bluuebunny/crossref_metadata_2025 huggingface dataset:
Empowering patients to self-identify financial assistance programs using an online application.
Authors: Nicolla Jonathan , Friedman Fred , Manners Ian , Zafar Yousuf
Published: April 2017

4

Background: Available financial resources are relatively unknown to many patients with cancer facing high treatment-related costs. PAPNavigator is a web-based app designed to reduce out-of-pocket treatment costs by connecting patients to financial assistance programs specific to them. Traditionally used by financial counselors, PAPNavigator was modified to be patient-facing for this study, testing preliminary usability and effectiveness. Methods: Eligible patients with cancer were receiving anti-cancer treatment and reported out-of-pocket treatment costs. Patients interacted with PAPNavigator, inputted personal and financial data, and reviewed personalized financial resource results. Usability was assessed via the validated System Usability Scale (SUS). Effectiveness was assessed by two measures: “PAPNavigator improved my knowledge about financial aspects of cancer care and what can be done about it” and “Using this website was helpful with my financial concerns.” For all items, patients responded using a 5-point Likert scale. Results: 19 of 20 patients completed pilot testing (95%, 1 withdrew due to illness). 53% of patients were male, 26% were non-white, 79% had greater than a high school education, and 21% were employed full- or part-time. Median annual household income was $77,500. The median SUS score was 75 out of 100 (with >68 considered above average.) In response to statements, “I think that I would need assistance to be able to use this website,” and “I felt very confident using this website,” the median scores were 2 and 5 respectively. Additionally, in response to the statements, “PAPNavigator improved my knowledge about financial aspects of cancer care and what can be done about it,” and “Using this website was helpful with my financial concerns,” the median score for each was 4. Conclusions: The modified version of PAPNavigator demonstrated high usability and preliminary effectiveness in improving knowledge about financial aspects of cancer care and potential interventions to reduce cost. Further testing in larger samples is necessary.
Association between caring for a high proportion of older patients and adhering to standard care for younger patients.
Authors: Kamitani Satoru , Watanabe Tomone , Iwamoto Momoko , Higashi Takahiro
Published: April 2017

41

Background: Multiple comorbidities and physiologic decline often prevent older patients from receiving the same standard care provided to younger patients. Therefore, providers who mainly treat older patients may become accustomed to not adhering to standards and thus might be less likely to provide standard care to younger patients. In this study, we compared the care provided to younger patients between facilities that care for a large number of elderly patients and those that treat relatively few older patients. Methods: We used a nationwide registry-linked claims database of 297 hospitals. Among the quality indicators (QIs) we formerly developed, we selected 2 and 3 QIs for lung cancer and gastric cancer, respectively, based on the variation in adherence across facilities. Facilities were divided into 2 groups based on the proportion of older patients (≥75) with each cancer type. We then compared the QI adherence in treating patients younger than 60 years old between the groups. The difference in adherence to standards of care (quality scores) between the 2 groups of facilities was assessed by using a logistic regression model adjusting for patient age and sex. Results: We analyzed data for 6,708 patients with lung cancer and 26,470 patients with gastric cancer. Respective quality scores for facilities with more older patients versus facilities with fewer older patients were 63.4% versus 66.1% (p=0.439) for the EGFR mutation test before the first chemotherapy among stage IV lung adenocarcinoma patients; 63.2% versus 52.5% (p=0.238) for concurrent chemoradiotherapy (CCRT) for localized small cell lung carcinoma patients; 51.6% versus 46.9% (p=0.229) for HER2 test before the first chemotherapy among patients with unresectable gastric cancer; 81.8% versus 79.7% (p=0.354) for Helicobacter pylori test on patients with gastric cancer who had ESD/EMR; and 60.9% versus 60.7% (p=0.948) for adjuvant chemotherapy within 6 weeks among pathological stage II/III gastric cancer patients. Conclusions: Caring for a high proportion of older patients is not associated with diminished provision of standard care to younger patients.
Potential drug-drug interaction events in patients treated with abiraterone acetate plus prednisone or enzalutamide.
Authors: Pilon Dominic , Behl Ajay S. , Emond Bruno , Xiao Yongling , Lefebvre Patrick , Kane Christopher J.
Published: April 2017

44

Background: The treatment of patients with advanced cancer generally requires multiple medications, and the consideration of potential drug-drug interactions (DDIs) is important to avoid unintended consequences; therefore, this study assessed potential DDIs in patients treated with oral metastatic castrate-resistant prostate cancer (mCRPC) therapies (abiraterone acetate plus prednisone [AA+P] and enzalutamide [ENZ]). Methods: The MarketScan databases from 03/2012 to 10/2015 were used to conduct a retrospective analysis, in which patients initiated on AA+P or ENZ after 09/2012 (index date) with ≥6 months of continuous eligibility prior to index date and ≥1 PC diagnosis were included. Inverse probability of treatment weighting (IPTW) was used to adjust for observed baseline confounders between groups. Weighted Kaplan-Meier (KM) rates and Cox proportional hazard models were used to compare the occurrence of potential DDIs. Potential DDI was defined as having a claim for a drug that can interact with the index drug (AA+P or ENZ) during the exposure to index treatment (i.e., the time between the first and last claim [plus days of supply] of the index treatment). Interaction drugs were selected based on the prescribing information for each drug and included strong CYP3A4 inducers and CYP2D6 substrates for AA+P and strong CYP3A4 inducers, CYP2C8 inhibitors, CYP2C9 substrates, CYP3A4 substrates, and CYP2C19 substrates for ENZ. Results: A total of 2,540 AA+P and 1,265 ENZ patients were identified. IPTW resulted in balanced baseline demographic, comorbidities, and disease characteristics. At 3, 6, 9, and 12 months post-index, patients initiated on ENZ were more likely to have a potential DDI during their exposure to ENZ treatment when compared to patients initiated on AA+P (ENZ vs. AA+P, KM rates at 12 months: 30.3% vs. 1.5%, hazard ratio [95% confidence interval]: 28.9 [14.5, 57.4], p < 0.0001). Conclusions: This study showed that mCRPC patients treated with ENZ were more likely to be exposed to a potential DDI during their treatment than those treated with AA+P.
Out of system (OOS) costs for oncology clinics treating patients with breast, colorectal, and non-small cell lung cancer in Washington state.
Authors: Fedorenko Catherine R. , Kreizenbeck Karma L. , Panattoni Laura , Walker Julia Rose , Greenwood-Hickman Mikael Anne , Lyman Gary H. , Conklin Ted , Smith Bruce , Barger Sarah , Ramsey Scott David
Published: April 2017

5

Background: As payers move from fee-for-service to episode-based reimbursement, there is a need for oncology providers to accurately measure in- and out-of-system resource use and cost for patients under their care. Medicare assigns management of a patient to only one provider, yet delivery systems may assume contractual responsibility for a patient with cancer’s entire episode costs, including care received outside of their system. Accordingly, the goal of this study was to estimate OOS care for patients with breast, colorectal (CRC), and non-small cell lung cancer (NSCLC). Methods: Cancer registry records for patients with breast, CRC, or NSCLC diagnosed in Western Washington State from January 2007 to June 2016 were linked with claims from two regional commercial insurers. The analysis focused on initial treatment phase: first day of treatment (surgery, radiation, chemotherapy) through the first 4-month gap in treatment. Patients were assigned an oncology provider group by identifying the clinic Tax ID Number (TIN) with the most Evaluation & Management (E&M) claims with a cancer diagnosis. Claims were considered in system if the TIN matched the assigned clinic. Costs included claims paid to all providers (adjusted to 2016 dollars). Results: The study included 7,686 newly diagnosed patients with breast, CRC, or NSCLC. The average cost for the initial treatment phase was $61,147/patient (SD $75,432, median $35,750). Nearly 31% of claims paid (mean $18,684, SD $32,649) were out of system. Among OOS costs, 24% were for inpatient care, 68% were for outpatient care, and 8% were for outpatient pharmacy. Conclusions: Among newly diagnosed patients with breast, CRC, or NSCLC, approximately 1/3 of costs for the initial treatment period stemmed from OOS care. Developing best practices for the reporting and management of OOS will be critical for organizations to succeed under episode-based reimbursement plans.[Table: see text]
Effect of the establishment of a hematological multidisciplinary oral chemotherapy clinic at a community hospital on the number of emergency department visits.
Authors: Disperati Patricia , Kagramanov Dalia , Bjorkman Hannah , Horsley Rose , Thede Katie
Published: April 2017

50

Background: Oral chemotherapy is an efficacious albeit toxic treatment of Malignant Hematological diseases. Multidisciplinary oral chemotherapy clinics (MOCC) have been proven to improve care in patients with solid tumors such as prostate and gastrointestinal cancer but there is little data in the Hematological setting. A MOCC was formed to determine if it would lead to a 20% decrease in emergency department (ED) visits and hospital admission over a 10-month period after implementation in patients with Malignant hematological disease on oral chemotherapy. Methods: A chart review of patients on oral Hematological drugs was performed for baseline data. A MOCC consisting of a nurse and a pharmacist was established, with physician backup. Checklists that were drug and disease specific were created for 5 different drugs (Lenalidomide, Ibrutinib, Dasatinib, Nilotinib and Idelalisib) for treatment initiation, follow-up and monitoring and incorporated into the electronic health record. This model was piloted and outcomes were measured to determine improvements in medicine reconciliation, documentation of adverse events, dose modification, patient compliance, unscheduled MD assessments and ED visits. Qualitative interviews were performed with patients and nurses to assess satisfaction with this team approach. Results: 30 patients with Hematological malignancies were enrolled sequentially during the 10-month period. After a median follow up of 7 months, there was 100% medicine reconciliation and 92% compliance with treatment protocols; 47% of patients had interventions requiring dose modifications that would not previously have been documented or addressed. There was a 20% increase in unscheduled MD assessments and a 33% decrease in ED visits and hospital admission from baseline. Both patients and nursing staff were satisfied with the team approach. Conclusions: In a community setting, the implementation of MOCC resulted in early recognition of AE and reduced ED visits. In addition, the new model lead to improved patient and staff satisfaction.
Measuring palliative and end-of-life care for cancer patients who die in hospital in Canada.
Authors: Decaria Kristen , Dudgeon Deborah , Green Esther , Shaw Moxam Raquel , Rahal Rami , Niu Jin , Daly Corinne , Bryant Heather E.
Published: April 2017

58

Background: High acute hospital utilization rates near end-of-life can signal that community-based palliative care may not be suiting patients’ needs. Early integration of comprehensive palliative care can greatly reduce unplanned visits to the emergency department, reduce multiple admissions to hospital, shorten hospital stays, and increase the number of home deaths as well as improving the quality of life of advanced cancer patients. This analysis reports on indicators that describe the current landscape of acute-care hospital utilization at end-of-life and indirectly examines access to palliative care in patients who died of cancer in a hospital. Methods: Data were provided by the Canadian Institute for Health Information. The Discharge Abstract Database was used to extract acute-care cancer death abstracts. Data on ICU admissions include only facilities that report ICU data. Emergency department visit data were obtained from the National Ambulatory Care Reporting System. The analysis was restricted to adults aged 18+ who died in an acute-care hospital in fiscal years 2014/15 and 2015/16 for nine provinces and three territories. Results: A total of 48,987 (43%) cancer patient deaths occurred in an acute-care hospitals, with 70% admitted through the emergency department. Preliminary analysis revealed interprovincial variation in the cumulative length of stay in hospital 6 months prior to death from a median stay of 17 to 25 days. Some variation was also seen in the proportion of patients admitted to hospital two or more times in the last month of life (ranging from 18% to 33%), and the proportion of cancer patients admitted to ICU in the last 14 days of life (ranging from 15% to 6%). Patient demographics (age, sex, place of residence) and clinical factors (cancer type) were often predictors of hospital utilization at end-of-life. Conclusions: This study provides information on the current landscape of acute-care hospital utilization by cancer patients at end-of-life across Canada and identifies interprovincial variations in management of end-of-life care. An area of focus for the Palliative and End-of-Life National Network continue to be developing nationally agreed upon system-wide palliative care indicators.
Continuous quality management for complex blood cancers in Sarah Cannon Blood Cancer Network.
Authors: Kambhampati Suman , Dodd Therese , Sheridan Cheryl , LeMaistre Charles F.
Published: April 2017

59

Background: Sarah Cannon Blood Cancer Network (SCBCN) is a network of seven markets dedicated to provide high quality and safe care to patients with complex blood cancers. Continuous quality management (QM) and improving patient safety are critical components to the mission of SCBCN. Methods: Four SCBCN disease-specific working groups have developed evidence-based pathways for complex blood cancers. However, there are currently no SCBCN clinical quality of care metrics to monitor value-based care. To address this unmet need, the SCBCN leadership endorsed a team-based approach to measure QM for complex blood cancers, using basic clinical performance metrics proposed by the American Society of Hematology, the American Medical Association-convened Physician Consortium for Performance Improvement, the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality National Quality Measures Clearinghouse, and Centers for Medicare & Medicaid Services. Results: Between 2012 and September 2015, 1221 new adult cases of Acute Myeloid Leukemia (AML) and 253 new adult cases of Myelodysplastic Syndrome (MDS), respectively, were reported within the SCBCN. Based on the volume of cases and to measure QM in AML and MDS, quality indicators were selected based on meaningfulness to program goals and feasibility of data capture, leading to development of quality metrics dashboard for AML and MDS in SCBCN. Also, keeping in mind the changing paradigm of personalized care using new and emerging therapies in AML and MDS, exploratory quality metrics are also proposed to evaluate access to new trials as QM of AML and MDS in SCBCN. Conclusions: SCBCN is a wide network of community hospitals with expertise in managing complex blood cancers. As proof of concept study, the AML and MDS dashboard was developed and chosen as a model for continuous QM for complex blood cancers. This dashboard will initially be tested to evaluate QM at two SCBCN sites to facilitate the overarching programmatic goal of continuous QM for all AML/MDS and other blood cancers presenting within the SCBCN.
Increasing Epic staging module adherence in an academic cancer center.
Authors: Porter Julie , Segura Smith Andrea , Cook Marta , Boncato Kristine , Bruels Mary , Duda-Stavlund Erik , Blayney Douglas W.
Published: April 2017

64

Background: Documenting tumor staging (TS) is an important quality measure from ASCO’s QOPI program as a useful Core component of care. Real-time, actionable TS documentation in structured fields is important to identify patient cohorts for value-based measurement and to trigger patient care interventions. TS at our institution was usually documented in plain text progress notes in our electronic health record (Epic, Verona WI), making it difficult to use for automating support services, clinical trial evaluation, pre-authorization, business operations, value-based initiatives, and clinical research. Methods: Entry of TS into structured fields in the Epic Staging Module was agreed upon as an internal cancer quality measure in Fiscal Year (FY) 16 (9/15 – 8/16). Patients with > 2 visits to an oncology outpatient department and who began surgical, radiation or chemotherapy treatment in the reporting month were included. The physician providing the first treatment was accountable. Monthly physician and patient-level reports were provided to physician leaders, in a phased roll-out. Targets were based off FY15 performance, which were doubled for a minimum of 40% and maximum of 70% adherence. Results: Nine cancer care programs (CCPs) participated. Average compliance increased from 24% in 9/15 to 79% in 8/16. 2089 of 2894 (72%) charts had clinical and/or pathologic TS entered in the Module. Adherence was driven by CCP leaders sharing data and allowing advanced practice providers staging privileges. We uncovered discordance among providers on what clinical information to input into the Module: original diagnosis or presenting diagnosis on which to base treatment. Conclusions: Our multidisciplinary care teams improved our ability to capture TS at first treatment. A rolled-out, rather than big-bang “hard stop,” approach was successful, as we uncovered unexpected flaws in the system including aligning clinical and staging privileges with Epic access privileges, inaccuracies in Module implementation, and unclear definition between stage and disease state. There are deficiencies in the current AJCC staging system, particularly in its use for relapsed or recurrent cancer, which make defining real-time actionable processes difficult.
Adoption of a regional physician peer review program for radiation oncology.
Authors: Harris Eleanor Elizabeth , Arastu Hyder Husain , Leinweber Clinton , Ju Andrew , McLaurin Robert , Blackburn Randall , Shelton Charles , Barnes Timothy , Holloman Michael
Published: April 2017

67

Background: Physician peer review is an important component of patient quality and safety programs. In 2012, the American Society for Radiation Oncology (ASTRO) published a white paper on peer review standards with recommendations to evaluate quality standards and compliance. Methods: Per ASTRO guidelines, physician peer review policy was adopted in 2013 by the Radiation Oncologists at the medical school and health system regional network. Peer review was conducted via WebEx by 5 regional centers. Reviews were done prior to start of treatment for all but emergent cases. Data were collected prospectively on 25 quality metrics, and scored by pre-defined peer consensus as follows: no change, minor change, major change, refer to chair. A description of recommended change was notated. Major changes were required to be represented. Aggregate data for the group and per physician were analyzed quarterly and incorporated into annual performance evaluations. Results: Aggregate categorical scores were compared for time periods from June to December 2014 (N = 283 cases) and June to December 2015 (N = 352 cases), showing an overall improvement in average scores per physician from 1.150 to 1.001. There were 56 (19.7%) total variances in 2014 compared to 32 (9%) variances in 2015. Level 2 changes (“minor”) decreased from 15.5% in 2014 to 7.2% in 2015 (p = 0.001). Level 3 changes (“major”) decreased from 4.2% to 1.9%, respectively (NS). The most common minor and major changes recommended related to dose parameters and target volumes. Variance rates over 5% were addressed by the department chair with individual practitioners and improvement programs instituted as needed. Conclusions: Peer review among a geographically diffuse physician group including an academic group practice and solo community physicians was feasible using a telemedicine system. Acceptance by the peer group was high, and over time the conference was increasingly used by physicians to review cases prior to initiating treatment planning, resulting in overall improved quality of treatment plans presented. Improved quality of care for radiation patients’ was demonstrated by significant reductions in the number and severity level of changes to treatment plans recommended.
Palliative care pharmacists as advocates to conduct advance care planning.
Authors: Ma Joseph , Dullea Alexandra , Hagmann Chelsea , Russell Michelle , Cramer Arlene , Cohen-Arazi Yael , Roeland Eric
Published: April 2017

73

Background: Advance care planning (ACP) is a process whereby individuals consider their end-of-life (EoL) treatment preferences and make them known to caregivers and clinicians in the event of decisional incapacity. We previously reported a focused ACP intervention led by a clinical social worker (J Palliat Med 2016). Based on this trial’s initial success, we aimed to evaluate this approach when led by a pharmacist. To date, no data exists regarding pharmacist-led ACP discussions. Methods: Advanced stage cancer patients were screened at a single, academic oncology palliative care clinic. Training of the pharmacist included observation of ACP interventions conducted by the clinical social worker, didactic lectures, and role playing. Subjects engaged in a 1-hour ACP intervention with a palliative care pharmacist within 4 weeks of consent. Details of the ACP intervention were documented in the electronic medical record and AD/POLST completion was encouraged but not required. The study outcome was the identification of an informed proxy. After the patient’s death, proxies were contacted to determine if EoL wishes were achieved. Descriptive analyzes were performed. Results: Patient demographics were 22 patients, who were mostly woman (n = 13), Caucasian (n = 17), married (n = 14), with a mean age ± SD of 60.3 ± 10.5 years and with gastrointestinal (n = 5) and genitourinary (n = 5) as the most common primary cancers. After the ACP intervention by the pharmacist, 21 of 22 patients identified an informed proxy. The most commonly identified proxy was a spouse (n = 13). Fourteen (64%) subjects completed an AD/POLST after the ACP intervention. As of October 2016, 27% (6/22) of patients have died. Four out of 6 patients died in a setting consistent with their EoL wishes. Mean time to death from ACP intervention was 133±132 days. Sixteen subjects remain in surveillance. Conclusions: Preliminary results suggest that a pharmacist can conduct ACP discussions to identify an informed HCP. To date, the majority of patients achieved a death concordant with their EoL wishes.
Improving immune-related adverse event management in a thoracic clinic.
Authors: Shea Meghan , Rangachari Deepa , Costa Daniel Botelho , Sato-DiLorenzo Aya , Zerillo Jessica A.
Published: April 2017

74

Background: Widespread use of immunotherapeutic agents has transformed the profile of adverse events associated with systemic cancer therapy. Management of immune-related adverse events (IRAEs) is contingent upon grading severity using the National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE). Nivolumab and Pembrolizumab were recently approved for metastatic non-small cell lung cancer (NSCLC). United States Food and Drug Administration (US FDA)-approved package label inserts provide guidance on IRAE management and are predicated on CTCAE grade, including when to discontinue drug. Currently, clinicians in the thoracic oncology group are documenting CTCAE grade of IRAEs infrequently, and management is varied. Methods: A retrospective chart review of baseline data revealed 45 patients (8 on Pembrolizumab, 37 on Nivolumab) who initiated immunotherapy for metastatic NSCLC between March 2015 and August 2016. A team of clinicians developed a process map from diagnosis of IRAE to initiation of toxicity management. Physicians were surveyed. The team’s aim is by February 1, 2017, at least 50% of patients who develop an IRAE on immunotherapy for metastatic NSCLC have documentation of toxicity grade using the CTCAE criteria. Results: The physician survey response rate was 12 of 16 (75%). Physicians reported not using grade to guide management of IRAEs over two thirds (67%) of the time. Time to look up CTCAE criteria and knowing that grade is needed ranked as the top barriers. At baseline, 18 of 45 (40%) patients had 22 IRAEs, of which 6 IRAEs (27%) had grading documented; all graded IRAEs (100%) were managed according to guidelines in the drug-specific package insert. IRAEs included hypothyroidism, pneumonitis, hepatitis, dermatitis, adrenal insufficiency, colitis, and encephalitis. Conclusions: Education on toxicity grading and ease of accessibility to information regarding management of IRAEs are needed. Because clinicians were engaged, a survey to evaluate the current process succeeded with a high response rate. At baseline, there are significant gaps and variability in current practice. Interventions are underway to standardize documentation of grade and management of patients experiencing IRAEs.
Feasibility of capturing radiation oncology quality metrics in a large integrated oncology practice.
Authors: Dubey Ajay , Bernard Jeff , Limmer Jeffrey , Heintz Bret , Antes Kyle , Hartman Stacy , Taylor Bernard , Cheek Brennan Scott , Wilfong Lalan S. , Hoverman John Russell
Published: April 2017

83

Background: Metrics to assess quality are important to improve processes of care. While such capture and reporting are common in medical oncology practices, it is less common with radiation oncology. As part of a large integrated oncology practice with more than 400 physicians and 57 radiation oncologists, we explored the feasibility of capturing and reporting a bundle of metrics at each of 52 radiation oncology practice sites. Methods: At the beginning of each quarter, the first 20 charts were sampled at each rad onc site of service to capture the following metrics: performance status at the start of radiation therapy, pain level at the start of XRT for patient with bone metastasis, cancer staging documented, dose limits to normal tissue tissues established and clearly documented for IMRT cases, and adherence to the 2015 US Oncology Breast Cancer XRT Pathways. Pathways adherence was captured via physician attestation. Beginning in the second quarter, Breast Cancer Pathways concordance with the final delivered plan was reported. Beginning in the 3rdquarter, additional pathways were captured (but not reported) for NSCLC, Prostate, Rectal Cancer, and Bone Metastasis sites. Results: See table. Conclusions: Availability of metrics data and compliance was greater than 80% in all 52 radiation oncology practice sites. Documentation of dose limits was seen as an opportunity for improvement via standardization of workflows, as there were multiple workflows within the record and verify system. Concordance rate between attestation of pathways compliance and the delivered plan was high. Breast cancer pathways compliance fell in the third quarter when additional pathways were added, suggesting that increasing complexity of metrics requirements may decrease performance. [Table: see text]
Stakeholder perspectives on the use of telehealth to improve ambulatory care for chemotherapy patients in a large urban cancer centre.
Authors: Doshi Samik , Chad Jeremy , Archer-Myles Karin , Krzyzanowska Monika K.
Published: April 2017

86

Background: Chemotherapy outpatients are often left in vulnerable positions without direct access to their providers between appointments, which can lead to Emergency Department (ED) visits to address side effects. Improved use of telehealth has been postulated in the literature as a potential low-cost tool to manage this problem. Our objective was to explore, as a case study, how telehealth can be optimized to provide better care to ambulatory chemotherapy patients. Methods: This study was done at Princess Margaret Cancer Centre in Toronto. Semi-structured interviews (n = 21) were conducted to elicit a broad set of perspectives on the feasibility and constraints of implementing new telehealth measures in the breast cancer (BC) clinic. Interviewees included hospital administrators (n = 3), nurse managers (n = 4), BC nurses (n = 3), BC physicians (n = 2), one non-BC nurse, one pharmacist, BC patients (n = 4), and telehealth and technology experts (n = 3). Transcripts were reviewed separately by each author and themes were extracted using content analysis. Key learnings were established based on stakeholder agreement and theme novelty. Results: Provider-initiated proactive calling of chemotherapy patients was felt to bethe most valuable and feasible potential change according to all stakeholders. A number of key considerations emerged regarding the creation of a successful proactive calling system: 1) calls should address symptoms that are predictable, regimen-specific, and most likely to result in ED visits; 2) patients most likely to benefit are those beginning chemotherapy, starting new drugs, or fitting certain high-needs criteria; 3) structured call questionnaires can be valuable, but must be flexible to best meet patient needs; 4) the caller’s expertise is more important than his or her familiarity with the patient; and 5) basic IT support systems are necessary for operationalization. Conclusions: Simple telehealth initiatives such as proactive calls can improve outpatient care for chemotherapy patients, and may reduce ED burden. This study provides key principles that should guide development and implementation of proactive calling programs at cancer care institutions.
A multidisciplinary effort to decrease time from admission to chemotherapy on an inpatient oncology unit.
Authors: Man Louise Ming-Wai , Sen Jeremy , Cahan Jeanne , Degregory Kathlene , Thomas Tanya , Daniels Elizabeth , McLoughlin Erin , Huntsinger Lisa , Keng Michael Kenneth
Published: April 2017

96

Background: Patients with established cancer diagnoses often experience delays in starting scheduled inpatient chemotherapy (CTX) after arrival on the University of Virginia (UVA) Medical Center oncology unit. These delays negatively impact hospital resource utilization. We formed a multidisciplinary team of physicians, nurses, and pharmacists to investigate these delays. We aim to decrease time-to-CTX (TTC) by 30% from baseline. Methods: From 340 planned inpatient CTX encounters in calendar year 2015, 100 were randomly reviewed to establish baseline retrospective data. The following were collected for each encounter: patient demographics; oncologic diagnosis; admitting team; CTX regimen and cycle; procedures and urinary parameters required prior to CTX start; times of lab orders and results, CTX signature and release, and start of intravenous fluid (IVF), premedications, and CTX; unit census data; available nursing staff; and length of stay. With guidance from ASCO’s Quality Training Program, we constructed a process map of the current state, an Ishikawa cause-and-effect diagram, a Pareto chart to assess causes of delays, and a priority matrix of potential interventions. XmR charts compared baseline and post-intervention data. Results: Baseline median TTC was 6.7 hours (range 1.5-105.3 h). Patients with pre-admission outpatient appointments started CTX 2.4 h earlier than those without appointments. Patients without urine parameters for treatment started CTX 3 h earlier than those with parameters. The Pareto chart indicated the longest delays occurred in pre-medicating patients, starting IVF, and signing CTX orders. In the first Plan-Do-Study-Act (PDSA) cycle, the CTX consent process was reformed. Post-intervention data showed no change in median TTC (7.2 h). Other PDSA cycles (setting patient arrival times and pre-admission pharmacy review of treatment plans) are ongoing; prospective data collection is pending. Conclusions: Retrospective data validate concerns that delays in starting inpatient CTX are longer than acceptable. They affect hospital length of stay, cost, and patient satisfaction. Our first PDSA cycle showed no change in TTC but additional interventions are ongoing.
Syncope
Authors: Cheshire William P.
Published: April 2017

Purpose of Review: Syncope is a prevalent syndrome with diverse causes, which have in common a sudden transient failure of the autonomic nervous system to maintain blood pressure against the force of gravity at a level sufficient for cerebral perfusion. Neurally mediated syncope is an episodic phenomenon in which autonomic nervous system function is normal the rest of the time. Although relatively benign, syncope increases the risk for injury from falling and can substantially impair patients’ quality of life. Recognition of its various clinical presentations and knowledge of the underlying pathophysiology are essential for accurate diagnosis and successful management.

Recent Findings: The most effective forms of treatment remain education of patients, avoidance of triggers, physical counterpressure maneuvers, and hydration or intravascular volume expansion. Pharmacologic interventions may be appropriate for some patients but, in general, have limited evidence of efficacy in preventing syncope. Based on the findings of a recent study, the possibility of pulmonary embolism should be considered in patients hospitalized for syncope, whether or not an alternative etiology for syncope is identified.

Summary: This article focuses on the neurologic diagnosis, differential diagnosis, physiology, and management strategies for syncope, with an emphasis on neurally mediated syncope.
Neuropathic Pain
Authors: Zilliox Lindsay A.
Published: April 2017

Purpose of Review: Neuropathic pain is a frequently encountered condition that is often resistant to treatment and is associated with poor patient satisfaction of their treatment. Several medications have been shown to be effective in treating neuropathic pain associated with diabetic neuropathy and postherpetic neuralgia, and these medications are often used to treat neuropathic pain associated with other conditions as well. This article summarizes the diagnosis and assessment of patients with neuropathic pain as well as available pharmacologic and interventional treatment options.

Recent Findings: Evidence-based recommendations for the treatment of neuropathic pain have been published, and first-line medications include antidepressants, anticonvulsants, topical agents, as well as opioid analgesics. Interventional options include anesthetic and steroid injections, nerve blocks, and spinal cord stimulation. Essential to the treatment algorithm of neuropathic pain is the assessment and treatment of psychosocial comorbidities and the utilization of a multidisciplinary team approach, including cognitive-behavioral and rehabilitative therapies. Questions remain about the comparative effectiveness of various medications and combination therapies. Increasing interest also exists in the optimization and personalization of pharmacotherapy based upon the underlying mechanism(s) of neuropathic pain according to the quality of the patient’s symptoms.

Summary: The management of chronic neuropathic pain is challenging and is best achieved with the use of a multidisciplinary team. Pain is a subjective experience, and it is important to validate a patient’s pain, address psychosocial comorbidities, and set realistic treatment goals. Evidence-based guidelines are available to guide treatment, but frequently, high-quality evidence-based recommendations are lacking.
Disorders of Taste and Smell
Authors: DeVere Ronald
Published: April 2017

Purpose of Review: This article aims to educate clinical neurologists on the importance of taste and smell disorders in clinical neurology. These disorders commonly occur in head trauma, multiple sclerosis, seizure disorders, and neurodegenerative diseases such as idiopathic Parkinson disease and dementia, mild cognitive impairment, and Alzheimer disease, just to name a few. This article covers the basic anatomy of smell and taste, notes the important points of taking a proper history, and discusses smell and taste testing, which are inexpensive, minimally time-consuming procedures. Recurrent bad smells and tastes are not uncommon in these disorders, which cause major impairment in quality of life, including loss of appetite, decreased eating, and weight loss. The diagnosis and treatment of these disorders will also be discussed.

Recent Findings: Despite past widespread negative prognoses of taste and smell disorders, more recent work in the last 10 years has shown an improved prognosis for smell and taste recovery in most disorders, and recommendations for changes in food preparation have helped many patients enjoy their food and increase their appetite. Recent experimental evidence has shown that smell loss and testing can assist in separating idiopathic Parkinson disease from other parkinsonian syndromes, can suggest which patients with rapid eye movement (REM) sleep behavior disorder will more likely develop Parkinson disease, and can be predictive of the progression of cognitive impairment and Alzheimer dementia.

Summary: This article discusses the common smell and taste disorders that a clinical neurologist will encounter in practice. The anatomy and function of smell and taste will be reviewed, followed by office evaluation and testing. The common disorders will be reviewed, along with their prognosis and management.
A role for planar cell polarity during early endoderm morphogenesis
Authors: Miles Lee B. , Mizoguchi Takamasa , Kikuchi Yutaka , Verkade Heather
Published: April 2017

The zebrafish endoderm begins to develop at gastrulation stages as a monolayer of cells. The behaviour of the endoderm during gastrulation stages is well understood. However, knowledge of the morphogenic movements of the endoderm during somitogenesis stages, as it forms a mesenchymal rod, is lacking. Here we characterise endodermal development during somitogenesis stages, and describe the morphogenic movements as the endoderm transitions from a monolayer of cells into a mesenchymal endodermal rod. We demonstrate that, unlike the overlying mesoderm, endodermal cells are not polarised during their migration to the midline at early somitogenesis stages. Specifically, we describe the stage at which endodermal cells begin to leave the monolayer, a process we have termed “midline aggregation”. The Planar Cell Polarity (PCP) signalling pathway is known to regulate mesodermal and ectodermal cell convergence towards the dorsal midline. However, a role for PCP signalling in endoderm migration to the midline during somitogenesis stages has not been established. In this report, we investigate the role for PCP signalling in multiple phases of endoderm development during somitogenesis stages. Our data exclude involvement of PCP signalling in endodermal cells as they leave the monolayer.
Rethinking cancer: current challenges and opportunities in cancer research
Authors: Cagan Ross , Meyer Pablo
Published: April 2017

Cancer therapeutics currently have the lowest clinical trial success rate of all major diseases. Partly as a result of the paucity of successful anti-cancer drugs, cancer will soon be the leading cause of mortality in developed countries. As a disease embedded in the fundamentals of our biology, cancer presents difficult challenges that would benefit from uniting experts from a broad cross-section of related and unrelated fields. Combining extant approaches with novel ones could help in tackling this challenging health problem, enabling the development of therapeutics to stop disease progression and prolong patient lives. This goal provided the inspiration for a recent workshop titled ‘Rethinking Cancer’, which brought together a group of cancer scientists who work in the academic and pharmaceutical sectors of Europe, America and Asia. In this Editorial, we discuss the main themes emerging from the workshop, with the aim of providing a snapshot of key challenges faced by the cancer research community today. We also outline potential strategies for addressing some of these challenges, from understanding the basic evolution of cancer and improving its early detection to streamlining the thorny process of moving promising drug targets into clinical trials.
Safe Assets, Liquidity, and Monetary Policy
Authors: Benigno Pierpaolo , Nisticò Salvatore
Published: April 2017

This paper studies monetary policy in models where multiple assets have different liquidity properties: safe and “pseudo-safe” assets coexist. A shock worsening the liquidity properties of the pseudo-safe assets raises interest rate spreads and can cause a deep recession-cum-deflation. Expanding the central bank’s balance sheet fills the shortage of safe assets and counteracts the recession. Lowering the interest rate on reserves insulates market interest rates from the liquidity shock and improves risk sharing between borrowers and savers. (JEL E31, E32, E43, E44, E52)
The Effects of the Real Oil Price on Regional Wage Dispersion
Authors: Kehrig Matthias , Ziebarth Nicolas L.
Published: April 2017

We find that oil supply shocks decrease average real wages, particularly skilled wages, and increase wage dispersion across regions, particularly unskilled wage dispersion. In a model with spatial energy intensity differences and nontradables, labor demand shifts, while explaining the response of average wages to oil supply shocks, have counterfactual implications for the response of wage dispersion. Only an additional response in labor supply can explain this latter fact, highlighting the importance of general equilibrium effects in a spatial context. We provide additional empirical evidence of regionally directed worker reallocation and housing prices consistent with our spatial model. Finally, we show that a calibrated version of our model can quantitatively match the estimated effects of oil supply shocks. (JEL E24, J22, J23, J24, J31, Q35, R23)
Case Report: Orbital metastasis as the presenting feature of lung cancer
Authors: Munakomi Sunil , Chaudhary Samrita , Chaudhary Pramod , Thingujam Jagdish , Mohan Kumar Bijoy , Cherian Iype
Published: April 2017

Orbital metastasis from lung cancer as an initial presenting symptom is a rare entity, which may paradoxically delay the diagnosis and initiation of correct management, due to the confusion of it being primary orbital pathology. Herein we report a case of a 58 year old woman, who presented with painful orbital swelling along with diminution in her vision. The patient was initially thought to have a primary eye lesion; however chest X-ray was suggestive of a lung mass, which was confirmed by chest computed topography followed by ultrasound guided fine needle aspiration cytology. The patient was then referred to a cancer centre for further management. This case report aims to increase the knowledge about this metastasis as a probable cause of orbital symptoms in certain subsets of patients, so that correct therapeutic decisions may be made in the future.
A cross-package Bioconductor workflow for analysing methylation array data
Authors: Maksimovic Jovana , Phipson Belinda , Oshlack Alicia
Published: April 2017

Methylation in the human genome is known to be associated with development and disease. The Illumina Infinium methylation arrays are by far the most common way to interrogate methylation across the human genome. This paper provides a Bioconductor workflow using multiple packages for the analysis of methylation array data. Specifically, we demonstrate the steps involved in a typical differential methylation analysis pipeline including: quality control, filtering, normalization, data exploration and statistical testing for probe-wise differential methylation. We further outline other analyses such as differential methylation of regions, differential variability analysis, estimating cell type composition and gene ontology testing. Finally, we provide some examples of how to visualise methylation array data.
Identifying, managing and preventing skin maceration: a rapid review of the clinical evidence
Authors: Whitehead F. , Giampieri S. , Graham T. , Grocott P.
Published: April 2017

Objective:

To identify the clinical empirical evidence for identifying, managing and preventing skin maceration in human subjects.

Method:

A rapid review of the current literature was undertaken between 5 September and 19 September 2016 using the electronic databases CINAHL, MEDLINE, PUBMED and Cochrane, with the key words: skin macerat*, wound macerat*, moisture associated skin damage, wound exudate and hyper-hydration of skin,

Results:

Of 526 papers found using an electronic database search, four were identified as fitting the search parameters, and a further two were retrieved from a manual search of reference lists. There were three themes that emerged: how to identify and measure maceration, how to manage and reduce maceration once it has already occurred, and how to prevent skin maceration. Hyper-hydration can reach greater skin depths than previously thought, thus engendering more extensive damage potential, which in turn can impact on treatments and healing time. Realistically, the deeper the hyper-hydration issue, the more extensive the damage and it will take longer to recover—a problem compounded if the hyper-hydration is due to incontinence and skin is also exposed to urine and/or faeces. In relation to wound management, the authors advocate the removal of moisture away from the wound or skin, either through superabsorbent dressings, or by allowing the excess moisture to evaporate through semi-permeable dressings to reduce maceration, enhance patient comfort and encourage healing. However, we found no evidence regarding the limits of hydration of the dermis and epidermis and thereby the optimal conditions for managing exuding wounds and promoting skin health. Each of the six papers in this review calls for further research to help identify, treat and prevent maceration.

Conclusion:

Maceration causes patients' discomfort and pain as well as prolonging healing time and deserves more focused research. This rapid review highlights how limited the clinical empirical research is on identifying and managing skin maceration from an early stage so that health professionals may be better equipped to prevent it. Further clinical research is also needed to determine when levels of hydration in the skin become damaging. The small number of studies within this review show that skin maceration can be avoided, but clearer guidance is needed.