Jenifer Jeba

Improving malodour management in advanced cancer: a 10-year retrospective study of topical, oral and maintenance metronidazole

Objectives To explore the relative effectiveness of topical or oral metronidazole used for malodour in necrotic cancers and to propose a protocol for metronidazole usage in managing malodour. Methods A retrospective case note review of the management of malodour over 10 years comparing outcomes with topical, intermittent and maintenance oral metronidazole. Results Among 179 patients treated for malodour, the commonest primaries were cervical (45%), and head and neck cancers (40%). Outcomes were poor during the period when only topical or intermittent oral metronidazole was used. Topical use gradually decreased (97% vs 55%) and the proportion of patients receiving maintenance oral metronidazole increased (0% in 2003–2004 vs 93% in 2011). Concurrently, there was reduction in documented malodour (12.5% of visits per patient in 2003–2004 vs 1.5% in 2011, p<0.01). Conclusions Our data support formulary guidelines recommending maintenance metronidazole for recurrent malodour. Dimethyl trisulfide, a product of anaerobic necrosis causes malodour and can attract maggot-producing flies to decaying tissues. Therefore, to reduce anaerobic malodour in vulnerable settings, we propose a ladder for metronidazole titration. High-risk patients should start with 400 mg thrice daily ×7 days and continue 200 mg once daily. The SNIFFF severity (Smell-Nil, Faint, Foul or Forbidding) can guide follow-up dosage: 200 mg once daily to continue for nil or faint smell; breakthrough courses of 400 mg thrice daily ×1 week for foul smell and 2 weeks for forbidding smell, followed by 200 mg once daily. The effectiveness and limitations of maintenance metronidazole and the SNIFFF ladder should be prospectively evaluated.

A survey of the domiciliary situation of urban and rural patients of a palliative care unit in south India

Aim: A demographic study was conducted to understand the social status of the urban and rural patients attending a palliative care unit in South India. Methods: Fifty rural and 50 urban patients attending the palliative care outpatient clinic of the Christian Medical College and Hospital, South India were prospectively surveyed using a structured interview and home visits. Parameters studied included age, gender, marital status, education, occupation, religion, caste, housing, economic status, diagnosis, distance to the nearest health resource personnel and hospitals. Results: Occupation, religion, caste, housing, electricity, toilet and accessibility to health care were found to be significantly different between urban and rural patients. Seventy percent of the patients were below 60 years of age. The majority were unskilled laborers or housewives. One-third had never been to school and only 3% had been educated beyond high school. Half the patients slept on the floor, 50% of the dwellings had only one or two rooms and did not have toilets or running water. Ninety-five percent had electricity. The economic status of the patients correlated significantly with age, occupation and facilities in the house such as number of rooms, availability of beds, toilets and water supply. Women and older patients were significantly less likely to have completed school education. Women were less likely to be the main decision-makers and more likely to be the main caregivers. Conclusion: Economic status was a strong predictor of the various facilities available to the patient. A significant proportion of this population lived in deprived circumstances. A knowledge and understanding of the social conditions of the palliative care patients helps provide better-tailored care.

Radiation Pneumonitis After Conventional Radiotherapy For Breast Cancer: A Prospective Study

BACKGROUND Loco-regional radiotherapy is an important treatment modality in breast cancer and radiation pneumonitis (RP) is one of the early toxicities. AIM To study the occurrence, correlation of RP with patient and radiotherapy related factors and the effects on pulmonary function following conventional radiotherapy in breast cancer. SETTINGS AND DESIGN Prospective study, from a tertiary hospital in a developing country. MATERIALS AND METHODS Prospective analysis of clinical symptoms, pulmonary function and radiologic changes was done prior to and 12 weeks after adjuvant radiotherapy (n=46). Statistical analysis was done using SPSS version 10 software. RESULTS Radiological and clinical RP was seen in 45.65% (n=21) and 19.56% (n=9) respectively. RP was significantly higher with age >50 years (OR 4.4), chest wall irradiation with electrons, (electrons 83.3% vs cobalt60 32.4%, p=0.02) and supraclavicular field treatment with 6 MV photons (p= 0.011). There was significant relationship between Inferior Lung Distance (ILD) and RP (p=0.013). The fall in Total Lung Capacity (TLC) was significantly more in those with RP (p=0.02). CONCLUSION Clinical RP occurs in almost one-fifth of breast cancer patients treated with conventional radiotherapy. Chest wall irradiation with electrons, supraclavicular field irradiation with 6 MV photons, higher ILD and age >50 years was associated with increased RP. The pulmonary function parameter most affected was TLC. The factors associated with increased RP should be considered when adjuvant radiotherapy is planned to minimize its likelihood and intervene appropriately.

Cancer and treatment related pains in patients with cervical carcinoma

Pain in carcinoma cervix is a multidimensional experience with sensory, affective and cognitive-evaluative components. Many patients do not receive adequate pain management because of a lack of proper assessment, misconceptions regarding the pharmacologic and non pharmacologic methods of pain management and failure to distinguish between different types of pain. In our audit pelvic and nodal recurrence were the commonest cause of pain presenting as as pelvic pain, [42%], lumbosacral plexopathy [40%] and abdominal pain [34%] [n = 30]. Pain on defaecation caused by rectal obstruction, and suprapubic pain due to pyometra can be relieved by colostomy and drainage. Very little literature is available on the pain syndromes associated with carcinoma cervix. The present article is a review of cancer and treatment related pains in carcinoma cervix.

Oral and gastrointestinal symptomatic metastases as initial presentation of lung cancer

Metastasis to the tongue, duodenum or pancreas from primary lung cancer is uncommon. Primary lung cancer presenting with symptoms related to metastases at these sites, at initial presentation is extremely rare. We report a 45-year-old man with disseminated lung malignancy who presented with dyspepsia, melena, symptoms due to anaemia and swelling in the tongue. Oral examination revealed a hard submucosal anterior tongue lesion. Biopsies from the tongue lesion and the duodenal ulcer seen on upper gastrointestinal endoscopy were suggestive of metastasis from lung primary. CT revealed lung primary with disseminated metastasis to lung, liver, adrenals, kidneys, head and body of pancreas, duodenum and intra-abdominal lymph nodes. The patient was treated with palliative chemotherapy. The unusual presentation and diagnostic details are discussed.

Nebulised furosemide in the palliation of dyspnoea in cancer: a systematic review

Background Dyspnoea is experienced by approximately two-thirds of cancer patients at the end-of-life. Despite the use and assessment of various interventions, palliation of dyspnoea poses a clinical challenge. The benefit of nebulised furosemide in the palliation of dyspnoea among cancer patients remains uncertain. This systematic review was conducted to study the effectiveness of nebulised furosemide for dyspnoea in cancer, to ascertain the most appropriate dose and adverse effects, and to quantify the effects on respiratory rate, oxygenation status, observer-rated dyspnoea and opioid dose. Methods A systematic literature search of four databases (Ovid MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials database and CINAHL) was carried out to identify randomised controlled trials (RCTs) on the effectiveness of nebulised furosemide for dyspnoea in cancer patients. Results The review identified 91 articles of which two RCTs met the inclusion criteria. The included RCTs had sample sizes of 7 and 15, respectively. Neither of the RCTs showed an improvement in dyspnoea with nebulised furosemide. Meta-analysis was not possible as the RCTs measured different domains of dyspnoea using different tools. Neither RCT highlighted significant adverse effects. Other outcomes of interest were not studied in the RCTs. Conclusions Evidence from this review, which is limited by the small number of RCTs and small sample size, does not show benefit with nebulised furosemide for the alleviation of dyspnoea in cancer. Adequately powered multicentre double-blinded RCTs are warranted to further define the potential role of this drug in the palliation of dyspnoea in advanced cancer.

Neuropathic pain due to fibromatosis: Does anticancer treatment help?

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.

Joint position statement Indian association of palliative care and academy of family physicians of India – The way forward for developing community-based palliative care program throughout India: Policy, education, and service delivery considerations

Purpose: This joint position statement, by the Indian Association of Palliative Care (IAPC) and Academy of Family Physicians of India (AFPI), proposes to address gaps in palliative care provision in the country by developing a community-based palliative care model that will empower primary care physicians to provide basic palliative care. Evidence: India ranks very poorly, 67th of 80 countries in the quality of death index. Two-thirds of patients who die need palliative care and many such patients spend the last hours of life in the Intensive care unit. The Indian National Health Policy (NHP) 2017 and other international bodies endorse palliative care as an essential health-care service component. NHP 2017 also recommends development of distance and continuing education options for general practitioners to upgrade their skills to provide timely interventions and avoid unnecessary referrals. Methods: A taskforce was formed with Indian and International expertise in palliative care and family medicine to develop this paper including an open conference at the IAPC conference 2017, agreement of a formal liaison between IAPC and AFPI and wide consultation leading to the development of this position paper aimed at supporting integration, networking, and joint working between palliative care specialists and generalists. The WHO model of taking a public health approach to palliative care was used as a framework for potential developments; policy support, education and training, service development, and availability of appropriate medicines. Recommendations: This taskforce recommends the following (1) Palliative care should be integrated into all levels of care including primary care with clear referral pathways, networking between palliative care specialist centers and family medicine physicians and generalists in community settings, to support education and clinical services. (2) Implement the recommendations of NHP 2017 to develop services and training programs for upskilling of primary care doctors in public and private sector. (3) Include palliative care as a mandatory component in the undergraduate (MBBS) and postgraduate curriculum of family physicians. (4) Improve access to necessary medications in urban and rural areas. (5) Provide relevant in-service training and support for palliative care to all levels of service providers including primary care and community staff. (6) Generate public awareness about palliative care and empower the community to identify those with chronic disease and provide support for those choosing to die at home.

Unusual sites of metastases of carcinoma cervix

We present a case of metastatic squamous cell carcinoma cervix with solitary bone metastases to the right tibia and multiple cutaneous metastases. A woman aged 52 years with cancer of the cervix and lung metastases, after 21 months of initial diagnosis and palliative chemotherapy presented with pain in the right knee and multiple nodular skin lesions. Bone scintigraphy revealed intense increased tracer activity in the proximal and mid shaft of the right tibia. Biopsy from the tibial lesion confirmed metastatic squamous cell carcinoma. The presentation, diagnosis and management of this rare case are discussed.

The patient who ‘must not be told’: demographic factors associated with collusion in a retrospective study in South India

Background Patients with cancer need adequate information about diagnosis, treatment options, and possible outcomes and prognosis to make therapeutic decisions. In cultures where the family plays the dominant role in healthcare decisions, doctors are often requested to collude in withholding distressing information from the patient. This challenging situation has not been well studied and there is limited knowledge on the different factors that may contribute to collusion. Objective To study the prevalence of collusion among adult cancer patients attending a palliative care outpatient clinic and the contributing factors. Methods The healthcare records of 306 adult cancer patients who had visited the palliative care outpatient clinic at least three times with follow-up until death were retrospectively reviewed. Details on information shared and why it was not shared were retrieved from the documentation in the communication sheet in the patient chart. The prevalence, sociodemographic and clinical factors that could contribute to collusion in doctor–patient communication were studied. Results Collusion was present in 40% of cases at the time of referral to the palliative care outpatient clinic (collusion regarding diagnosis in 18%; collusion regarding prognosis in 40%). Collusion was later addressed in 35%. Collusion was significantly higher among female patients (p=0.005), manual workers (p=0.035), those not accompanied by a spouse (p=0.000) and with no oncological treatment (p=0.001). Conclusions Collusion regarding diagnosis or prognosis is common among cancer patients referred for palliative care. It was more prevalent among female patients, manual workers, patients who had not received oncological treatment, and patients not accompanied by a spouse.