An evidence-base for the implementation of hospital-based palliative care programs in routine cancer practice: A systematic review.

BACKGROUND: Despite global support, there remain gaps in the integration of early palliative care into cancer care. The methods of implementation whereby evidence of benefits of palliative care is translated into practice deserve attention. AIM: To identify implementation frameworks utilised in integrated palliative care in hospital-based oncology services and to describe the associated enablers and barriers to service integration. DESIGN: Systematic review with a narrative synthesis including qualitative, mixed methods, pre-post and quasi experimental designs following the guidance by the Centre for Reviews and Dissemination (PROSPERO registration CRD42021252092). DATA SOURCES: Six databases searched in 2021: EMBASE, EMCARE, APA PsycINFO, CINAHL, Cochrane Library and Ovid MEDLINE searched in 2023. Included were qualitative or quantitative studies, in English language, involving adults >18 years, and implementing hospital-based palliative care into cancer care. Critical appraisal tools were used to assess the quality and rigour. RESULTS: Seven of the 16 studies explicitly cited the use of frameworks including those based on RE-AIM, Medical Research Council evaluation of complex interventions and WHO constructs of health service evaluation. Enablers included an existing supportive culture, clear introduction to the programme across services, adequate funding, human resources and identification of advocates. Barriers included a lack of communication with the patients, caregivers, physicians and palliative care team about programme goals, stigma around the term 'palliative', a lack of robust training, or awareness of guidelines and undefined staff roles. CONCLUSIONS: Implementation science frameworks provide a method to underpin programme development and evaluation as palliative care is integrated within the oncology setting.

Barriers and enablers of contraceptive use among adolescent girls and women under 30 years of age in Cambodia: a qualitative study.

OBJECTIVE: Unintended pregnancy and an unmet need for modern contraception remain high among adolescent girls and women in Cambodia. Qualitative descriptive research was conducted to explore the barriers to contraceptive use among young women in urban Cambodia. METHODS: Semi-structured interviews were conducted among 30 adolescent girls and women aged 16-27 years, using purposive and snowball sampling strategies until data saturation was achieved. The audio-recorded interviews were transcribed verbatim and quality-checked. Inductive thematic data analysis was conducted. The results are presented using Bronfenbrenner's theoretical social ecological model. RESULTS: The emerging major and minor themes indicate misconceptions about hormonal contraception as well as women's preference for using oral contraceptive pills for family planning after an unintended pregnancy. Women had low autonomy in choosing a contraceptive method, as their partners or husbands tended to prefer the withdrawal method. Young women faced cultural and supply chain barriers in accessing short- and long-acting reversible modern contraceptive methods at health centres. CONCLUSION: Cambodian women aged 16-27 years are a vulnerable group who have low autonomy and sexual and reproductive health literacy and also face gender inequality.

The method of loci as a mnemonic device to facilitate learning in endocrinology leads to improvement in student performance as measured by assessments.

Cognitive psychology has demonstrated that the way knowledge is structured in memory determines the ability to retain, recall, and use it to solve problems. The method of loci (MOL) is a mnemonic device that relies on spatial relationships between "loci" (e.g., locations on a familiar route or rooms in a familiar building) to arrange and recollect memorial content. In the present study, we hypothesized that the use of MOL leads to better understanding of the topic among students, which can be observed through better student performance on assessments. Students were divided into two groups: group 1 was taught insulin and diabetes mellitus through didactic lectures and a self-directed learning session, whereas group 2 was taught insulin and diabetes mellitus through didactic lectures and MOL. Memory palaces for insulin and diabetes mellitus were generated by students under supervision of the teacher and taught by students as well. A questionnaire survey and open-ended questions were given to the participants. Group 2, which underwent didactic lectures followed by a MOL interactive session, showed significantly improved performance on the assessments compared with group 1, which had been taught through didactic lectures and a self-directed learning session. Descriptive analysis showed that all students found MOL to be a helpful technique.

Combination of didactic lectures and review sessions in endocrinology leads to improvement in student performance as measured by assessments.

There can be no single best way of learning, and each teaching mode has its own merits and demerits. Didactic lectures in and of themselves are insufficient, whereas a problem-based tutorial alone can be as ineffective. This study was conducted to determine if a problem-based review after didactic lectures would lead to better student performance. To compare performance, the same student group was taught three units of endocrinology (growth hormone, thyroid hormone, and diabetes). Students were divided into the following three groups: diabetes didactic lectures only, growth hormone didactic lectures plus review, and thyroid hormone didactic lectures plus review. All three topics were covered in the didactic lectures, but only growth hormone and thyroid hormone topics were covered in the review session. At the end of the course, all students were given formative assessments in the form of multiple-choice questions. A highly significant increase (P < 0.000) in the percentage of correct responses on the questions covering growth hormone (mean: 0.838, SD: 0.158) and thyroid hormone (mean: 0.686, SD: 0.232) compared with diabetes (mean: 0.478, SD: 0.259) was observed. In conclusion, this study provides further evidence that the combination of didactic lectures and an active review session leads to an improvement in student performance.

Reasons for discontinuation of contraceptive methods among couples with different family size and educational status.

BACKGROUND: High rates of contraceptive discontinuation for reasons other than the desire for pregnancy are a public health concern because of their association with negative reproductive health outcomes. The objective of this study was to determine reasons for discontinuation of contraceptive methods among couples with different family size and educational status. METHODS: This cross-sectional study was carried out at the Obstetrics/Gynaecology Out-Patient Department of Pakistan Institute of Medical Sciences, Islamabad from April-September 2012. Patients (241) were selected by consecutive sampling after informed written consent and acquiring approval of Ethical Committee. The survey interview tool was a semi-structured questionnaire. RESULTS: Majority (68%) of women belonged to urban, and the rest were from rural areas. Mean age of these women was 29.43 +/- 5.384 year. Reasons for discontinuation of contraceptives included fear of injectable contraceptives (2.9%), contraceptive failure/pregnancy (7.46%), desire to become pregnant (63.48%), husband away at job (2.49%), health concerns/side effects (16.18%), affordability (0.83%), inconvenient to use (1.24%), acceptability (0.83%) and accessibility/lack of information (4.56%). Association of different reasons of discontinuation (chi square test) with the family size (actual number of children) was significant (p = 0.019) but was not significant with husband's or wife's educational status (p = 0.33 and 0.285 respectively). CONCLUSIONS: Keeping in mind the complex socioeconomic conditions in our country, Family planning programmers and stake holders need to identify women who strongly want to avoid a pregnancy and finding ways to help the couples successfully initiate and maintain appropriate contraceptive use.

Patient satisfaction for levonorgestrel intrauterine system and norethisterone for treatment of dysfunctional uterine bleeding.

BACKGROUND: Dysfunctional uterine bleeding (DUB) is a common problem with complex management. It can be quite harrowing for the physicians as in most instances they are unable to pinpoint the cause of abnormal bleeding even after a thorough history and physical examination. Aim was to compare patient satisfaction for Levonorgestrel intra uterine system (LNG-IUS) and Norethisterone for the treatment of Dysfunctional Uterine Bleeding (DUB). It is Descriptive case series conducted in Department Obstetrics and Gynaecology, Shifa International Hospital, Islamabad from September, 2011 to September, 2012. METHODS: One hundred and nineteen (119) female patients of reproductive age Group with DUB were selected by consecutive sampling. Informed written consent was obtained. A structural patient satisfaction questionnaire (PSQ) was used to collect information regarding age of patients, type of method used for treatment of DUB (Levonorgestrel or Norethisterone), treatment outcome in terms of patient satisfaction scale, and decrease in bleeding after 6 months. RESULTS: The mean age of the patients was 41.03 +/- 4.415 year ranging from 28-60 years. The mean parity of women in the study was 3.22 +/- 1.188 with a range of 1-7. The satisfaction level was significantly (p < 0.05) greater (90% versus 20%) in Group A (levonorgesterol-releasing intrauterine system) as compared with Group B (Norethisterone). The blood loss was significantly (p < 0.05) decreased in Group A (98%) as compared with Group B (80%). The preference of continuing the method as well as recommendation to a friend was significantly greater in Group A as compared to Group B. CONCLUSION: The levonorgesterol-releasing intrauterine system (LNG-IUS) is a better choice as compared to Norethisterone, for treatment of DUB with 90% patients highly satisfied.

Oral misoprostol for induction of labour.

OBJECTIVE: To determine the effect of oral Misoprostol in labour induction with respect to ease of administration and induction-to-delivery time interval. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Gynaecology/Obstetrics Department, Holy Family Hospital, Rawalpindi, from March to August 2006. METHODOLOGY: Women with live singleton pregnancy of > 37 weeks gestation with cephalic presentation, with an indication for induction of labour were inducted. Oral misoprostol 50 microg to 400 microg was given in divided doses at 4 hours interval upto a maximum of 4 doses, till labour was induced. Fetomaternal outcome and induction to delivering time interval in hours was noted. RESULTS: In 6 months duration, 250 mothers were recruited for the study. The main indication for labour induction was post date pregnancy (52%) and oxytocin was given in 50% cases. The majority (96%) of mothers went into labour but 4% (9) had failed induction. The majority (73%, n=176/241) of mothers delivered vaginally, 99% being delivered in the first 24 hours. Mean induction-delivery interval was 11+/-2.7 hours. Sixty five (27%) had to undergo emergency lower segment caesarean section, the major indication being fetal distress (41.5%, n=27) and meconium staining of liquor (40%, n=26). Again, a majority (95%) of the babies were delivered with good Apgar score. However, 10.8% developed meconium aspiration syndrome. Early neonatal deaths occurred in 0.8% (2) cases. Maternal hyper stimulation was seen in 1 case (0.4%). CONCLUSION: Oral misoprostol as an agent for labour induction in term pregnancy was easy to administer and the majority of women (99%) delivered in the first 24 hours.

Patient satisfaction of depot medroxyprogesterone acetate (dmpa-sc) injection as contraceptive.

OBJECTIVE: To determine Patient Satisfaction of DMPA-SC (104 mg/0.65 mL) injected subcutaneously once every 3 months. METHODS: It was a Descriptive case series with the centre in Rawalpindi (Holy Family Hospital, Gynecology and Obstetrics Unit), Pakistan. Twenty five patients were selected by purposive sampling and followed up in Rawalpindi center (Holy Family Hospital, Gynaecology and Obstetric Unit) for one year as a part of the Asian Trial These patients had successfully completed their contraception using DMPA-sc at 3 months interval. Hospital Ethical Committee Permission was obtained prior to commencement of study. Informed written consent was taken from the patients. Body weight was measured at baseline and every 3 months thereafter. Bleeding analysis was also done at 3 months interval using a 5 point scale based on patient's own records. Participant satisfaction with treatment results was evaluated using a patient satisfaction questionnaire (PSQ). It collected data regarding the respondent's experience with the study, the aspects of treatment that were liked and disliked and the likelihood of selecting that method for future contraceptive purposes. RESULTS: Out of twenty five, 15 (60%) patients had a high inclination Six (24%) patients and 9 (36%) very highly likely to use this contraceptive method in future. Eleven (44%) women replied that the probability of recommending this contraceptive method to their friends was very highly likely. CONCLUSIONS: DMPA-SC has a very high percentage score of Patient Satisfaction for the contraceptive method as well as its likelihood of selecting it in future (JPMA 60:536; 2010).

Factors influencing unmet need for contraception amongst adolescent girls and women in Cambodia.

BACKGROUND: Unmet need is the gap between women's need and their practice of using contraception. Unmet need for contraception in female adolescents and women in Cambodia is a public health concern which may lead to unintended pregnancies or abortions that can contribute to maternal morbidity and mortality. METHODS: Bronfenbrenner's Social Ecological Model was used as a theoretical framework to analyze data from the 2014 Cambodian Demographic and Health Survey to ascertain demographic and social factors potentially associated with unmet need for contraception. Bivariate and weighted multiple logistic regression analyses with adjusted odds ratios (AOR) were conducted for 4,823 Cambodian, sexually active females aged 15-29 years. RESULTS: The percentage of unmet need for contraception was 11.7%. At the individual level of the Social Ecological Model, there was an increased likelihood of unmet need in adolescent girls 15-19 years and women 20-24 years. Unmet need was decreased in currently employed women. At the microenvironment level, there was an increased likelihood of unmet need with the husband's desire for more children and when the decision for a woman's access to healthcare was made by someone else in the household. At the macroenvironment level, unmet need was decreased in women who could access a health facility near their residence to obtain medical care. There were no urban rural differences found in the Cambodian sample population. CONCLUSION: Unmet need for contraception in Cambodian females adolescents and women is associated with younger age, unemployment and low personal autonomy for accessing healthcare but not with education or wealth status. There is a need to implement culturally appropriate reproductive and sexual health literacy programs to increase access to modern contraception and to raise women's autonomy.

Using Social Ecological Theory to Identify Factors Associated With Risky Sexual Behavior in Cambodian Adolescent Girls and Young Women Aged 10 to 24 Years: A Systematic Review.

There is an increase in risky sexual behavior (RSB) in Cambodian female youth aged 10 to 24 years, which can contribute to detrimental sexual and reproductive health due to the increased risk of acquiring sexually transmitted infections, unintended pregnancies, or abortions. Bronfenbrenner's social ecological model was used to identify factors at personal, microenvironment, and macroenvironment levels potentially associated with RSB. A systematic literature review employing PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted to search 8 databases for articles published between 1994 and 2019. A risk of bias tool was applied for methodological quality of the 4 included studies. RSB is associated with multiple factors including sexual debut at young age, alcohol and substance abuse, multiple partners, living away from parents or orphan status, peer delinquency, non-use of condoms by partners, transactional sex, low education and socioeconomic status, and no access to sexual and reproductive health services. Multipronged preventive strategies operating at different levels are recommended in terms of including sex education and increasing reproductive health literacy programs at the schools and community programs for safe sex, condom use and sexual negotiation skills, and access to modern contraceptive methods.

Body weight and bleeding pattern changes in women using DMPA-SC.

OBJECTIVE: To determine the 1-year efficacy of contraception, changes in bleeding pattern and weight with the use of Depot medroxyprogesterone acetate-subcutaneous injected subcutaneously once every 3 months. STUDY DESIGN: Descriptive case-series. PLACE AND DURATION OF STUDY: Gynaecology and Obstetrics Unit, Holy Family Hospital, Rawalpindi, from March 2003 to June 2004. METHODOLOGY: Twenty five patients were selected by purposive sampling and followed up in Holy Family Hospital, Gynaecology and Obstetric Unit for a one-year period using DMPA-SC every three months. Hospital Ethical Committee permission was obtained prior to commencement of the study. Informed written consent was taken. Body weight was measured at baseline and every 3 months thereafter. Bleeding analysis in terms of blood flow and severity of bleeding was also done at 3 months interval using a 5-point scale. RESULTS: DMPA-SC showed 100% efficacy in preventing pregnancy in the 25 patients who were followed up. Mean and SD of age was 34.24+/-3.57 years. Mean and SD of weight was 63.44+/-13.81 kg.There was a mean weight gain of 0.1 kg at visit 1-3 (first 3 months) and an average weight gain of 1.036 kg at the end of the year. There was a trend towards amenorrhea with 56% of the patients included in the category of bleeding less than usual at the end of treatment period. CONCLUSION: DMPA-SC can be used in women desiring reversible contraception with unremarkable weight gain and overall bleeding pattern leading towards amenorrhea.

Presentation and complications of snakebite in a tertiary care hospital.

OBJECTIVE: To determine frequency of various modes of presentation, complications and management of snakebite. STUDY DESIGN: Descriptive case series. PLACE AND DURATION OF STUDY: Medical Unit II, Rawalpindi General Hospital, Rawalpindi, Pakistan, from September 2006 to August 2007. METHODOLOGY: All patients over 12 years of age and presenting to emergency department with history of snakebite and features of envenomation were included in the study. All these patients were given Anti-Snake Venom. Symptomatic treatment of complications was done. Semi-structured questionnaire was filled during hospital stay to analyze various characteristics of snakebite and people's attitude towards this problem. RESULTS: A total of 65 patients were enrolled in the study with 40 males (61.5%) and 25 (38.5%) females. Maximum cases 15 (23%) were seen in the month of August. Age group, that was maximally affected, was between 26-30 years (12 cases or 18.5%). Only 2 patients had neurotoxic snakebite, whereas rest of the cases were vasculo toxic in nature. Gum bleeding and cellulitis were the main presenting complaints. Mortality was 4.6% (3 cases). A great majority of patients arrived late in the hospital because of lack of awareness and use of traditional though ineffective measures. CONCLUSION: Snakebite is a major public health problem. Patients with snakebite can be managed effectively provided timely administration of anti-snake Venom is done.

Treatment induced leucopenia in hepatitis C and Role of G-CSF in its management.

OBJECTIVE: To determine the frequency and severity of leucopenia during antiviral treatment in patients with hepatitis C and the effectiveness of G-CSF (Granulocyte-Colony Stimulating Factor) in its management. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Shafi Clinic, Rawalpindi, from July 2005 to July 2007. METHODOLOGY: Patients with Polymerase Chain Reaction (PCR) positive for Hepatitis C Virus-Ribonucleic Acid (HCVRNA) by Enzyme Linked Immunosorbent Assay (ELISA) method were included in the study. Standard combination therapy was given to all i.e. interferon and ribavirin. Those with total leukocyte count (TLC)<4000/cmm were given injection Granulocyte-Colony Stimulating Factor (G-CSF) according to severity of leucopenia. Response to therapy was noted and dose titration was done accordingly. RESULTS: A total of 208 patients were enrolled in the study with 99 (48%) males and 109 (52%) females. Total leukocyte count (TLC)<4000/cmm was observed in 78 (37.5%) cases. Conventional interferon induced leucopenia was seen in 60 out of 172 (35%) cases. Pegylated interferon induced leucopenia was seen in 18 out of 36 (50%) cases. Patients on Pegylated interferon had more severe leucopenia as compared to those on conventional interferon. Granulocyte-Colony Stimulating Factor (G-CSF) administration resulted in an increase in mean total leukocyte count from 2300 to 5200/cmm. No patient required antiviral dose reduction or discontinuation. CONCLUSION: Recombinant Granulocyte-Colony Stimulating Factor (G-CSF) administration tends to manage leucopenia, which is a common adverse effect of antiviral treatment for hepatitis C.

Factors Influencing Unintended Pregnancies amongst Adolescent Girls and Young Women in Cambodia.

Background: Unintended pregnancies in Cambodian youth are a major reproductive health concern with detrimental personal and socioeconomic consequences. A social ecological model was used to identify sociodemographic factors potentially associated with unintended pregnancies, and an analysis of data from the 2014 Cambodian Demographic and Health Survey was used to determine associations. Methods: Weighted data were analysed using multiple logistic regression analyses for 3406 Cambodian sexually active single, in union or married females aged 15-29 years. Results: The prevalence of unintended pregnancy was 12.3%. Unintended pregnancy was significantly associated with younger age groups (15-24 years), multiparity, history of abortion, and current use of modern contraceptive methods. All women had an increased likelihood of unintended pregnancy when the husband alone or someone else in the household made decisions about their access to healthcare. Conclusion: The burden of unintended pregnancies is associated with young age, multiparity, history of abortions, unemployment, and low autonomy for accessing healthcare. Multi-pronged, holistic reproductive and sexual health program interventions are needed to increase literacy and accessibility to modern contraception and to raise awareness about women's health and status in Cambodia.

A systematic review of intravaginal testosterone for the treatment of vulvovaginal atrophy.

OBJECTIVES: Intravaginal testosterone has emerged as a potential treatment for vulvovaginal atrophy (VVA) in women, in general, and women taking an aromatase inhibitor (AI). A systematic review of the literature was undertaken to determine whether available clinical trial data support efficacy and safety of intravaginal testosterone for the treatment of VVA. METHODS: Scopus, MEDLINE, EMBASE, and the Cochrane Library databases were systematically searched on July 26, 2017, for human studies published in English of clinical trials of intravaginal testosterone. RESULTS: Six separate clinical trials were identified that ranged in size from 10 to 80 participants, with either single dose, or durations of 4 to 12 weeks. Only one study incorporated a double-blind design. Three studies were of women taking an AI.Taken together, the studies suggest that intravaginal testosterone may lower vaginal pH, increase the proportion of vaginal lactobacilli, and possibly improve the vaginal maturation index. The lack of a placebo treatment in four studies, and failure to adjust for baseline differences, resulted in uncertainty of the effect on sexual function. Safety remains uncertain because of the small number of women exposed, short study durations, and inconsistent and incomplete outcome reporting for sex steroid levels. CONCLUSION: Adequately powered double-blind, placebo-controlled clinical trials of intravaginal testosterone therapy are needed to establish both efficacy and safety.

Vasomotor symptoms in women in Asia appear comparable with women in Western countries: a systematic review.

OBJECTIVE: There is a belief that menopausal symptoms, particularly vasomotor symptoms (VMS), are a Western phenomena and less likely to be experienced in women in Asian countries. This systematic review of the literature was undertaken to evaluate the prevalence of VMS in Asian countries. METHODS: MEDLINE, EMBASE, PsycINFO, CINAHL, SCOPUS, and Google scholar were searched systematically for relevant population-based prevalence studies published between 1981 and 2016. The included studies were assessed for risk of bias using a risk-of-bias tool developed explicitly for the systematic review of prevalence studies. RESULTS: A total of 43 articles, comprising 31,945 women, were included. In South Asian and Middle Eastern countries, the prevalence of VMS in perimenopausal and postmenopausal women reported by studies that used random sampling and validated questionnaires was comparable with that reported for Western countries. The other Asian studies that used convenience-sampling procedures, irrespective of questionnaire validation, provided more disparate results. The reasons for the variation in reporting of prevalences of VMS in the included studies are likely to be a function of methodological issues, rather than ethnic, cultural, or socioeconomic differences. Most of the included studies had a medium-to-high risk of bias. CONCLUSIONS: The reported prevalences of VMS in Asia, particularly in South Asian and Middle Eastern countries, are consistent across studies that used random sampling and validated questionnaires, and are comparable with those in Western countries. Data from nationally representative studies that employ validated instruments are still needed in several Asian countries to ascertain the true prevalence of VMS.