Inhaled lidocaine for prevention of hemodynamic changes in laryngoscopy and intubation

This study was undertaken to examine the efficacy of lidocaine aerosol pretreatment in attenuating hemodynamic (HD) responses secondary to laryngoscopy and tracheal intubation in patients undergoing surgery for intracranial space occupying lesions (ICSOL). A semiclosed breathing system was improvised to generate aerosol of consistent density. Five percent lidocaine was nebulized in two different dosages (0.2 and 0.1 ml/kg in groups A and B, respectively); group C (control) received aerosol of normal saline. The average aerosol-treatment time was 24, 12, and 16 min in groups A, B, and C, respectively. Changes in heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and rate pressure product (RPP) were analyzed by analysis of variance (ANOVA). In group A, tracheal intubation did not cause significant HD changes. In group B, a significant increase was observed in each HD parameter which, when compared with control, was less severe. Lidocaine toxicity, regurgitation, nausea, vomiting, or aspiration did not occur in any patient. Patients accepted the procedure well. This study found efficacy of the technique to be related to duration of aerosol treatment.     

Competing causes of death and second primary tumors in patients with locoregionally advanced head and neck cancer treated with chemoradiotherapy.

PURPOSE: The purpose of this retrospective analysis was to evaluate the emergence of second primary malignancies and the contribution of different causes of death to the outcome of patients with locoregionally advanced head and cancer receiving primary chemoradiotherapy. EXPERIMENTAL DESIGN: We studied 324 patients with stage IV squamous cell head and neck cancer who were enrolled on five consecutive multicenter Phase II studies of concurrent chemoradiotherapy. All of the regimens included concurrent 5-fluorouracil and hydroxyurea on an alternate week schedule with radiotherapy, either alone (FHX) or with cisplatin (C-FHX) or paclitaxel (T-FHX). The cumulative incidence of second primary tumors or death from any cause was estimated using methods of competing risk analysis. RESULTS: Median follow-up of surviving patients was 5.2 years (2-10.6 years). The 5-year overall survival and progression-free survival of the cohort were 46% and 65%, respectively. Causes of death and median time of occurrence were as follows: disease (n = 88; 1.5 years), treatment-associated acute or late complications (n = 30; 4 months), second primary tumors (n = 18; 3.5 years), comorbidities (n = 41; 1.9 years), and unknown (n = 20; 5.1 years). Predominant causes of death from comorbidities were cardiac and respiratory illnesses. Twenty-six patients (8%) developed a second primary tumor at a median time of 2.8 years (4 months to 10 years). The cumulative incidence of second primary tumors was 5%, 7%, and 13% at 3, 5, and 10 years, respectively. The most frequent site of second primaries was the lung (n = 13), followed by the esophagus (n = 3) and head and neck (n = 2) CONCLUSIONS: Patients with locoregionally advanced head and neck cancer treated with concurrent chemoradiotherapy are potentially curable but face significant risks of mortality from causes other than disease progression. Ameliorating toxicity, and implementing secondary screening and chemoprevention strategies are major goals in the management of head and neck cancer.     

A comparison of self-reported colorectal cancer screening with medical records.

The purpose of this study was to compare self-reports of colorectal cancer (CRC) screening by fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy with medical records in a multiprovider health care setting. Relatives of CRC patients residing in Ontario, Canada completed a questionnaire indicating whether or not they had ever had any CRC screening tests. Medical records from physician's offices and hospitals were compared with the self reports, and where possible, reasons were obtained for nonmatching reports. Medical records for colonoscopies were readily available from various sources, and self-reports of this procedure were very accurate (kappa statistic for agreement beyond chance = 0.87). For sigmoidoscopy and FOBT, the agreement was poorer (kappa = 0.29 and 0.32, respectively); however, there were difficulties in obtaining records for these two procedures. Sigmoidoscopy procedures that took place many years ago were difficult to document, and physician's offices were unable to provide FOBT reports in many cases. Self-reports of colonoscopy were very accurate in this population, whereas self-reports of sigmoidoscopy and FOBT are somewhat less accurate, although this is likely due to challenges in obtaining a confirmatory record rather than an overreporting of tests. In a multiprovider publicly insured health care setting such as Canada, using self-reported information is likely to provide sufficiently accurate information for colonoscopy, but for other CRC screening tests, there may be difficulty in obtaining true estimates of the frequencies of these procedures.     

Weekly carboplatin and paclitaxel followed by concomitant paclitaxel, fluorouracil, and hydroxyurea chemoradiotherapy: curative and organ-preserving therapy for advanced head and neck cancer.

PURPOSE: The paclitaxel, fluorouracil, and hydroxyurea regimen of paclitaxel, infusional fluorouracil, hydroxyurea, and twice-daily radiation therapy (TFHX) administered every other week has resulted in 3-year survival rates of 60% of stage IV patients. Locoregional and distant failure rates were 13% and 23%, respectively. To reduce distant failure rates, we added a brief course of induction chemotherapy to TFHX. PATIENTS AND METHODS: Sixty-nine patients received six weekly doses of carboplatin (AUC2) and paclitaxel (135 mg/m2) followed by five cycles of TFHX. RESULTS: Ninety-six percent had stage IV disease. Response to induction chemotherapy was partial response 52% and complete response (CR) 35%. Symptomatically, there was a significant reduction in mouth and throat pain. The most common grade 3 or 4 toxicity was neutropenia (36%). Best response following completion of TFHX was CR in 83%. Toxicities of TFHX consisted of grade 3 or 4 mucositis (74% and 2%) and dermatitis (47% and 14%). At a median follow-up of 28 months, locoregional or systemic disease progression were each noted in five patients. The overall 3-year progression-free survival was 80% (95% confidence interval [CI], 71% to 90%), and the 2- and 3-year overall survival rates were 77% (95% CI, 66% to 87%) and 70% (95% CI, 59% to 82%), respectively. At 12 months, five patients were completely feeding-tube dependent. CONCLUSION: Administration of carboplatin and paclitaxel before TFHX chemoradiotherapy results in high response activity and may decrease distant failure rates. Overall survival, progression, and organ preservation/functional outcome data support definitive evaluation of this approach.     

Induction chemotherapy followed by concomitant chemoradiotherapy in the treatment of locoregionally advanced nasopharyngeal cancer.

BACKGROUND: Since 1990, we have treated patients with advanced nasopharyngeal cancer with induction chemotherapy and concomitant chemoradiotherapy. We herein report the results of our experience. PATIENTS AND METHODS: From 1990 to 1999, 27 patients with locoregionally advanced nasopharyngeal cancer were treated with induction chemotherapy followed by concomitant chemoradiotherapy. Using the American Joint Committee on Cancer's 1992 stage classification, all patients were stage III (11%) or IV (89%). By histology, 63% were poorly differentiated carcinoma and 37% squamous cell carcinoma. The median age was 42 years. Three cycles of induction chemotherapy consisting of cisplatin, 5-fluorouracil, leucovorin and interferon-alpha2b were administered, followed by concomitant chemoradiotherapy consisting of seven cycles of 5-fluorouracil, hydroxyurea and once-daily radiotherapy (FHX) on a week-on week-off schedule. The median radiotherapy dose was 70 Gy. RESULTS: Clinical response to induction chemotherapy was 100%, 54.2% complete response (CR) and 45.8% partial response. Clinical and/or pathological (37% of all patients had post-treatment biopsy with or without neck dissection) CR after FHX was 100%. At a median follow-up of 52 months, three failures were observed. Two patients have died of disease, one of local failure and one of distant metastases. One patient is alive with an isolated rib metastasis. At 5 years, actuarial locoregional control is 93% and actuarial distant control 92%. The overall survival at 3 and 5 years is 88% and 77%, respectively. Four patients died of unrelated illnesses and had no evidence of disease with respect to their nasopharyngeal cancer. The progression-free survival at 3 and 5 years is 92% and 86%, respectively. Thirty-three per cent of patients required a reduction in the chemotherapy dose due to acute toxicity. Chronic toxicity was not observed, with all patients able to eat orally without dietary restrictions. CONCLUSIONS: Treatment of locoregionally advanced nasopharyngeal cancer with induction chemotherapy followed by concomitant chemoradiotherapy resulted in excellent overall survival with acceptable toxicity. These results are encouraging and warrant further investigation of intensified approaches.     

National Data Sources on the Care and Outcomes of Patients with Community Acquired Pneumonia

Despite improved understanding and treatment of community acquired pneumonia (CAP), variations in clinical practice and patient outcomes still exists, resulting in excess healthcare dollars spent and decreased patient satisfaction. The use of treatment and outcomes research data can help providers improve their methods and standardize techniques to control costs and provide the best care for their patients. To better understand the utility and capabilities of this research, this article will compare several administrative and clinical databases. Two, data sources in particular, the EPI-Q Inc. CAP-Compare database and the University HealthSystem Consortium's (UHC) CAP Benchmarking Program contain clinical and utilization data specific to CAP. In addition there are several government and non-government sponsored data sources that include administrative data on many diagnosis including CAP. These include: Healthcare Benchmarking Systems International's EXPLORE database, the Center for Healthcare Industry Performance Studies database, the National Center for Health Statistics'--National Hospital Discharge Survey, and the Medicare Provider Analysis and Review data files.     

Perspectives on colorectal cancer screening: a focus group study

Objective To assess attitudes and acceptability of Ontario consumers and doctors towards colorectal screening with faecal occult blood testing (FOBT) and colonoscopy. Design, setting and participants Focus groups with gender‐specific samples of the population, high‐risk gastroenterology patients and family doctors. Method Semi‐structured interview guides used by facilitator to lead groups through knowledge of risk factors and prevention of colorectal cancer, the screening modalities, requirements for implementing screening programmes, barriers to screening and preferences towards screening. Main findings There were low levels of knowledge about colorectal cancer and its prevention in the general population. FOBT was an acceptable screening modality, but considerable education about its use and benefits would be necessary to implement a screening programme. Colonoscopy was not perceived to be a good choice for a primary screen in the general population. The high‐risk group supported use of FOBT in the general population and emphasized the need for education. The doctors were more reluctant about screening, requesting clear guidelines. They also identified the time and resources that would be required if a screening programme were initiated. Conclusion While colorectal screening is acceptable in this sample, information and decision aids are required to enable consumers and providers to make effective decisions. Implementation of colorectal screening programmes requires substantial educational efforts for both consumers and doctors.