) and 20 out of 36 patients in Group 2 (55.6%) reported chronic pain (P = 0.407). There was no difference between the severity of chronic pain (numeric rating scale ≥ 4) in both groups (P = 0.307). Incidence of adverse effects was comparable in both groups. Conclusion: This RCT shows that perioperative pregabalin may not have a role in the prevention of chronic pain after breast surgeries.

Symptom palliation in advanced gallbladder cancer: An institutional experience Amit Gupta, Sweety Gupta, Udit Chauhan, Utkarsh Kumar, Nidhi Sharma, Rachit Ahuja, Deepak Rajput, Manoj Gupta Indian Journal of Palliative Care 2019 25(4):514-516 Aim: Palliation of symptoms of patients with advanced carcinoma gallbladder (GB). Materials and Methods: Sixty-two newly diagnosed patients of unresectable advanced and metastatic GB cancers were enrolled, and following clinicoradiological assessment patients were considered for palliative symptom management. Results: The most common presenting symptom was pain in 57 (92%) patients. Obstructive jaundice was observed in 29 (46.7%) patients. Patients were considered for percutaneous biliary drainage/internal stenting, therapeutic ascitic tapping, and pain control. Patients with good performance status were considered for palliative chemotherapy. Conclusion: Patients with advanced carcinoma GB were managed with various palliative procedures with the aim to improve the quality of life of patients because of jaundice, loss of appetite, nausea, pain, etc. Symptoms are distressing for patients.

Nurses' strategies for conscience-based care delivery: A qualitative study Madineh Jasemi, Sima Purteimor, Roghaieh Esmaili Zabihi, Masumeh Hemmati Maslak Pak, Samereh Eghtedar Indian Journal of Palliative Care 2019 25(4):517-522 Introduction: Conscience is the core of ethical values. It helps nurses protect patients' rights and provide quality dignified care. Therefore, assessing nurses' strategies for conscience-based care may help facilitate conscience-based care delivery. Aim: This study aimed to explore nurses' strategies for conscience-based care delivery. Methods: This qualitative study was conducted in 2018 on twelve hospital nurses purposively recruited from four teaching hospitals in Urmia, Iran. Data were collected through in-depth interviews and inductively analyzed through conventional content analysis. Ethical Considerations: This study was approved by the Ethics Committee of Urmia University of Medical Sciences. All the participants were informed of the aim of the study and a written consent was obtained from each of them. Participation in the study was entirely voluntary and the participants could withdraw at any stage of the study. Results: Participants' strategies for conscience-based care delivery were grouped into two main themes, namely self-empowerment for clinical role performance and attempt to deliver care beyond the routines. Conclusion: Clinical self-empowerment and attempt to deliver care beyond the routines are nurses' main psychosocial strategies for conscience-based care delivery. Mentorship programs are recommended for the development of nurses' time management and clinical skills and thereby, empower them for conscience-based care delivery. Moreover, continuing education programs and curricular revisions are recommended to strengthen their religious beliefs.

Bleomycin in Hodgkin's lymphoma – A boon or a bane? – A retrospective study of bleomycin pulmonary toxicity in Hodgkin's lymphoma Chethana Babu K Udupa, Prakashini Koteshwar, Karthik S Udupa Indian Journal of Palliative Care 2019 25(4):523-526 Introduction: Hodgkin's lymphoma (HL) is one of the most curable malignancies with cure rates of above 85% across all stages. Bleomycin containing regimen is routinely employed in the treatment of HL. Pulmonary toxicity due to this drug is the most feared side effect in these regimens where the mortality rate is approximately 2%–3%. We have conducted this study to assess the genetic susceptibility among the Indian HL patients to bleomycin pulmonary toxicity (BPT). Materials and Methods: In a retrospective study conducted at a tertiary care hospital from South India between January 2013 and May 2019, we reviewed 100 HL patients who were treated with bleomycin-containing regimen (adriamycin, bleomycin, vinblastine, and dacarbazine or cyclophosphamide, vincristine, procarbazine, and prednisone/adriamycin, bleomycin, and vinblastine) for BPT. Results: A total of 100 patients with HL who had received bleomycin-containing regimen were analyzed, which included 23 females and 77 males. Twenty-nine patients had BPT and five deaths were attributed to the same. Radiology reports showed that 15 patients had acute BPT and eight patients had chronic changes. Four patients had rare findings of bleomycin-induced lung damage and computed tomography of the chest could not be done for two patients, whose chest X-ray showed features suggestive of BPT. Conclusion: The incidence of bleomycin induced pulmonary toxicity and mortality was significantly higher in our study compared to that of other Western studies. This could be probably due to the increased susceptibility of the Indian patients to bleomycin induced lung damage. In a highly curable cancer such as HL, it is unacceptable to have such a high life-threating toxicity. Hence, an alternative chemotherapy regimen without bleomycin is to be explored which would prevent toxicity and hence the compromise on survival.

Conventional fractionation versus quad shot in advanced head-and-neck cancers: A randomized controlled trial Akansha Choudhary, Ajay Gupta Indian Journal of Palliative Care 2019 25(4):527-534 Context: A significant number of patients with head-and-neck cancers have an incurable disease with limited life expectancy. The objective of the present study was to compare two different short courses of hypofractionated palliative radiotherapy regimens to evaluate symptoms, disease response, and acute toxicity. Materials and Methods: Previously untreated 50 patients of Stage IV B and IV C head and neck cancers were randomized to receive conventional hypofractionated palliative radiotherapy 30 Gy/10 fractions/2 weeks (control group) or Quad Shot regimen (study group) 14 Gy in 4 fractions given twice a day at least 6 h apart for 2 consecutive days. This regimen was repeated at 4 weekly intervals for a further two courses if there was no tumor progression. Results: Symptom relief was similar among the two schedules for pain (60.86 vs. 57.17), dysphagia (60.86 vs. 52.17%), and hoarseness (43.85 vs. 38.09%). Overall response (that is partial response and stable disease) was seen in majority (>70%) of the patients in both the groups. Treatment was very well tolerated with no patient experiencing more than Grade 3 toxicity in the control group and Grade 2 toxicity in the study group. Conclusions: Quad Shot regimen is an effective hypofractionated palliative radiotherapy schedule with minimal toxicity, good symptom relief, and response rate as compared to conventionally used regimen (30 Gy/10 fractions/2 weeks).

Emergency department visits by head-and-neck cancer patients Akshat Malik, Vivek Sukumar, Ameya Pai, Aseem Mishra, Sudhir Nair, Devendra Chaukar, Pankaj Chaturvedi Indian Journal of Palliative Care 2019 25(4):535-538 Aim: This study was conducted to assess the disease status of head-and-neck cancer patients visiting the emergency department (ED) and their reason for presentation. We wanted to analyze if these visits could be avoided by incorporating any changes in our clinical practice. Methods: This was a retrospective analysis of head-and-neck cancer patients attending the ED at a tertiary care cancer center in 2017. Clinical details were noted from the electronic medical records, and descriptive statistics was calculated. The analysis was performed using SPSS version 21 software. Results: Three hundred and thirty-nine head-and-neck cancer patients attended the ED. Of these, 80.2% were males and 48.1% of patients had oral cavity cancers. About 37.2% required palliative care treatment. Nearly, 47.2% of patients presented during their initial evaluation period. About 22.7% required hospital admission and only 14.7% required any sort of emergency intervention. Conclusion: Majority of visits to ED could have been avoided with better counseling of the patients and their attendants.