Recurrent disease detection after resection of pancreatic ductal adenocarcinoma using a recurrence-focused surveillance strategy (RADAR-PANC): protocol of an international randomized controlled trial according to the Trials within Cohorts design.

BACKGROUND: Disease recurrence remains one of the biggest concerns in patients after resection of pancreatic ductal adenocarcinoma (PDAC). Despite (neo)adjuvant systemic therapy, most patients experience local and/or distant PDAC recurrence within 2 years. High-level evidence regarding the benefits of recurrence-focused surveillance after PDAC resection is missing, and the impact of early detection and treatment of recurrence on survival and quality of life is unknown. In most European countries, recurrence-focused follow-up after surgery for PDAC is currently lacking. Consequently, guidelines regarding postoperative surveillance are based on expert opinion and other low-level evidence. The recent emergence of more potent local and systemic treatment options for PDAC recurrence has increased interest in early diagnosis. To determine whether early detection and treatment of recurrence can lead to improved survival and quality of life, we designed an international randomized trial. METHODS: This randomized controlled trial is nested within an existing prospective cohort in pancreatic cancer centers in the Netherlands (Dutch Pancreatic Cancer Project; PACAP) and the United Kingdom (UK) (Pancreas Cancer: Observations of Practice and survival; PACOPS) according to the "Trials within Cohorts" (TwiCs) design. All PACAP/PACOPS participants with a macroscopically radical resection (R0-R1) of histologically confirmed PDAC, who provided informed consent for TwiCs and participation in quality of life questionnaires, are included. Participants randomized to the intervention arm are offered recurrence-focused surveillance, existing of clinical evaluation, serum cancer antigen (CA) 19-9 testing, and contrast-enhanced computed tomography (CT) of chest and abdomen every three months during the first 2 years after surgery. Participants in the control arm of the study will undergo non-standardized clinical follow-up, generally consisting of clinical follow-up with imaging and serum tumor marker testing only in case of onset of symptoms, according to local practice in the participating hospital. The primary endpoint is overall survival. Secondary endpoints include quality of life, patterns of recurrence, compliance to and costs of recurrence-focused follow-up, and the impact on recurrence-focused treatment. DISCUSSION: The RADAR-PANC trial will be the first randomized controlled trial to generate high level evidence for the current clinical equipoise regarding the value of recurrence-focused postoperative surveillance with serial tumor marker testing and routine imaging in patients after PDAC resection. The Trials within Cohort design allows us to study the acceptability of recurrence-focused surveillance among cohort participants and increases the generalizability of findings to the general population. While it is strongly encouraged to offer all trial participants treatment at time of recurrence diagnosis, type and timing of treatment will be determined through shared decision-making. This might reduce the potential survival benefits of recurrence-focused surveillance, although insights into the impact on patients' quality of life will be obtained. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04875325 . Registered on May 6, 2021.

A preoperative predictive tool to assess the need for staging laparoscopy in oesophagogastric cancer patients.

INTRODUCTION: Staging laparoscopy (SL) has become commonplace in the preoperative staging pathway for oesophagogastric (OG) cancer. SL is often performed before curative treatment to examine for macroscopic peritoneal metastases (PM) or positive peritoneal cytology (PPC). The aim of this study was to develop an objective risk scoring system to predict both PM and PPC at SL. METHODS: A prospectively collected and maintained database of all OG cancer patients treated between 2006 and 2020 was reviewed. Univariate and multivariate analyses were performed to identify risk factors for both PM and PPC at SL. A risk score was produced for both PM and PPC, and then validated internally. RESULTS: Among 968 patients who underwent SL, 96 (9.9%) had PM and 81 (8.4%) had PPC at SL. Tumour site (p < 0.001), computed tomography (CT) T stage (p < 0.001) and N stage (p = 0.029) were significantly associated with PM at SL (p < 0.001). Tumour site (p < 0.001), biopsy histology (p = 0.041), CT T stage (p < 0.001) and N stage (p < 0.001) were significantly associated with PPC. The risk scoring model for PM included cancer site and CT T stage. This was successfully tested on the validation set (area under the receiver operating characteristic [AUROC] = 0.730). The risk scoring model for PPC included cancer site, CT T and N stage. This was successfully tested on the validation set (AUROC = 0.773). CONCLUSIONS: The current risk scores are valid tools with which to predict the risk PM and PPC in patients undergoing SL for OG cancer and may help to avoid subjecting patients to unnecessary SL.

Are physical performance and frailty assessments useful in targeting and improving access to adjuvant therapy in patients undergoing resection for pancreatic cancer?

BACKGROUND: Many patients fail to receive adjuvant chemotherapy following pancreatic cancer surgery. This study implemented a multimodal, multidisciplinary approach to improving recovery after pancreatoduodenectomy (the 'Fast Recovery' programme) and measured its impact on adjuvant chemotherapy uptake and nutritional decline. The predictive accuracies of a bundle of frailty and physical performance assessments, with respect to the recipient of adjuvant chemotherapy, were also evaluated. RESULTS: The N = 44 patients treated after the introduction of the 'Fast Recovery' programme were not found to have a significantly higher adjuvant chemotherapy uptake than the N = 409 treated before the pathway change (80.5 vs. 74.3%, p = 0.452), but did have a significantly lower average weight loss at six weeks post-operatively (mean: 4.3 vs. 6.9 kg, p = 0.013). Of the pre-operative frailty and physical performance assessments tested, the 6-min walk test was found to be the strongest predictor of the receipt of adjuvant chemotherapy (area under the ROC curve: 0.91, p = 0.001); all patients achieving distances ≥ 360 m went on to receive adjuvant chemotherapy, compared to 33% of those walking < 360 m. CONCLUSIONS: The multimodal 'Fast Recovery' programme was not found to significantly improve access to adjuvant chemotherapy, but did appear to have benefits in reducing nutritional decline. Pre-operative assessments were found to be useful in identifying patients at risk of non-receipt of adjuvant therapies, with markers of physical performance appearing to be the best predictors. As such, these markers could be useful in targeting pre- and post-habilitation measures, such as physiotherapy and improved dietetic support.

Three-year Clinical Performance of Two Giomer Restorative Materials in Restorations.

CLINICAL RELEVANCE: The clinical performance of both conventional and flowable giomer restorative materials was particularly good in Class I restorations after three years of service. SUMMARY: This study evaluated and compared the clinical performance of a flowable and a conventional giomer restorative material after three years. Forty-four pairs of restorations (total n=88) were placed in Class I cavities with either a flowable giomer (Beautifil Flow Plus F00; Shofu Inc, Kyoto, Japan) or a conventional giomer restorative material (Beautifil II; Shofu Inc) after the application of a dentin adhesive (FL-Bond II; Shofu Inc) and a flowable liner (Beautifil Flow Plus F03; Shofu Inc). After 3 years, 39 pairs of restorations were evaluated with the modified United States Public Health Service criteria, and digital color photographs of restorations were taken at each patient visit. The evaluation parameters were as follows: color match, marginal integrity, marginal discoloration, retention, secondary caries formation, anatomic form, surface texture, and postoperative sensitivity. Evaluations were recorded as a clinically ideal situation (Alpha), a clinically acceptable situation (Bravo), or a clinically unacceptable situation (Charlie). Data were analyzed with Fisher's exact and McNemar tests (α=0.05).None of the restorations showed retention loss, postoperative sensitivity, secondary caries, or color change. The performance of Beautifil II in terms of marginal integrity, marginal discoloration, and surface anatomic form was significantly lower at the 36-month follow-up than at baseline (p=0.007). There were no significant differences between the baseline and 36-month follow-up scores for the other criteria for Beautifil II (p>0.05). No differences were found between the baseline and the 36-month follow-up scores for any of the criteria for Beautifil Flow Plus F00 (p>0.05). No statistically significant difference in overall clinical performance was found between the 2 materials after 36 months (p>0.05).The three-year clinical performance of both restorative materials (Beautifil Flow Plus F00 and Beautifil II) was very good and not significantly different for any of the parameters evaluated.

Urgent surgical repair of symptomatic Bochdalek hernia containing an intrathoracic kidney.

Bochdalek hernias rarely contain an intrathoracic kidney, and there are few reports of their operative repair. A woman presented with progressive dyspnoea limiting her quality of life. Imaging showed a Bochdalek hernia containing omentum, large bowel and the left kidney. The woman was unexpectedly admitted to the intensive care unit with respiratory failure secondary to gallstone pancreatitis whilst awaiting elective repair of her hernia. Surgical repair of the hernia was performed via laparotomy with cholecystectomy to treat both problems. The woman recovered well and is independently mobile without any exertional dyspnoea.

Do dehydroepiandrosterone, progesterone, and testosterone influence women's depression and anxiety levels? Evidence from hair-based hormonal measures of 2105 rural Indian women.

Depressive and anxiety disorders substantially contribute to the global burden of disease, particularly in poor countries. Higher prevalence rates for both disorders among women indicate sex hormones may be integrated in the pathophysiology of these disorders. The Kshetriya Gramin Financial Services study surveyed a random sample of 4160 households across 876 villages in rural Tamil Nadu, India. An interviewer-administered questionnaire was conducted to quantify depressive (K6-D) and anxiety (K6-A) symptoms. Alongside, hair samples for sex hormone profiling were collected from a subsample of 2105 women aged 18-85 years. Importantly, 5.9%, 14.8%, and 46.3% of samples contained non-detectable hormone levels for dehydroepiandrosterone, progesterone, and testosterone, respectively. Our primary analysis imputes values for the non-detectable sample and we check robustness of results when non-detectable values are dropped. In this cohort of women from rural India, higher depressive symptomatology is associated with lower levels of dehydroepiandrosterone and higher depressive and anxiety symptoms are associated with higher levels of testosterone. Progesterone shows no clear association with either depressive or anxiety symptoms. These results support a potential protective effect of higher endogenous dehydroepiandrosterone levels. An important caveat on the potential negative effect of hair testosterone levels on women's mental health is that the testosterone analysis is sensitive to how non-detectable values are treated.

Evaluation of the clinical and economic impact of delays to surgery in patients with periampullary cancer.

Background: Early treatment is the only potential cure for periampullary cancer. The pathway to surgery is complex and involves multiple procedures across local and specialist hospitals. The aim of this study was to analyse variability within this pathway, and its impact on cost and outcomes. Methods: Patients undergoing surgery for periampullary cancer (2011-2016) were identified retrospectively and their pathway to surgery was analysed. Patients who had early surgery (shortest quartile, Q1) were compared with those having late surgery (longest quartile, Q4). Results: A total of 483 patients were included in the study, with 121 and 124 patients in Q1 and Q4 respectively. The median time from initial CT to surgery was 21 days for Q1 versus 112 days for Q4 (P < 0·001). Diagnostic delays were common in Q4; these patients required significantly more investigations than those in Q1 (endoscopic ultrasonography (EUS): 74·2 versus 18·2 per cent respectively, P < 0·001; MRI: 33·6 versus 20·6 per cent, P = 0·036). The median time to diagnostic EUS was 13 days in Q1 versus 59 days in Q4 (P < 0·001). Some 42·1 per cent of jaundiced patients in Q1 underwent preoperative biliary drainage, compared with all patients in Q4. There were significantly more unplanned admissions and associated longer duration of hospital stay per patient and costs in Q4 than in Q1 (median: 8 versus 3 days respectively; €5652 versus €2088; both P < 0·001). There was a higher likelihood of potentially curative surgery in Q1 (82·6 per cent versus 66·9 per cent in Q4; P = 0·005). Conclusion: There is wide variation across the entire pathway, suggesting that multiple strategies are required to enable early surgery. Defining an effective pathway by anticipating the need for investigations and avoiding biliary drainage reduces unplanned admissions and costs and increases resection rates.

Contemporary characteristics of blunt abdominal trauma in a regional series from the UK.

INTRODUCTION Blunt abdominal trauma (BAT) is a common injury in recent trauma series. The characteristics of patients with BAT have changed following the reconfiguration of UK trauma services. The aim of this study was to build a new profile for BAT patients undergoing immediate or delayed laparotomy. METHODS All 5,401 consecutive adults presenting with major trauma between April 2012 and April 2014 in the 3 major trauma centres in the West Midlands were analysed to identify all patients with BAT. A total of 2,793 patients with a mechanism of injury or symptomatology consistent with BAT were identified (52%). Outcomes were analysed using local electronic clinical results systems and notes. RESULTS Of the 2,793 patients, 179 (6.4%) had a mesenteric or hollow viscus injury, 168 (6.0%) had a hepatobiliary injury, 149 (5.4%) had a splenic injury and 46 (1.6%) had a vascular injury. Overall, 103 patients (3.7%) underwent an early (<12 hours) laparotomy while 30 (1.1%) underwent a delayed (>12 hours) laparotomy. Twenty (66.7%) of those undergoing a delayed laparotomy had a hollow viscus injury. In total, 170 deaths occurred among the BAT patients (6.1%). In the early laparotomy group, 53 patients died (51.5%) whereas in the delayed laparotomy group, 6 patients died (20.0%). CONCLUSIONS This series has attempted to provide the characteristics of patients with BAT in a large contemporary UK cohort. BAT was found to be a common type of injury. Early and delayed laparotomy occurred in 3.7% and 1.1% of these patients respectively, mostly because of hollow viscus injury in both cases. Outcomes were comparable with those in the international literature from regions with mature trauma services.

Colorectal cancer screening characteristics of patients presenting with symptoms of colorectal cancer and effect on clinical outcomes.

INTRODUCTION: National colorectal cancer screening, utilising a faecal occult blood test (FOBT), is now well established in the UK. The aim of this study was to define the screening characteristics of patients presenting to secondary care with symptoms of colorectal cancer and to assess the effect of screening outcome on subsequent symptomatic presentation. METHODS: This was a retrospective analysis of all patients of screening age presenting within one calendar year in a tertiary trust via a two-week wait (2WW) pathway owing to suspicion of colorectal cancer. Colorectal cancer related outcomes were compared between patients in the cohort who had previously accepted bowel cancer screening and patients who had previously declined bowel cancer screening. The primary endpoint was overall incidence of colorectal neoplasia. Secondary endpoints included incidence of colorectal malignancy, cancer related mortality, cancer related outcomes and polyp related outcomes. RESULTS: Overall, 2,227 patients presented via the 2WW pathway; 955 were aged 60-75 years. Among the latter, 411 (43%) had been screened previously and had a negative FOBT, and 544 (57%) had declined screening. Incidence of colorectal neoplasia did not differ between the two groups (113 [27%] vs 143 [26%], p=0.7). Of those with a negative FOBT and subsequent symptomatic presentation, 16 (3.9%) were diagnosed with a colorectal malignancy compared with 36 (6.6%) of those who declined screening and had subsequent symptomatic presentation (relative risk: 1.7, 95% confidence interval: 0.96-3.02, p=0.08). There were no differences between the two groups with regard to TNM (tumour, lymph nodes, metastasis) stage, Dukes' stage, metastases, number of polyps or cancer related mortality (median follow-up duration: 20 months). CONCLUSIONS: The incidence of colorectal neoplasia was similar among patients who previously had a negative FOBT and those who declined screening. There was a higher incidence of colorectal cancer detected among those who declined screening but it did not reach statistical significance. All other cancer and polyp outcomes were similar between the groups.

Impact of the United kingdom national bowel cancer awareness campaign on colorectal services.

BACKGROUND: Poor public awareness may account for the advanced stage at diagnosis, hence, poorer survival. With the aim of reducing colorectal cancer deaths, the United Kingdom National Bowel Cancer Awareness Campaign was rolled out from January 2012. Currently, the United Kingdom government target is to have all patients suspected to have cancer seen within 2 weeks of referral from general practitioners. This has significant impact on the workload for endoscopists. OBJECTIVE: The study aimed to measure the impact on colorectal services following the National Bowel Cancer Awareness Campaign. DESIGN: The data between February and July 2012 (onset of campaign) were prospectively collected and compared with data retrospectively collected between February and July 2011 inclusive (before campaign). SETTINGS: This study was conducted at a single center, university hospital. PATIENTS: The number of 2-week wait referrals, investigations, and colorectal cancers detected were assessed. MAIN OUTCOME MEASURES: Demographics, staging, and treatment of cancers were compared between groups along with the uptake of colorectal cancer screening. RESULTS: The total number of 2-week wait referrals increased by 47% with a resultant 38% increase in colonic investigations (p = 0.034) and a 23% increase in cancers detected (p = 0.0157). There was a 6.5% increase in the uptake of screening (p = 0.001) and a 62.5% decrease in the number of patients with colorectal cancer presenting as an emergency. LIMITATIONS: This short period of study is a major limitation. Although the data were from prospectively maintained databases, some data were analyzed retrospectively. Because only a single unit was assessed, results across a wider population may be more pronounced. There was also a referral bias in the compliance of primary care in the adherence to the 2-week wait referral criteria, because these criteria can be abused to get anxious patients into secondary care quickly. CONCLUSIONS: The National Bowel Cancer Awareness Campaign significantly increased the demand for colorectal services. With a potentially more favorable oncological outcome, further evaluation of supporting this greater workload demand is warranted.

Survival outcome of patients with screening versus symptomatically detected colorectal cancers.

AIM: The national Bowel Cancer Screening Programme has been rolled out nationwide following pilot screening in two health authorities in the UK. The aim of this study was to define overall 5-year survival of screen detected cancers and to compare the overall survival outcome of screened vs symptomatic patients over a 10-year period. METHOD: All patients with colorectal cancer treated at one trust in patients of screening age (50-69 years) during the pilot screening programme (2000-2008) were analysed. Patients were defined as screen detected or symptomatically detected. Disease pathology and recurrence data were obtained from the hospital's computerized results reporting system and mortality was cross-matched with data from the West Midlands Cancer Intelligence Network. RESULTS: In all, 633 patients aged 50-69 were identified in the study period; 155 patients had a screen detected cancer and 478 did not. A log-rank test completed on survival outcomes indicated that survival was significantly worse in the symptomatic group. This difference persisted if only patients treated with curative intent were considered. CONCLUSION: Survival outcome was significantly better in the screened vs the symptomatic population in all groups and also in those treated for curative intent. There was a trend towards better survival for screen detected cancer when compared stage for stage.

Emergency presentation of retrograde intussusception as a late complication of gastric bypass.

Retrograde intussusception is a rare complication of a Roux-en-Y gastric bypass. With the rising number of gastric bypass operations being performed in the UK, the incidence of retrograde intussusception is likely to increase. We report the first case in the UK and highlight its insidious presentation and the importance of considering intussusception in any patient with a history of a Roux-en-Y gastric bypass.

Prevalence and Clinical Features of Arterial Hypertension in Ruhengeri District Hospital; Musanze; Rwanda

The prevalence of arterial hypertension (AH) varies among countries and within sub-classes of a country. It has been estimated that hypertension accounts for 6 deaths worldwide. Though it is said to be a disease of developed countries; its prevalence is not lower in under-developed countries. Hypertension is a major modifiable risk factor for cardiovascular disease that can; if untreated; result in serious morbidity and mortality from cardiac; cerebrovascular; vascular; and renal diseases [1]. Optimal control of diabetes and hypertension is needed to prevent development of heart failure [2]. Rwanda is one of the most densely populated (344 persons/Sq. km; 2006) [3] under-developed countries in Eastern Africa. This study was undertaken to study the prevalence of hypertension and its clinical presentations; comorbidities and prognosis in the department of internal medicine of the Ruhengeri district hospital. It was a retrospective study in which records of hospitalized patients for the period of January to June 2008 were studied. Data of patients were collected and analyzed using SPSS (Statistical Package for the Social Sciences) version 11.5 and Epidata. Total number of patients with hypertension was 57 which were 2.53.Hypertension was more common in women (64.9); than men (35.1). The majority of patients had more than 50 years of age (64.9). The most Common symptom was headache (47.4); followed by dizziness (36.8); palpitations (28.1) and visual disturbances (19.3); epistaxis (5); miscellaneous symptoms like loss of consciousness; tinnitus; e.t.c. (59.6). The majority of patients had severe hypertension (47.4) and patients over 50 years of age had the highest prevalence of severe hypertension (67). Alcohol consumption; diabetes mellitus; congestive heart failure had significant association with hypertension. Among the patients studied; 5.26 died during the period of study. The Study revealed that the hypertension prevalence and severity of its effect were more for the patients above 50 years of age; and women were more affected as compared to men. Headache was the most common symptom among patients with hypertension

Efficacy of intraperitoneal local anaesthetic techniques during laparoscopic cholecystectomy.

BACKGROUND: Pain following laparoscopic cholecystectomy (LC) is a barrier to early discharge. Some studies have demonstrated that local anaesthetic (LA) washed over the liver and gallbladder decreases postoperative pain. In many patients pain is partially of diaphragmatic origin which may not be treated effectively by topical wash. This study assesses the efficacy of LA injected to the peritoneum of the right hemidiaphragm or topical wash with a control group. METHODS: We performed a double-blind randomized sham controlled trial of 128 consecutive subjects who underwent elective LC. Patients received subcutaneous bupivacaine, a diaphragmatic injection of bupivacaine or sham, and topical wash over the liver/gallbladder with bupivacaine or sham depending upon allocation. The primary outcome was VAS pain scores on the ward. Secondary outcomes included VRS pain scores in theatre recovery, analgesic use, physiological observations, time to eating and ambulation, and successful day-case surgery. RESULTS: Pain scores were significantly lower in both LA groups versus control in theatre recovery but only in the subperitoneal diaphragm injection group when the patients returned to the ward. Subperitoneal diaphragm injection was associated with a reduced time in theatre recovery (p = 0.04). CONCLUSIONS: Intraperitoneal techniques of LA during LC decrease postoperative pain and shorten time in theatre recovery. Injection of LA to the right hemidiaphragm is associated with lower pain scores for a longer period following LC than a previously validated wash technique.

Acute pancreatitis following adder bite in the UK: a case report.

Adder bites are common in the UK usually manifesting with localised swelling and gastrointestinal symptoms. We report a rare case of acute pancreatitis secondary to an adder bite in Wales and highlight this serious complication which was managed with standard treatment.

Essential thrombocythemia in a young man treated for myocardial infarction.

Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm which can cause thrombohaemorrhagic complications usually involving microvasculature. Medium-sized arterial thrombosis has been reported, but coronary occlusion usually occurs with additional risk factors, for example, smoking, hyperlipidaemia and so on. We present a case of acute myocardial infarction (AMI) in a young man (29 years) with ET but without any coronary artery associated risk factors. He was successfully treated for his AMI and ET with cytoreductive treatment and has recovered well. Due to automated platelet counting, ET is being increasingly identified; early detection can prevent long-term complications, and patients can have normal life span.

Immunoprofile of Hodgkin's lymphoma in India.

AIMS AND BACKGROUND: The immunoprofile of the Reed Sternberg cell with respect to immunoreactivity for CD20 and lack of CD15 has been described as a poor prognostic factor. Large scale studies analyzing the immunoprofile of Hodgkin's lymphoma (HL) from India are lacking. The aim of this study was to obtain baseline information on relative frequencies and immunoprofiles of the two major types of HL and comparing reports from developed and developing countries. MATERIALS AND METHODS: 451 cases of HL were classified as per the WHO into classical (n= 397) HL (cHL) and nodular lymphocyte predominant HL (NLPHL) (n=54). Cases of cHL were divided into 5 immunophenotypic groups; Group A (CD15+,CD30+,CD20-), Group B (CD15-,CD30+,CD20-), Group C (CD15+,CD30+,CD20+), Group D (CD15-,CD30+,CD20+)and Group E (CD15-,CD30-,CD20+). In cases of NLPHL, the immunophenotype of lymphocytes in the background, whether T(CD3) or B(CD20) rich was observed. RESULTS: Most cases of cHL belonged to Group A (44.58%) followed by Group B (40.05%), C(5.54%), D(9.57%) and E(0.25%). Half, (50.89%) the cases of cHL were immunonegative for CD15, whereas CD20 was expressed by 15.61% of the cases. Three (5.55%) cases of NLPHL showed a CD3 (T) cell rich background. Significant differences were also observed with respect to the age distribution of cHL as compared to the west. CONCLUSION: Our study demonstrates that India has a high number of CD15 negative and a relatively higher number of CD20 positive cHL cases as compared to the western population. Favorable treatment response and good cure rates that one sees in western cHL may not apply to India.

Breathing comfort associated with different modes of ventilation: a comparative study in non-intubated healthy Nepalese volunteers.

OBJECTIVE: To compare subjective experience of comfort associated with various commonly used supportive modes of mechanical ventilation for weaning in the intensive care unit (ICU). SUBJECTS AND METHODS: The study was carried out in general ICU of a community-based teaching hospital in 30 healthy adult Nepalese volunteers of either sex and 19-37 years of age. The subjects were randomly made to experience breathing via anatomical facemask through ventilator circuit with synchronized intermittent mandatory ventilation (SIMV), assisted spontaneous breathing (ASB), biphasic positive airway pressure (BiPAP), and continuous positive airway pressure (CPAP) modes of ventilation with parameters set at intermediate level of respiratory support. Subjective comfort of breathing was noted using a 10 cm visual analogue scale (VAS) with no discomfort at one end and maximum imaginable discomfort at the other. Inspiratory and expiratory experience of discomfort was also noted using a four point ranking scale (0-no discomfort, 1-mild discomfort, 2-moderate discomfort and 3-severe discomfort). In addition, presence or absence of feeling of breathlessness and inflation was also noted. RESULTS: BiPAP was the most comfortable mode of ventilation (p<0.01) on visual analogue scale. SIMV and CPAP modes were associated with higher discomfort than other modes during inspiratory and expiratory phases respectively. Breathlessness and inflation were least felt in BiPAP and SIMV modes respectively. CONCLUSION: Perception of breathing comfort can vary widely with various supportive modes of ventilation in the ICU. Hence, no single supportive mode should be used in all patients during weaning from mechanical ventilation. Key words: assisted spontaneous breathing; biphasic positive airway pressure; breathing comfort; continuous positive airway pressure; mechanical ventilation; supportive modes synchronized intermittent mandatory ventilation; weaning.

Percutaneous tracheostomy.

The purpose of this review is to discuss the various techniques of percutaneous tracheostomy and to assess their safety and efficacy profile, indications and contraindications, early and late complications. Literature was reviewed from Medline and MD Consult databases. Early techniques by Sheldon, toye and Schachner have been abandoned due to their high complication rates. Percutaneous dilational tracheostomy using the Ciaglia kit (Wiliam Cook Europe Bjaeverskov) and a Griggs kit (Portex PDT kit, POrtex, Hythe, Kent, UK) has been used most often. Griggs guide Wire Dilator Forceps kit (SIMS, Portex, Hythe, Kent, UK) is the next most common in use but its long-term studies are few. Fantoni (TLT set, Mallinckrodt Medical) and PercuTwist device (Riisch, Kernen, Germany) are two new techniques currently under study. Percutaneous dilational tracheostomy and conventional surgical tracheostomy are still competing methods to provide an airway for intensive care patient requiring assisted ventilation. Review of literature shows that percutaneous tracheostomy is safe, cost-effective and compares favourably with the open surgical tracheostomy. Many intensive care units now use the percutaneous tracheostomy as a procedure of choice. Percutaneous tracheostomy has a learning curve and requires appropriate case selection and meticulous attention to the technique by all those who want to use this method.