BackgroundBereavement profoundly impacts caregivers, especially adult children who lose a parent. Grief may become complicated when cultural, relational, and spiritual conflicts remain unresolved. Rituals rooted in local tradition can serve as powerful psychospiritual interventions, yet they remain underutilised in mainstream palliative bereavement care.Case PresentationWe describe the case of a 32-year-old unmarried man who developed severe grief-related distress following the death of his 60-year-old mother from metastatic ovarian carcinoma. As her sole caregiver and emotionally dependent companion, he experienced intrusive images of her suffering, guilt, insomnia, anorexia, and inability to work. He also expressed a culturally rooted fear that his mother's soul remained in distress, creating profound spiritual dissonance. The Brief Grief Questionnaire (BGQ) score was 9 out of 10, indicating high risk for complicated grief. His bereavement occurred during Diwali, intensifying a sense of incompleteness in shared rituals of light and remembrance. Conventional counselling offered minimal relief, as his grief was anchored in unaddressed cultural-spiritual obligations. A culturally informed intervention, the Pāyā Śhrāddha ritual in Odisha, was recommended to provide symbolic fulfilment of filial duty and spiritual release. Following the ritual, he reported significant emotional relief, cessation of intrusive imagery, restored sleep, and functional recovery. His BGQ score improved from 9 to 3, remaining stable at 6-week follow-up.ConclusionThis case highlights the therapeutic power of culturally grounded rituals in addressing grief sustained by spiritual-moral conflict. Integrating indigenous practices such as Pāyā Śhrāddha into bereavement care can promote meaning-making, resolve guilt, and support recovery where conventional counselling alone may be insufficient. Culturally responsive, ritual-aware approaches should be recognised as vital components of holistic palliative care.

Major head and neck oncologic surgeries cause significant systemic inflammation, with elevated CRP and IL-6. Vitamin C may help reduce perioperative inflammation and improve hemodynamic stability. In this double-blind study, 60 ASA I–II adults scheduled for elective head and neck cancer surgery with flap reconstruction were randomized to receive either intravenous vitamin C (Group C, n = 30; 1 g in 100 mL preoperatively, pre-incision, and before extubation/weaning) or placebo (saline, Group S, n = 30). Serum CRP and IL-6 were measured preoperatively and on postoperative days 1 (POD1) and 4 (POD4). The primary outcome was the serum CRP level on POD1, representing the early postoperative inflammatory response. Secondary outcomes included CRP on POD4, IL-6 levels at POD1 and POD4, vasopressor use, analgesic requirements, postoperative complications, and lengths of ICU and hospital stay. Baseline demographics and preoperative inflammatory markers were similar across groups. On POD1, the mean CRP and IL-6 levels were lower in the vitamin C group compared to placebo (CRP 7.6 ± 1.8 vs. 12.7 ± 6.5 mg/dL, p = 0.001; IL-6 43.3 ± 11.4 vs. 62.2 ± 21.5 pg/mL, p = 0.041). By POD4, these values showed no significant differences. No significant differences were observed in ICU stay, vasopressor use, analgesic requirements, or postoperative complications. However, hospital stay was significantly shorter in the vitamin C group. Perioperative vitamin C reduced early postoperative inflammatory markers, but the effect was transient. The shorter hospital stay observed in the vitamin C group requires confirmation in larger studies.

BACKGROUND:Thymoma is the most common anterior mediastinal neoplasm in adults and often requires surgical resection for curative treatment. Traditional approaches, including open surgery and multiportal thoracoscopic techniques, are associated with significant morbidity. The uniportal subxiphoid approach offers a minimally invasive, patient-friendly alternative, with potential benefits in operative efficiency and post-operative recovery. This technique may be particularly advantageous in low-resource settings, given its simplicity and reduced need for specialized equipment or personnel. METHODS:This study included 27 patients who underwent uniportal subxiphoid thymectomy at our institution between January 2022 and December 2024. The technique involves pre-operative planning based on tumour staging, with resections possible for tumours up to 15 cm. The patient is placed supine, with no carbon dioxide insufflation or epidural anaesthesia used. An incision below the xiphoid process provides access for tumour dissection, utilizing a thoracoscope. The thymoma is carefully removed through the incision, followed by a mediastinal drain placement. RESULTS:In 27 patients, tumour sizes ranged from 2 to 15 cm. The mean operative time was 106.9 min, with minimal blood loss (46.7 mL). All procedures were R0 resections, with no conversions to open surgery. Post-operative pain was minimal, and the mean hospital stay was 2.6 days. CONCLUSIONS:The uniportal subxiphoid thymectomy is an effective, minimally invasive technique, offering excellent outcomes in terms of operative time, blood loss, and recovery. It provides a safe, efficient, and cost-effective alternative, especially for low-resource settings.

339 Background: Inpatient mortality in palliative care units ranges 10-30% globally, yet prognostic data from low- and middle-income countries (LMICs) remain limited. Whether admission-day clinical and laboratory variables can identify high-risk patients in resource-limited settings is unclear. Methods: Retrospective analysis of a prospectively maintained database from two inpatient palliative care wards at a tertiary cancer centre in North India. All consecutive index admissions (January-December 2025) were included. Primary outcome: terminal event (inpatient death or discharge for end-of-life home-based care). Predictors: ECOG performance status, admission reason, number of complaints, serum albumin, haemoglobin, estimated glomerular filtration rate, total leukocyte count, age, sex, weekend admission, cancer type, distance. Multivariable logistic regression with stepwise selection identified independent predictors. Sensitivity analysis examined mortality alone. Results: Among 1,458 patients (mean age 52.3±14.1 years, 51% male), terminal events occurred in 275 (18.9%) and deaths in 182 (12.5%). Multivariable analysis retained 6 independent predictors (Table). ECOG PS 4 showed strongest association (OR 42.3). Symptom-based predictors included dyspnoea (OR 33.8), delirium (OR 23.3), and symptom complexity with ≥3 complaints (OR 17.1). Laboratory markers included severe renal impairment (OR 3.3) and albumin (OR 0.55 per g/dL, protective). Weekend admission was associated with increased risk (OR 2.5). Sensitivity analysis using mortality alone yielded consistent findings. Conclusions: Basic admission day variables can reliably forecast terminal outcomes among palliative care inpatients. ECOG PS, initial symptoms, albumin, and kidney function, all accessible at the bedside without advanced tests, help guide triage, care planning, and resource distribution in LMICs. The results encourage early prognosis discussions and care preparation. Independent admission-day predictors of terminal event in palliative care inpatients (n=1458). Predictor OR (95% CI) P-value ECOG PS 4 (vs 1-2) 42.3 (17.8 - 100.6) <0.001 Dyspnoea (vs pain) 33.8 (8.7 - 132.1) <0.001 Delirium (vs pain) 23.3 (5.9 - 92.6) <0.001 ≥3 complaints (vs 0-1) 17.1 (3.5 - 83.2) <0.001 Severe CKD (vs normal) 3.3 (1.8 - 6.1) <0.001 Weekend admission 2.5 (1.4 - 4.4) 0.002 Albumin (per g/dL) 0.55 (0.39 - 0.76) <0.001

Interventional pain management plays a pivotal role in addressing distressing symptoms, notably pain, in palliative care patients with locally advanced rectal cancer. Ganglionic impar block and caudal epidural block have emerged as promising approaches for refractory pain relief. This case report discusses a 61-year-old female with locally advanced rectal cancer experiencing severe perianal pain, unresponsive to high-dose opioids. The patient underwent ganglion impar and caudal epidural block, resulting in a significant reduction in pain intensity. However, she developed transient confusion postprocedure, which resolved spontaneously within 2 h. This unusual complication underscores the importance of meticulous technique and patient monitoring in interventional pain management. While rare, transient neurological symptoms following such procedures necessitate understanding their potential etiologies and effective management strategies. This case highlights the efficacy of interventional pain management in rectal cancer-associated pain and emphasizes the need for continued research to optimize patient outcomes in cancer pain management.

Breast cancer is the most common malignancy among women in India, with patients often experiencing high symptom burden and compromised quality of life (QoL). Despite evidence supporting early supportive care integration, significant implementation gaps persist in low- and middle-income countries (LMICs). This study addresses the lack of feasible intervention models for resource-constrained settings and inadequate characterization of mechanisms through which early supportive care improves outcomes—particularly symptom-specific contributions and financial burden reduction. This single-centre, randomised controlled trial at All India Institute of Medical Sciences, New Delhi, randomised 110 newly diagnosed adult female breast cancer patients (1:1) into intervention (early supportive care plus standard care) or control (standard care only) groups. Supportive care included symptom management, psychosocial counselling, and educational support. Outcomes were assessed at baseline and 3 months using EORTC QLQ-C30 and Edmonton Symptom Assessment Scale (ESAS). Statistical analyses included t-tests, multivariate regression, and mediation modelling. Both groups showed significant QoL improvement, but greater symptom reduction occurred in the intervention group (mean ± SD ESAS reduction: 30.69 ± 15.51 vs. 22.9 ± 15.99; p = 0.014). Fatigue and pain were significantly lower in the supportive care group (Cohen’s d = 0.55 [95

BackgroundParents caring for children with cancer face substantial physical, emotional, social, and financial challenges, especially in low- and middle-income countries like India.ObjectiveIn this study, we aimed to assess caregiver burden and quality of life among parents of children with cancer in the Indian context, and to describe the socio-cultural and economic factors influencing these outcomes.MethodsIn this cross-sectional study, 200 primary caregivers of paediatric oncology patients were assessed using the Zarit Burden Interview (ZBI), WHOQoL-BREF, and the Multidimensional Scale of Perceived Social Support (MSPSS). Socio-demographic and clinical data were collected through interviews and review of medical records.ResultsThe median ZBI score was 66 (IQR 23.5), with 66% of caregivers experiencing severe burden. Caregiver burden was higher among mothers, caregivers with lower education, those unemployed, and those living in nuclear families. Burden negatively correlated with duration of illness (r = -0.75, P < 0.05) and quality of life across all domains. Perceived social support was low, particularly among caregivers living alone or in nuclear families.ConclusionsHigh caregiver burden and impaired quality of life were observed among caregivers in a resource-limited setting. Strengthening social support and implementing family-centred interventions may help reduce the burden and improve outcomes.

Objectives:Burnout is a significant occupational hazard among palliative care physicians, driven by the emotionally demanding and high-stress nature of their work. Despite its implications for physician well-being and patient care, limited data are available on burnout within Indian palliative care settings. This study aimed to assess the prevalence of burnout and explore associated demographic and occupational factors among palliative care physicians across India. Materials and Methods:A cross-sectional survey was conducted among 68 palliative care physicians across India using a non-probabilistic convenience sampling approach. Participants completed a semi-structured socio-demographic questionnaire along with the Copenhagen Burnout Inventory (CBI), which measures burnout across three domains: personal, work-related and client-related. Given the non-normal distribution of data, non-parametric statistical tests were employed for analysis. Results:The majority of physicians (85.3%) reported low overall burnout, whereas 10.3% experienced moderate burnout and 4.4% reported high burnout, based on established CBI cut-off scores. Notably, higher work-related and client-related burnout scores were observed among junior physicians and those practising in mixed-care settings. Engagement in regular physical activity was significantly associated with reduced overall burnout (P = 0.039), indicating its potential protective effect. Conclusion:Although most palliative care physicians in India demonstrated low levels of burnout, a significant minority exhibited moderate to high burnout-particularly in domains related to work and patient care. These findings highlight the need for targeted interventions aimed at improving institutional support, encouraging physical well-being and optimising work environments to mitigate burnout and enhance the sustainability of palliative care practice.

Perineal pain in patients with pelvic malignancies, such as rectal cancer, can be debilitating and significantly impair quality of life. The ganglion impar block (GIB) is an established interventional technique for managing such pain. However, anatomical changes following pelvic radiotherapy, particularly sacrococcygeal fusion, may render conventional approaches to GIB ineffective or unsafe. We report the case of a 41-year-old male with locally advanced rectal cancer and radiation-induced sacrococcygeal fusion who presented with severe, refractory perineal pain. Pain was poorly controlled despite systemic opioids and adjuvant analgesics, and conventional trans-sacrococcygeal GIB attempts under fluoroscopy failed due to the inability to traverse the fused joint. A novel coaxial transosseous technique was employed. A large-bore (21G) needle was used in a rotatory fashion to drill through the ossified sacrococcygeal joint. Subsequently, a 27G spinal needle was introduced coaxially through the first needle, facilitating precise placement and administration of therapeutic agents under fluoroscopic guidance. The patient reported significant and sustained pain relief. Post-procedure, the patient experienced substantial pain reduction (Numerical Rating Scale 8/10 to 2/10), improved defecation-related symptoms, and enhanced functional status. No procedural complications were observed. Follow-up at one week confirmed ongoing analgesic benefit with reduced opioid requirements. The coaxial transosseous GIB is a safe, effective, and innovative technique for managing refractory perineal pain in patients with radiation-induced sacrococcygeal fusion. It offers a viable alternative when conventional approaches fail and warrants further evaluation through prospective studies.

BACKGROUND:Nasotracheal intubation (NTI) is particularly challenging in patients with rigid neck or micrognathia. Advancements in video laryngoscopy may improve NTI outcomes. We compared performance of direct laryngoscope (DL), King Vision videolaryngoscope (KVL), and C-MAC videolaryngoscope (VL) in normal, rigid neck, and micrognathia airway. METHODS:A randomized, self-controlled crossover trial was conducted with 20 anesthesiologists who performed NTI on a high-fidelity mannequin under three airway conditions. Device order was randomized using a computer-generated sequence, and outcome assessors were blinded to the sequence of devices used. Primary outcomes were time to glottic view and intubation. Secondary outcomes included ease of intubation and force on incisors. RESULTS:The median difference (95%CI) in time to intubation suggested that CMAC was better than KVL in normal airway (-9.0[-13.0 to-6.0], p < 0.001), rigid neck (-12.0[-18.0 to -6.5], p < 0.001) and micrognathia (-16.5[-20.0 to -13.5], p < 0.001). When compared to DL, CMAC was better for micrognathia (-8.0[-5.5 to-10.5], p = 0.001) but comparable for normal airway and rigid neck. C-MAC also exerted the least force on incisors, minimizing dental trauma. CONCLUSION:The C-MAC VL demonstrated superior performance across all airway conditions, offering faster, safer, and easier NTI, making it the preferred device in challenging scenarios. TRIAL REGISTRATION:Clinical Trial Registry of India: (CTRI/2022/05/042821) www.ctri.nic.in.

Background and Aims: Traditional airway assessment methods likely miss findings, resulting in unanticipated difficult airways. Surgeons routinely do computed tomography (CT) scans of head and neck cancer patients to determine the extent and resectability of the disease. We used these images for 3-dimensional CT (3D CT) reconstruction to provide additional airway-related information to the anaesthesiologist and studied its impact on airway management. Methods: We randomly allocated 60 patients into two groups to formulate the airway management plan: Group A (Conventional airway assessment) and Group B (Conventional airway assessment along with 3D CT findings). A CT reporting format was prepared based on a literature review after discussion with radiologists and airway experts. In the case of luminal obstruction, a virtual endoscopy video was also created. These findings were shown to the anaesthesiologist managing the airway, and any change in the primary plan was noted. The primary outcome was the total time required for successful airway management. Secondary outcomes included the number of attempts, number of alternative techniques, other manoeuvres required, incidence of failed intubation, and any complications. Data were analysed using the SPSS statistics software. Results: The airway management time between both groups was comparable, with a median difference of 0 [95% confidence interval (CI): −14, 20; P = 0.752]. Among the manoeuvres used, optimal external laryngeal manipulation (OELM) was required more in Group A ( P = 0.007). Both groups had no difference in the number of attempts ( P > 0.99), number of alternative techniques ( P = 0.052), and complications ( P > 0.99). There was a significant change in the endotracheal tube size after CT findings were shown ( P < 0.001). It aided in selecting the preferred side of the nostril for nasotracheal intubation (kappa = 0.545, showing moderate agreement between before and after CT groups). As per the feedback from anaesthesiologists who rated 3D CT on a Likert scale, it was considered beneficial for airway assessment. Conclusion: 3D CT reconstruction and virtual endoscopy can be a valuable method of airway assessment.

Patients with inoperable hepatobiliary cancers often endure severe abdominal pain, which impacts their quality of life. This pain is usually a combination of both nociceptive and neuropathic pain, which necessitates a comprehensive multimodal approach for effective management. Splanchnic nerve plexus block (SNB) has shown promising results in this regard. This case series reviews the literature and clinical practices, exploring the potential benefits of early SNB in the palliative care of patients with hepatobiliary cancers. We describe three cases illustrating SNB's potential in achieving notable pain relief. Each patient reported a pain reduction from 10/10 to less than 1/10, a reduced requirement for opioids and sustained relief at a 1-month follow-up. This case series suggests the potential role of SNB in select patients with ongoing oncology therapy for alleviating severe pain, decreasing opioid requirements and potentially enhancing overall functional status.

BACKGROUND:Postoperative pulmonary complications (PPCs) are defined heterogeneously and have major adverse effects in increasing morbidity. Oncosurgeries themselves are complex, are of long duration, and extensive handling of body tissues occurs in them, leading to various complications including PPCs. So, we conducted this prospective study intending to find the incidence and risk factors for PPCs in patients undergoing major oncosurgeries. METHODS:This prospective observational study was conducted after obtaining institutional ethical approval in patients undergoing major oncosurgeries. The demographic, preoperative, and intraoperative details were noted, and patients were followed in the postoperative period for the occurrence of PPC till discharge. Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score was used to predict the occurrence of PPC. Data were analyzed using multivariable regression analysis for the risk factors, and the Chi-square trend was used to see the trend of PPC with the change in ARISCAT score. RESULTS:The overall incidence of PPC in patients undergoing major oncosurgeries was 28.05%. The most common PPCs were respiratory insufficiency (19.2%) and atelectasis (17.6%). The highest incidence of PPC was found in thoracotomies (41.6%), followed by cytoreductive surgeries (40.6%). The risk factors for PPCs included body mass index (BMI) <18.5 or >25 kg/m2, smoking, use of nasogastric tube, age >60 years, and albumin <3.5 g/dL. Patients with low ARISCAT scores had a low incidence of PPC compared to those with high and intermediate ARISCAT scores. CONCLUSION:The incidence of PPC in patients undergoing major oncosurgeries was 28.05% in our study. The independent risk factors for PPC in oncological surgeries were BMI <18.5 kg/m2 or >25 kg/m2, use of nasogastric tube, age <60 years, serum albumin <3.5 g/dL, and smoking.

Pancreatic cancers have a poor prognosis and generally present with uncontrollable pain. Thermal radiofrequency ablation (RFA) is a safe and effective technique that can be employed in this subset of patients. It has been proven that it is a minimally invasive technique that can be performed under fluoroscopy technique with local anesthesia. Thus, it helps in the better palliation of suffering patients. Especially in patients where the coeliac plexus cannot be targeted due to encasement, the splanchnic nerve can be targeted easily. Here is reported a case in which pancreatic cancer pain was successfully managed with thermal RFA.

There is a paucity of literature regarding the effect of anesthetic techniques on antitumor immunity, especially in gall bladder malignancies. We designed a study to compare the effect of propofol-based total intravenous anesthesia and sevoflurane-based general anesthesia-on antitumor immunity, including tumor growth factor-β (TGF-β), T-helper cell profile, and inflammatory markers. A pilot prospective randomized trial was conducted in 64 patients undergoing surgery for gall bladder malignancy under general anesthesia in a tertiary specialty cancer hospital. Adult cancer patients of ASA physical status I-III fulfilling the inclusion criteria were randomized to either group S (sevoflurane-based general anesthesia) or group T (propofol-based total intravenous anesthesia). Preoperative (morning of surgery) and postoperative (24 h and 1 month after surgery) blood samples were obtained. Demographic profile and preoperative parameters were comparable between both groups. There was a statistically significant difference in the postoperative value of TGF-β (higher in group T). There was a statistically significant difference in postoperative interleukin-17A value (indicative of TH17 cells), and it was found to be higher in group S. Propofol-based TIVA increases serum TGF-β levels. At the same time, Sevoflurane modulates T-helper cells-based immunity to increase TH17 cells in patients with gall bladder cancer. Multiple larger studies will be required to validate the results and provide useful recommendations.

Background: Patients with primary brain tumors navigate a distinct illness trajectory, characterized by an uncertain prognosis, a rapid decline in physical functioning, and a significant deterioration in the quality of life. These unique challenges underscore the importance of our research in understanding and addressing the needs of these patients. Methods: The EORTC QLQ C30 & EORTC BN 20 questionnaires assessed the quality of life and symptom burden in patients with primary brain tumors. The scores were analyzed using SPSS statistical software. Results: 100 patients - 61 males and 39 females—were included with radiological or histopathological diagnoses of primary brain tumours. Seizures (38%) was the most common presenting symptom, followed by headache (18%), loss of consciousness (13%), focal neurological deficit (9%), and blurring of vision (8%). The mean quality of life at baseline was 78.29, with a standard deviation of 9.67 on a scale of 0 to 100, and the brain tumor-specific symptom burden score was 46.9, with a standard deviation of 17.95 on a scale of 0 to 100. There was a significant difference in the global health status score between the first and third visits at 3 months ( P value = .03). Conclusion: Despite the aggressive and often incurable nature of primary brain tumors, there is hope in the form of palliative care. By addressing unmet symptoms, uncertainties about the future, and social functioning, palliative care can significantly improve the quality of life of these patients.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy carries the risk of perioperative metabolic and renal derangements. Central diabetes insipidus (CDI) is a rare endocrine disorder of serum and urine osmolality with serum sodium disturbances. Herein, we describe the perioperative challenges of a CDI undergoing major abdominal oncological surgery and its management.

Purpose To assess the End of life care (EOLC ) practices and the magnitude of futile care in a tertiary cancer center. To find out the barriers in provision of good EOLC in cancer patients. Methods An observational study was done on 129 patients. Patients were enrolled using the palliative prognostic index (PPI) in the end of life stages. Socio-demographic and clinical details were recorded. Detailed counselling done by the palliative physician or the oncologist was recorded. The barriers in provision of care were recorded. Results In this study initial experience of 129 patients were analyzed. PPI score was > 6 (survival shorter than 3 weeks) in 85 (65.89%) ; 34 (26.36%) had PPI score between > 4 to 6 (survival between 3 to 6 weeks); and 10 (7.75%) patients had PPI score less than equal to 4( survival more than 6 weeks).77 (59.69%) patients preferred home as their place for EOLC while 41(31.78%) preferred hospital, 7 (5.43%) preferred hospice while 4 (3.10%) opted ICU for their EOLC. The most common barrier associated was caregiver related in 34 case, followed by physician related in 14 cases and patients related in 3 cases, because of hope of being cured in hospital, social stigma, fear of worsening of symptoms at home, denial. Conclusion EOLC is the least studied part of patient care with various barriers. With proper communication and a good palliative care support, futile treatment can be avoided. With healthy communication we can empower family members and patients for a good EOLC.

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.