Patients with NwAfib perioperatively have increased risk of stroke and early death after discharge independent of other clinical risk factors.

BackgroundTo assess the functional donor site morbidity of the forearm free flap in patients surviving at least 2 years after ablative head and neck cancer surgery in a tertiary care centre.MethodsThis study involved nine long-term survivors (2 year post-operative) who had forearm free flaps to reconstruct head and neck defects. All flaps were raised from the non-dominant arm. The non-donor side acted as a control for all patients. Objective measurements were as follows: grip, tip pinch and key pinch strength measured with dynamometers; flexion, extension, radial and ulnar deviation and pronation and supination range of motion at the wrist measured with goniometry; A timed manual dexterity task was performed with a grooved pegboard test, and sensation of the radial nerve was tested with Semmes Weinstein monofilaments. Subjective measurements included a validated patient questionnaire of hand function and opinions of scar appearance as well as a validated scar assessment from two different observers.ResultsPronation at the wrist, manual dexterity and sensation were found to be significantly reduced in the donor side compared to the non-donor side. Inter-rater agreement between the two observers was found to be poor, except for an acceptable correlation between overall scar opinions. No correlations were found between any subjective or objective items or between the patient’s and the observers’ subjective evaluations.ConclusionsDonor site morbidity can be demonstrated with objective testing however this is accepted and well tolerated by head and neck cancer patients.

Objective Evaluate the oncologic outcomes and cost analysis of transitioning to a specimen oriented intraoperative margin assessment protocol from a tumour bed sampling protocol in oral cavity (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC). Study design Retrospective case series and subsequent prospective cohort study Setting Tertiary care academic teaching hospital Subjects and methods Retrospective case series of all institutional T1-T2 OCSCC or OPSCC treated with primary surgery between January 1st 2009 – December 31st 2014. Kaplan-Meier survival estimates with log rank tests were used to compare patients based on final margin status. Cost analysis was performed for escalation of therapy due to positive final margins. Following introduction of a specimen derived margin protocol, successive prospective cohort study of T1-T4 OCSCC or OPSCC treated with primary surgery from January 1st 2017 – December 31st 2018. Analysis and comparison of both protocols included review of intraoperative margins, final pathology and treatment cost. Results Analysis of our intra-operative tumour bed frozen section protocol revealed 15 of 116 (12.9%) patients had positive final pathology margins, resulting in post-operative escalation of therapy for 14/15 patients in the form of re-resection (7/14), radiation therapy (6/14) and chemoradiotherapy (1/14). One other patient with positive final margins received escalated therapy for additional negative prognostic factors. Recurrence free survival at 3 years was 88.4 and 50.7% for negative and positive final margins respectively (p = 0.048). Implementation of a specimen oriented frozen section protocol resulted in 1 of 111 patients (0.9%) having positive final pathology margins, a statistically significant decrease (p < 0.001). Utilizing our specimen oriented protocol, there was an absolute risk reduction for having a final positive margin of 12.0% and relative risk reduction of 93.0%. Estimated cost avoidance applying the specimen oriented protocol to our previous cohort was $412,052.812017 CAD. Conclusion Implementation of a specimen oriented intraoperative margin protocol provides a statistically significant decrease in final positive margins. This change in protocol leads to decreased patient morbidity by avoiding therapy escalation attributable only to positive margins, and avoids the economic costs of these treatments. Graphical abstract

As the COVID-19 pandemic continues to unfold, guidelines related to the delivery of medical and cancer care are being disseminated in an effort to flatten the curve of transmission while continuing to provide appropriate guideline based care for cancer patients. Head and neck squamous cell carcinoma (HNSCC) is unique in its location in the upper aerodigestive tract, a known location that harbors SARS-Cov2, the causative virus in COVID-19. Otolaryngologists and associated multidisciplinary team members caring for head and neck cancer patients are at heightened risk of transmission through mucus, blood, and aerosolized particles. A high rate of transmission to otolaryngologists has been reported in China, Italy, and Iran, with reports of morbidity and death [1]. The limited availability of COVID-19 testing, personal protective equipment (PPE), disposable medical supplies, hospital and ICU beds, ventilators, and ancillary staff force clinicians to triage which procedures are "essential" and which can be safely delayed. Healthcare providers who contract the virus have generally been mandated to selfquarantine, thereby reducing the availability of the hospital workforce. In the midst of the ongoing pandemic, patients diagnosed with HNSCC now have the added stress in how COVID-19 will impact their care and treatment. The current evidence supports that cancer patients have a higher risk of infection and serious complications from COVID-19 relative to other patient subgroups [2]. Uncertainties such as whether treatment will continue and how these high risk patients will continue to access services, are being addressed as the situation continues to evolve. Patients, physicians, health care workers, health care systems, ethicists, and attorneys among others have become aware of the number of complex dilemmas and issues that have arisen during this pandemic that include but are not limited to the following: