Feasibility of the ERAS (Enhanced Recovery After Surgery) Protocol in Patients Undergoing Gastrointestinal Cancer Surgeries in a Tertiary Care Hospital-A Prospective Interventional Study.

Enhanced Recovery After Surgery (ERAS) protocols have emerged as a promising approach to optimize perioperative care and improve outcomes in various surgical specialties. Despite feasibility studies on ERAS in various surgeries, there remains a paucity of research focusing on gastrointestinal cancer surgeries in the Indian context. The primary objective is to evaluate the compliance rate of the ERAS protocol and secondary objectives include the compliance rate of individual components of the protocol, the complications, the length of hospital stay, and the challenges faced during implementation in patients undergoing gastrointestinal cancer surgeries in our tertiary care cancer center. In this prospective interventional study (CTRI/2022/04/041657; registered on 05/04/2022), we evaluated 50 patients aged 18 to 70 years undergoing surgery for gastrointestinal malignancies and implemented a refined ERAS protocol tailored to our institutional resources and conditions based on standard ERAS society recommendations for gastrointestinal surgeries and specific recommendations for colorectal, pancreatic, and esophageal surgeries.Our study's mean overall compliance rate with the ERAS protocol was 88.54%. We achieved a compliance rate of 91.98%, 81.66%, and 92.00% for pre-operative, intraoperative, and post-operative components respectively. Fourteen (28%) patients experienced complications during the study. The median length of stay was 6.5 days (5.25-8). Challenges were encountered during the preoperative, intraoperative, and postoperative phases. The study highlighted the feasibility of implementing the ERAS protocol in a cancer institute, but specific challenges need to be addressed for its optimal success in gastrointestinal cancer surgeries. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-024-01897-y.

Marching Ahead through the Pandemic: Continuing Anesthesia Services in COVID Era-Our Experience from a Tertiary Care Cancer Centre.

Swati BhanIntroduction This paper aims to provide an overview of the administrative and clinical preparations done in a tertiary care cancer hospital in continuing operation theatre (OT) services through the COVID pandemic. Methods Retrospective data collection, data for the past 1.5 years (COVID period) March 2020 to August 2021 were compared to surgical output for a similar duration of time before the COVID era (September 2018-February 2020). Results A total of 1,022 surgeries were done under anesthesia in the COVID period as against 1,710 surgeries done in a similar time frame in the pre-COVID era. Overall, we saw a 40%drop in the total number of cases. Thorax, abdominal, and miscellaneous surgeries (soft tissue sarcomas, urology, and gyneconcology) saw a maximum fall in numbers; however, head and neck cases saw an increase in numbers during the pandemic. Surgical morbidity and mortality were similar in the COVID and pre-COVID era. No cases of severe COVID infection were reported among the healthcare staff working in OT. Discussion We could successfully continue our anesthesia services with minimal risk to healthcare staff throughout the pandemic by adopting major guidelines in a pragmatic and practical approach with minor changes to suit our setup.

Quality of life and symptom burden in hematological cancer patients receiving hematopoietic stem cell transplantation: an observational study at Regional Cancer Centre, India.

PURPOSE: Hematopoietic stem cell transplant (HSCT) is an intense form of treatment, resulting in major symptom burden but can prove curative. The quality of life (QOL) is a major endpoint for these patients as the survival rate in them has improved over time. The aim of the study is to assess the QOL and symptom burden of hematological malignancy patients at admission to hospital for HSCT, at 1 month and at 3 months following HSCT. METHODS: This prospective observational study was done on hematological malignancy patients who were admitted for HSCT in a regional cancer center. The study subjects were assessed by the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale (FACT-BMT Scale), Edmonton Symptom Assessment Scale-revised (r-ESAS), and Depression, Anxiety and Stress Scale-21 Items (DASS-21) at the time of hospital admission for transplantation, on day 30 (~ 1 month) and day100 (~ 3 months) of transplantation. RESULTS: A total of 68 patients were included in this study. FACT-BMT scores have decreased from baseline (F0) to the first follow-up (F1) and then increased in the third follow-up (F2). The maximum r-ESAS mean score was for tiredness among all other symptoms at F0 as well as at F1 and at F2. The DASS 21 scores for depression, anxiety, and stress were maximum during F1 and minimum during F2. CONCLUSION: Symptom burden is maximum during the first month of BMT, which improves later and QOL becomes improved with time.

Can cell-free DNA (cfDNA) in pleural lavage serve as a predictive and prognostic biomarker among surgically treated Stage I-III a nonsmall cell lung cancer (NSCLC)? A pilot study.

BACKGROUND AND OBJECTIVES: The role of cell-free DNA (cfDNA) in operable nonsmall cell lung cancer (NSCLC) is unclear. This study was aimed to evaluate the feasibility for identification of cfDNA in pleural lavage fluid and its correlation with plasma in resectable NSCLCs. METHODS: Consecutively resected NSCLCs were evaluated for cfDNA levels in preoperative plasma (PLS1), intraoperative pleural-lavage (PLV) and postoperative (at 1 month) plasma sample (PLS2). CfDNA was isolated and measured quantitatively by qPCR in a TaqMan probe-detection approach using the human ß-actin gene as the amplifying target. RESULTS: All (n = 34) except one were negative for malignant cells in PLV cytology. CfDNA could be isolated from all the three samples (PLS1, PLV, and PLS2) successfully in each patient. The median cfDNA levels in PLS1, PLV and PLS2 were 118 ng/mL (IQR 61-158), 167 ng/mL (IQR 59.9-179.9) and 103 ng/mL (IQR 66.5-125.4) respectively. The median follow-up was 34.1 months (IQR 25.2-41.6). A significant overall-survival (OS) and disease-free survival (DFS) were recorded for patients with cfDNA level cut-offs at 125, 170, and 100 ng/mL, respectively for PLS1, PLV, and PLS2. Patients with raised cfDNA in PLS1 (>125 ng/mL) and PLV (>170 ng/mL) had significantly poorer 2-year OS, p = 0.005 and p = 0.012, respectively. The hazards (OS) were also higher for those with raised cfDNA in PLV (HR = 5.779, 95% CI = 1.162-28.745, p = 0.032). PLV (>170 ng/mL) had increased pleural recurrences (p = 0.021) and correlated significantly with poorer DFS at 2-years (p = 0.001) with increased hazards (HR = 9.767, 95% CI = 2.098-45.451, p = 0.004). Multivariable analysis suggested higher cfDNA in PLV as a poor prognostic factor for both OS and DFS. CONCLUSIONS: Among patients with operable NSCLC, it is feasible to identify cfDNA in pleural lavage and correlate PLV cfDNA with pleural recurrences and outcomes.

Comparison of lung aeration loss in open abdominal oncologic surgeries after ventilation with electrical impedance tomography-guided PEEP versus conventional PEEP: a pilot feasibility study.

BACKGROUND: Existing literature lacks high-quality evidence regarding the ideal intraoperative positive end-expiratory pressure (PEEP) to minimize postoperative pulmonary complications (PPCs). We hypothesized that applying individualized PEEP derived from electrical impedance tomography would reduce the severity of postoperative lung aeration loss, deterioration in oxygenation, and PPC incidence. METHODS: A pilot feasibility study was conducted on 36 patients who underwent open abdominal oncologic surgery. The patients were randomized to receive individualized PEEP or conventional PEEP at 4 cmH2O. The primary outcome was the impact of individualized PEEP on changes in the modified lung ultrasound score (MLUS) derived from preoperative and postoperative lung ultrasonography. A higher MLUS indicated greater lung aeration loss. The secondary outcomes were the PaO2/FiO2 ratio and PPC incidence. RESULTS: A significant increase in the postoperative MLUS (12.0 ± 3.6 vs 7.9 ± 2.1, P < 0.001) and a significant difference between the postoperative and preoperative MLUS values (7.0 ± 3.3 vs 3.0 ± 1.6, P < 0.001) were found in the conventional PEEP group, indicating increased lung aeration loss. In the conventional PEEP group, the intraoperative PaO2/FiO2 ratios were significantly lower but not the postoperative ratios. The PPC incidence was not significantly different between the groups. Post-hoc analysis showed the increase in lung aeration loss and deterioration of intraoperative oxygenation correlated with the deviation from the individualized PEEP. CONCLUSIONS: Individualized PEEP appears to protect against lung aeration loss and intraoperative oxygenation deterioration. The advantage was greater in patients whose individualized PEEP deviated more from the conventional PEEP.

A comparison of two techniques of postoperative analgesia: lignocaine-fentanyl intravenous infusion and ropivacaine-fentanyl epidural infusion in patients undergoing cytoreductive cancer surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)-prospective randomized control study.

BACKGROUND: Extensive surgical dissection, hemodynamic alterations associated with cytoreductive surgery (CRS), and hyperthermic intraperitoneal chemotherapy (HIPEC) make pain management challenging. We hypothesized that infusions of intravenous lignocaine and fentanyl provide comparable analgesia to epidural ropivacaine and fentanyl in these patients. METHODS: Fifty patients scheduled to undergo CRS and HIPEC were enrolled in the study. The patients in group IV (Intravenous) received a bolus dose of 1.5 mg/kg lignocaine over 15 min, starting approximately 15 min before the surgical incision and fentanyl 0.5 mcg/kg, about 2 min before the surgical incision, following which patient received lignocaine infusion at 1 mg/kg/hr and fentanyl infusion at 0.5 mcg/kg/hr intraoperatively. Patients in group EPI (Epidural) received 6 mL of Ropivacaine 0.2% and fentanyl (2mcg/mL) approximately 15 min before surgical incision, followed by continuous infusion at the rate of 5 mL/hr. The procedure for induction and maintenance of anesthesia was standardized for both groups. In the postoperative period, the infusion of analgesics was reduced to half the intraoperative rates and continued for 24 h. RESULTS: Demographic profile and clinical parameters were comparable between both groups (p > 0.05). There was no difference between the number of fentanyl doses given in the IV group [Langenbecks Arch Chir 373(3):189-196, 4, IQR (2-11)] and the EPI group [Reg Anesth Pain Med 35(4):370-376, 12, IQR (5-21)] in the postoperative period (p = 0.229). The need for intraoperative rescue analgesia was comparable among the groups (p = 0.882). CONCLUSION: The two techniques, epidural (ropivacaine and fentanyl) and IV (lignocaine and fentanyl) infusions, provide comparable analgesia in patients undergoing CRS and HIPEC. TRIAL REGISTRATION NUMBER: CTRI/2020/08/027052 dated 09/08/2020.

Re-operative surgery for differentiated thyroid cancer: A single institutional experience of 182 cases.

INTRODUCTION: Re-operative thyroid surgery (RTS) is performed in patients of differentiated thyroid cancer (DTC) with residual or recurrent disease. However, there is a paucity of literature discussing experience and technique of RTS. This study aims to address this gap by providing a comprehensive review of RTS for DTC, utilizing experiences from a dedicated complex thyroid surgical oncology program at the apex hospital in a developing country. METHODS: A retrospective analysis was conducted using data from the Department of Surgical Oncology's thyroid cancer database. The study period spanned from 2006 to 2022. Clinical presentation, prior surgical history, operative details of RTS, and post-operative outcomes were assessed. Descriptive analysis was performed. RESULTS: During the study period, a total of 182 patients underwent re-operative thyroid surgery (RTS). The primary surgeries performed prior to RTS included near-total or total thyroidectomy in most cases (69.2%), and approximately half of the patients (48.4%) had prior neck node interventions. The RTS procedures consisted of completion total thyroidectomy in 30.8% of cases and surgery for thyroid bed recurrence in 9.9% of cases, while central node dissection was performed in 46.2% of patients and unilateral or bilateral template neck dissection was performed in 41.8% of cases. Extended resections were required in 9.3% of patients. Post-operative complications included permanent hypoparathyroidism (2.7%) and unilateral recurrent laryngeal nerve palsy (1.6%). CONCLUSIONS: RTS is a complex procedure with high rates of post-operative morbidity reported in literature. Optimal outcomes require a multidisciplinary approach, thorough assessment, and skilled surgeons.

Comparison of the Efficacy of UltrasoundGuided Serratus Anterior Plane Block Versus Erector Spinae Plane Block for Postoperative Analgesia After Modified Radical Mastectomy: A Randomised Controlled Trial.

OBJECTIVE: Several interfascial interfacial plane blocks have been described in patients undergoing modified radical mastectomy. We conducted this study to evaluate the analgesic efficacy of ultrasound-guided serratus anterior plane block and erector spinae plane block in patients undergoing modified radical mastectomy. METHODS: Totally, 80 female patients (18-70 years) undergoing modified radical mastectomy were randomised into 2 groups of 40 each and were given ultrasound-guided serratus anterior plane block or erector spinae plane block with 0.4 mL kg-1 of 0.375% ropivacaine in this prospective double-blind control trial. The groups were compared for the time to request of first dose of rescue analgesic, requirement of rescue analgesics, and patient satisfaction score. RESULTS: The time to request of the first rescue analgesia was comparable in both groups (P =.056). Postoperative pain scores at rest at 0 minute were significantly lower in serratus anterior plane group as compared to erector spinae plane group (P =.03). The intraoperative fentanyl requirement and postoperative diclofenac and tramadol requirements were comparable between the 2 groups. The number of patients requiring rescue doses of fentanyl intraoperatively and rescue analgesics postoperatively was similar in both groups. The mean patient satisfaction score was also comparable in both groups. CONCLUSION: Ultrasound-guided serratus anterior plane block and erector spinae plane block have comparable postoperative analgesic efficacy after modified radical mastectomy.

Perioperative anaesthetic management in cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC): a retrospective analysis in a single tertiary care cancer centre.

Objectives: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with increased morbidity and mortality. We retrospectively analysed the perioperative anesthetic management in patients undergoing HIPEC surgery. Methods: After ethics approval, we reviewed the records of patients who underwent CRS/HIPEC from 2015 until 2020. We noted the peritoneal carcinomatosis index (PCI), blood loss, anastomoses done, total amount of fluid given, delta temperature and duration of surgery. These were correlated with the need for postoperative ventilation, length of ICU stay, Clavien-Dindo score and 30 day mortality. Results: Of the 180 patients reviewed, the majority were women (85%) with a mean age of 48 years who had ovarian tumors (n=114). The total amount of fluid given was associated with an increased length of ICU stay (p=0.008). Prolonged surgery resulted in increased length of ICU stay (p<0.001), need for postoperative ventilation (p=0.006) and a poor Clavien-Dindo score (p=0.039). A high PCI score correlated with increased ICU stay, 30 day mortality (p<0.001), and the need for postoperative ventilation (0.005). Conclusions: PCI, duration of surgery and blood loss were major predictors of postoperative morbidity. Additionally, the amount of fluid given and delta temperature affected patient outcome and should be individualized to the patient's needs.

Development of management strategies for immune-related adverse effects of immunotherapies used in oncological treatment.

Development of immunotherapy agents has changed the cancer treatment paradigm with better outcomes and lesser side effects. Yet, there are adverse events associated with them. Owing to the increased stimulation of the immune system, the normal homeostatic mechanisms protecting the body from its own immune response can become disrupted, leading to a variety of side effects termed immune-related adverse effects (irAEs). irAEs can have significant associated morbidity and in many cases lead to discontinuation of therapies with unpredictable impact on the course of patients' disease. Few key articles laying out guidelines for the management of irAEs provide general treatment algorithms for the majority of the common irAEs. Nurses should have knowledge of the mechanism and adverse events associated with such therapies. Oncology nurses have a crucial role in identification of irAEs. irAEs may involve multiple systems, and thus, it is necessary to identify and manage these adverse events according to the case these at soon as possible.

Dexmedetomidine Versus Midazolam for Sedation During Medical Thoracoscopy: A Pilot Randomized-Controlled Trial (RCT).

BACKGROUND: Studies comparing the utility of dexmedetomidine with other drugs for sedation during medical thoracoscopy are lacking. In this pilot study, we compared dexmedetomidine with midazolam for sedation in thoracoscopy. METHODS: Consecutive subjects were randomized to receive either dexmedetomidine (n=30) (group D) or midazolam (n=30) (group M). All received fentanyl for procedural analgesia. The primary endpoint was pulmonologist-rated overall procedure satisfaction on the visual analog scale (satisfaction VAS). Key secondary outcomes were pulmonologist-rated cough on VAS (cough VAS), patient-rated faces pain scale scores, change in hemodynamic variables, total additional fentanyl dose, and adverse events during procedure. RESULTS: The satisfaction VAS score (mean±SD) was significantly greater in group D versus group M (7.5±1.4 and 6.5±1.1, respectively) ( P =0.003). The cough VAS scores (mean±SD) were 2.1±1.5 (group D) and 3.1±1.3 (group M) ( P =0.014). The scores (mean±SD) for patient-rated faces pain scale were 2.9±1.8 and 4.2±2.3 ( P =0.019) in group D and group M, respectively. The additional dose of fentanyl administered in group M was significantly greater than in group D ( P =0.001). The responses at the local anesthesia infiltration, skin incision, thoracoscope insertion, and biopsy between both groups were similar. The hemodynamic parameters were comparable in both groups. Also, more patients were willing for repeat thoracoscopy if needed; in the dexmedetomidine group. CONCLUSION: The findings of this pilot RCT indicate that dexmedetomidine may be more efficacious than midazolam for sedation in patients undergoing medical thoracoscopy. These observations need to be confirmed in an adequately powered RCT.

The COVID-19 pandemic: a new epoch and fresh challenges for cancer patients and caregivers-a descriptive cross-sectional study.

PURPOSE: Cancer patients and their caregivers are overwhelmed with features of uncertainty, fear, shock, worry, anxiety, sadness, and grief. To add on to their misery, the COVID-19 pandemic has severely afflicted the cancer care delivery. The study was conducted to observe the challenges faced by cancer patients and their caregivers and to formulate strategies for oncological setups to overcome those challenges. METHODS: After obtaining institutional ethical clearance, a descriptive cross-sectional study was conducted to observe the challenges faced by patients and their caregivers at the level of various domains (physical, logistic, psychological, socioeconomic, and spiritual) who visited the outpatient and inpatient department of cancer pain and palliative care unit. The results were expressed in absolute numbers. RESULTS: Major challenges encountered were suffering from physical symptoms like pain, nausea, vomiting, dyspnea (90%), postponement of cancer treatment (80%), fear of contracting COVID infection due to hospital visit (93.5%), lack of accommodation (70%), and lack of spiritual clarity and hope (50%). CONCLUSIONS: Major challenges faced by patients were in physical and psychological domains, and those by caregivers were in socioeconomic domains and handling physical symptoms of their patients. It is imperative to recognize and be cognizant of the challenges faced by cancer patients and their caregivers. Health care setups should formulate strategies to alleviate these challenges and provide holistic care to cancer patients. These strategies will hold in good stead for future pandemics also.

Need for Palliative Care in Patient with Rheumatoid Arthritis: A Cross-sectional Observational Study.

OBJECTIVES: Rheumatoid arthritis (RA) is a chronic disorder causing inflammation in the joints and achieving remission is often the primary goal of physicians. We evaluated the suffering from RA and assessed the need for palliative care services in these patients. MATERIALS AND METHODS: This cross-sectional observational study was done in 100 adult RA cases who attended the outpatient department. The Disease Activity Score 28 (DAS28), Health Assessment Questionnaire Disability Index, depression, anxiety and stress score, Short Form 36 Health Survey and numeric rating scale were assessed. The relationship between DAS28 with the other parameters and scores was assessed using Spearman's rho correlation coefficient. RESULTS: About 90% of patients in our study were female and majority (50%) had a moderate disease activity. The DAS28 showed a positive correlation with the degree of depression (r = 0.671, P = 0.000), anxiety (r = 0.609, P = 0.000) and stress levels (r = 0.474, P = 0.000). The patients with severe disease had a poor quality of life (QoL) [physical functioning (r = -0.737, P = 0.000); role limitation (r = -0.662, P = 0.000); emotional problem (r = -0.676, P = 0.000); energy/fatigue (r = -0.638, P = 0.000); social functioning (r = -0.658, P = 0.000); emotional well-being (r = -0.605, P = 0.000); general health (r = -0.643, P = 0.000); health change (r = -0.376, P = 0.000) and numerical rating scale score for pain (r = 0.656, P = 0.000)]. CONCLUSION: RA patients with high disease activity suffer from depression, anxiety, stress and poor QoL. Palliative care physicians and rheumatologists must be vested with the power to provide comprehensive care to these patients.

A Questionnaire-based Survey on Challenges Faced and Strategies Adopted by Pain and Palliative Care Physicians Working in Oncology Setup During Novel COVID-19 Pandemic - A Descriptive Cross-sectional Study.

OBJECTIVES: Novel coronavirus (COVID-19) pandemic has brought to the fore various challenges faced by pain and palliative care physicians working in oncology setup all over the country. Cancer care has been afflicted a lot during the pandemic, with challenges faced by patients and their caregivers as well as the healthcare workers. The questionnaire based online survey was conducted to explore the personal challenges faced, strategies adopted and to compare the challenges between different oncology setups. MATERIALS AND METHODS: After obtaining institutional ethical clearance the online questionnaire prepared through Google forms was rolled out to pain and palliative care physicians working all over the country with the help of social media platforms. The results were expressed in absolute number, percentage and comparisons were made with the help of Fisher's exact test. RESULTS: Maximum challenges faced were the fear of carrying infection back home (91%), the possibility of attending to a COVID positive case in day to day clinical practice because of inadequate space and screening (62%) and limited services provided by NGO's during pandemic (71%). Strategies commonly adopted were the provision of necessary personal protective equipment (83%), the conduct of educational sessions for the task force members (67%), maximum utilization of available space in the hospital (85%) and stockpiling of necessary medications and equipment (75%). CONCLUSION: It is the need of the hour to formulate strong and effective strategies to overcome the challenges encountered by pain and palliative care physicians so that we are equipped in the future to deal with any kind of pandemics.

Role of Complementary and Alternative Medicine in the Management of Cancer Cachexia.

Cancer cachexia is an important concern in cancer patients in view of advanced stage at presentation. The treatment goal for cachexia is the reversal of the loss of body weight and muscle mass with a variety of pharmacological agents. Various treatment guidelines focus on patients with advanced cancer who are likely to suffer from refractory cachexia. There is a paucity of data on research directed to cancer cachexia on cancer patients. Complementary and alternative medicines (CAMs) are widely use at some or other point of time by the majority of cancer patients in spite of little or no evidence to support that. There are many CAM which have been tried in different set up for cancer cachexia. These medicines are well accepted in view of lesser side effects and easy to use. There is a need for more randomized controlled trials with larger sample size with longer follow-up to generate more evidence in support to the use of CAM in cancer and cancer cachexia.

Primary lung cancer with chest wall involvement: Outcomes of a multimodality management approach.

INTRODUCTION: The incidence of lung cancer with chest wall (CW) involvement is approximately 5%. Surgical resection with tumor-free margin is the mainstay of the treatment but these patients generally require multimodality management. CW resection for lung cancer is a complex procedure and requires a balance of radical oncological resection and reconstruction. Herein, we shared an experience of primary lung cancer with CW involvement. MATERIALS AND METHODS: Outcome analysis of a prospectively maintained lung cancer database was done for the patients having primary lung cancer with CW involvement. All the patients underwent radical surgical resection of the primary tumor along with the CW. RESULTS: Among the 208 patients undergoing surgery for non-small cell lung cancer, 20 (9.5%) were found to have CW involvement radiologically. The most common symptom was chronic cough. A total of 11 patients received neoadjuvant chemotherapy (NACT) and the rest were taken for upfront surgery. Six patients had a partial response to NACT and none of them had tumor progression during the chemotherapy. All the patients underwent en bloc resection of the CW with anatomical resection of lung and systematic mediastinal lymphadenectomy. The mean duration of surgery was 199 min and the average blood loss was 560 ml. Reconstruction was done with a combination of prosthetic mesh and pedicled muscle flap. Median disease-free and overall survivals were 21 and 26 months, respectively. CONCLUSION: Radical resection with reconstruction is required for optimal long-term oncological and functional outcomes for NSCLC with CW involvement.

The comparison of the efficacy of ultrasound-guided paravertebral block versus erector spinae plane block for postoperative analgesia in modified radical mastectomy: A randomized controlled trial.

INTRODUCTION: The ultrasound (US)-guided erector spinae plane (ESP) block is a new regional anesthetic technique that offers significant advantages over paravertebral block as it is easy and safe to perform. We aim to compare the efficacy of US-guided paravertebral block with ESP block for postoperative analgesia in modified radical mastectomy (MRM). METHODS: Eighty female patients of age group 18-70 years, belonging to physical status American Society of Anesthesiologists (ASA) I and II, undergoing MRM were included in the study. In Group P, patients received paravertebral block and in Group E, patients received ESP block before induction of general anesthesia. Both the groups received 0.5% 20 mL ropivacaine. The time to first rescue analgesia and total doses of rescue analgesics were recorded in the postoperative period. Numeric Rating Scale (NRS) scores at 0 min, 30 min, 1 h, 2 h, 6 h, 12 h, and 24 h were noted, and patient satisfaction was evaluated at 24 h. Unpaired t-test or the Mann-Whitney U test was used to compare quantitative variables while Chi-square test or Fisher's exact test was used to compare qualitative variables. RESULTS: The time for the first analgesic request was 232.5 min (140-1200) in ESP group as compared to paravertebral group in which the duration was 205 min (135-1190) (P value = 0.29). The total dose of rescue analgesics and NRS scores in postoperative period were comparable. However, the time to perform ESP block was significantly shorter than that of paravertebral block. CONCLUSION: ESP block can be used as a safe and easy to perform alternative analgesic technique over paravertebral block in breast cancer surgeries.

The incidence of anosmia in patients with laboratory-confirmed COVID 19 infection in India: An observational study.

BACKGROUND AND AIMS: Acute loss of smell or anosmia is a common and sometimes the only symptom observed in patients with coronavirus disease-2019 (COVID-19). The objective of the study was to determine the prevalence, time of onset, and duration of anosmia in patients with COVID-19 infection and the association of anosmia with other symptoms and eosinophil count. MATERIAL AND METHODS: Two hundred patients with laboratory-confirmed COVID-19 infection, who were asymptomatic or mildly symptomatic were assessed for olfaction with a nonirritant odor. The presence of anosmia was recorded, and a questionnaire integrating the anosmia reporting tool was filled. Patients with anosmia/hyposmia were followed telephonically at 7 and 14 days for resolution of anosmia and other symptoms. The presence of anosmia was correlated with eosinophil count. RESULTS: Of the 200 COVID-19 patients, 87% were symptomatic. More than half of the patients had fever (56%). Anosmia was observed in 30% of the patients and hyposmia in 4% of patients. In 41% of the patients, olfactory loss was reported before diagnosis. The mean duration of anosmia was 7.8 (± 5) days; 97% of patients recovered with a resolution of symptoms within 2 weeks. Ageusia was the most commonly and significantly associated symptom with anosmia (66%, n = 45) followed by sore throat (41%), and rhinorrhea (28%). The symptoms in both the sexes were comparable. Absolute eosinophil count of <40/µL was observed in 59 patients (29.5%) and an absolute eosinophil count of 0 in 17 patients (8.5%). Among the 68 anosmic patients, 36 (47%) patients had eosinopenia, which was statistically significant. CONCLUSION: Anosmia is an early and sometimes the only symptom in approximately one-third of the patients with COVID-19 infection. Eosinophil count should be checked in anosomic patient with suspicion of COVID-19 infection. Objective tools for olfactory and gustatory assessment should be brought into practice for early and prompt diagnosis to control the spread of the disease.

Awareness and Attitudes of Primary Caregivers toward End-of-Life Care in Advanced Cancer Patients: A Cross-Sectional Study.

INTRODUCTION: Awareness of end-of-life care (EOLC) has been at grass root level in our country. The caregivers are clueless about the concept of comfort care and that terminally ill cancer patients need care at home rather than the paraphernalia of the hospital ward. The basic aim of the study was to assess the awareness of the EOLC in the caregivers of the advanced cancer patients. METHODS: After Ethics Committee approval, this prospective cross-sectional observational study was conducted among primary caregivers of patients receiving palliative care for advanced cancer. The primary caregiver was identified and written informed consent was obtained. The questionnaire for assessing awareness and attitudes of primary caregivers toward EOLC in advanced cancer patients was prepared and validated. The standardized study questionnaire was completed by the primary caregiver assisted by the researcher. The categorical data were analyzed using Fisher's exact test and Chi-square tests. The intergroup correlation was done using the Chi-square and nonparametric tests. RESULTS: The results showed that only mere 26% of caregivers were aware of the term palliative care. The female population was more knowledgeable about EOLC, with 68% of them willing to initiate the same. The rural population was more willing to adopt palliative care (47%) and was more receptive about discontinuing aggressive definitive therapy. CONCLUSION: We conclude that the awareness about EOLC remains poor in caregiver if patients with advanced cancer in spite of good awareness of the disease. The consequences of the outcome of disease, EOLC understanding, futility for definitive care, acceptability, and understanding of palliative care lacked in most of the caregivers.