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Cannon ST, Gabbard J, Walsh RC, Statler TM, Browne JD, Marterre B. Concordant palliative care delivery in advanced head and neck cancer. Am J Otolaryngol 2023; 44:103675. [PMID: 36302326 PMCID: PMC9743959 DOI: 10.1016/j.amjoto.2022.103675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/16/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the palliative care consultation practices in an academic head and neck surgery practice. METHODS This is a retrospective review of a palliative care database and the health record for all palliative care consultations of patients suffering from advanced stage head and neck cancer within a 21-month period. RESULTS Ten head and neck cancer patients received palliative care consults while on the otolaryngology service. One consultation occurred preoperatively; nine occurred postoperatively, on a median of hospital day 9. At the time of referral, seven patients were in the ICU and three were on a surgical floor. Code status de-escalation occurred in six patients and psycho-socio-spiritual suffering was supported in all consultations. Nine patients died within six months, with a median post-consultation survival of 35 days. Of these, two died in an ICU, five were discharged to hospice, one to a SNF, and one to a LTACH. CONCLUSION Palliative care consultation in this advanced head and neck cancer cohort was commonly late, however, significant suffering was mitigated following most consults. Palliative care specialists are experts at eliciting patient values, determining acceptable tradeoffs and suffering limitations by employing a shared decision-making process that ends with a patient-centered value-congruent treatment recommendation. Oftentimes, this embraces curative-intent or palliative surgery, along with contingency plans for unacceptable value-incongruent postoperative outcomes. Enhanced awareness of the benefits of embracing concordant palliative care in advanced head and neck cancer patients may help overcome the significant barriers to involving palliative care experts earlier.
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Affiliation(s)
- Sydney T. Cannon
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America
| | - Jennifer Gabbard
- Department of Internal Medicine, Section on Palliative Care, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America
| | - Rebecca C. Walsh
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America
| | - Tiffany M. Statler
- Department of Internal Medicine, Section on Palliative Care, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America
| | - J. Dale Browne
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America,Corresponding author at: 1 Medical Center Blvd, Winston-Salem, NC 27157, United States of America. (J.D. Browne)
| | - Buddy Marterre
- Department of Internal Medicine, Section on Palliative Care, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America,Department of General Surgery, Wake Forest School of Medicine and Atrium Health-Wake Forest Baptist, Winston-Salem, NC, United States of America
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Levitsky J, Kaneku H, Jie C, Walsh RC, Abecassis M, Tambur AR. Donor-Specific HLA Antibodies in Living Versus Deceased Donor Liver Transplant Recipients. Am J Transplant 2016; 16:2437-44. [PMID: 26896194 DOI: 10.1111/ajt.13757] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/11/2016] [Accepted: 02/13/2016] [Indexed: 01/25/2023]
Abstract
With less ischemia, improved donor selection and controlled procedures, living donor liver transplantation (LDLT) might lead to less HLA donor-specific antibody (DSA) formation or fewer adverse outcomes than deceased donor liver transplantation (DDLT). Using the multicenter A2ALL (Adult-to-Adult Living Donor Liver Transplantation Cohort Study) biorepository, we compared the incidence and outcomes of preformed and de novo DSAs between LDLT and DDLT. In total, 129 LDLT and 66 DDLT recipients were identified as having serial samples. The prevalence of preformed and de novo DSAs was not different between DDLT and LDLT recipients (p = 0.93). There was no association between patient survival and the timing (preformed vs. de novo), class (I vs. II) and relative levels of DSA between the groups; however, preformed DSA was associated with higher graft failure only in DDLT recipients (p = 0.01). De novo DSA was associated with graft failure regardless of liver transplant type (p = 0.005) but with rejection only in DDLT (p = 0.0001). On multivariate analysis, DSA was an independent risk factor for graft failure regardless of liver transplant type (p = 0.017, preformed; p = 0.002, de novo). In conclusion, although similar in prevalence, DSA may have more impact in DDLT than LDLT recipients. Although our findings need further validation, future research should more robustly test the effect of donor type and strategies to mitigate the impact of DSA.
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Affiliation(s)
- J Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.,Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - H Kaneku
- UCLA Paul Terasaki Institute, Los Angeles, CA
| | - C Jie
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - R C Walsh
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - M Abecassis
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - A R Tambur
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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Robinson JO, Carroll TM, Feuerman LZ, Perry DL, Hoffman-Andrews L, Walsh RC, Christensen KD, Green RC, McGuire AL. Participants and Study Decliners' Perspectives About the Risks of Participating in a Clinical Trial of Whole Genome Sequencing. J Empir Res Hum Res Ethics 2016; 11:21-30. [PMID: 26928896 DOI: 10.1177/1556264615624078] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
An increasing number of individuals are being recruited to whole genome sequencing (WGS) research. When asked hypothetically, the majority of the public express willingness to participate in this type of research, yet little is known about how many individuals will actually consent to research participation or what they perceive the risks to be. The MedSeq Project is a clinical trial exploring WGS in clinical care. We documented primary reason(s) for declining participation and reviewed audio-recorded informed consent sessions to identify participants' concerns. Of 514 individuals recruited, 173 (34%) actively declined, 205 (40%) enrolled, and the remaining 136 (26%) were ineligible, unresponsive or waitlisted. Although the majority of active decliners cited logistical barriers, 40% cited risks related to the ethical, legal, and social implications (ELSI) of WGS research. Participants similarly discussed ELSI-related concerns but felt the potential benefits of participation outweighed the risks. Findings provide insight into the perspectives of potential WGS research participants and identify potential barriers to participation.
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Affiliation(s)
| | | | | | | | | | | | | | - Robert C Green
- Harvard Medical School, Boston, MA, USA Partners Personalized Medicine, Boston, MA, USA
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Abstract
BACKGROUND When parents of newborns are presented with the hypothetical possibility of obtaining genomic sequencing (GS) for their newborn infants immediately after birth, they express substantial interest. This study examined associations between expressed interest in GS and demographic and psychosocial variables some months after birth. METHODS A total of 1096 parents were enrolled in a study on GS of newborns shortly after the birth of their infants, before discharge from the postpartum floor. Of these parents, 663 (60.5%) completed a follow-up survey 2 to 28 months later that queried their interest in GS for their infant and whether they received worrisome health information during pregnancy, labor, and delivery. They were also administered the Parenting Stress Index. Multivariate logistic regression was used to examine factors associated with interest in GS of newborns. RESULTS Of parents, 76.1% indicated at least some interest in GS. A 10-point increase on the Parenting Stress Index was associated with an increase in the odds of having some interest in GS (odds ratio: 1.15; 95% confidence interval: 1.01-1.32). Age, gender, race, ethnicity, marital status, education, anxiety, and whether this was the first biological child were not significantly associated with interest in GS. Receiving worrisome health information was associated with greater interest in GS but this did not reach significance (odds ratio: 1.42; 95% confidence interval: 0.95-2.12). CONCLUSIONS This hypothetical survey study suggests that previous experiences leading to worrisome health information and parenting stress need to be considered when GS is offered. Additional research, currently underway, is exploring factors associated with real-life parental choices around whether to obtain GS of their newborns.
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Affiliation(s)
- Susan E. Waisbren
- Boston Children’s Hospital;,Harvard Medical School; and,Address correspondence to Susan E. Waisbren, PhD, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail:
| | - Caroline M. Weipert
- Division of Genetics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Rebecca C. Walsh
- Division of Genetics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Robert C. Green
- Harvard Medical School; and,Division of Genetics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Woodle ES, Shields AR, Ejaz NS, Sadaka B, Girnita A, Walsh RC, Alloway RR, Brailey P, Cardi MA, Abu Jawdeh BG, Roy-Chaudhury P, Govil A, Mogilishetty G. Prospective iterative trial of proteasome inhibitor-based desensitization. Am J Transplant 2015; 15:101-18. [PMID: 25534446 DOI: 10.1111/ajt.13050] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 08/14/2014] [Accepted: 08/19/2014] [Indexed: 01/25/2023]
Abstract
A prospective iterative trial of proteasome inhibitor (PI)-based therapy for reducing HLA antibody (Ab) levels was conducted in five phases differing in bortezomib dosing density and plasmapheresis timing. Phases included 1 or 2 bortezomib cycles (1.3 mg/m(2) × 6-8 doses), one rituximab dose and plasmapheresis. HLA Abs were measured by solid phase and flow cytometry (FCM) assays. Immunodominant Ab (iAb) was defined as highest HLA Ab level. Forty-four patients received 52 desensitization courses (7 patients enrolled in multiple phases): Phase 1 (n = 20), Phase 2 (n = 12), Phase 3 (n = 10), Phase 4 (n = 5), Phase 5 (n = 5). iAb reductions were observed in 38 of 44 (86%) patients and persisted up to 10 months. In Phase 1, a 51.5% iAb reduction was observed at 28 days with bortezomib alone. iAb reductions increased with higher bortezomib dosing densities and included class I, II, and public antigens (HLA DRβ3, HLA DRβ4 and HLA DRβ5). FCM median channel shifts decreased in 11/11 (100%) patients by a mean of 103 ± 54 mean channel shifts (log scale). Nineteen out of 44 patients (43.2%) were transplanted with low acute rejection rates (18.8%) and de novo DSA formation (12.5%). In conclusion, PI-based desensitization consistently and durably reduces HLA Ab levels providing an alternative to intravenous immune globulin-based desensitization.
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Affiliation(s)
- E S Woodle
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
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Abstract
AMR is being recognized with increasing efficiency, but continues to present a significant threat to renal allograft survival. Traditional therapies for AMR (IVIG, plasmapheresis, rituximab, and antilymphocyte preparations) in general have provided inconsistent results and do not deplete the source of antibody production, viz., the mature plasma cell. Recently, the first plasma cell-targeted therapy in humans has been developed using bortezomib (a first in class PI) for AMR treatment in kidney transplant recipients. Initial experience with bortezomib involved treatment of refractory AMR. Subsequently, the efficacy of bortezomib in primary therapy for AMR was demonstrated. In a multicenter collaborative effort, the initial results with bortezomib in AMR have been confirmed and expanded to pediatric and adult heart transplant recipients. More recently, results from a prospective, staged desensitization trial has shown that bortezomib alone can substantially reduce anti-HLA antibody levels. These results demonstrate the significant potential of proteasome inhibition in addressing humoral barriers. However, the major advantage of proteasome inhibition lies in the numerous potential strategies for achieving synergy.
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Affiliation(s)
- E S Woodle
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
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Abstract
Recent evidence suggests that heat shock proteins (Hsps) may have an important systemic role as a signal to activate the immune system. Since acute exercise is known to induce Hsp72 (the inducible form of the 70-kDa family of Hsp) in a variety of tissues including contracting skeletal muscle, we hypothesized that such exercise would result in the release of Hsp72 from stressed cells into the blood. Six humans (5 males, 1 female) ran on a treadmill for 60 minutes at a workload corresponding to 70% of their peak oxygen consumption. Blood was sampled from a forearm vein at rest (R), 30 minutes during exercise, immediately postexercise (60 minutes), and 2, 8, and 24 hours after exercise. These samples were analyzed for serum Hsp72 protein. In addition, plasma creatine kinase (CK) was measured at these time points as a crude marker of muscle damage. With the exception of the sample collected at 30 minutes, muscle biopsies (n = 5 males) were also obtained from the vastus lateralis at the time of blood sampling and analyzed for Hsp72 gene and protein expression. Serum Hsp72 protein increased from rest, both during and after exercise (0.13 0.10 vs 0.87+/-0.24 and 1.02+/-0.41 ng/mL at rest, 30 and 60 minutes, respectively, P < 0.05, mean SE). In addition, plasma CK was elevated (P < 0.05) 8 hours postexercise. Skeletal muscle Hsp72 mRNA expression increased 6.5-fold (P < 0.05) from rest 2 hours postexercise, and although there was a tendency for Hsp72 protein expression to be elevated 2 and 8 hours following exercise compared with rest, results were not statistically significant. The increase in serum Hsp72 preceded any increase in Hsp72 gene or protein expression in contracting muscle, suggesting that Hsp72 was released from other tissues or organs. This study is the first to demonstrate that acute exercise can increase Hsp72 in the peripheral circulation, suggesting that during stress these proteins may indeed have a systemic role.
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Affiliation(s)
- R C Walsh
- Department of Physiology, University of Melbourne, Parkville, Victoria, Australia
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Abstract
Recent evidence suggests that heat shock proteins (Hsps) may have an important systemic role as a signal to activate the immune system. Since acute exercise is known to induce Hsp72 (the inducible form of the 70-kDa family of Hsp) in a variety of tissues including contracting skeletal muscle, we hypothesized that such exercise would result in the release of Hsp72 from stressed cells into the blood. Six humans (5 males, 1 female) ran on a treadmill for 60 minutes at a workload corresponding to 70% of their peak oxygen consumption. Blood was sampled from a forearm vein at rest (R), 30 minutes during exercise, immediately postexercise (60 minutes), and 2, 8, and 24 hours after exercise. These samples were analyzed for serum Hsp72 protein. In addition, plasma creatine kinase (CK) was measured at these time points as a crude marker of muscle damage. With the exception of the sample collected at 30 minutes, muscle biopsies (n = 5 males) were also obtained from the vastus lateralis at the time of blood sampling and analyzed for Hsp72 gene and protein expression. Serum Hsp72 protein increased from rest, both during and after exercise (0.13 0.10 vs 0.87+/-0.24 and 1.02+/-0.41 ng/mL at rest, 30 and 60 minutes, respectively, P < 0.05, mean SE). In addition, plasma CK was elevated (P < 0.05) 8 hours postexercise. Skeletal muscle Hsp72 mRNA expression increased 6.5-fold (P < 0.05) from rest 2 hours postexercise, and although there was a tendency for Hsp72 protein expression to be elevated 2 and 8 hours following exercise compared with rest, results were not statistically significant. The increase in serum Hsp72 preceded any increase in Hsp72 gene or protein expression in contracting muscle, suggesting that Hsp72 was released from other tissues or organs. This study is the first to demonstrate that acute exercise can increase Hsp72 in the peripheral circulation, suggesting that during stress these proteins may indeed have a systemic role.
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Affiliation(s)
- R C Walsh
- Department of Physiology, University of Melbourne, Parkville, Victoria, Australia
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Sass GL, Mohler JD, Walsh RC, Kalfayan LJ, Searles LL. Structure and expression of hybrid dysgenesis-induced alleles of the ovarian tumor (otu) gene in Drosophila melanogaster. Genetics 1993; 133:253-63. [PMID: 8436274 PMCID: PMC1205316 DOI: 10.1093/genetics/133.2.253] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Mutations at the ovarian tumor (otu) gene of Drosophila melanogaster cause female sterility and generate a range of ovarian phenotypes. Quiescent (QUI) mutants exhibit reduced germ cell proliferation; in oncogenic (ONC) mutants germ cells undergo uncontrolled proliferation generating excessive numbers of undifferentiated cells; the egg chambers of differentiated (DIF) mutants differentiate to variable degrees but fail to complete oogenesis. We have examined mutations caused by insertion and deletion of P elements at the otu gene. The P element insertion sites are upstream of the major otu transcription start sites. In deletion derivatives, the P element, regulatory regions and/or protein coding sequences have been removed. In both insertion and deletion mutants, the level of otu expression correlates directly with the severity of the phenotype: the absence of otu function produces the most severe QUI phenotype while the ONC mutants express lower levels of otu than those which are DIF. The results of this study demonstrate that the diverse mutant phenotypes of otu are the consequence of different levels of otu function.
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Affiliation(s)
- G L Sass
- Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill 27599-3280
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Steinhauer WR, Walsh RC, Kalfayan LJ. Sequence and structure of the Drosophila melanogaster ovarian tumor gene and generation of an antibody specific for the ovarian tumor protein. Mol Cell Biol 1989; 9:5726-32. [PMID: 2511440 PMCID: PMC363746 DOI: 10.1128/mcb.9.12.5726-5732.1989] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Sequencing cDNA and genomic DNA from the ovarian tumor gene revealed a gene with seven introns spanning 4.5 kilobases. The proline-rich, hydrophilic otu protein is novel. An antibody prepared to a beta-gal-otu fusion protein recognized a 110-kilodalton ovarian protein which was altered in the ovaries of otu gene mutants.
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Affiliation(s)
- W R Steinhauer
- Department of Biochemistry, University of North Carolina, Chapel Hill 27599
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Morris SL, Walsh RC, Hansen JN. Identification and characterization of some bacterial membrane sulfhydryl groups which are targets of bacteriostatic and antibiotic action. J Biol Chem 1984; 259:13590-4. [PMID: 6436249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Covalent modification of sulfhydryl groups which become sensitive toward sulfhydryl agents during germination of Bacillus cereus spores exerts a profound bacteriostatic effect, resulting in outgrowth inhibition. The modified spore components are membrane species of 13,000, 28,000, and 29,000 daltons. Detergent disruption of the membrane inactivated the sulfhydryl groups. A highly sigmoid inhibition curve (n = 11.8) with diamide suggested the participation of closely neighboring sulfhydryl groups. Substate and substrate analogs of the lactose and dicarboxylic acid permeases protected the sulfhydryl groups against modification. Nisin, a 34-residue peptide antibiotic, inhibited spore outgrowth and sulfhydryl modification at a concentration of about 0.1 microM. Since these sulfhydryl groups have been implicated as involved with the bacteriostatic action of nitrite, substances directed toward them may be a useful new class of bacteriostatic agents and antibiotics.
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Morris SL, Walsh RC, Hansen JN. Identification and characterization of some bacterial membrane sulfhydryl groups which are targets of bacteriostatic and antibiotic action. J Biol Chem 1984. [DOI: 10.1016/s0021-9258(18)90734-9] [Citation(s) in RCA: 110] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
Dihydrocytochalasin B (H2CB) disrupts the actin structure of Swiss/3T3 mouse fibroblasts and inhibits the ability of serum growth factors to stimulate DNA synthesis in quiescent cultures. Low doses of H2CB (2-10 X 10(-7) M) added to serum-arrested cells reversibly block initiation of DNA synthesis by serum; by epidermal growth factor and insulin; or by epidermal growth factor, fibroblast growth factor and insulin. H2CB is effective only when added to cells within 8-10 hr after stimulation. Low doses of H2CB cause cell rounding and a loss of actin microfilament bundles, but they do not interfere with glucose or thymidine transport. These results suggest that stimulation of 3T3 cells involves at least one obligatory actin-mediated step. Transformed cells appear to obviate this step, for H2CB does not inhibit the entry into S phase of SV40-transformed or Moloney murine sarcoma virus-transformed 3T3 cells synchronized by mitotic shake-off.
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Fox DJ, Diamond LK, Walsh RC, Knopf L, Hodgin J. Nursing students' perceptions of the psychiatric nursing experience. Perspect Psychiatr Care 1965; 3:30-40. [PMID: 5174394 DOI: 10.1111/j.1744-6163.1965.tb01450.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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