Advance care planning in adults with oral cancer: Multi-institutional cross-sectional study.

PURPOSE: Patients undergoing head and neck surgery are often elderly and frail with significant comorbidities. Discussion and documentation of what patients would desire for end-of-life care and decision-making is, therefore, essential for delivering patient-centered care. MATERIALS AND METHODS: This was a retrospective, cross-sectional study of patients undergoing surgery for head and neck cancer at two large, academic, tertiary care centers in Canada. Advance care planning was defined as any documentation of advance directives, resuscitation orders, or end-of-life care preferences. RESULTS: Among 301 patients, advance care planning was documented for 31 (10.3%). Patients with locally advanced disease (T3+) were twice as likely to have advance care planning documentation compared to those with early disease (RR 1.97, 95%CI [0.98, 3.97]). CONCLUSIONS: In this multi-institutional cross-sectional study of two large academic centers, we have demonstrated that advance care planning and documentation is overall poor in patients undergoing surgery for oral cancer. These findings may have health policy implications, as advance care planning is associated with increased patient and provider satisfaction and improved alignment of patient goals and care delivered. Future work will investigate barriers and facilitators to advance care-planning documentation in this setting.

Predator exposure-induced immunosuppression: trade-off, immune redistribution or immune reconfiguration?

Although predator exposure increases the risk of wound infections, it typically induces immunosuppression. A number of non-mutually exclusive hypotheses have been put forward to explain this immunosuppression, including: trade-offs between the immune system and other systems required for anti-predator behaviour, redistribution of immune resources towards mechanisms needed to defend against wound infections, and reconfiguration of the immune system to optimize defence under the physiological state of fight-or-flight readiness. We tested the ability of each hypothesis to explain the effects of chronic predator stress on the immune system of the caterpillar Manduca sexta Predator exposure induced defensive behaviours, reduced mass gain, increased development time and increased the concentration of the stress neurohormone octopamine. It had no significant effect on haemocyte number, melanization rate, phenoloxidase activity, lysozyme-like activity or nodule production. Predator stress reduced haemolymph glutathione concentrations. It also increased constitutive expression of the antimicrobial peptide attacin-1 but reduced attacin-1 expression in response to an immune challenge. These results best fit the immune reconfiguration hypothesis, although the other hypotheses are also consistent with some results. Interpreting stress-related changes in immune function may require an examination at the level of the whole organism.