Complicated appendicitis in a patient with myelodysplastic syndrome and pancytopenia.

ABSTRACT: Patients with immunocompromise presenting with abdominal pain can present a diagnostic challenge, because they may have atypical or vague symptoms. This case report discusses nonoperative management of a patient with immunocompromise, complicated appendicitis, and intra-abdominal infection.

Understanding the Prevalence of Prediabetes and Diabetes in Patients With Cancer in Clinical Practice: A Real-World Cohort Study.

BACKGROUND: This study aimed to understand the prevalence of prediabetes (preDM) and diabetes mellitus (DM) in patients with cancer overall and by tumor site, cancer treatment, and time point in the cancer continuum. METHODS: This cohort study was conducted at Huntsman Cancer Institute at the University of Utah. Patients with a first primary invasive cancer enrolled in the Total Cancer Care protocol between July 2016 and July 2018 were eligible. Prevalence of preDM and DM was based on ICD code, laboratory tests for hemoglobin A1c, fasting plasma glucose, nonfasting blood glucose, or insulin prescription. RESULTS: The final cohort comprised 3,512 patients with cancer, with a mean age of 57.8 years at cancer diagnosis. Of all patients, 49.1% (n=1,724) were female. At cancer diagnosis, the prevalence of preDM and DM was 6.0% (95% CI, 5.3%-6.8%) and 12.2% (95% CI, 11.2%-13.3%), respectively. One year after diagnosis the prevalence was 16.6% (95% CI, 15.4%-17.9%) and 25.0% (95% CI, 23.6%-26.4%), respectively. At the end of the observation period, the prevalence of preDM and DM was 21.2% (95% CI, 19.9%-22.6%) and 32.6% (95% CI, 31.1%-34.2%), respectively. Patients with myeloma (39.2%; 95% CI, 32.6%-46.2%) had the highest prevalence of preDM, and those with pancreatic cancer had the highest prevalence of DM (65.1%; 95% CI, 57.0%-72.3%). Patients who underwent chemotherapy, radiotherapy, or immunotherapy had a higher prevalence of preDM and DM compared with those who did not undergo these therapies. CONCLUSIONS: Every second patient with cancer experiences preDM or DM. It is essential to foster interprofessional collaboration and to develop evidence-based practice guidelines. A better understanding of the impact of cancer treatment on the development of preDM and DM remains critical.

Modified early warning score-based clinical decision support: cost impact and clinical outcomes in sepsis.

OBJECTIVE: The objective of this study was to assess the clinical and financial impact of a quality improvement project that utilized a modified Early Warning Score (mEWS)-based clinical decision support intervention targeting early recognition of sepsis decompensation. MATERIALS AND METHODS: We conducted a retrospective, interrupted time series study on all adult patients who received a diagnosis of sepsis and were exposed to an acute care floor with the intervention. Primary outcomes (total direct cost, length of stay [LOS], and mortality) were aggregated for each study month for the post-intervention period (March 1, 2016-February 28, 2017, n = 2118 visits) and compared to the pre-intervention period (November 1, 2014-October 31, 2015, n = 1546 visits). RESULTS: The intervention was associated with a decrease in median total direct cost and hospital LOS by 23% (P = .047) and .63 days (P = .059), respectively. There was no significant change in mortality. DISCUSSION: The implementation of an mEWS-based clinical decision support system in eight acute care floors at an academic medical center was associated with reduced total direct cost and LOS for patients hospitalized with sepsis. This was seen without an associated increase in intensive care unit utilization or broad-spectrum antibiotic use. CONCLUSION: An automated sepsis decompensation detection system has the potential to improve clinical and financial outcomes such as LOS and total direct cost. Further evaluation is needed to validate generalizability and to understand the relative importance of individual elements of the intervention.

Automated home monitoring and management of patient-reported symptoms during chemotherapy: results of the symptom care at home RCT.

Technology-aided remote interventions for poorly controlled symptoms may improve cancer symptom outcomes. In a randomized controlled trial, the efficacy of an automated symptom management system was tested to determine if it reduced chemotherapy-related symptoms. Prospectively, 358 patients beginning chemotherapy were randomized to the Symptom Care at Home (SCH) intervention (n = 180) or enhanced usual care (UC) (n = 178). Participants called the automated monitoring system daily reporting severity of 11 symptoms. SCH participants received automated self-management coaching and nurse practitioner (NP) telephone follow-up for poorly controlled symptoms. NPs used a guideline-based decision support system. Primary endpoints were symptom severity across all symptoms, and the number of severe, moderate, mild, and no symptom days. A secondary endpoint was individual symptom severity. Mixed effects linear modeling and negative binominal regressions were used to compare SCH with UC. SCH participants had significantly less symptom severity across all symptoms (P < 0.001). On average, the relative symptom burden reduction for SCH participants was 3.59 severity points (P < 0.001), roughly 43% of UC. With a very rapid treatment benefit, SCH participants had significant reductions in severe (67% less) and moderate (39% less) symptom days compared with UC (both P < 0.001). All individual symptoms, except diarrhea, were significantly lower for SCH participants (P < 0.05). Symptom Care at Home dramatically improved symptom outcomes. These results demonstrate that symptoms can be improved through automated home monitoring and follow-up to intensify care for poorly controlled symptoms.

Combined Hydroxyurea and Verapamil in the Clinical Treatment of Refractory Meningioma: Human and Orthotopic Xenograft Studies.

OBJECTIVE: Previous in vitro and in vivo results suggested that hydroxyurea (HU) and verapamil could suppress meningioma growth individually and synergistically. We evaluated the clinical efficacy and safety of this approach for the treatment of refractory recurrent/progressive meningiomas and expanded our studies in a xenograft orthotopic mouse model. METHODS: Six women and 1 man, aged 26-76 years (median, 56 years), with magnetic resonance imaging-proven progression of ≥ 25% in cross-sectional area of recurrent meningioma (2 World Health Organization grade I, 5 grade II) within the preceding 6 months received HU 1000 or 1500 mg/day (20 mg/kg/day, twice daily) as well as verapamil sustained-release tablets with dose escalation every 2 weeks (120-240 mg/day). They underwent magnetic resonance imaging every 3 months during therapy. To augment the clinical trial results, we performed mouse orthotopic xenograft experiments using similar dosing to test tumor growth, vascularity, and drug bioavailability. RESULTS: After a mean of 8.1 cycles of treatment, the patients demonstrated no significant radiographic responses during mean follow-up of 14.5 ± 4.8 months. Median progression-free survival (PFS) was 8.0 months, and 6-month PFS was 85%. Side effects occurred in 6 (86%) patients. Xenograft studies showed no effect of individual or combined treatments on meningioma growth. Neither HU nor verapamil was detectable in mouse brain tumor tissue despite adequate serum levels within therapeutic ranges. CONCLUSIONS: Our results showed no effect of HU or verapamil on tumor recurrence, PFS, and in vivo tumor burden reduction. Drug delivery to the tumor may be a major limitation.

Impacts of hydroperiod on growth and survival of larval amphibians in temporary ponds of Central Pennsylvania, USA.

The effects of variable hydroperiod (three levels) and initial density of amphibians (two levels) on survival, growth rate, and time to and mass at metamorphosis were studied for wood frogs (Rana sylvatica), Jefferson salamanders (Ambystoma jeffersonianum), and spotted salamanders (A. maculatum). Experiments were carried out in 260-1 mesocosms set up outdoors in a forest. These pond simulations were designed to mimic conditions that occur in palustrine temporary wetlands in central Pennsylvania. No animals reached metamorphosis in the short hydroperiod (56 days). However a greater proportion (66%) of tadpoles of R. sylvatica survived to the end of the 56-day, treatment than the 84- or 158-day treatments (29 and 14%, respectively), from which all survivors metamorphosed. In contrast, neither of the salamanders metamorphosed by 84 days; survival to metamorphosis at 158 days was 15% for A. jeffersonianum and 10% for A. maculatum. Average instantaneous growth rates for A. jeffersonianum decreased with each increase in hydroperiod. Growth of R. sylvatica was greater in the 56-day hydroperiod than in hydroperiods of 84 or 158 days. Initial amphibian density had no effect on growth or survival of any species. It appears that salamander larvae were predatory on tadpoles, since survival of R. sylvatica was negatively correlated with survival of A. jeffersonianum in 84-day treatments and with growth of A. maculatum in 158-day treatments.

Insect species interactions and resource effects in treeholes: are helodid beetles bottom-up facilitators of midge populations?

The insect community living in central Pennsylvania treeholes in autumn consists primarily of larvae of two species of helodid beetles, Prionocyphon discoideus and Helodes pulchella, and larvae of one species of ceratopogonid midge,Culicoides guttipennis. We manipulated treehole volume and the densities of these insects in laboratory microcosms. We hypothesized that: (1) helodid beetle larvae, which are shredders, would enhance growth and survival of ceratopogonid midge larvae (deposit feeders) in a processing chain commensalism, and (2) the quantity of resources expressed as water volume plus leaf litter would affect helodids and protozoans directly. Intraspecific competition was not found in midges, nor was interspecific competition between the two helodid species. Protozoan population densities decreased or grew slower in the presence of insects and in smaller microcosms. Development time and adult wing length of the midge (C. guttipennis) were affected by both total microcosm volume and insect species combination. Under resource limitation, midges grew larger in the presence of helodids, and in general, midges were larger in treatments with higher ratios of helodids to midges. Water chemistry in the microcosms was affected both temporally and by insect presence. Hydrogen ion levels decreased over time, and microcosms with no insects had lower hydrogen ion levels. Specific conductance increased in all treatments over time, and microcosms with no insects had lower conductivity than most treatments. Helodid larvae have a positive effect on midges, possibly due to a processing chain facilitation. If helodids are keystone decomposers in this system, their presence could affect resource availability and affect other organisms in the community. Similar processing chain commensalisms occur in other phytotelmata. These types of interactions may therefore be important in the structure and function of detritus-based communities.

Interaction of pH, density, and priority effects on the survivorship and growth of two species of hylid tadpoles.

We examined the interactions of an abiotic factor (pH) and a biotic factor (density) on the survival and growth of two species of anuran larvae (Hyla gratiosa and Hyla femoralis) in outdoor tanks. Three levels of pH (4.3, 4.6, or 6.0) and three levels of density (0, 30 or 60 embryos) were arranged in a blocked design and replicated three times for Hyla gratiosa. At the end of this experiment the effects of pH (4.3, 4.6, or 6.0), density of H. femoralis (30 or 60), and prior use by H. gratiosa (at 0, 30, or 60 larvae per tank) on the survival and growth of H. femoralis, were examined. Higher density increased larval period and decreased size at metamorphosis of H. gratiosa. Lower pH decreased survival rate and also decreased size at metamorphosis. Body sodium concentrations were lowest at the low pH values. Lower pH increased the susceptibility of H. gratiosa tadpoles to the adverse effects of higher densities. For H. femoralis higher density decreased survival, increased larval period and decreased size at metamorphosis. Hyla femoralis also had lower survivorship at low pH and exhibited decreased size at metamorphosis. However, unlike the results with Hyla gratiosa, there were no interactive effects between pH and density for any of the life-history traits studied. The effect of previous colonization by H. gratiosa on H. femoralis survival was facilitative. Body sodium concentrations of H. femoralis were lowest at the highest pH value. Metamorphs of the same size had much lower levels of sodium in H. femoralis than H. gratiosa. In general, H. femoralis was less affected by pH variation than H. gratiosa. These results demonstrate that abiotic factors can interact strongly with biotic effects such as density and they suggest that interspecific interactions can be strongly modulated by the background abiotic environment.