Progress in improving the treatment of sarcoma of the head and neck has been slow due to the lack of a large clinical experience with this rare neoplasm. Advances continue and are anticipated to be most striking in the study of genetic mechanisms.

Long-term anticoagulant therapy with warfarin is part of standard therapy for several disorders commonly present in patients seen in hospice and palliative care programs. Yet warfarin is also the drug most implicated in adverse drug reactions and its risks rise with increasing age and comorbidity. Clinicians caring for patients with multiple comorbidities or a limited life expectancy often are faced with the decision as to whether anticoagulation should be continued. Published guidelines for the use of warfarin in venous thromboembolism and nonvalvular atrial fibrillation are based on studies in which such patients were underrepresented or excluded. Our review of the randomized trials on which these guidelines are based shows that the annual risk of recurrent venous thromboembolism after stopping warfarin is 2%-10%. No similar evidence is available for patients with atrial fibrillation, but the published CHADS(2) index uses multiple factors to estimate stroke risk. The risk of bleeding complications with warfarin is most closely linked to degree of anticoagulation. Nutritional compromise and changes in drug therapy increase this risk and require that any patient remaining on warfarin must undergo frequent monitoring of anticoagulant effect.

The clinical features, treatment, and course of 6 patients with multiple myeloma, who presented initially with spinal cord compression, are reviewed. These 6 represent 12% of all patients with myeloma seen at our institution since 1979. Eighty-three similar patients were identified from the medical literature. There are no patient characteristics predictive for this presentation. A higher than expected proportion of patents have clinically localized disease, but progression to myelomatosis is common. As these patients present without a known diagnosis of malignancy, a prompt, invasive diagnostic procedure and the immediate institution of definitive local therapy is mandatory. Despite such an aggressive approach, the prospect for significant return of neurologic function is poor. Survival does not appear to be different from that of other patients with myeloma. Unlike other malignancies, a presentation with cord compression is not inconsistent with long-term survival, although significant morbidity secondary to the resultant functional disability can be expected.

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Difficulty clearing upper airway secretions (death rattle) is a frequent problem at the end of life. Treatment often includes the use of anticholinergic drugs. Myasthenia gravis is a disease characterized by muscle weakness and fatigue caused by an immune-mediated deficiency of acetylcholine receptors at the neuromuscular junction, and it is treated with anticholinesterase agents. We report the case of a patient dying of myasthenia gravis who had problems with the "death rattle" and who presented a dilemma as to whether the use of anticholinergics would be helpful or would cause deterioration of her myasthenia. This is accompanied by a review of the relevant literature.