Unintended Consequences: Risk of Opportunistic Infections Associated With Long-term Glucocorticoid Therapies in Adults

Glucocorticoids are widespread anti-inflammatory medications used in medical practice. The immunosuppressive effects of systemic glucocorticoids and increased susceptibility to infections are widely appreciated. However, the dose-dependent model frequently used may not accurately predict the risk of infection in all patients treated with long-term glucocorticoids. In this review, we examine the risks of opportunistic infections (OIs) in patients requiring glucocorticoid therapy by evaluating the influence of the glucocorticoid dose, duration, and potency, combined with biological and host clinical factors and concomitant immunosuppressive therapy. We propose strategies to prevent OIs, which involve screening, antimicrobial prophylaxis, and immunizations. While this review focuses on patients with autoimmune, inflammatory, or neoplastic diseases, the potential risks and preventative strategies are likely applicable to other populations. Clinicians should actively assess the benefit-harm ratios of systemic glucocorticoids and implement preventive efforts to decrease their associated infections complications.

Executive Summary: State-of-the-Art Review: Unintended Consequences: Risk of Opportunistic Infections Associated with Long-term Glucocorticoid Therapies in Adults

Glucocorticoid-induced immunosuppression is linked to the dose, duration, and intensity, but the dose-dependent model may inaccurately predict the risk of opportunistic infections. We discuss details of glucocorticoid treatments to determine their effect on immune function and risk of opportunistic infections.

Utilizing an advanced practice provider (APP) led acute care clinic to improve access to high quality, patient centered, cost effective cancer care

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Background: The medical oncology patient population is at high risk for adverse effects and complications related to anti-cancer treatments. The cost of oncology care is projected to reach almost $160 billion in 2020. The ongoing cost trajectory has placed a significant financial burden on patients, families, and society as a whole. The Centers for Medicare and Medicaid Service (CMS) has developed a new payment and delivery model that identifies potentially preventable conditions for ED visits/rehospitalizations among patients that are receiving anti-cancer therapies. Proposed CMS changes have created increased urgency around avoiding preventable ED visits/rehospitalizations. In response to the need for high quality, patient centered, cost effective care, we have established an APP-led acute care clinic that specializes in oncology care. Methods: The Clinical Assessment and Rapid Evaluation (CARE) Clinic offers acute care and symptom management catered to the oncology population. Patients are able to receive lab and imaging work up in addition to intervention with IV fluids, anti-emetics, opioids, electrolytes or antibiotics, as well as blood/platelets as warranted. To assess patient satisfaction, we created an anonymous four question survey delivered to CARE clinic patients over a two month period. Results: Seventy five surveys were collected. Pain and nausea were the leading reasons for encounters. 91% of patients rated their care as excellent, while 9% of patients rated their care as good. 33% of patients reported they would have been seen in the ED if the CARE Clinic was not available. Conclusions: The CARE Clinic represents a unique, one of the first of its kind, acute care and symptom management entity that utilizes an APP model to provide high quality care at a low cost. More research is needed to identify if this model can create statistically significant reduction in ED visits and rehospitalizations, however current data suggests that patients are highly satisfied with this unique method of care delivery. Sources Handley NR, Schuchter LM, Bekelman JE. Best Practices for Reducing Unplanned Acute Care for Patients With Cancer. Journal of Oncology Practice. 2018;14(5):306-313. doi:10.1200/jop.17.00081.

Classical polylogarithms for amplitudes and Wilson loops

We present a compact analytic formula for the two-loop six-particle maximally helicity violating remainder function (equivalently, the two-loop lightlike hexagon Wilson loop) in N=4 supersymmetric Yang-Mills theory in terms of the classical polylogarithm functions Lik with cross ratios of momentum twistor invariants as their arguments. In deriving our formula we rely on results from the theory of motives.