Recurrent appendicitis of vermiform appendix after a prior appendectomy: A case report and review of the literature

Introduction

Acute appendicitis is one of the leading causes of acute abdominal pain and surgical emergency. Stump appendicitis is a known complication of appendectomy whereby a retained appendiceal tip serves as a nidus for recurrent bouts of inflammation. Nevertheless, full-blown appendicitis of the vermiform appendix after a prior appendectomy remains a diagnostic conundrum.

Case presentation

A 45-year-old woman presented with a six-month history of right iliac fossa pain. Pertinently, she had undergone a prior open appendectomy twelve years ago. Further investigative workup revealed full-blown appendicitis, which was not attributable to a retained appendiceal stump. A subsequent laparoscopic appendectomy was performed, and the resultant specimen was sent for further evaluation, confirming the diagnosis of recurrent appendicitis.

Clinical discussion

Acute appendicitis is one of the most common life-threatening abdominal surgical emergencies worldwide, with 300000 appendectomies performed annually in the United States alone. Stump and chronic appendicitis are two separate and exceedingly rare clinical entities that may present simultaneously and develop serious complications unless promptly recognized and appropriately managed. The present paper prompts the clinicians to distinguish amongst the two at the initial surgery in order to thwart further exacerbations.

Conclusion

While stump appendicitis is a rare but well-characterized complication of a prior appendectomy, full-blown appendicitis of vermiform appendix remains elusive. It is therefore imperative to distinguish between a duplicated and a recurrent appendix at the initial operative procedure to facilitate optimal patient management.

Economic Evaluation of a Geriatric Oncology Clinic

Simple Summary

There is increasing evidence supporting geriatric assessment (GA) prior to starting cancer treatment in older adults. However, GA is not widely available. One reason may be the lack of persuasive economic data demonstrating its value. We performed an economic evaluation of an academic geriatric oncology clinic and included 152 patients aged 65 years and older who underwent a GA in the pre-treatment setting. We carefully calculated the costs of the proposed treatment (prior to the GA), costs of the GA and associated recommendations, costs of the final treatment, and overall value. We found a GA saved CAD 7387 per patient seen. Extensive sensitivity analyses supported our finding that a GA is economically attractive and should be implemented more widely.

Abstract

Geriatric assessment (GA) is supported by recent trials and guidelines yet rarely implemented due to a lack of resources. We performed an economic evaluation of a geriatric oncology clinic. Pre-GA proposed treatments and post-GA actual treatments were obtained from a detailed chart review of patients seen at a single academic centre. GA-based costs for investigations and referrals were calculated. Unit costs were obtained for surgical, radiation, systemic therapy, laboratory, imaging, physician, nursing, and allied health care (all in 2019 Canadian dollars). A six-month time horizon and government payer perspective were used. Consecutive patients aged 65 years or older (n = 152, mean age 82 y) and referred in the pre-treatment setting between July 2016 and June 2018 were included. Treatment plans were modified for 51% of patients. Costs associated with planned treatment were CAD 3,655,015. Costs associated with GA and related interventions were CAD 95,798. Final treatment costs were CAD 2,436,379. Net savings associated with the clinic were CAD 1,122,837, or CAD 7387 per patient seen. Findings were robust in multiple sensitivity analyses. Combined with mounting trial data demonstrating the clinical benefits of GA, our data can inform a strong business case for geriatric oncology clinics in health care environments similar to ours, but additional studies in diverse health care settings are warranted.

Positive Airway Pressure Usage in Youth with Obstructive Sleep Apnea Following Transition to Adult Health Care

BACKGROUND

There is increasing prevalence of moderate to severe obstructive sleep apnea (OSA) in adolescents, the majority of whom receive treatment with positive airway pressure (PAP). Adherence to PAP is sub-optimal in adolescents with OSA. Moreover, the impact of transition from pediatric to adult healthcare system on PAP adherence is unknown. This is relevant as the transition period is a time of increased stress for youth with chronic illnesses.

RESEARCH QUESTION

Does PAP adherence decrease during the 1-year transition period from pediatric to adult healthcare system in those with OSA?

STUDY DESIGN AND METHODS

Youth previously diagnosed with persistent OSA and treated with PAP in a large academic center (Toronto, Canada) between 2017 and 2019 were enrolled on transfer from the pediatric to adult sleep clinic and followed at 12 months. Mixed-effects linear regression models were used to investigate the effect of time since the transfer on objective PAP adherence with adjustment for confounders.

RESULTS

Among the 45 enrolled participants, 42.2% were female, the median age was 18 years (interquartile range [IQR]: 17-18), median BMI was 30.3 (IQR: 24.0-37.1), and the median apnea-hypopnea index (AHI) was 17.8 events/hour (11.8-30.7). In univariate analysis, we observed a significant reduction in the 12-month average PAP usage in days used at follow-up compared to PAP use at the time of enrolment: median of 5.0 hours/day (IQR: 1.3-8.0) vs 2.6 hours/day (0.0-6.4), p < 0.0001. Following adjustment for age, level of education, employment status and living arrangement, the 12-month average PAP usage in days remained significantly decreased at follow-up compared to at the time of enrolment: change in hours of -1.14; 95% CI -2.27 to -0.01.

INTERPRETATION

Among youth with OSA treated with PAP, there is a clinically significant reduction in PAP adherence over the first year during the transition from pediatric to adult health care.

Transition to Adult Care for Obstructive Sleep Apnea

Obstructive sleep apnea may occur throughout the lifespan, with peak occurrences in early childhood and during middle and older age. Onset in childhood is overwhelmingly due to adeno-tonsillar hypertrophy, while in adulthood, contributors include risk factors, such as obesity, male sex, and aging. More recently, there has been a precipitous increase in the prevalence of obstructive sleep apnea in youth. Drivers of this phenomenon include both increasing obesity and the survival of children with complex medical conditions into adulthood. Appropriate treatment and long-term management of obstructive sleep apnea is critical to ensure that these youth maintain well-being unfettered by secondary comorbidities. To this end, patient engagement and seamless transition of care from pediatric to adult health care systems is of paramount importance. To date, this is an unacknowledged and unmet need in most sleep programs. This article highlights the need for guideline-driven sleep disorder transition processes and illustrates the authors’ experience with the development of a program for sleep apnea.

Delirium incidence, risk factors, and treatment in older adults receiving chemotherapy: A scoping review

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Background: Older adults with cancer are at increased risk of delirium given their advanced age, multiple comorbidities and medications, prevalence of cognitive impairment, and possibly cancer treatment. Awareness of such risks and interventions to prevent or treat delirium is important to clinicians and to provide high quality care. However, there is scant published information on the risks of delirium with chemotherapy or evidence-based approaches to prevent or treat it. We performed a scoping review to summarize the available evidence. Methods: We conducted a scoping review using the framework of Arksey and O’Malley. We systematically searched peer-reviewed journal articles in English, French, and German from Medline, Embase, PsychINFO, CINAHL Plus, and Cochrane Central from inception until January 2017 to identify studies that examined delirium in patients receiving chemotherapy. We also attempted to identify any studies that reported on multivariable delirium risk prediction models and any clinical trials that examined prevention or treatment of delirium. Article titles and abstracts as well as full text articles were reviewed using Covidence software by two or more reviewers independently. Similarly, data extraction was performed by two independent reviewers. Results: A total of 21,678 titles and abstracts were screened, and 1,166 full-text articles were reviewed. Nineteen articles with varying study designs (retrospective administrative databases to clinical trials) reported on delirium using an acceptable diagnostic standard. Sample sizes varied from 15 to over 21,000. No one tumour site or treatment protocol constituted the majority of studies. The incidence of delirium ranged from 0 to 51% (mean 13.5%). The time course of delirium relative to the cycle of chemotherapy was inconsistently reported. No studies reported on risk prediction models for delirium, and no intervention studies to prevent or treat delirium were identified. An additional 109 studies reported on outcomes that could be part of the delirium syndrome but did not meet even our broad inclusion criteria (e.g. cognitive disturbance). Conclusions: Delirium may occur in over 1 in 8 older adults receiving chemotherapy, although there were substantial limitations in reported studies. This scoping review highlights the dearth of knowledge in the area, particularly for risk factors, prevention, and treatment, and emphasizes the need for high-quality studies examining these important outcomes in the oncology setting.

Montelukast Reduces the Risk of Dengue Shock Syndrome in Dengue Patients

A significant percentage of dengue patients develop Dengue Shock Syndrome (DSS) which is characterized by increased vascular permeability, circulatory failure and often death. Montelukast, a cysteinyl leukotriene receptor antagonist regulates vascular permeability and we hypothesized that it may be effective in protecting against DSS. An open label, parallel, randomized controlled trial (RCT) was thus carried out at Mayo Hospital, Department of Medicine, Lahore. A total of 200 patients of dengue fever were recruited and randomized into two groups. The group A was treated with Montelukast 10 mg once daily for 5 days along with general supportive treatment. Group B received the standard supportive treatment and served as the control group. The frequency of DSS was compared in the two groups by Chi square test. A binary logistic regression analysis was conducted to assess the effects of montelukast treatment on onset of DSS after adjusting for gender, age, white cell count, platelet count, haematocrit, serum alanine transaminase (ALT) and aspartate transaminase (AST). Relative risk (RR), absolute risk reduction (ARR), relative risk reduction (RRR) and numbers needed to treat (NNT) were calculated. Significance level was set at p0.001, Odds ratio=5.01, 95% CI=2.17-11.60) even after adjusting for confounders. Montelukast reduced the absolute risk (ARR=22%) and the relative risk (RRR=71%) of DSS in dengue fever. Numbers needed to treat were 4.55. We thus conclude that treatment with oral montelukast may protect patients of dengue fever from DSS and greatly reduce mortality.

Multi-day radon signals with a radioactive decay limb—Occurrence and geophysical significance

Multi-day signals, generally with duration of 2-10 days, are a prominent temporal variation type of radon (Rn) in geogas in the unsaturated zone. Rare multi-day Rn signals have been found which are characterized by: (a) a declining limb lasting up to 10 days which conforms to the radioactive decay of Rn, (b) recurs at the same location and (c) is recorded in diverse situations-volcanic and seismogenic. It suggested that a Rn blob is injected at a lower level on a steady upward flow of geogas whereby the rise and final fall of the signal are attributed to the edges of the blob while the central Rn-decay segment records the passing of the decaying blob itself. Rn-decay signals are a small subset of multi-day Rn signals which are considered as highly irregular and unusable for the understanding of geophysical processes. In difference, it is concluded that multi-day Rn signals are probably proxies of subtle geodynamic processes at upper crustal levels and are therefore significant for studying such processes.

Phase I trial of pegylated liposomal doxorubicin and docetaxel in advanced breast cancer

PURPOSE

To develop a combination of pegylated liposomal doxorubicin (Doxil; Alza Pharmaceuticals, Palo Alto, CA) and docetaxel (Taxotere; Aventis Pharmaceutical, Parsipanny, NJ) that can be safely used for the treatment of advanced breast cancer.

PATIENTS AND METHODS

Forty-one patients with locally advanced (n = 10) or metastatic (n = 31) breast cancer received Doxil (30-, 40-, or 45-mg/m(2) intravenous [IV] infusion over 30 to 60 minutes), followed 1 hour later by docetaxel (60 or 75 mg/m(2) by IV infusion over 1 hour) in cohorts of three to six patients. Dose-limiting toxicity (DLT) was defined as febrile neutropenia, prolonged neutropenia, or grade 3 to 4 nonhematologic toxicity that occurred during cycle 1.

RESULTS

In conjunction with docetaxel 75 mg/m(2) every 4 weeks, the MTD of Doxil was 30 mg/m(2) and required granulocyte colony-stimulating factor (G-CSF) to prevent febrile neutropenia. Without G-CSF, the MTD was docetaxel 60 mg/m(2) and Doxil 30 mg/m(2) every 3 weeks; only 1 (7%) out of 15 patients treated at this dose level had cycle 1 DLT. Infusion reactions were common with Doxil with the recommended infusion schedule during the first cycle (55%) but were reduced with a modified schedule (7%). There was no clinically significant cardiac toxicity. Objective response occurred in eight of nine assessable patients with stage III disease and in 16 (52%) of 31 patients (95% confidence interval, 34% to 70%) with stage IV disease.

CONCLUSION

The recommended dose and schedule of this combination for further evaluation is Doxil 30 mg/m(2) and docetaxel 60 mg/m(2) given every 3 weeks without G-CSF. When used with G-CSF, it is Doxil 30 mg/m(2) and docetaxel 75 mg/m(2) every 4 weeks.

Therapeutic efficacy of theophylline in chronic lymphocytic leukemia

Theophylline, a methylxanthine commonly used as a treatment for asthma, has been shown to induce apoptosis in chronic lymphocytic leukemia (CLL) cells both in vitro and in vivo. We have treated three advanced CLL patients with theophylline, and seen responses in two. The clinical courses of the responders are presented, and the literature concerning theophylline as therapy for CLL is reviewed.

Acquired Glanzmann's thrombasthenia associated with Hodgkin's lymphoma: a case report and review of the literature

BACKGROUND

Acquired Glanzmann's thrombasthenia is a rare hemorrhagic diathesis resulting from impaired adhesive function of the platelet receptor GPIIb/IIIa (alpha(IIb)beta3). Typically, this disorder develops during adulthood, with patients manifesting fluctuating clinical and laboratory findings. To date, the underlying defect of most if not all cases of acquired Glanzmann's thrombasthenia results from an autoantibody or plasma protein inhibitor directed toward a demonstrably normal GPIIb/IIIa glycoprotein.

METHODS

In this report, a patient with a history of treated Hodgkin's lymphoma presented with a severe hemorrhagic diathesis characterized by mild thrombocytopenia, a prolonged bleeding time, and defective platelet aggregation.

RESULTS

Examination of the patient's platelet GPIIb/IIIa by Western blot analysis revealed no abnormality. Mixing studies demonstrated a non-immunoglobulin G plasma inhibitory factor, whereas flow cytometry analysis revealed elevated platelet-associated immunoglobulin (Ig) M. After an emergency colectomy for severe hemorrhage, the patient's qualitative and quantitative platelet parameters significantly improved. Pathology of the resected colonic segment demonstrated atypical lymphoid hyperplastic lesions.

CONCLUSIONS

To the authors' knowledge, this is the first reported case of acquired Glanzmann's thrombasthenia associated with a putative IgM autoantibody. Furthermore, this report verifies the association of acquired thrombasthenia with lymphoproliferative disease. Although rare, awareness of this hemorrhagic diathesis as a possible sequelae of active or treated lymphoid disorders should encourage clinical vigilance of these patients.

Phase I trial of high-dose mitoxantrone plus cyclophosphamide and filgrastim in patients with advanced breast carcinoma

PURPOSE

To determine the maximum-tolerated dose (MTD) of mitoxantrone that could be safely used in combination with cyclophosphamide and filgrastim in patients with advanced breast carcinoma.

PATIENTS AND METHODS

Twenty-seven patients with metastatic (n = 24) or locally advanced (n = 3) breast carcinoma received escalating doses of mitoxantrone (16, 20, 24, 28, or 32 mg/m2) plus cyclophosphamide at one of three dose levels: group 1, 1,200 mg/m2; group 2, 2,400 mg/m2; and group 3,600 mg/m2. All patients also received filgrastim 5 micrograms/kg administered subcutaneously beginning on day 2 and continuing until the post-nadir absolute neutrophil count (ANC) was > or = 10,000/microL. Treatment was repeated every 3 weeks if the ANC was > or = 2,000/microL and platelet count > or = 90,000/microL for a maximum of six cycles. Dose escalation occurred within each group if zero of three or one of four patients had dose-limiting toxicity during the first cycle.

RESULTS

The MTD of mitoxantrone was 24 mg/m2 in group 1, less than 16 mg/m2 in group 2, and 28 mg/m2 in group 3. Neutropenia was dose-limiting, and cumulative neutropenia and thrombocytopenia occurred with continued therapy. Nonhematologic toxicity consisted predominantly of nausea, vomiting, alopecia, and fatigue. Three patients (11%) had a > or = 10% decrease in the left ventricular ejection fraction (LVEF), one patient (4%) had a decrease in the LVEF below normal, and none developed clinical congestive heart failure. Of patients with stage IV breast carcinoma who had not received prior chemotherapy for advanced disease, objective responses occurred in nine of 20 (45%), and the median response duration was 5 months.

CONCLUSION

In combination with 600 mg/m2 of cyclophosphamide and filgrastim, the MTD of mitoxantrone is 28 mg/m2, a dose that is approximately twofold to 2.8-fold higher than the conventional dose used without a hematopoietic growth factor.

Intravenous gamma-globulin inhibits binding of anti-GM1 to its target antigen

In this study, we preincubated the sera of 3 patients with neuropathies associated with elevated titers of IgM anti-GM1 antibodies, with increasing concentrations of intravenous Ig (IVIg) and assayed the inhibitory effect of this mixture on antibody binding to immobilized GM1 by an enzyme-linked immunosorbent assay. Pharmacologic concentrations of IVIg, ranging from 0.1 microgram/ml to 100 mg/ml, inhibited anti-GM1 binding to its target antigen from 26 +/- 3 to 71 +/- 7%, respectively, in a dose-dependent manner. A similar inhibition of binding was also observed with IVIg F(ab')2 fragments. These findings provide a possible mechanism for the clinical efficacy of IVIg in motor neuropathies.

Endoscopic injection for the treatment of bleeding ulcers: local tamponade or drug effect?

Fifty-two patients with Forrest Ia or Ib bleeding ulcers were randomized to receive endoscopic injection therapy with either 1:10,000 epinephrine in water (Group I) or distilled water (Group II). Twenty-five out of 27 patients in group I, versus 22 out of 25 patients in group II, achieved initial hemostasis after endoscopic injection therapy (p > 0.05). Five patients who did not respond to local injection had bleeding controlled by heater probe thermocoagulation or surgical intervention. Three patients in each group developed rebleeding after initial hemostasis. Four of these patients had bleeding controlled by surgical intervention, while the other two died of underlying diseases. No change in systemic blood pressure, but a significant drop in the pulse rate were noted in both groups after injection therapy. Patients with shock at admission or ulcer size greater than 2 cm had a significantly higher rebleeding rate after initial hemostasis than patients with normal blood pressure and ulcers under 2 cm (p < 0.05). No serious complications were observed after injection therapy, and no significant difference in the amounts of solution required for successful hemostasis was noted between the two groups. We conclude that a local tamponade with distilled water is as effective and safe as diluted epinephrine solution for endoscopic injection therapy.

Endoscopic injection sclerotherapy versus conservative treatment for patients with unresectable hepatocellular carcinoma and bleeding esophageal varices

We performed endoscopic injection sclerotherapy (EIS) in the treatment of 37 patients with bleeding esophageal varices due to unresectable hepatocellular carcinoma (HCC). The results were compared with those in another 33 HCC patients treated only conservatively, without EIS, during the same period. A majority of both groups died within 3 weeks after treatment. Comparing the two groups, there was no significant difference in fatal bleeding (66% vs 75%), but significantly fewer of the EIS patients died of the index hemorrhage (43% vs. 83%; p less than 0.01). Also, in the absence of portal vein thrombosis, EIS significantly reduced the risk of fatal bleeding (31% vs. 73%; p less than 0.25). The mean days of survival were 32 +/- 15 (range, 2 to 320) in the EIS group and 10 +/- 14 (range, 2 to 270) in the compared group (p less than 0.001). We conclude that EIS provides temporary control of acute esophageal variceal bleeding in patients with unresectable HCC. The major factors contributing to EIS failure are the lethal propensity of the underlying disease and portal vein thrombosis.

Health, attitudes and beliefs of working women

A cross-sectional case-control study was conducted comparing working women employed by the Women's Work Centres of the Orangi Pilot Project with non-working matched controls. Differences in the knowledge, attitude and practice of several variables were elicited. Working women's families had significantly higher immunization rates, 73% vs 55%, and shorter duration of illness, 5.9 days vs 8.8 days, compared to controls. More working than non-working women supported contraception, 100% vs 74%, desired equal education for sons and daughters (P less than 0.005), and had a dominant role in family health decision-making, 48% vs 12%. We conclude that these working women in Orangi have a different set of beliefs and practices than non-working women and this may be one important factor responsible for the lower morbidity in their children.

Macromolecular biosynthesis in Mycobacterium smegmatis ATCC 607 in the presence of antibodies to mannophosphoinositides

The biosynthesis of DNA, proteins, RNA and phospholipids in Mycobacterium smegmatis ATCC 607 was investigated by studying the incorporation of radiolabelled components in the presence of antiserum to mannophosphoinositides. The antiserum had an inhibitory effect on the rate of synthesis of these macromolecules. However, the inhibition was greater when antibody was present together with complement.

Suppression of the antibody response to sulfolipids in leprosy patients by 4,4'-diaminodiphenyl sulfone (DDS)

Antibodies to sulfolipids were demonstrated in patients suffering from lepromatous leprosy. The antibody titre was found to decrease gradually on treatment with DDS. This effect was maximum for patients undergoing treatment for more than 1 year.

Immunological studies with sulpholipids of mycobacteria

Antibodies to sulpholipids of mycobacteria were produced in rabbits when injected as sulpholipid-MBSA complexes and were detected by kaolin agglutination and double diffusion techniques. Sulpholipid antibodies did not cross react with any other lipids of mycobacteria except cord-factor. The antigenicity of sulpholipids appears to be due to alpha-D-trehalose and sulphate groups. Guinea pigs immunized with sulpholipid-MBSA complexes showed partial protection against tuberculous infection with M. tuberculosis H37Rv, as revealed by mortality rate and score of lesions.

Antibody response to sulfolipids in experimental tuberculosis

Live Mycobacterium tuberculosis H37Rv, when injected into guinea pigs, induced antibodies to sulfolipids whereas antibodies were not detected in animals injected with heat killed cells. The antibody titre was found to be related to the degree of infection. A significant decrease in the titre was noted after streptomycin treatment, suggesting that antibodies were produced in response to an increasing bacterial load that occurred as the infection progressed.

Effect of growth temperature on the lipid composition of Mycobacterium smegmatis ATCC 607

The total lipid content of Mycobacterium smegmatis ATCC 607 was the same whether it was grown at 27 or 37 degrees C. The total phospholipid content, however, increased significantly at 27 degrees C. Phosphatidylethanolamine increased most markedly with a simultaneous decrease in phosphatidylinositol mannosides. Among individual phosphatidylinositol mannosides, tri- and tetra-acylated dimannophosphoinositides and tetra-acylated hexamannophosphoinositides all decreased at the lower growth temperature. Triacylglycerols and monoacylglycerols increased at the lower temperature but diacylglycerols were unaffected. Unsaturated fatty acids of total phospholipids increased as the temperature was lowered.