Clinical Decision Making with Head and Neck Cancer Patients with Dysphagia

Dysphagia is a common challenge faced by patients with head and neck cancer. Management of these patients is quite distinct from many other dysphagia etiologies due to the nature of surgical removal of organs critical to swallowing, the ability to provide preventative therapies, and the variable risk for complications related to dysphagia. Thus, clinicians providing care to the head and neck cancer population need to understand these differences when employing clinical decision making. In addition, changes in the demographics of head and neck cancer, related predominantly to the epidemic of oropharyngeal cancer associated with the human papillomavirus, have further transformed both the types of patients and the types of treatments offered. These epidemiologic factors further complicate the decision-making process for clinicians. This article provides a framework for decision making in the surgical and nonsurgical patient with head and neck cancer.

Safe Transcatheter Aortic Valve Replacement in a Patient with a Highly Mobile Aortic Valve Mass

Some cardiac valve masses may have embolic potential with worrisome consequences. We describe the dilemmas of and solutions for a highly mobile papillary fibroelastoma on the aortic valve in a nonsurgical patient undergoing transcatheter aortic valve replacement. It was performed safely. The potential strategies to minimize the risk of embolization are discussed.

Propionibacterium acnes: A Treatable Cause of Constrictive Pericarditis

In this case report we share a case of infective Pericarditis caused byPropionibacterium acnes(P. acnes) in an immune-competent, nonsurgical patient. This case and review will illustrate the importance of consideringP. acnesas a cause of idiopathic pericardial effusion and effusive constrictive disease. The patient was a 61-year-old male with history of osteoarthritis of the knee. He received an intra-articular steroid injection in July 2013. Two months later, he presented with atrial fibrillation and heart failure. He was found to have pericardial and bilateral pleural effusions which grewP. acnes. This organism was initially considered to be contaminant; however, asP. acneswas isolated from both pleural and pericardial fluids, he was started on oral amoxicillin. He was noted to have recurrence of effusions within 2 weeks with evidence of constrictive physiology by echocardiography. Treatment was subsequently changed to intravenous Penicillin G with marked symptomatic improvement, resolution of pericardial/pleural effusions, and no echocardiographic evidence of constrictive pericarditis at 10 weeks follow-up. Pursuit and treatment ofP. acnescould lead to prevention of constrictive pericarditis. We believe that further studies are needed to assess prevalence ofP. acnesand response to intravenous Penicillin G in patients presenting with effusive constrictive disease.

Intravenous Amiodarone for the Treatment of Atrial Fibrillation in the Nonsurgical Patient

Purpose: To review the literature to define the efficacy of intravenous (IV) amiodarone in the treatment of atrial fibrillation in the nonsurgical patient. Method: A MEDLINE search was conducted using the key words “intravenous amiodarone” and “atrial fibrillation.” All trials evaluating the use of intravenous amiodarone in the surgical setting were excluded. Results: Twenty articles were identified, which were divided into acute and chronic atrial fibrillation. Within the acute setting, IV amiodarone was used alone, compared to a placebo-control, or compared to active drug regimens. In the trials without a control group, it was difficult to determine how much of the effect was due to spontaneous conversion. When compared to placebo, IV amiodarone offered a 61% to 92% conversion at 24 hours. Compared to active drug therapy, there was a trend to increased efficacy at 24 hours. However, amiodarone was no more effective for the conversion of atrial fibrillation than alternative therapies. In the case of chronic atrial fibrillation, intravenous amiodarone had no benefit. The incidence of thrombophlebitis, bradycardia, and hypotension was quite high, reported to be around 15% to 30% in many of the trials. Conclusion: The use of intravenous amiodarone should not be recommended as the first line agent for the conversion of atrial fibrillation.