Nationwide Study to Assess the Psychosocial, Financial, and Professional Impact of COVID-19 Pandemic on Radiation Therapy Technologists.

PURPOSE: Radiation therapy technologists (RTTs), being the frontline health care workers, are vulnerable to COVID-19 disease and subsequent detrimental consequences of the pandemic. Hence, the study was undertaken for the comprehensive assessment of adverse effects of COVID-19 pandemic on RTTs. MATERIALS AND METHODS: This cross-sectional, survey-based study was carried out among RTTs working in various cancer centers across India. Assessment was carried out by using a questionnaire comprising the demographic profile and a structured instrument to quantify psychological, social, financial, and professional impact of COVID-19 pandemic. Responses were collected between February 1, 2021, and April 31, 2021. RESULTS: Of 302 responders, more than two third of the RTTs were concerned for getting COVID-19 disease either outside the hospital (n = 210, 69.5%) or from patients or attendants (n = 220, 72.8%). More than one third of RTTs were very much concerned for increased financial burden of COVID-19 pandemic (n = 94, 34.1%), and one third (n = 92, 30.5%) were very much concerned for newly imposed restrictions. RTTs working in a private setup (P = .000), living in a tier 1 city (P = .028), and lacking the coverage of COVID-19 disease in health insurance (P = .010) faced a significantly higher financial burden. RTTs living in tier 1 city (P = .023) and those who were in profession for > 5 years (P = .013) had significantly higher concern for ensuring proper sanitization of the professional environment. More than half (n = 171, 56.6%) were interested in taking COVID-19 vaccine. CONCLUSION: COVID-19 pandemic adversely affected psychosocial, financial, and professional well-being of RTTs even after subsidizing the initial wave, and a timely intervention is warranted for their well-being and to sustain oncologic facilities.

Diabetic ketoacidosis with severe hypokalemia and persistent hypernatremia in an adolescent girl with COVID-19 infection.

We report a case of new-onset type 1 diabetes in a girl presenting with severe diabetic ketoacidosis, complicated by profound hypokalemia and hypernatremia. We describe the clinical course, management challenges, and the potential role of the concomitant COVID-19 infection in the complexity of this case.

Prevalence of dyspnoea and usage of opioids in managing dyspnoea in advanced cancer patients: a longitudinal observational multi-centre study from India.

Context: Breathlessness is one of the devastating symptoms experienced by patients with advanced cancer and can be very challenging to manage. Objectives: To find the point prevalence of dyspnoea in advanced cancer patients presenting to palliative care out-patient clinics, and the usage of opioids in palliation of dyspnoea. Methods: We conducted a prospective observational study among all consecutive patients presenting to the outpatient clinics of six cancer centres in India from different parts of the country. In addition to routinely documented demographic and clinical data from patient charts, study investigators collected information on the Edmonton Symptom Assessment System, Cancer Dyspnoea Scale (CDS) and European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Core 15 Palliative Care. We calculated the prevalence of dyspnoea and documented the usage of opioids in palliation of dyspnoea using tests of differences across patient characteristics. Results: Between May 1, 2019, and April 30, 2020, 5,541 patients were screened for eligibility, and 288 were enrolled (48 patients from each of the six centres). We analysed the data of 288 patients, of which 36.4% had dyspnoea, with 28.5% with moderate to a severe degree (>4/10). Tiredness and loss of appetite were found to have associations with dyspnoea which were statistically significant on multivariate analysis. Standard palliative care management and routine usage of opioids preceded improvement in dyspnoea scores, CDS scores and quality of life scores throughout 7 days. Conclusion: Dyspnoea is a common symptom in advanced cancer patients, presenting to outpatient clinics, and routine documentation of dyspnoea with appropriate usage of opioids helps in mitigation. Key message: The article suggests that breathlessness is a common problem in advanced cancer patients and opioid prescription preceded symptom improvements in such patients.

Safe and effective use of a hybrid closed-loop system from diagnosis in children under 18 months with type 1 diabetes.

The management of type 1 diabetes in infancy presents significant challenges. Hybrid closed loop systems have been shown to be effective in a research setting and are now available for clinical use. There are relatively little reported data regarding their safety and efficacy in a real world clinical setting. We report two cases of very young children diagnosed with type 1 diabetes at ages 18 (Case 1) and 7 months (Case 2), who were commenced on hybrid closed-loop insulin delivery using the CamAPS FX™ system from diagnosis. At diagnosis, total daily dose (TDD) was 6 and 3.3 units for Case 1 and 2, respectively. Closed loop was started during the inpatient stay and weekly follow up was provided via video call on discharge. Seven months from diagnosis, Case 1 has an HbA1C of 49 mmol/mol, 61% time in range (TIR, 3.9-10 mmol/L) with 2% time in hypoglycemia (<3.9 mmol/L) with no incidents of very low blood glucose (BG; <3 mmol/L, 54 mg/dL) over 6 months. Given the extremely small TDD of insulin in Case 2, we elected to use diluted insulin (insulin aspart injection, NovoLog, Novo Nordisk Inc., Plainsboro, NJ, Diluting Medium for NovoLog®). Six months from diagnosis, the estimated HbA1c is 50 mmol/mol, TIR 76% with 1% hypoglycemia and no incidents of very low BG (<3 mmol/L, 54 mg/dL) over 6 months. We conclude that the use hybrid closed-loop can be safe and effective from diagnosis in children under 2 years of age with type 1 diabetes.

Organising Home-based Palliative Care Services: A Quality Improvement project at the Homi Bhabha Cancer Hospital and Research Centre, Vishakhapatnam.

OBJECTIVES: The key component of a comprehensive palliative care (PC) unit is provision of a regular and sustainable home-based PC (HBPC) service. This quality improvement project aimed to plan, organise and sustain a regular HBPC service in a government cancer centre in Southeast India. The aim was to regularise and increase the number of home care visits among the patients identified for HBPC services through sustainable interventions. MATERIALS AND METHODS: The A3 methodology with its team-based, structured problem-solving approach was the tool used. The situational process map at baseline was followed up with a sequential cause and effect analysis and team discussions to create sustainable and reliable interventions. These included creating the electronic data system for data collection in PC, allocation of resources and implementation of systems to coordinate HBPC services. The roles and ownership to maintain improvement were established by designation and this requirement has been included in the job description to ensure reliability and sustainability. RESULTS: The regularisation of home care services with a consistent increase in the number of home visits from 2/week to over 6/week helped achieve the Specific, Measurable, Achievable, Relevant and Time bound goal. Better documentation, coordination and accountability were also positive outcomes. Working with different departments and teams along the project helped build trust and understanding along with a sound base for collaborative research. CONCLUSION: The A3 way of problem solving through dialogue and consensus helped to organise HBPC services and this methodology can be extended to other areas in future.

The Palliative Care-Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative.

Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care-Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care-Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.

Approaches and Best Practices for Managing Cancer Pain within the Constraints of the COVID-19 Pandemic in India.

Novel corona virus disease 2019 (COVID-19) is an ongoing pandemic that has impacted the entire world. The Indian government has responded strongly and very stringently to the crisis, through a nationwide lockdown. The health-care (HC) systems in the country are striving hard to maintain equitable care across illness spectra, while responding the emergencies imposed by the COVID-19 crisis. Under these circumstances, guidelines for managing several diseases including that for cancer care have been modified. As modified guidelines for cancer care have their focus on disease management, cancer pain management and maintaining continuity of care for patients with advanced progressive disease have taken a backseat in the available cancer care guidelines. This article describes the challenges, approaches to solutions with evidence-based practices that can be utilized to ensure competent management of cancer pain during the COVID-19 pandemic in India. It provides an overview of adapting to telehealth consultations for identification, evaluation and management of cancer pain, safe and rational use of analgesics and adjuvant drugs, recognizing and responding to holistic care needs and addressing the total pain, ensuring continuity of pain management, and strategies when complying with narcotic drug regulations, while ensuring safety of patients and HC providers.

Palliative care and end-of-life measure outcomes: Experience of a tertiary care institute from South India.

INTRODUCTION: Desisting from disease directed treatment in the past weeks of life is a quality criterion in oncology service. Patients with advanced cancer have unrealistic expectations from chemotherapy and hold on to it as a great source of hope. Many oncologists continue futile and unnecessary treatments, instead of conveying to the patients the lack of benefit, resulting in delayed referral for palliative care (PC). MATERIALS AND METHODS: This is a retrospective analysis of case records from June 2014 to December 2015. The primary objective was to study, how far back in time terminally ill cancer patients received definitive cancer directed therapy (DCDT). Apart from patient demographics, the diagnosis, stage, and details of DCDT, and death were captured. PC referral data were recorded. DCDT to death was taken as treatment-free interval (TFI). Analysis was performed using IBM SPSS Statistics for Windows, Version 20. RESULTS: A total of 292 case records were evaluated. Seventy-three had inadequate treatment details. Hence, 219 records were analyzed. PC referral was done in 78.5% of patients. Only best supportive care (BSC) without any DCDT was given in 27 patients. The most common reason for BSC was a poor performance status in 92.5%. The median time from PC referral till death was 43.5 days (range: 1-518 days). Chemotherapy was the most common DCDT in 52.9% of patients. The median time from DCDT and death was 49 days (range: 0-359 days). Cervical and ovarian cancers patients had the longest TFI; shortest in unknown primary. Most patients died at home (70.4%). Patients receiving PC preferred home or hospice as place of death. Of the 80 patients given hospice care, 39 (36.5%) died in the hospice. CONCLUSION: While DCDT needs to be started at the right time, it should also be discontinued when futile. Early involvement of the PC team, even while patients are on DCDT makes the transition smoother and more meaningful.

Challenges of Using Methadone in the Indian Pain and Palliative Care Practice.

Palliative care providers across India lobbied to gain access to methadone for pain relief and this has finally been achieved. Palliative care activists will count on the numerous strengths for introducing methadone in India, including the various national and state government initiatives that have been introduced recognizing the importance of palliative care as a specialty in addition to improving opioid accessibility and training. Adding to the support are the Non-Governmental Organizations (NGOs), the medical fraternity and the international interactive and innovative programs such as the Project Extension for Community Health Outcome. As compelling as the need for methadone is, many challenges await. This article outlines the challenges of procuring methadone and also discusses the challenges specific to methadone. Balancing the availability and diversion in a setting of opioid phobia, implementing the amended laws to improve availability and accessibility in a country with diverse health-care practices are the major challenges in implementing methadone for relief of pain. The unique pharmacology of the drug requires meticulous patient selection, vigilant monitoring, and excellent communication and collaboration with a multidisciplinary team and caregivers. The psychological acceptance of the patient, the professional training of the team and the place where care is provided are also challenges which need to be overcome. These challenges could well be the catalyst for a more diligent and vigilant approach to opioid prescribing practices. Start low, go slow could well be the way forward with caregiver education to prescribe methadone safely in the Indian palliative care setting.

Hospice-Where Peace and Turmoil Coexist.

It is often said that a hospice is much more than just a place providing supportive care for the terminally ill. This narrative describes Neha, a young mother who found her solace in the hospice and spent her last days there by choice. It reinforces the fact that the hospice is truly a philosophy of care where powerful and contrasting emotions do coexist.

Processing and surface modification of polymer nanofibers for biological scaffolds: a review.

Polymeric fibrous constructs possess high surface area-to-volume ratios when compared with solid substrates and are quite commonly used as tissue engineering and cell growth scaffolds. An overview of important design and material considerations for fibrous scaffolds as well as an outline of both established and emerging solution- and melt-based fabrication techniques is provided. Innovative post-process surface modification avenues using "click" chemistry with both single and dual active cues as well as gradient cues, which maintain the fibrous structure are described. By combining process parameters with post-process surface modification, researchers have been able to selectively tune cellular response after seeding and culturing on fibrous constructs.

A Lesson in Spirituality.

Understanding spirituality during palliative care training is not easy. It slowly unravels itself when one starts caring for patients and meeting their caregivers. One such experience in the hospice has been described in this narrative. A person with advanced incurable cancer is initially in severe distress. Over time, he slowly comes to terms with the situation and eventually, a question from his illiterate wife--an insightful question about any last wish--brings out his desire to have certain religious rituals that were alien to his own religion. After his death, the family members concur with his last wish and also indulge in some religious rituals of their own choice. This story reaffirms that the essence of spirituality is the coexistence of harmony and humanity.