Head and neck squamous cell carcinoma (HNSCC) in solid organ transplant recipients - Results from the scientific registry of transplant recipients (SRTR) database.

BACKGROUND: Solid organ transplant recipients have an elevated risk of cancer following organ transplantation than the age-adjusted general population. We assessed incidence of head and neck squamous cell carcinoma (HNSCC) in heart, lung, and liver recipients. BASIC PROCEDURES/METHODS: This retrospective cohort study included 124,966 patients from the United States Scientific Registry of Transplant Recipients (SRTR) database who received heart, lung, or liver transplantation between 1991 and 2010. Follow-up data were available until 2018. Patients with prevalent HNSCC at transplantation were excluded. Incident cases of HNSCC post organ transplantation were identified, and incidence rates (per 100,000 person-years) were reported by gender, race, organ type, year and age at organ transplantation. MAIN FINDINGS: The majority of patients received liver transplantation (58.64 %), followed by heart (28.64 %), and lung (12.72 %) transplantation. During follow-up, 4.14 % patients developed HNSCC. Overall incidence rate of HNSCC was 426.76 per 100,000 person-years. Male recipients had a higher HNSCC incidence rate than female recipients (571.8 and 177.0 per 100,000 person-years, respectively). Lung recipients had the highest overall HNSCC incidence rate (1273.6 per 100,000 person-years), followed by heart (644.2 per 100,000 person-years), and liver recipients (207.1 per 100,000 person-years). Overall, an increase in HNSCC incidence rate was observed with increase in age at organ transplantation. An increase in incidence rates of HNSCC over time was observed in lung recipients; however, incidence rates decreased over time in heart recipients. CONCLUSION: Solid organ transplant recipients have a high incidence of HNSCC following organ transplantation, and the incidence varies by type of organ received.

Laryngeal Cancer and the End of Life (As We Know It).

Patients with laryngeal cancer undergo life-changing interventions that impact their individual and social well-being. There remains to be an in-depth characterization of the multidimensional symptom burden faced by patients with laryngeal cancer at the end of life. Care at end of life must attend to symptoms that manifest earlier in the course of illness. This article characterizes the suffering experienced by patients with laryngeal cancer, including societal shame, poor mental health, and inequitable outcomes. For patients with advanced laryngeal cancer, surgical palliative care provides a necessary and helpful paradigm for caregiver support, goals-of-care conversations, and treatment counseling.

Development of surgical palliative care as a field and community building in palliative care: past, present, and future directions.

The professionalization of hospice and palliative medicine has been well documented, as has its associated rise to specialty status. The movement to formalize hospice and palliative medicine in the United States included ten sponsoring boards for initial certification through a practice pathway. Thus, it began with the potential for subspecialty interests, advocacy, and training. This review will examine the emergence of surgical palliative care as a field within hospice and palliative medicine as well as its unique place within the specialty of surgery, where it is sometimes hailed as an inherent, historically present body of knowledge and skill, and just as often, remarked upon as an ahistorical oxymoron. The phases of formation, early adoption, popularization, and normalization will be described and illustrated by the benchmarks of formal education requirements, board eligibility and certification, and professional relationships fostered by medical societies and online communities. Community building in palliative care must acknowledge the diversity of its constituents and the differences in subspecialty identity formation and sources of professional credibility and legitimacy. Metaphors for practitioners of surgical palliative care range from the rarity of the unicorn to the swarm intelligence principles of the beehive. Future directions include facing the questions about the role of specialty training and practice in surgical palliative care compared to renewed emphasis on palliative principles in general surgical training and practice.

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement.

BACKGROUND: This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking. METHODS: An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements. CONCLUSIONS: This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

Concurrent palliative care in the surgical management of head and neck cancer.

Head and neck cancer affects vital functions of speech, swallowing, breathing, and appearance. Overall survival remains poor and symptom burden is high for both patients with incurable disease at the end of life and for long-term survivors. Early and concurrent palliative care helps guide treatment decision making and support quality of life during and after treatment. Both narrative competence and directive counsel can affect the concordance of patient goals and tolerance of treatment and outcomes.

Continuous Sedation Until Death Should Not Be an Option of First Resort.

Samuel H. LiPuma and Joseph P. DeMarco argue for a positive right to continuous sedation until death (CSD) for any patient with a life expectancy less than six months. They reject any requirement of proportionality. Their proposed guideline makes CSD an option for a decisional adult patient with an appropriate terminal diagnosis regardless of whether suffering (physical or existential) is present. This guideline purports to "empower" the patient with the ability to control the timing and manner of her death. This extends even to the option to "opt out" of the awareness and experience of dying and to avoid suffering altogether, even if one's symptoms and suffering could be effectively treated. We respond first with a critique of their terminology. We then turn to some purely practical considerations of how this guideline might be enacted in the current atmosphere of American hospice and palliative care medicine. We close with a consideration of one philosophical concern that might ground the discussion of risks, benefits, and alternatives necessary for informed consent.

Sildenafil increases muscle protein synthesis and reduces muscle fatigue.

Reductions in skeletal muscle function occur during the course of healthy aging as well as with bed rest or diverse diseases such as cancer, muscular dystrophy, and heart failure. However, there are no accepted pharmacologic therapies to improve impaired skeletal muscle function. Nitric oxide may influence skeletal muscle function through effects on excitation-contraction coupling, myofibrillar function, perfusion, and metabolism. Here we show that augmentation of nitric oxide-cyclic guanosine monophosphate signaling by short-term daily administration of the phosphodiesterase 5 inhibitor sildenafil increases protein synthesis, alters protein expression and nitrosylation, and reduces fatigue in human skeletal muscle. These findings suggest that phosphodiesterase 5 inhibitors represent viable pharmacologic interventions to improve muscle function.

How virtue ethics informs medical professionalism.

We argue that a turn toward virtue ethics as a way of understanding medical professionalism represents both a valuable corrective and a missed opportunity. We look at three ways in which a closer appeal to virtue ethics could help address current problems or issues in professionalism education-first, balancing professionalism training with demands for professional virtues as a prerequisite; second, preventing demands for the demonstrable achievement of competencies from working against ideal professionalism education as lifelong learning; and third, avoiding temptations to dismiss moral distress as a mere "hidden curriculum" problem. As a further demonstration of how best to approach a lifelong practice of medical virtue, we will examine altruism as a mean between the extremes of self-sacrifice and selfishness.

Artificial nutrition and hydration: the evolution of ethics, evidence, and policy.

INTRODUCTION: The debate over use of artificial nutrition and hydration (ANH) in terminal illness, including advanced dementia, remains contentious despite extensive ethical and empirical investigation. METHODS: For this narrative review we undertook a focused, selective review of literature reflecting ethical analysis, empirical assessment of outcomes, legal responses, and thinking within the Roman Catholic religious tradition. RESULTS: The history of the debate over the past 60 years results from a complex interplay of ethical concerns, a growing empirical database, legal changes, public opinion, and financial as well as institutional concerns. Discussions of ANH today are often conducted without any understanding of this historical context. DISCUSSION: Patients' interests could be better protected through remedial action at both the individual and the policy levels.

L-selectin-mediated lymphocyte-cancer cell interactions under low fluid shear conditions.

Cell migration in blood flow is mediated by engagement of specialized adhesion molecules that function under hemodynamic shear conditions, and many of the effectors of these adhesive interactions, such as the selectins and their ligands, are well defined. However, in contrast, our knowledge of the adhesion molecules operant under lymphatic flow conditions is incomplete. Among human malignancies, head and neck squamous cell cancer displays a marked predilection for locoregional lymph node metastasis. Based on this distinct tropism, we hypothesized that these cells express adhesion molecules that promote their binding to lymphoid tissue under lymphatic fluid shear stress. Accordingly, we investigated adhesive interactions between these and other cancer cells and the principal resident cells of lymphoid organs, lymphocytes. Parallel plate flow chamber studies under defined shear conditions, together with biochemical analyses, showed that human head and neck squamous cell cancer cells express heretofore unrecognized L-selectin ligand(s) that mediate binding to lymphocyte L-selectin at conspicuously low shear stress levels of 0.07-0.08 dynes/cm(2), consistent with lymphatic flow. The binding of head and neck squamous cancer cells to L-selectin displays canonical biochemical features, such as requirements for sialylation, sulfation, and N-glycosylation, but displays a novel operational shear threshold differing from all other L-selectin ligands, including those expressed on colon cancer and leukemic cells (e.g. HCELL). These data define a novel class of L-selectin ligands and expand the scope of function for L-selectin within circulatory systems to now include a novel activity within shear stresses characteristic of lymphatic flow.