bluuebunny/crossref_metadata_2025 huggingface dataset:
An Integrative Model Accounting for the Symptom Cluster Triggered After an Acoustic Shock
Authors: Noreña Arnaud J. , Fournier Philippe , Londero Alain , Ponsot Damien , Charpentier Nicolas
Published: September 2018

Acoustic shocks and traumas sometimes result in a cluster of debilitating symptoms, including tinnitus, hyperacusis, ear fullness and tension, dizziness, and pain in and outside the ear. The mechanisms underlying this large variety of symptoms remain elusive. In this article, we elaborate on the hypothesis that the tensor tympani muscle (TTM), the trigeminal nerve (TGN), and the trigeminal cervical complex (TCC) play a central role in generating these symptoms. We argue that TTM overuse (due to the acoustic shock), TTM overload (due to muscle tension), and ultimately, TTM injury (due to hypoxia and “energy crisis”) lead to inflammation, thereby activating the TGN, TCC, and cortex. The TCC is a crossroad structure integrating sensory inputs coming from the head–neck complex (including the middle ear) and projecting back to it. The multimodal integration of the TCC may then account for referred pain outside the ear when the middle ear is inflamed and activates the TGN. We believe that our model proposes a synthetic and explanatory framework to explain the phenomena occurring postacoustic shock and potentially also after other nonauditory causes. Indeed, due to the bidirectional properties of the TCC, musculoskeletal disorders in the region of the head–neck complex, including neck injury due to whiplash or temporomandibular disorders, may impact the middle ear, thereby leading to otic symptoms. This previously unavailable model type is experimentally testable and must be taken as a starting point for identifying the mechanisms responsible for this particular subtype of tinnitus and its associated symptoms.
Toward a Sociology of Colonial Subjectivity: Political Agency in Haiti and Liberia
Authors: Hammer Ricarda , White Alexandre I. R.
Published: September 2018

The authors seek to connect global historical sociology with racial formation theory to examine how antislavery movements fostered novel forms of self-government and justifications for state formation. The cases of Haiti and Liberia demonstrate how enslaved and formerly enslaved actors rethought modern politics at the time, producing novel political subjects in the process. Prior to the existence of these nations, self-determination by black subjects in colonial spaces was impossible, and each sought to carve out that possibility in the face of a transatlantic structure of slavery. This work demonstrates how Haitian and Liberian American founders responded to colonial structures, though in Liberia reproducing them albeit for their own ends. The authors demonstrate the importance of colonial subjectivities to the discernment of racial structures and counter-racist action. They highlight how anticolonial actors challenged global antiblack oppression and how they legitimated their self-governance and freedom on the world stage. Theorizing from colonized subjectivities allows sociology to begin to understand the politics around global racial formations and starts to incorporate histories of black agency into the sociological canon.
Mixed Messages: Iran versus Saudi Arabia and GCC
Authors: Abuelghanam Debbie , Tahboub Naser
Published: September 2018

Much has been written about the relationship between Iran and the Gulf states. This relationship, while extremely complex, historic as well as deep rooted, needs to be revisited, especially in the light of the growing discords. This article investigates the contest over the balance of power in the Middle East which is impacted by state interests, foreign policy, ideology, sectarianism, and geography. There are three questions that need to be asked: (a) What role does Iran play in the Gulf region? (b) What is its relationship with the Gulf Cooperation Council (GCC)? and (c) Is there room for the two regional powers (Iran and Saudi Arabia) in the Gulf region? Iran’s role in the Middle East has expanded exponentially by both diplomatic means as well as by proxy and direct interventions. It has become apparent that while once Saudi Arabia controlled the GCC, due to recent events, the regional group has become trivialized. As Saudi Arabia and Iran vie for power, the Gulf is tension-filled and fraught with the possibility of misperceptions and miscalculations.
You’re Hired! Applying the Human Resource Selection Process to Team Formation
Authors: McCloskey Donna , Crowne Kerri Anne
Published: September 2018

This article explains an activity that can be conducted to form teams in university business classes. It allows students to actively participate in the team selection process and learn valuable human resource management skills. Students are placed in the role of hiring managers. They have to identify the skills and characteristics needed to complete a project and then review and evaluate résumés to select appropriate team members. The exercise provides students with practical experience in a key managerial function, as well as insight into how they are presenting their own skills and accomplishments on their résumés. While this activity has been primarily conducted in an undergraduate project management course where the team project is a substantial part of the student’s grade, the exercise is also applicable in other business courses.
Increased acute care utilization in a prospective cohort of adults with sickle cell disease
Authors: Lanzkron Sophie , Little Jane , Field Joshua , Shows Joseph Ryan , Wang Hang , Seufert Rebecca , Brooks Jasmine , Varadhan Ravi , Haywood Carlton , Saheed Mustapha , Huang Chiung Yu , Griffin Brandi , Frymark Steven , Piehet Allie , Robertson Derek , Proudford Marc , Kincaid Adrienne , Green Charles , Burgess Lorri , Wallace Marcus , Segal Jodi
Published: September 2018

The ESCAPED (Examining Sickle Cell Acute Pain in the Emergency vs Day Hospital) trial is an ongoing prospective study comparing outcomes of people with sickle cell disease (SCD) seeking care for acute pain management in either an emergency department or specialty infusion clinic. The objective of this paper is to describe the baseline characteristics and health care utilization of patients in the trial. This is a multicenter study across 4 US cities that enrolled all adults with SCD living within 60 miles (96.6 km) of a study site who were expected to have acute care utilization over the study period. Twenty-one percent of participants had no acute care visits in the first 12 months of follow-up. Using negative binomial regression, we describe subject characteristics that predict acute care utilization. Three hundred ninety-one subjects have completed 12 months of follow-up with a mean age of 34.5 years (standard deviation, 11.4), 60% are female. Fifty-four percent of subjects with hemoglobin SS disease and 46% with hemoglobin SC disease had 3 or more acute visits over the study period. The prevalence of chronic pain in this cohort was 68%. Predictors of higher rates of acute care utilization included being unemployed, having chronic pain, being on chronic transfusion therapy, having a history of stroke, and being on disability or on Medicaid. This is the first prospective cohort in the modern era, and it demonstrates much higher rates of acute care utilization than reported in the Cooperative Study of Sickle Cell Disease.
Snail promotes metastasis of nasopharyngeal carcinoma partly by down‐regulating TEL2
Authors: Sang Yi , Cheng Chun , Zeng Yi‐Xin , Kang Tiebang
Published: September 2018

Background

Metastasis is the major cause of treatment failure in patients with nasopharyngeal carcinoma (NPC). We previously reported that TEL2, a negative regulator of SERPINE1, could inhibit NPC metastasis to lymph nodes.

Method

A series of in vivo and in vitro assays were performed to elucidate the regulation between Snail and TEL2. TEL2 expression was analyzed in three representative NPC cell lines expressing low levels of Snail (S26, 6‐10B, HK1) and two cell lines expressing high levels of Snail (S18, 5‐8F). Luciferase and chromatin immunoprecipitation assays were used to analyze the interaction between Snail and TEL2. The roles of the Snail/TEL2 pathway in cell migration and invasion of NPC cells were examined using transwell assays. Metastasis to the lungs was examined using nude mouse receiving NPC cells injection through the tail vein.

Results

Ectopic Snail expression down‐regulated TEL2 at the mRNA and protein levels, whereas knockdown of Snail using short hairpin RNA up‐regulated TEL2. Luciferase and chromatin immunoprecipitation assays indicated that Snail binds directly to the TEL2 promoter. Ectopic Snail expression enhanced migration and invasion of NPC cells, and such effects were mitigated by TEL2 overexpression. TEL2 overexpression also attenuated hypoxia‐induced cell migration and invasion, and increased the number of metastatic pulmonary nodules. Snail overexpression reduced the number of metastatic pulmonary nodules.

Conclusions

TEL2 is a novel target of Snail and suppresses Snail‐induced migration, invasion and metastasis in NPC.
Chinese expert consensus on clinical prevention and treatment of scar+
Authors: Lv Kaiyang , Xia Zhaofan ,   On behalf of the Chinese consensus panel on the prevention and treatment of scars
Published: September 2018

Following injury, Asian skin has a tendency toward hyperpigmentation and scar formation than Caucasians. A standardized algorithm tailored to Asian patients, especially Chinese patients, is in great demand. Twelve independent, self-selected academic and military physicians from the department of burn/trauma, plastic surgery and dermatology with extensive experience in treating scars were assembled on January 17, 2015, establishing the consensus panel. This consensus was then appraised, drafted, reviewed, and finalized during the following 3 years, aiming to standardize and improve scar prevention and treatment in China. Hopefully, it may also provide some advices and references for the management of scarring in Asian patients.
Deep-learning-based seismic data interpolation: A preliminary result
Authors: Wang Benfeng , Zhang Ning , Lu Wenkai , Wang Jialin
Published: September 2018

Seismic data interpolation is a longstanding issue. Most current methods are only suitable for randomly missing cases. To deal with regularly missing cases, an antialiasing strategy should be included. However, seismic survey design using a random distribution of shots and receivers is always operationally challenging and impractical. We have used deep-learning-based approaches for seismic data antialiasing interpolation, which could extract deeper features of the training data in a nonlinear way by self-learning. It can also avoid linear events, sparsity, and low-rank assumptions of the traditional interpolation methods. Based on convolutional neural networks, eight-layers residual learning networks (ResNets) with a better back-propagation property for deep layers is designed for interpolation. Detailed training analysis is also performed. A set of simulated data is used to train the designed ResNets. The performance is assessed with several synthetic and field data. Numerical examples indicate that the trained ResNets can help to reconstruct regularly missing traces with high accuracy. The interpolated results in the time-space domain and the frequency-wavenumber ([Formula: see text]-[Formula: see text]) domain demonstrate the validity of the trained ResNets. Even though the accuracy decreases with the increase of the feature difference between the test and training data, the proposed method can still provide reasonable interpolation results. Finally, the trained ResNets is used to reconstruct dense data with halved trace intervals for synthetic and field data. The reconstructed dense data are more continuous along the spatial direction, and the spatial aliasing effects disappear in the [Formula: see text]-[Formula: see text] domain. The reconstructed dense data have the potential to improve the accuracy of subsequent seismic data processing and inversion.
Source-independent elastic least-squares reverse time migration
Authors: Fang Jinwei , Zhou Hui , Chen Hanming , Wang Ning , Wang Yufeng , Sun Pengyuan , Zhang Jianlei
Published: September 2018

Elastic least-squares reverse time migration (LSRTM) has been developed recently for its high accuracy imaging ability. The theory is based on minimizing the misfit between the observed and simulated data by an iterative algorithm to refine seismic images toward the true reflectivity. We have developed a new elastic LSRTM with the same modeling equations for source and receiver wavefield extrapolations, except for their source terms. The LSRTM has a natural advantage to solve the source and receiver wavefields using the same modeling system; thus, it is easy to implement LSRTM. In practice, it is difficult to obtain an accurate source wavelet, so a convolution-based objective function is used in our source-independent elastic LSRTM. Such an objective function can relax the requirement of an accurate wavelet, and improve the robustness of the inverse problem in the presence of noise. The numerical examples indicate that our method has the ability to recover the reflectivity models with an incorrect source wavelet from noisy data.
Rock-physics templates based on seismic Q
Authors: Picotti Stefano , Carcione José M. , Ba Jing
Published: September 2018

We build rock-physics templates (RPTs) for reservoir rocks based on seismic quality factors. In these templates, the effects of partial saturation, porosity, and permeability on the seismic properties are described by generalizing the Johnson mesoscopic-loss model to a distribution of gas-patch sizes in brine- and oil-saturated rocks. This model addresses the wave-induced fluid flow attenuation mechanism, by which part of the energy of the fast P-wave is converted into the slow P (Biot) diffusive mode. We consider patch sizes, whose probability density function is defined by a normal (Gaussian) distribution. The complex bulk modulus of the composite medium is obtained with the Voigt-Reuss-Hill average, and we show that the results are close to those obtained with the Hashin-Shtrikman average. The templates represent the seismic dissipation factor (reciprocal of seismic quality factor) as a function of the P-wave velocity, acoustic impedance, and [Formula: see text] (P to S velocity ratio), for isolines of saturation, porosity, and permeability. They differentiate between oil and brine on the basis of the quality factor, with the gas-brine case showing more dissipation than the gas-oil case. We obtain sensitivity maps of the seismic properties to gas saturation and porosity for brine and oil. Unlike the gas-brine case, which shows higher sensitivity of attenuation to gas saturation, the gas-oil case shows higher sensitivity to porosity, and higher acoustic impedance and [Formula: see text] sensitivity values versus saturation. The RPTs can be used for a robust sensitivity analysis, which provides insights on seismic attributes for hydrocarbon detection and reservoir delineation. The templates are also relevant for studies related to [Formula: see text]-storage monitoring.
Efficient time-domain 3D elastic and viscoelastic full-waveform inversion using a spectral-element method on flexible Cartesian-based mesh
Authors: Trinh Phuong-Thu , Brossier Romain , Métivier Ludovic , Tavard Laure , Virieux Jean
Published: September 2018

Viscoelastic full-waveform inversion is recognized as a challenging task for current acquisition deployment at the crustal scale. We have developed an efficient formulation based on a time-domain spectral-element method on a flexible Cartesian-based mesh. We consider anisotropic elastic coefficients and isotropic attenuation. Complete gradient expressions including the attenuation contribution spread into those of elastic components are given in a consistent way. The influence of attenuation on the P-wave velocity reconstruction is illustrated through a toy configuration. The numerical implementation of the forward problem includes efficient matrix-vector products for solving second-order elastodynamic equations for 3D geometries: An original high-order integration for topography effects is performed at nearly no extra cost. Combined adjoint and forward field recomputation from the final state and previously saved boundary values allows the estimation of misfit gradients for density, elastic parameters, and attenuation factors with no I/O efforts. Two-level parallelism is implemented over the sources and domain decomposition, which is necessary for a realistic 3D configuration. The misfit gradient preconditioning is performed by a so-called Bessel filter using an efficient differential implementation based on finite-element ingredients on the forward mesh instead of the often-used, costly convolution approach. A 3D synthetic illustration is provided on a subset ([Formula: see text]) of the SEG Advanced Modeling (SEAM) Phase II Foothills model with 4 lines of 20 sources. The structurally based Bessel filter and a simple data hierarchy strategy considering early body waves before all waves including surface waves allow a precise reconstruction of the P- and S-wavespeeds while keeping a smooth density description.
Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial
Authors: Killackey Eóin , Allott Kelly , Jackson Henry J. , Scutella Rosanna , Tseng Yi-Ping , Borland Jeff , Proffitt Tina-Marie , Hunt Sally , Kay-Lambkin Frances , Chinnery Gina , Baksheev Gennady , Alvarez-Jimenez Mario , McGorry Patrick D. , Cotton Susan M.
Published: September 2018

Background

High unemployment is a hallmark of psychotic illness. Individual placement and support (IPS) may be effective at assisting the vocational recoveries of young people with first-episode psychosis (FEP).

Aims

To examine the effectiveness of IPS at assisting young people with FEP to gain employment (Australian and Clinical Trials Registry ACTRN12608000094370).

Method

Young people with FEP (n = 146) who were interested in vocational recovery were randomised using computer-generated random permuted blocks on a 1:1 ratio to: (a) 6 months of IPS in addition to treatment as usual (TAU) or (b) TAU alone. Assessments were conducted at baseline, 6 months (end of intervention), 12 months and 18 months post-baseline by research assistants who were masked to the treatment allocations.

Results

At the end of the intervention the IPS group had a significantly higher rate of having been employed (71.2%) than the TAU group (48.0%), odds ratio 3.40 (95% CI 1.17–9.91, z = 2.25, P = 0.025). However, this difference was not seen at 12- and 18-month follow-up points. There was no difference at any time point on educational outcomes.

Conclusions

This is the largest trial to our knowledge on the effectiveness of IPS in FEP. The IPS group achieved a very high employment rate during the 6 months of the intervention. However, the advantage of IPS was not maintained in the long term. This seems to be related more to an unusually high rate of employment being achieved in the control group rather than a gross reduction in employment among the IPS group.

Declaration of interest

None.
Hospitalization and hospital discharge destinations after chemotherapy: Using the Oncology Care Model (OCM) methodology in 2012–2015 Medicare data.
Authors: Peng Yi , Liu Jiannong , Raskin Leon , Kelsh Michael Anthony , Zaha Rebecca , Hernandez Rohini K. , Henry David , Lyman Gary H.
Published: September 2018

113

Background: The Medicare OCM gives financial incentives for efficient, high-quality care. Hospitalizations of cancer patients receiving chemotherapy substantially increases costs. We assessed reasons for hospitalization and hospitalization discharge destinations after chemotherapy in cancer patients. Methods: We applied OCM methodology in a Medicare fee-for-service 20% sample data to estimate 6-month patient episodes triggered by chemotherapy from 2012 to 2015. We summarized the most frequent reasons for hospitalization (using ICD-9-CM codes in the first 5 positions of hospital claims) and the discharge destinations among all episodes and by cancer type. Results: Of 485,186 6-month episodes in 255,229 patients, 121,886 (25%) episodes had ≥1 hospitalization. The most frequent reasons for hospitalization were infection (13%), anemia (7%), dehydration (5%), and congestive heart failure (CHF; 3%; Table). Most hospitalized patients were discharged to home (71%) or a skilled nursing facility (SNF; 13%); some died in the hospital (6%) or went to hospice (5%). Reasons for hospitalization and discharge destination varied by cancer type. Patients with lung cancer had the highest rates of infection and anemia and higher proportions of death and hospice discharge compared with other cancers. Conclusions: Among Medicare beneficiaries receiving chemotherapy, hospitalizations most often occurred as a result of infection or anemia. Patients were most often discharged to home or SNF. Variations across cancer types in the reasons for hospitalization, as well as discharge destinations, should be considered when evaluating OCM practice performance. [Table: see text]
Health system stakeholder perceptions of financial assistance programs at a comprehensive cancer center.
Authors: Spencer Jennifer , Manning Michelle L. , Rosenstein Donald L. , Samuel Cleo A. , Reeder-Hayes Katherine Elizabeth , Sellers Jean , Wheeler Stephanie B.
Published: September 2018

114

Background: Cancer-related financial burden is a growing problem that has been linked to psychosocial distress, treatment delays and non-adherence, and excess mortality risk. Comprehensive cancer centers often provide financial support resources to mitigate financial burden, but the scope of these services and the processes involved are poorly understood. We conducted an in-depth qualitative analysis of key health system stakeholders to understand these processes and identify areas for improvement. Methods: Semi-structured interviews were conducted with 12 stakeholders involved in the financial assistance process at a public comprehensive cancer center. Interviews elicited descriptions of programs, perceived strengths and weakness, and the stakeholders' roles in helping patients obtain financial assistance. A codebook was developed inductively and interviews were coded in duplicate, with codes added as new themes emerged. Coded data were used to develop and revise a system-wide process map of financial support resources. Results: Stakeholders described numerous resources for financial assistance, both internal (e.g., Charity Care) and external (e.g., manufacturer assistance). Although participants described feeling pride at helping patients obtain assistance, numerous barriers were identified, including delays in processing applications, duplicative processes, insufficient time to address patients' concerns, lack of dedicated staff to address the complexity of navigating resources, and perception that existing resources are inadequate to meet patient needs. Conclusions: Processes required to obtain financial support for cancer patients often place a high administrative burden on patients who must proactively seek resources, understand complex eligibility criteria and complete multiple, often overlapping applications, even within comprehensive cancer center environments. Dedicated financial navigators may assist patients in accessing existing available resources, and health systems should consider moving beyond patient-activated pathways of access to financial support to avoid exacerbating disparities for the most vulnerable patients.
The challenges of implementing the CMS oncology care model (OCM) in a large multi-center community oncology practice.
Authors: Brown John , King Kelly , Hunis Brian
Published: September 2018

115

Background: Our oncology practice has participated in the OCM program since July 2016. The purpose was to build improvement in quality care delivery and create methodology to reduce costs. We peered our work with ten cancer centers from ten states along the east coast. Methods: For all performance periods, we focused on building our strengths via five teams: Access, Care Mgmt., Post-acute transition, Finance, and Reporting. A registry was created in Epic. Data was collated and categorized as “OCM Eligible” and “OCM patients.” The Care Team worked with IT to create beneficiary identifications, discrete chart elements, financial estimations, and reports. Results: From Oct. to Dec. 2017 (latest quarter review), 589 patients were attributable. Our black and Hispanic population was +72.9% and +413.3% v. OCM (+76.6% and +381.2% v. all). We were categorized as high risk in the hierarchal condition category: +14% v. OCM, +17.7% v. all at the 25th percentile; +21.6% and +32.6% at the 50th percentile, +14.2% and +17.5 % at the 75th percentile respectively. Our dually enrolled, Medicare / Medicaid was 29% (+113% v. OCM). ED visit utilization was +2.6% (not leading to admits or observations (Obs). IP admits were utilized at a rate of 27.3 per 100 beneficiaries v. 25.8 for OCM (+5.9%) and 26.1 for all (+4.9%). Those that resulted from ED visits only were 15.8 v. 16.2 (-2.5%). Those resulted from Obs were 0.8 v. 0.3 OCM (+142.4%). Unplanned readmits within 30 days were 6.4 (per 100) v. 5.7 OCM (+13.9%). Imaging utilization was -35.2% v. OCM and -38.5% v. all. Hospice use was 3.7% v. a 5% median OCM rate. Home health was +26% v. OCM and +15.8% v. all. Risk-adjusted four Qtr. avg. expenditures were +14.5% per beneficiary v. OCM (Jan. – Dec. 2017); however, mortality rates were -10.9% v. OCM. Conclusions: Our practice data led us to identify and prioritize PI initiatives, helped us engage providers, and educate stakeholders. While certain costs were lower, drug utilization remains high. The ED and IP admits from Obs have been a challenge, even with phone triage assistance developed previously as participants of the ASCO Quality Training Program. Our PI plan is to develop oncology expanded care clinics to reduce ED and Obs utilization.
Impact of a comprehensive copay assistance and drug recovery system in a community cancer center.
Authors: Siegel Robert D. , Standifer Theresa , Spann Terra , Borron Michael , Slough Richard , Pringle Dionne , Helms Bonnie , Stoeppler-Biege Kristina
Published: September 2018

121

Background: The cost of oncology drugs has escalated rapidly while rollbacks in health care coverage and the emergence of high deductible and limited policies have made these drugs unaffordable for many. Many pharmaceutical companies offer drug replacement for those uninsured or for whom coverage is inadequate. Previously Bon Secours St. Francis Cancer Center (BSSFCC) had contracted with a third-party to recover replacement drug from these pharmaceutical programs. In 2017, we opted to suspend that third-party contract and take the process internally. Methods: BSSFCC is located in Greenville, SC. Nearly1500 new cases of cancer were diagnosed in 2016, of which, 3.5% are uninsured. We hired 2.5 FTE's to manage our drug recovery program. After clearance with legal and compliance officers, limited power of attorney was obtained to pursue these efforts on the patients’ behalf. Patients who had no drug coverage, inadequate coverage, or off-label denials were identified at the time of chemotherapy education, pre-authorization, or by after-the-fact processing of claims. Our efforts at drug recovery are noted below. Results: We recovered drug for 71 patients during fiscal 2017. The total cost of those recovered drugs was $3.25 million. This compared with $389,000 recovered by our third-party vendor (pre-commission) in FY 2016. $842,000 of drug replacement were for off-label use in insured patients, while $587,000 represented use in the uninsured. The remainder represented replacement drug for those with inadequate drug coverage and an ipilimumab replacement program for adjuvant therapy for melanoma. Conclusions: Embedding a process within a community cancer center to manage drug recovery for the un- and underinsured proved to have a substantial return on investment. The drug expenses which had to be written off were decreased substantially but most importantly, our ability to replace drug with some reliability allowed many of our patients to receive effective therapy that otherwise would have been cost prohibitive. Although the ability to recover drugs in this fashion is both helpful and appreciated, our program does nothing to rein in the unsustainable rise in the cost of cancer care.
Reducing infusion wait time: Redesigning medication order verification workflow at a comprehensive cancer center.
Authors: Kearney Michael D , Wolfberg Rachel A , Sudol Mark , Shukla Shital , Fine Barbara , Rabin Michael S. , Matulonis Ursula A. , Yakowec Jing Jing Wang , Hilton Nancy , Wagner Andrew J. , Bartel Sylvia , Lakhani Hakim
Published: September 2018

129

Background: Many factors contribute to long wait times for cancer patients on the day of their infusion. At Dana-Farber Cancer Institute (DFCI), a contributing factor is patient flow between exam and infusion. Order verification affects patient flow and begins when the following two criteria are met: provider signed an order and the patient’s scheduled infusion appointment arrives. Patients often check-in to infusion before their scheduled infusion appointment. Order verification has three sequential steps: nurse verification, pharmacist 1 verify (V1), and pharmacist 2 verify (V2). Methods: A team of pharmacists, nurses, providers, and process improvement leads designed a pilot in which V1 moved before nurse verification, concurrent with patient check-in to infusion. Further, V1 began as soon as an order was signed; the pharmacist did not wait for a patient’s scheduled infusion appointment. Nurse verification and V2 occurred in sequence after V1. Timestamp data were extracted from Epic and analyzed via Tableau to assess reduction in verification throughput, defined as time between infusion check-in and V2. Fourteen providers and one pharmacist joined a 6-week pilot to adopt the redesigned workflow beginning 4/23/18. Results: At baseline, time between check-in and V2 was consistent for pilot and non-pilot orders. During the pilot, time between check-in and V2 was shorter for pilot orders, showing a sustained decrease of approximately 10 minutes. The table below provides time in minutes between infusion check-in and V2 for pilot and non-pilot orders at baseline (3/12/18-4/20/18) and following workflow redesign (4/23/18-6/1/18). Conclusions: Implementing the pilot workflow reduced order verification throughput time and enabled drug preparation to begin sooner. Expanding this workflow to all medication orders can decrease infusion wait time at DFCI.[Table: see text]
Economic burden of brain metastases in patients with anaplastic lymphoma kinase positive (ALK+) non–small cell lung cancer (NSCLC) receiving second-line ALK inhibitors.
Authors: Lin Huamao Mark , Pan Lucy , Hou Peijie , Huang Hui , Desai Avinash , Jahanzeb Mohammad
Published: September 2018

13

Background: De-novo brain metastases (BM) occur in 15-35% of patients with ALK+ NSCLC, and the prevalence increases to as high as 60% over the course of first-line crizotinib therapy. Reports on the economic burden of brain metastases in patients who progress on first-line therapy are scarce. The objective of this study was to evaluate the economic impact of BM among patients with ALK+ NSCLC treated with second-line ALK inhibitors. Methods: This retrospective study used the Optum Research database to identify adult patients with a lung cancer diagnosis code (≥1 inpatient claim or ≥2 outpatient claims ≥30 days but ≤1 year apart) and use of a second-line ALK inhibitor (e.g. alectinib or ceritinib) after crizotinib, between January 2011 and March 2017. Index date was defined as the date of the first claim with a second-line ALK inhibitor. BM were identified if the patient had BM diagnosis prior to index date. Healthcare costs and resource utilization were calculated on a per-patient-per-month (PPPM) basis up to 12 months of follow up after index date. Multivariate regression was used to assess the impact of BM on PPPM cost, while controlling for patient demographics, comorbidities and type of second-line ALK inhibitor. Results: 523 patients with NSCLC received at least one ALK inhibitor during the study period. Use of a second-line ALK inhibitor (alectinib or ceritinib post-crizotinib) was observed in 112 patients (43 alectinib, 69 ceritinib). Among second-line ALK inhibitor users, 52.7% (n = 59) had BM. In those with BM, the PPPM total healthcare costs were $26,415 compared with $21,278 in those without BM. Regression results showed that the adjusted mean total PPPM cost for those receiving second-line ALK inhibitor with BM was 1.39 times as high as those without BM (p-value = 0.0287). Conclusions: Economic burden of brain metastases is high for ALK+ NSCLC patients receiving second-line ALK inhibitors. The study highlights the economic value of novel therapies to delay brain metastases during early lines of therapy in these patients.
Advanced care planning and selection of therapy: Influence on hospitalization for patients with metastatic lung cancer.
Authors: Drzayich Jankus Dana Angela , DeClue Richard W , Stemkowski Stephen , Casebeer Adrianne Waldman , Lobo Francis , Loy Bryan A. , Korytowsky Beata
Published: September 2018

130

Background: Advanced care planning (ACP) allows patients to express preferences for medical treatment toward the end of life. Reduced healthcare resource utilization has been observed with ACP. The association of ACP and hospitalization was assessed among patients who initiated second line (2L) therapy for metastatic non-small cell lung cancer (mNSCLC). Methods: Adults who received 2L treatment for mNSCLC were identified in a retrospective study of claims from Humana Medicare Advantage, following its launch of ACP programs in 2015. In this cohort, patients who participated in ACP programs and patients who did not were matched 2:1 by age, sex, race, population density of residence, and year of 2L termination. Categories of 2L therapy were chemotherapy, immuno-oncology (IO), and targeted therapy. Extent of comorbidity was assessed using the Deyo-Charlson Comorbidity Index (DCCI). The odds of hospitalization in the 12 months following initiation of 2L therapy for patients who participated in ACP programs and patients who did not were assessed with a logistic regression model, offset for patient months of follow-up, and considering therapy category and DCCI. Results: Ninety-eight patients who participated in ACP programs were matched to 196 patients who did not. More than half the cohort was male; median age was 71. There was no difference in therapy category or DCCI by ACP program participation. A greater proportion of patients with no ACP were hospitalized post-2L treatment, 57.7% vs 42.9%, P< 0.001. ACP was associated with a 52.1% decreased odds of hospitalization. Patients treated with IO or targeted therapy had reduced odds of hospitalization, 54.8% and 75.4% respectively, relative to patients treated with chemotherapy. Conclusions: This early assessment of ACP programs in patients with mNSCLC suggests ACP program participants may have fewer hospitalizations near the end of life. Possibly, ACP program participation presents opportunities for staff to identify changes in health status and prevent escalation to hospitalization. Also, because of its potential to reduce hospitalizations, selection of therapy should be considered as a part of ACP.
Efficacy of an antiemetic therapeutic interchange protocol driven by a medically integrated pharmacy.
Authors: Wilfong Lalan S. , Patt Debra A. , Wallace Kathryn , Mikan Sabrina Q. , Portnoy Carla , Kipley Leigh , Dave Neal , Schwartz Jim R. , Hoverman J. Russell
Published: September 2018

133

Background: Control of chemotherapy induced nausea and vomiting (CINV) remains an unmet need. An antiemetic therapeutic interchange protocol was developed to enhance control of CINV. This abstract reports the efficacy results of patients treated with highly emetogenic regimens as defined by NCCN guidelines. Methods: Medically integrated pharmacists imbedded within 2 centers of a community oncology practice evaluated each new chemotherapy order and adjusted antiemetics including a 5HT3 antagonist, steroids, olanzapine and an NK1 inhibitor using an NCCN based protocol. Exact medications depended on insurance coverage and copays. Medications were adjusted for patient comorbidities, drug interactions and patient refusal. All patients were given prochlorperazine and ondansetron for breakthrough nausea and vomiting. Medication education to increase adherence was provided by the pharmacist, nurse and advance practice provider. Patients were evaluated by nursing or pharmacist calls on day 2 and 3 and as needed to characterize CINV using the Multinational Association of Supportive Care in Cancer (MASCC) antiemesis tool that scores CINV on a Likert scale. Based on review of the literature, a score of 3 or higher reflected symptom management failure. Additionally, due to drowsiness as the most commonly reported side effect of olanzapine, each center sought to characterize the risk of drowsiness. Results: 367 consecutive patients treated with highly emetogenic chemotherapy regimens were identified at two centers by pharmacists and followed by nursing or pharmacy calls over a 9-month timeframe: November 2016 to August 2017. 89% of patients had complete control of nausea with only 11% reporting nausea greater than a 3. Additionally, 11% of patients reported drowsiness greater than a 3. Conclusions: Administering a pharmacist driven antiemetic protocol is an effective way to control CINV. While CINV did occur, evaluation shows CINV was mild. We have shown that utilizing an antiemetic therapeutic interchange protocol with a collaborative care team including medically integrated pharmacists facilitates excellent control of CINV.
Improving support for smoking cessation in medical oncology patients: A quality improvement initiative.
Authors: Raskin William , Phillips Cameron , Perdrizet Kirstin , Raphael Michael J. , Herman Michael , Del Paggio Joseph , Panetta Monica , Gandhi Sonal , Enright Katherine
Published: September 2018

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Background: Smoking cessation is integral to cancer care. Active smoking is associated with increased toxicity of treatment, poorer response to therapy and is associated with worse overall survival. Patients who quit smoking at diagnosis have better survival outcomes. Cancer Care Ontario has aimed to improve rates of smoking screening and referral to smoking cessation programs based on the validated Ottawa model. Methods: We aimed to implement an “opt-out” referral process for recent or current smokers to a smoking cessation program at the Credit Valley Hospital. We aimed to achieve a referral rate of 20%, based on an institutional baseline of 8.5% and a provincially defined target of 20%. Key stakeholders targeted included nursing, administration, physicians, smoking cessation counsellors and patients. Sequential education interventions were delivered to address gaps in patient and provider knowledge; these included grand rounds, an informal lecture and an educational pamphlet. Results: After the initiative was launched, the referral rate increased from 8.5% to 14.3%. The impact of each intervention is summarized in Table 1. Conclusions: Smoking cessation referrals increased with new process but not to target. Patient refusals lead to a low rate of referral, warranting efforts aimed at addressing patient barriers. Future outcome measures may include smoking cessation rates. [Table: see text]
Assessment of scheduled pharmacy follow-up for patients receiving oral chemotherapy.
Authors: Mackler Emily R. , Beekman Kathleen W. , Yarrington Carol , Gentz Anne , Bushey Laura , Davis Kathleen , Griggs Jennifer J. , Farris Karen B
Published: September 2018

151

Background: Management of oral chemotherapy presents many challenges to oncology practitioners. The purpose of this study is to describe how incorporation of pharmacy scheduled calls to oncology patients receiving oral chemotherapy can identify patients who are experiencing moderate-to-severe symptom burden and/or medication non-adherence and require a therapeutic intervention. Methods: We utilized multiple resources from a statewide quality collaborative aimed at the management of patients receiving oral chemotherapy including patient education, a patient reported outcome (PRO) assessment, and templated documentation. As part of our planned workflow enhancements, our pharmacist provided patient education before chemotherapy started and regularly called patients within 2 weeks of starting their oral therapy. The pharmacist asked the patient about symptoms and adherence using the PRO assessment. A chart audit was performed to summarize the patient reports and recorded interventions. Results: 203 patients taking oral chemotherapy were called by the pharmacist in an 18-month time period between 10/1/16 - 3/28/18. In this study, we will summarize patient demographic information including age, gender, diagnosis, oral chemotherapy medication; PRO assessment results including symptom burden based on the Edmonton Symptom Assessment Scale (ESAS), most bothersome symptom, confidence to self-manage, medication adherence, and reasons for non-adherence, and pharmacist interventions and consequential treatment modifications. Conclusions: Patients taking oral chemotherapy for the treatment of cancer are at risk of side effects from their treatment and suboptimal therapeutic benefits in the setting of non-adherence. Our analysis will summarize the degree of symptom burden patients experience in the first couple weeks of treatment and areas were a pharmacist may optimize their medication regimen prior to their scheduled follow-up with their oncologist. We plan to use this data to improve patient self-management support.
A tale of 2,000 charts: Measuring provider response to patient-reported outcome measures.
Authors: Hurwitz Gillian , Ismail Zahra , Moody Lesley , Barbera Lisa Catherine
Published: September 2018

157

Background: Patients undergoing cancer treatment often experience physical and psychosocial symptoms that go undetected by clinicians, which highlights the need to incorporate patient-reported outcome measures (PROMs) in routine care. Systematic symptom screening for cancer patients using the Edmonton Symptom Assessment System (ESAS) is standard practice in Ontario. However, provider response to PROMs is essential to addressing symptom burden. To measure provider response, Regional Cancer Centre (RCC) Leads and Cancer Care Ontario developed a chart audit process. The objective was to determine whether the clinical team acknowledged, assessed and/or addressed symptoms identified by ESAS screening. Methods: RCCs received a chart audit tool with preset options and a data dictionary. Sites audited at least 140 charts for seven of the ESAS symptoms. Sites used a business intelligence tool to access patient charts based on sampling parameters. RCCs were required to audit charts of patients whose ESAS symptom scores were moderate to severe (4-10), with at least five charts in the moderate range (4-6). Results: 2,380 charts from 13 RCCs were audited based on ESAS scores from September to December 2016. Symptoms were most often acknowledged when the intensity was severe (69.9%), regardless of symptom type. Acknowledgement (71.5%), assessment (67.7%) and intervention (55.8%) were most often offered to patients reporting pain. Patients reporting depression and anxiety were the least likely to have the symptom acknowledged (44.5%, 45.0%, respectively) and be offered assessments (45.8%, 50.1%, respectively) and interventions (35.7%, 36.6%, respectively). Patients reporting moderate to severe depression and anxiety most commonly declined interventions (7.8%, 7.7%, respectively). Conclusions: These data show that providers disproportionately respond to physical symptoms, which may be easiest to treat due to clear management plans and referral pathways. To truly offer person-centred care, the emotional burden related to cancer must also be addressed, and providers must be trained to properly respond to psychosocial symptoms. Chart audits identify gaps in symptom management and areas for quality improvement.
Cancer burden: Exploring the parallels between cancer hardship and the well-being of cancer caregivers.
Authors: Raymond Martha
Published: September 2018

162

Background: The latest 2016 data from the National Cancer Institute’s Surveillance, Epidemiology & End Results (SEER) Program estimates there are 15.5 million cancer survivors in the U.S. Millions of cancer survivors rely on cancer caregivers every day. Cancer caregivers play a vital role throughout the care continuum, and greatly impact a patient’s quality of life. Caring for a cancer patient affects all aspects of a caregiver’s life, including: changes to daily routine, work and family life; financial hardship; and emotional and psychological distress. Our study explores the cancer burden, unmet needs and well-being of cancer caregivers. Methods: Beginning in September 2015-September 2017, our professional facilitator with over 25 years of cancer advocacy experience hosted nationwide caregiver focus groups. Primary goals were reaching caregivers in rural, urban and community oncology settings to gain perspective from diverse populations. We met with cancer caregivers in 32 states via traditional focus group settings and online via facetime conferencing. Results: 778 caregivers (42% male, 58% female) participated in our focus groups. 88% reported high levels of stress and anxiety (I struggle to concentrate & walk around feeling like I was kicked in the stomach); 78% were employed full time with an average of an additional 20+ hours per week devoted to caregiving responsibilities (Pulled in every direction – need balance); 66% reported self-health decline (No time for me – worry I will get sick and then what?) Describing in one word their current feelings, the top three responses were: Exhausted; Lonely; Overwhelmed. Conclusions: The burden of caring for a cancer patient is immense and all-consuming. Our conversations with caregivers will continue as we collaborate with partners, develop meaningful programs, and expand our outreach and resources to help lessen the burdens of cancer on caregivers.