Change in Sleep Quality of Residents the Night Before High-Fidelity Simulation: Results From a Prospective 1-Year National Survey

Objective:

The stress level of participants in high-fidelity simulation stems from various factors but may result in anticipatory anxiety causing sleep disturbances during the night prior to simulation. The objective of this survey was to determine the change in sleep quality of residents during the night prior to the simulation.

Methods:

The survey was proposed for 1 year to all residents at the beginning of the simulation, in 10 simulation centres. The questionnaire combined demographics and the Leeds Sleep Evaluation Questionnaire using visual analogue scales divided into 4 sleep qualitative domains. The primary outcome was the prevalence of sleep disturbance (>10 mm on 1 domain). Secondary outcomes were the prevalence of severe sleep disturbance (>25 mm), as well as qualitatively and quantitatively reported explanatory sleep parameters.

Results:

Among respondents, 66% [95% CI: 63 to 69] of residents had more than 10 mm and 27% [95% CI: 24 to 30] had more than 25 mm of sleep disturbance. Residents with a sleep disturbance of more than 10 mm had fewer hours of sleep (6.4 [standard deviation = 1.8] vs 7.3 [standard deviation = 1.3], difference: −0.9 [95% CI: −1.1 to −0.7]; P < .0001), with a higher number of night-time awakenings (1.3 [standard deviation = 1.5] vs 0.7 [standard deviation = 0.9], difference: 0.6 [95% CI: 0.4 to 0.8]; P < .0001).

Conclusion:

Among residents participating in the simulation, a high prevalence of change in sleep quality during the night before the simulation was noted. Strategies to help residents achieve better sleep prior to simulation should be explored.

S’exercer à l’afflux massif de victimes hospitalières… Comment faire ?

La capacité à accueillir un afflux massif de victimes au sein d’un hôpital fait partie des obligations de tout établissement de santé (ES). Les modalités de cet accueil sont définies de façon réglementaire par le plan blanc d’établissement. Chaque ES doit s’entraîner. Les exercices sont un élément clé pour apprendre à mieux faire face à ces situations sanitaires exceptionnelles et inhabituelles. Ils permettent de tester les dispositifs et procédures en place, d’acquérir de l’expérience, de déterminer les points forts, les faiblesses et les axes d’amélioration. La conception d’un exercice nécessite avant tout la définition de ses grandes caractéristiques (contexte, type, objectifs), la détermination du cadre et du périmètre de l’exercice (convention d’exercice), la détermination des ressources humaines (animateurs, plastrons, évaluateurs, observateurs) et matérielles nécessaires. Il faudra aussi écrire le scénario (initial, cadence, évolutions prévues), organiser les conditions d’animation (dossier d’exercice) et d’observation, définir les modalités de briefing, de débriefing et les modalités d’évaluation (outils et critères). L’exercice devra mener à un retour d’expérience avec propositions de mesures correctrices si nécessaire. Il doit être piloté par un comité de pilotage multiprofessionnel sous l’égide du directeur d’établissement ou de son représentant. Il doit être conçu comme une étape dans un processus d’amélioration des pratiques professionnelles au profit des patients.

[Design and creation of a simulation centre]

The design of a simulation centre must be based on a well thought out pedagogical project which meets the training needs of health professionals. Beyond the architectural design, the organisational and financial aspects of the centre are fundamental elements to be taken into consideration.

Shedding light on the effective fluorophore structure of high fluorescence quantum yield carbon nanodots

The unique luminescence properties of carbon nanodots (CDs) originate from pyridone-like fluorophores bound to carbon core.

Evolution of stress in anaesthesia registrars with repeated simulated courses: An observational study

BACKGROUND AND OBJECTIVE

High-fidelity medical simulation is a source of stress for participants. The aim of this study was to assess if repeated simulated courses decrease perceived stress and/or physiological stress level and increase performance in anaesthesiology registrars.

METHOD

Fourteen anaesthesiology specialty registrars participated individually in three successive sessions of crisis simulation in the operating room. Participants' perceived stress levels were measured by self-assessment (simple numerical scale from 0 to 10 [0=no stress, 10=maximum stress]) and physiological stress was estimated via the maximal heart rate measured by a Holter system). Technical and non-technical performances were also assessed. Data are expressed as medians with interquartile ranges and extremes (median (IQR [Min-Max])).

RESULTS

Between the first and third session, simulation repetition was associated with a decrease in perceived stress (9 (8-10 [5-10]) versus 7 (5-8 [2-9]) from session 1 to session 3 respectively, P=0.02), whereas physiological stress assessed by the maximum heart rate remained unchanged (130 beats per minute (116-141 [85-170]) and 123 beats per minute (115-136 [88-166]) between sessions 1 and 3 respectively). There was also a significant inverse correlation between perceived stress levels experienced by registrars during the session and non-technical performance (P=0.008).

CONCLUSION

We observed a reduction in perceived stress levels experienced by registrars while physiological stress was unchanged with repeating simulation sessions combining simulated practice and debriefing. Learning through simulation could improve perceived stress management in critical situations.

TEM investigations on the local microstructure of electrodeposited galfenol nanowires

The local microstructure of Fe-Ga nanowires is investigated considering dependence on the deposition technique. Using a complexed electrolyte, smooth and homogeneous Fe80Ga20 nanowires are deposited into anodic aluminum oxide templates by either applying pulse potential or potentiostatic deposition technique. At optimized deposition conditions the wires show the desired composition of Fe80±2Ga20±2 without a gradient along the growth direction. Composition distribution, structure and microstructure are examined in detail and reveal only minor differences. Line EELS and crystal lattice measurements reveal a negligible oxygen content for both preparation routines. Neither Fe/Ga oxides nor hydroxides were found. Both potentiostatically deposited as well as pulse deposited nanowires exhibit a preferred 〈110〉orientation, the latter with slightly larger crystals. Different contrast patterns were found by TEM that appear more pronounced in the case of pulse deposited wires. High resolution transmission electron microscopy analysis and comparison of differently prepared focused ion beam lamellas reveal that these contrasts are caused by defects in the alternating potential deposition itself and are not induced during the TEM preparation process. The alternating potential mode causes periodic growth thereby inducing different layers with reduced wire thickness/defects at the layer interfaces.

Strategy for recruitment and factors associated with motivation and satisfaction in a randomized trial with 210 healthy volunteers without financial compensation

Background

The aim was to describe a strategy for recruitment of healthy volunteers (HV) to a randomized trial that assessed the efficacy of different telephone techniques to assist HV in performing cardiac massage for vital emergency. Participation in the randomized trial was not financially compensated, however HV were offered emergency first-aid training. We also studied factors associated with HV motivation and satisfaction regarding participation in the trial.

Methods

Strategy for recruitment of 210 HV aged 18 to 60 years was based on: (1) the updated records of all telephone number since January 2000 of HV registered in the Rouen Clinical Investigation Centre HV database, (2) a communication campaign for the general public focussing on posters and media advertisements. Data on the recruitment, socio-demographics, motivation and satisfaction of the 210 HV were collected by anonymous self-administered questionnaire.

Results

Of the 210 HV included, 63.3% (n = 133) were recruited from the HV database and 36.7% (n = 77) by the communication campaign. On the one hand, the HV database enabled screening of 1315 HV, 54.8% (n = 721) of whom were reached by phone, 55.2% (n = 398) of these latter accepted to participate in the study and 10.1% of the initial screening (n = 133) were finally included. One the other hand, for the 77 HV not recruited from the HV database, word-of-mouth (56.1%) was the main means of recruitment. The male/female ratio of the 210 HV was 0.5 and mean age 43.5 years (Standard Deviation = 12.4). The main motivations given for participating in the trial were to support research (87.6%) and receive emergency first-aid training (85.7%). Overall satisfaction with the welcome process was significantly higher for older HV (46–60 years) (adjusted odds ratio (AOR): 3.44; 95% confidence interval (95% CI): 1.48-7.99), and for HV in management jobs (AOR: 4.26; 95% CI: 1.22-14.87). Satisfaction with protocol management was higher for women (AOR: 2.33; 95% CI: 1.18-4.60) and for older HV (46–60 years) (AOR: 4.76; 95% CI: 1.97-11.52).

Conclusions

Recruitment of non-compensated HV required broad screening with a primary HV database alongside word-of-mouth communication which seemed more efficient than media advertising. To enhance HV recruitment to randomized trials without financial compensation it seems crucial to provide them not only with a direct interest but also to ensure their satisfaction.

Delamination of graphite in a high pressure homogenizer

A scalable industrial method for graphene and Few-Layer-Graphene (FLG) production by graphite delamination in N-methylpyrrolidone and water–surfactant mixtures using a high pressure homogenizer is presented.

Synthesis of silver nanoparticles in melts of amphiphilic polyesters

The current work presents a one-step procedure for the synthesis of amphiphilic silver nanoparticles suitable for production of silver-filled polymeric materials. This solvent free synthesis via reduction of Tollens' reagent as silver precursor in melts of amphiphilic polyesters consisting of hydrophilic poly(ethylene glycol) blocks and hydrophobic alkyl chains allows the production of silver nanoparticles without any by-product formation. This makes them especially interesting for the production of medical devices with antimicrobial properties. In this article the influences of the chain length of the hydrophobic block in the amphiphilic polyesters and the process temperature on the particle size distribution (PSD) and the stability of the particles against agglomeration are discussed. According to the results of spectroscopic and viscosimetric investigations the silver precursor is reduced to elemental silver nanoparticles by a single electron transfer process from the poly(ethylene glycol) chain to the silver ion.

[Reliability of pulsatile saturometry in patients with shock. Digital standard sensors are not reliable for facial measurement!]

INTRODUCTION

Non-invasive monitoring of oxygen saturation by pulse oxymetry (SpO(2)) is sometimes perturbed on fingers during shock states. Other sites are possible (toes, forehead, nose, ear). Self-adhesive standard digital sensors are commonly used off-label in these sites. We have assessed their reliability for all of these sites.

METHODS

We have studied patients presenting a stabilized shock state and receiving vasoconstrictive catecholamines. When an arterial blood gas was ordered, six SpO(2) were measured quasi-simultaneously (self-adhesive standard sensors): right and left index, toe, forehead, nose and ear. SpO(2) at "finger", "toe", "forehead", "nose" and "ear" were compared to the arterial oxygen saturation (SaO(2)) by using the Bland and Altman method. The plethysmographic curve was assessed as "correct" or "unsatisfactory".

RESULTS

Hundred and ten patients were included (63 ± 15 years, SAPSII 46 ± 16, catecholamines: 0.6 ± 0.5 μg/kg/min). Plethysmographic curves are more often of "correct" quality for fingers (90%) than for the other locations (50 to 70%). Bias are low for all the locations (-0.1 to +1.5%). Limits of agreement are around ±5% for fingers and toes, but as high as ±15% for the face locations. When the analysis is restricted to plethysmographic curves of "good" quality, the limits of agreement are unchanged for fingers and toes, but improved (between ±5 to ±10%) for face locations.

CONCLUSION

In patients with a shock receiving vasoconstrictive catecholamines, the reliability of SpO(2) measurements with standard sensors appears better for fingers than for toes and face locations. These standard sensors should be discouraged for facial measurement because of their low reliability, even when the plethysmographic curve seems correct. Sensors specifically designed for each facial site exist, and their reliability should be estimated in patients receiving vasoconstrictive catecholamines.

UV and Visible Light Acrylate Photopolymerisation Initiated by Nitrogen- or Carbon-Doped Titanium Dioxide

Nitrogen and carbon doped titania powders initiate acrylate polymerisation upon UV excitation. Time resolved photovoltage measurements afford surface charge carrier lifetimes of 7–8 ms for undoped and N-doped titania, whereas 12 ms are observed for the C-doped semiconductor. These values correlate with the observation that the polymerisation rate constants are similar for titania or N-doped titania but about two times larger for the C-doped material. Wavelength dependent polymerisation experiments indicate that visible light polymerisation is possible only with carbon-doped titania. This suggests that hole relaxation to dopant-centered surface states is much more efficient in nitrogen-doped titania. These experimental findings are in accord with the assumption that polymerisation is initiated by hole oxidation of the acrylate.

Kinetics of radical formation during the mechanical activation of quartz

The kinetics of radical formation during the mechanical activation of quartz by wet grinding or sonication was investigated using 2,2-diphenyl-1-picrylhydrazyl (DPPH) as a scavenger. The consumption of DPPH during the sonication of quartz in an ethanol suspension is a zeroth-order process. A linear relationship between the rate constant of the DPPH consumption and the quartz concentration in the suspension indicates that radical formation under sonication increases with the growing total surface area of the quartz particles. Sonication leads to the formation of free radicals by the mechanical activation of the particle surface. The kinetics of the DPPH consumption during wet grinding of quartz in a stirred media mill is described successfully by a modified zeroth-order rate law taking the total surface area of the quartz particles into account. The surface-normalized rate constant of the DPPH consumption decreases from 1.8x10(-7) mol L(-1) h(-1) m(-2) to 4.8x10(-8) mol L(-1) h(-1) m(-2) if the specific surface area of the feed material increases from 0.5 to 84 m2/g. This finding indicates that the breakage of the quartz particles contributes much more to radical formation than does the mechanical activation of the particles in the mill because the breakage rate increases with growing particle diameter. Ethanol but not DPPH was found on the surface of the ground quartz particles. From this finding, it can be concluded that radicals on the surface of the quartz particles react with ethanol, leading to the formation of ethanol radicals and H radicals. DPPH reacts with the H radicals. As a side reaction, radicals can react with oxygen, leading to the formation of peroxides.

Validity of medical staff assessment at admission of patient's risk of nosocomial infection: a prospective study in a surgical intensive care unit

OBJECTIVE

To evaluate the ability of a surgical intensive care unit (SICU) medical staff to assess at admission the individual risk of nosocomial infection (NI) during SICU stay in patients admitted for at least 48 h.

DESIGN

Prospective observational study.

SETTING

A tertiary-care university hospital.

PATIENTS AND PARTICIPANTS

201 admissions to the SICU from November 19, 2003, until April 16, 2004.

MEASUREMENTS AND RESULTS

Assessment by medical staff at admission of each patient's estimated risk of NI (pneumonia, venous central catheter-related infection, symptomatic urinary tract infection, and bacteremia) during SICU hospitalization, in order to classify patients into four groups: NI risk very low or absent (group 1), low (group 2), high (group 3), very high or certain (group 4). NI was diagnosed via routine surveillance according to Centers for Disease Control case definitions.

RESULTS

154 patients were assessed; the percentage of patients with NI increased with estimated risk at admission, from 0% in group 1 to 14.3% in group 4. Positive predictive value of medical assessment varied from 8.4% to 14.5%, according to the cutoff value. Negative predictive value varied from 92.1% to 100%.

CONCLUSION

Our study suggests that ICU physicians encounter a major difficulty when informing patients or patients' families about the risk of NI occurrence, as they cannot predict this risk accurately. This limitation should be explained to patients and their families.

Complications durant le transport intrahospitalier de malades critiques de réanimation

INTRODUCTION

Intrahospital transport (IHT) of mechanically ventilated critically ill patients is associated with an important risk of complications.

OBJECTIVES

The purpose of this study was to assess the incidence of complications occurring during the IHT and to analyse the causes and the consequences of such complications.

PATIENTS AND METHODS

All the IHT performed in mechanically ventilated patients, hospitalised in medical and surgical intensive care units of a university hospital were prospectively included during a three-month period. Complications were defined as follows: patient related problems (desaturation, restlessness, haemodynamic instability, extubation) and ventilator related problems (breakdown or defect of the material).

RESULTS

123 IHT concerning 64 patients were analysed, with 64 IHT were realised for diagnostic procedure (computed tomography) and 59 for therapeutic procedure (surgical procedure or interventional radiology). At least one patient related problem occurred during 41 IHT (33%) (desaturation n = 11, agitation n = 21, haemodynamic alterations n = 19, extubation n = 0). In two patients, these complications led to cardiac arrest. Patient related problems were observed more frequently in sedated patient (66 %, p = 0.0001) as well as during IHT for diagnostic procedure (p = 0.03). A ventilator problem occurred in 26 transports (21 %) and was more frequently reported when a turbine ventilator was used (p = 0.0056).

CONCLUSION

This study supports the fact that IHT of mechanically ventilated critically ill patients, is a high-risk procedure associated with potentially severe complications. This finding emphasises the need of standardised procedures and medical surveillance during IHT.

Transarterial aortic valve replacement with a self expanding stent in pigs

OBJECTIVES

To evaluate the feasibility of percutaneous aortic valve replacement without cardiac arrest in animal experiments.

METHODS

A self expanding nitinol stent, containing pulmonary valves from pigs in its proximal part, was implanted in six pigs (94-118 kg) by means of a 25 French catheter through the left subclavian artery under guidance of fluoroscopy and transoesophageal echocardiography. During stent deployment the original aortic valve was pushed against the aortic wall by the self expanding force of the stent while the new valve was expanded.

RESULTS

It was possible to replace the aortic valve in the beating heart in four pigs (67%) with no complication or relevant drop in blood pressure. The procedure failed in two pigs (33%) due to dysfunction of the catheter device in one case and to problems with correct positioning in the left ventricular outflow tract in the other. After successful stent valve implantation, dopamine was infused in doses of 5 microg/kg/min, 10 microg/kg/min, and 15 microg/kg/min. Cardiac output increased from 4.4 to 8.8 l/min and the mean arterial pressure rose from 79 to 105 mm Hg. The maximum peak to peak pressure gradient across the valve carrying stent reached a maximum of 8 mm Hg under dopamine infusion. All pigs were killed six hours after transvascular aortic valve replacement. The chest was opened, and the left ventricle and the ascending aorta were carefully inspected. There were no signs of malfunction of the implant, of damage of the aortic vessel wall, or of obstruction of the coronary ostia.

CONCLUSIONS

Percutaneous aortic valve replacement with a self expanding nitinol stent in the beating heart is possible. The device was safe under pharmacological stress test. After successful chronic animal experiments, this concept may become a feasible option for treating patients with relevant aortic valve disease but where open heart surgery would be risky.

Effect of keratinocyte growth factor on the proliferation, clonogenic capacity and colony size of human epithelial tumour cells in vitro

PURPOSE

The effect of recombinant human keratinocyte growth factor (rHuKGF) on the proliferation, clonogenic capacity and colony size of low-passage human epithelial tumour cells was tested in vitro.

MATERIALS AND METHODS

Five tumour cell cultures derived from head and neck squamous cell carcinomas, three cultures derived from pleural effusions of carcinomas of different origin and normal human nasal epithelial cells were analysed in passages 2-4. Expression of FGF7 and its receptor (FGFR2) were determined by the RNase protection assay. Cells were incubated with rHuKGF (10-200 ng ml(-1)) 3 days before or immediately after plating for clonal growth in serum-depleted media. To determine cellular radiosensitivity, single doses of 1-8 Gy X-rays were applied. Colony formation as well as colony size, reflecting the number of cell divisions, was determined after 10-15 days of growth in rHuKGF-treated and control cells.

RESULTS

Normal nasal epithelial cells showed a two- to threefold increase in the number of cell divisions due to rHuKGF-treatment. In tumour cell cultures, significant stimulation of proliferation occurred in only one of eight samples. Tumour cells expressed FGF7 mRNA and protein, and low levels of FGFR2 mRNA. The addition of rHuKGF to the medium of the tumour cell cultures influenced neither radiation-induced impairment of proliferation nor clonogenic cell survival.

CONCLUSION

rHuKGF has been shown to ameliorate the radiation tolerance of normal epithelia. The minimum in vitro tumour cell response to rHuKGF compared with normal epithelial cells suggests a potential for selective protection of normal epithelia during radiotherapy. The low FGFR2 expression as well as the FGF7 expression in the tumour cells may contribute to their resistance to rHuKGF treatment.

Independent regulatory elements in the upstream region of the Drosophila beta 3 tubulin gene (beta Tub60D) guide expression in the dorsal vessel and the somatic muscles

The beta 3 tubulin gene (beta Tub60D) is a structural gene expressed during mesoderm development from the extended germ band stage onward. Expression within the individual mesodermal derivatives is guided by different control elements. The upstream regions allow expression in the dorsal vessel and the somatic mesoderm while enhancers localized in the first intron guide expression in the visceral mesoderm. Deletion analysis carried out in transgenic flies revealed independent regulatory elements for the dorsal vessel and the somatic mesoderm. For expression in the somatic mesoderm, a 279-bp region is absolutely essential. This region contains a binding site for the Drosophila myocyte-specific enhancer binding factor 2 (D-MEF2), a MADS-box transcription factor known to be essential for mesoderm development. Deletion or mutation of this D-MEF2 binding site strongly reduces transcription. This pattern is consistent with the strongly reduced expression of beta 3 tubulin in D-mef2 mutant embryos. This analysis furthermore reveals that the D-MEF2 binding site acts in concert with nearby cis regulatory elements. These data show that the upstream control region of the beta 3 tubulin gene is an early target of the D-MEF2 transcriptional activator.

The mesodermal expression of rolling stone (rost) is essential for myoblast fusion in Drosophila and encodes a potential transmembrane protein

In homozygous rolling stone embryos, the fusion of myoblasts to syncytial myotubes is diminished. Nevertheless, the visceral mesoderm, the heart mesoderm, and few somatic muscles are properly formed. Thus, we postulate a central role of rolling stone for the fusion process within the somatic mesoderm. We have cloned the rolling stone gene, and the deduced protein sequence is in accordance with a transmembrane protein, which agrees with the enrichment of Rost in the membrane fraction of Drosophila embryos. No homologous genes have been described so far. rolling stone is expressed in the embryonic nervous system and cells of the somatic mesoderm, most notable in muscle founder cells. To elucidate the function of rolling stone for myoblast fusion, we applied a knock-out strategy. The expression of an antisense rolling stone transcript specifically within the mesoderm of wild-type embryos results in fusion defects of myoblasts, proving that the rolling stone expression in the mesoderm is responsible for the rolling stone phenotype. We suggest that rolling stone is a member of a group of genes that are necessary for the fusion process during myogenesis.

Concurrent radiation therapy, 5-fluorouracil, and cisplatin for stage II, III, and IV, node-negative, squamous cell head and neck cancer. Results and surgical implications

METHODS

Between 1983 and 1989, 42 patients with Stage II, III, and IV, node-negative, squamous cell head and neck cancer were treated with concurrent 5-fluorouracil, cisplatin, and radiation therapy. Two courses of chemotherapy with 30 Gy of concurrent radiation therapy were to be followed in all patients by definitive surgery and then an additional 30 Gy of radiation therapy and one to two courses of chemotherapy. The patients who achieved a complete response to the initial induction treatment, however, did not undergo surgery.

RESULTS

After the completion of all therapy, 41 of the 42 patients (98%) were considered disease-free. Only 4 of these 41 had relapses, for a projected Kaplan-Meier disease-free survival rate of 86%. Treatment failure occurred in no patients with Stage II, 1 of 17 patients with Stage III, and 4 of 14 patients with Stage IV disease. Of the 42 patients, 23 (55%) did not require surgery after achieving a complete response to induction therapy, and only 1 of these 23 patients subsequently had a relapse.

CONCLUSIONS

Although the value of adding chemotherapy to conventional treatment remains unproven in squamous cell head and neck cancer, this treatment schedule appears promising in node-negative disease. Randomized trials will be necessary, however, to validate the efficacy of this approach and confirm the suggestion by the authors that surgery can be avoided in most patients with N0 disease.

Long-term results after chemoradiotherapy for locally confined squamous-cell head and neck cancer

The long-term results after simultaneous chemoradiotherapy in 54 patients with previously untreated or minimally treated, locally confined (M0) squamous-cell carcinoma of the head and neck are presented. Multiple concurrent courses of radiation therapy and chemotherapy with cisplatin and a four-day 5-fluorouracil infusion were given. Twenty-eight patients underwent definitive surgery and 26 were treated without surgical resection. Treatment-associated toxicity was significant, including mucositis, myelosuppression, and a mean 12% loss of initial body weight. Of the 54 patients, 51 were ultimately rendered disease free by this combined modality protocol. With a follow-up ranging from 42-68 months, the projected Kaplan-Meier relapse-free survival for the entire patient cohort is 70%, with all relapses occurring within 17 months of patient entry. The projected Kaplan-Meier relapse-free survival for patients with Stage IV disease is 62%. The durability of these remissions suggests that there is a significant likelihood of cure in all patients with locally confined disease, and justifies comparative trials with standard treatment.

Simultaneous versus sequential combined technique therapy for squamous cell head and neck cancer

Forty-eight patients with locally confined (M0) squamous cell head and neck cancer were prospectively randomized to receive either simultaneous (SIM) or sequential (SEQ) combined technique therapy with a 5-fluorouracil infusion, a cisplatin bolus injection, and radiation therapy. Patients with residual resectable disease underwent surgery after induction therapy, whereas those achieving a complete response to induction did not require surgery. Patients on the two treatment arms were equivalent in all measured variables, including disease extent. Toxicities of the SIM and SEQ arms also were equivalent except for mucositis and the resultant weight loss, which were more severe on the SIM arm (P = 0.002). With a follow-up time ranging from 9 to 41 months, seven of the 24 SIM patients and 14 of the 24 SEQ patients are considered treatment failures. The relapse-free survival is significantly better on the SIM arm (P = 0.03), although an overall survival advantage has not yet been demonstrated (P = 0.13). The achievement of a complete response after induction therapy correlates with both the relapse-free (P = 0.0005) and overall (P = 0.05) survival, and the likelihood of an induction complete response also is significantly better for those treated with the SIM schedule (P = 0.02). Eighteen patients did not require surgery after achieving an induction complete response. Relapse-free survival does not appear to be compromised in this patient subset.

Chemoradiotherapy as initial management in patients with squamous cell carcinoma of the head and neck

Thirty-nine previously untreated or minimally treated patients with squamous cell carcinoma of the head and neck were entered onto a chemoradiotherapy protocol employing multiple courses of simultaneous radiation therapy, cisplatin, and a 4-day 5-FU infusion. Thirty-eight patients were evaluable for response and toxicity. Twenty-three patients underwent surgical resection midway through this therapy and 11 (48%) were pathologically free of disease. Thirty-five of the 38 patients (92%) were ultimately rendered disease-free by this combined modality protocol. Thirty-one patients remain disease-free, with a projected 2-year disease-free survival of 74%. Although the treatment-associated mucositis and myelo-suppression were significant, this chemoradiotherapeutic approach is promising and merits further study.

Combination chemotherapy prior to definitive local therapy in squamous cell carcinoma of the head and neck

30 patients with locally advanced squamous cell carcinoma of the head and neck were given chemotherapy with methotrexate, bleomycin and cis-Platinum prior to planned definitive surgery and/or radiation therapy. Chemotherapy was well tolerated and 90% of patients responded. Of 14 initially unresectable patients, 6 became operable after chemotherapy. After definitive therapy 70% of patients were considered complete responders, and 43% of the entire cohort remain disease-free. All partial responders have died. Patients receiving chemotherapy, surgery and radiation had a significantly greater likelihood of achieving a complete response than those receiving chemotherapy and radiation alone. Although this initial chemotherapy is highly active in this disease its contribution to ultimate survival is unclear. Overall treatment success is determined by the results of definitive therapy.