| 1. |
- Adumala, Aruna, et al.
(author)
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Oral Methadone versus Morphine IR for Patients with Cervical Cancer and Neuropathic Pain : A Prospective Randomised Controlled Trial
- 2023
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In: Indian Journal of Palliative Care. - 0973-1075. ; 29:2, s. 200-206
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Journal article (peer-reviewed)abstract
- Objectives: In India, cervical cancer is the most common cancer among women and makes up for up to 29% of all registered cancer in females. Cancer-related pain is one of the major distressing symptoms for all cancer patients. Pain is characterised as somatic or neuropathic, and the total pain experience is often mixed. Conventional opioids are the backbone of analgesic treatment but are most often not sufficient in alleviating neuropathic pain, common in cervical cancer. Accumulating evidence of the advantage of methadone compared to conventional opioids, due to agonist action at both μ and δ opioid receptors, N-methyl-D-aspartate (NMDA) antagonist activity and the ability to inhibit the reuptake of monoamines has been demonstrated. We hypothesised that, with these properties’, methadone might be a good option for the treatment of neuropathic pain in patients with cervical cancer. Material and Methods: Patients with cervical cancer stages ll-lll were enrolled in this randomized controlled trial. A comparison was made between methadone versus immediate release morphine (IR morphine), with increasing doses until pain was controlled. Inclusion-period was from October 3rd to December 31st 2020, and the total patient-study period was 12 weeks. Pain intensity was assessed according to the Numeric Rating Scale (NRS) and Douleur Neuropathique (DN4). The primary objective was to determine whether methadone was clinically superior versus noninferior to morphine as an analgesic for the treatment of cancer related neuropathic pain in women with cervical cancer. Results: A total of 85 women were included; five withdrew and six died during the study period, leaving 74 patients completing the study. All participants showed a reduction in mean values of NRS and DN4 from the time of inclusion and to the end of the study period, for IR morphine and methadone 8.4–2.7 and 8.6–1.5, respectively (P < 0.001). The DN4 score mean reduction for Morphine and Methadone were 6.12–1.37 and 6.05–0, respectively (P < 0.001). Side effects were more common in the group of patients receiving IR morphine compared to the patients treated with methadone. Conclusion: We found that Methadone had a superior analgesic effect with good overall tolerability compared with morphine as a first-line strong opioid for the management of cancer-related neuropathic pain.
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| 2. |
- Jacob, Jean, et al.
(author)
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End-of-life treatments in pediatric patients at a government tertiary cancer center in India
- 2018
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In: Journal of Palliative Medicine. - : Mary Ann Liebert Inc. - 1096-6218 .- 1557-7740. ; 21:7, s. 907-912
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Journal article (peer-reviewed)abstract
- Aim: The primary objective of this study was to describe demographics and end-of-life treatments of children with cancer at a government tertiary cancer center in India. Methods: A retrospective review was undertaken of medical charts of all children younger than 18 years, who died as inpatients while undergoing treatment at the pediatric oncology department between April and September 2016. Data were collected on demographics, diagnosis, treatments, survival, palliative care involvement, and symptoms at end of life. Results: There were 44 pediatric oncology patients who died in the hospital during the study period. The most frequent diagnoses were hematological malignancies (n = 29). Tumor-specific treatment was given to 38/44 (86%) patients in the last 30 days of life, and 13 patients in the last day of life or 1 day before. Of all deaths, 23/44 (52%) occurred within 30 days of admission to the pediatric ward and 34/44 (77%) within 90 days. Of the 44 patients, 25 (57%) were referred to palliative care. The median number of days between referral and death was 14 (0-78) days. Frequent symptoms documented were bleeding (11/44), dyspnea (10/44), pain (7/44), seizures (7/44), and delirium (5/44), with each patient having one or more of these symptoms. Only patients with a palliative care referral received opioid analgesics or benzodiazepines at the end of life. Conclusions: This study highlights the demographics of suffering, death, and end-of-life care in children with cancer at a government tertiary cancer center in India.
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| 3. |
- Palat, Gayatri, et al.
(author)
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Specialized palliative care and the quality of life for hospitalized cancer patients at a low-resource hospital in India
- 2018
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In: Indian Journal of Palliative Care. - 0973-1075. ; 24:3, s. 289-299
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Journal article (peer-reviewed)abstract
- Aim: This study aimed to compare the quality of life (QoL) of cancer patients, with an Eastern Cooperative Oncology Group (ECOG) performance of 3-4, in contact with or without contact, with a specialized palliative care unit (PCU) at a low-resource governmental cancer hospital, as well as studying the impact of this contact on the QoL in their caregivers. Materials and Methods: Hospitalized patients with an ECOG performance of 3 or 4 and their primary caregiver were asked to participate in this observational study. Patients in contact with the specialized PCU and their closest caregivers formed Group A, while patients and families without this contact formed Group B. Contact was mainly one consultation. The patients were asked to complete the Palliative Care Outcome Scale (POS), and the caregivers were asked to complete the Hospital Anxiety and Depression Scale (HADS) and the distress thermometer (DT). Results: There was no statistically significant difference between the median POS values of the patient groups, neither regarding the total sum nor per any item. There were also no statistically significant differences between the median HADS values and median DT values when comparing the caregivers to Group A and B. Conclusion: Consultation with a specialized PCU at this tertiary referral center did not alter the QoL of patients with an ECOG performance of 3-4 nor did it affect the psychological well-being of their caregivers. We argue that monitoring prescribed treatment and follow-up is a necessary component of PC.
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| 4. |
- Palat, Gayatri, et al.
(author)
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The introduction and experiences of methadone for treatment of cancer pain at a low-resource governmental cancer center in india
- 2021
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In: Indian Journal of Palliative Care. - 0973-1075. ; 27:3, s. 382-404
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Journal article (peer-reviewed)abstract
- Objectives: This study aimed to describe the clinical experience of the health-care professionals (HCPs) responsible for the introduction of methadone, for the treatment of complex cancer pain, at a low-resource hospital in India in a patient-group, burdened by illiteracy, and low socio-economic status. Materials and Methods: Ten HCPs: Four medical doctors, four nurses, one pharmacist, and one hospital administrator were interviewed. The interviews are examined using a qualitative conventional content analysis. Results: The interviews showed a confidence amongst the HCPs, responsible for the safe introduction of methadone in a stressful and low-resource surrounding, to patients with cancer pain and the different aspects of methadone, as initiation, titration, and maintenance of treatment. Conclusion: Introduction of methadone for cancer pain management is safe and feasible although low resources in a challenging hospital setting and care environment.
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| 5. |
- Palat, Gayatri, et al.
(author)
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The use of Methadone in adult patients with cancer-pain at a governmental cancer centre in India
- 2021
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In: Indian Journal of Palliative Care. - 0973-1075. ; 27:1, s. 139-145
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Journal article (peer-reviewed)abstract
- Background: Management of cancer-related pain relies on the access to opioids. When regular opioids as morphine are not tolerated or are insufficient, adjuvant opioids as methadone are an affordable and effective analgesic. Aim: The aim of the project was to describe the pattern of use and clinical experiences of methadone in patients with cancer-related pain at a low-resource hospital in Hyderabad, one of few Indian cancer centers with permission to prescribe methadone. Methods: Medical records of all patients who had been prescribed methadone, September 9, 2017 and November 19, 2019 were studied retrospectively. Data on analgesic treatment and opioid side effects were analyzed. Results: A total of 93 adult cancer patients were included in the study. A majority of patients (79%) were prescribed opioid analgesic, mainly morphine, before methadone introduction. The initial daily dose of methadone ranged between 5 and 22.5 years and in the vast majority of the patients 5 mg, divided in two daily administrations. A good analgesic effect, with decreased pain, was reported in 60% of the patients. No severe side effects were reported. Conclusions: In this study, methadone as a primary opioid was used with a good analgesic effect for cancer pain in a low-resource setting. Indication for methadone was mainly uncontrolled pain with a regular opioid treatment. No severe adverse effects were reported. Further research and prospective studies are needed on methadone treatment in low-resource settings to establish the robust guidelines to support prescribing physicians.
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| 6. |
- Palat, Gayatri, et al.
(author)
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The use of methadone in pediatric cancer pain - a retrospective study from a governmental cancer center in India
- 2021
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In: Indian Journal of Palliative Care. - 0973-1075. ; 27:1, s. 133-138
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Journal article (peer-reviewed)abstract
- Background: The management of cancer-related pain relies on access to opioids. When regular opioids are not tolerated, or are insufficient, methadone is an affordable and effective analgesic. Aim: The aim of the project was to describe the pattern of use and clinical experience of methadone in pediatric cancer pain at a governmental cancer hospital in Hyderabad, one of the four Indian cancer centers with permission to prescribe methadone. Methods: This was a retrospective study of medical records of all children, under the age of 18, who had been prescribed methadone from September 9, 2017, to November 19, 2019. Data on analgesic effect, prior and concomitant analgesic treatment, opioid side effects, and the handling of methadone were analyzed. Results: A total of 11 children were identified and studied. Methadone was introduced mainly when pain was uncontrolled by regular opioids. Initial daily doses ranged from 1 to 15 mg. The duration of treatment ranged from 7 to 307, with a median of 50 days in the nine patients where treatment exceeded one single dosage. Good analgesic effect was reported in 5/9 children, unchanged from previous analgesic treatment in three patients and without any effect in one child. No severe side effects were reported. Conclusion: Low-dose methadone in the treatment of pediatric cancer pain at a low-resource cancer center was safe and well tolerated by the patients, with long treatment durations. It was safely managed, administered with single to double daily dosages, hence easy for patients and family to handle, and an affordable treatment option.
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| 7. |
- Rayala, Spandana, et al.
(author)
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Low-dose oral ketamine as a procedural analgesia in pediatric cancer patients undergoing bone marrow aspirations at a resource-limited cancer hospital in India
- 2019
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In: Indian Journal of Palliative Care. - 0973-1075. ; 25:4, s. 501-507
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Journal article (peer-reviewed)abstract
- 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.
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| 8. |
- Rayala, Spandana, et al.
(author)
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Low-Dose Oral Ketamine for Procedural Analgesia in Pediatric Cancer Patients Undergoing Lumbar Puncture at a Resource-Limited Cancer Hospital in India
- 2019
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In: Journal of Palliative Medicine. - : Mary Ann Liebert Inc. - 1096-6218 .- 1557-7740. ; 22:11, s. 1357-1363
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Journal article (peer-reviewed)abstract
- Aim: The aim of this study was to evaluate the therapeutic efficacy and safety profile of orally administered low-dose ketamine for procedural pain management in pediatric cancer patients undergoing lumbar puncture (LP) in a resource-limited hospital setting. Methods: Patients between 4 and 15 years of age, with leukemia, undergoing LP were asked to participate. The study was designed as a two-armed blinded placebo-controlled trial where 0.8 mg/kg (bodyweight) of ketamine mixed in juice was given 30 minutes before the procedure to Group K (ketamine) compared with placebo, only juice, to Group P (placebo). In addition, topical analgesia (EMLA®) was given according to established standard of care. Patients and caregivers assessed the pain using the Wong-Baker Faces Pain Rating Scale. Results: A total number of 52 patients, equally distributed between Group K and Group P, were included in the study. The placebo-controlled group had significantly higher self-reported pain score than the group receiving ketamine (p = 0.046), as well as in caregiver-assessed pain (p = 0.033). Only three incidents of mild adverse effects were reported. Conclusion: Low-dose oral ketamine can be safely administered for procedural analgesia in pediatric cancer patients undergoing LP in a resource-limited hospital setting and have significant pain-reducing effect compared with placebo.
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| 9. |
- Sinha, Sudha, et al.
(author)
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Cancer Treatment and End-of-Life Care
- 2018
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In: Journal of Palliative Medicine. - : Mary Ann Liebert Inc. - 1096-6218 .- 1557-7740. ; 21:8, s. 1100-1106
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Journal article (peer-reviewed)abstract
- AIM: To study to what extent tumor-specific treatment (chemo- or radiotherapy) was given during the last 30 days in life and to examine how many of the patients were referred to a specialized palliative care unit (PCU), at a low-resource governmental hospital in India.PATIENTS AND METHODS: Medical records of adult cancer patients deceased between April 1 and May 31 in 2016, and pediatric cancer patients deceased between April 1 and September 30 in 2016 were collected. Data regarding gender, age at admission, cancer diagnosis, tumor-specific treatment received, referral to the PCU, and date of death, were sampled.RESULTS: A total of 96 patients (52 adults and 44 pediatric patients) were included in the study. In the last 30 days of life, tumor-specific treatment was given to 39 adult patients and 38 pediatric patients. During the last week in life, 26 adult and 25 pediatric patients, respectively, received tumor-specific treatment. Twenty-six adult and 25 pediatric patients, respectively, were referred to the PCU. End-of-life (EoL) tumor therapy was given to a lesser extent among referred patients.CONCLUSIONS: Eighty percent of the patients were given tumor-specific treatment near EoL. Half of the patients had been referred for specialized palliative care (SPC).
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| 10. |
- Sinha, Sudha, et al.
(author)
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Procedural pain in lumbar punctures and the impact of preparation in pediatric cancer patients
- 2019
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In: Indian Journal of Medical and Paediatric Oncology. - : Georg Thieme Verlag KG. - 0971-5851 .- 0975-2129. ; 40:2, s. 182-192
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Journal article (peer-reviewed)abstract
- Aim: Childhood cancer patients are subjected to recurring painful medical procedures. In low- and middle-income countries (LMIC), where the majority of the world's childhood cancer patients live, pain management is often unsatisfactory due to limited resources. This study aimed to evaluate the possibility of conducting a preprocedural preparation for lumbar punctures (LPs) at a pediatric oncology unit in a LMIC and to assess whether this intervention would decrease procedural pain and fear. Methods: Patients aged 5-18 who underwent LPs between February 25, 2017, and April 12, 2017, were eligible and invited to participate. Included patients were interviewed to assess the procedural pain and fear in conjunction with the LP and the patients' understanding of why an LP was done. Closest caregivers and the medical staff were interviewed to compare the perceptions of pain. The study was conducted in two separate phases; patients included in the period of February 25-March 9 underwent LP according to routines without preparation while patients included in the period of March 10-April 12 received procedural preparation with information. Results from the interviews from the two study groups were compared. Results: Out of 79 patients who met the inclusion criteria, 76 were included and preparation was successfully implemented for 25 of them. The pain decreased significantly (P = 0.022) after preparation. The physicians underestimated the patients' pain (P < 0.0001). The understanding of the reason for the LP increased significantly among patients (P = 0.0081) and their caregivers (P < 0.0001). Conclusions: Preparation by preprocedural information, created to fit the situation at a state-run hospital in a LMIC, is feasible and efficient.
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| 11. |
- Sinha, Sudha, et al.
(author)
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Treatment adherence and abandonment in acute myeloid leukemia in pediatric patients at a low-resource cancer center in India
- 2019
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In: Indian Journal of Medical and Paediatric Oncology. - : Georg Thieme Verlag KG. - 0971-5851 .- 0975-2129. ; 40:4, s. 501-506
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Journal article (peer-reviewed)abstract
- Aim: One of the causes for lower cure rates in acute childhood leukemia in low- and middle- income countries (LMIC) compared to high-income countries is abandonment from treatment. The International Society of Pediatric Oncology (SIOP) defines abandonment as failure to begin treatment or an absence of 4 weeks during treatment. The aim of this study was to evaluate the extent of abandonment among patients diagnosed with acute myeloid leukemia (AML) at the pediatric ward at a low-resource cancer center in India. Methods: Medical records of all patients, aged 0-15 years, diagnosed with AML between January 1, 2014, and March 31, 2015, at the hospital were reviewed. Age, sex, date of diagnosis, and survival during the short follow-up time after completed treatment and information regarding abandonment were collected. SIOP definition of abandonment was used. Eight patients were diagnosed with AML at the hospital whereof 65 met the inclusion criteria of this study. Results: Of the included 65 patients, 6 died before treatment could be initiated and 3 were referred to palliative care upfront. Thus, 56 patients were offered curatively intended treatment. Of these patients, six refused treatment at this stage and another five abandoned during therapy. Altogether, 11 children abandoned treatment. Conclusion: In this study, the abandonment rate from treatment of childhood AML was 20%, which is in concordance from other studies conducted in India and other LMIC, stating that abandonment is a problem and hindrance when treating with a curative intent.
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