bluuebunny/crossref_metadata_2025 huggingface dataset:
Referral to infertility counseling in cancer patients undergoing chemotherapy.
Authors: Hathaway Amanda Redden , Rocque Gabrielle Betty
Published: April 2017

220

Background: Reproductive concerns in survivorship are associated with distress, depression and anxiety. Patients who receive pretreatment fertility counseling report a better quality of life after treatment. Despite this, only about 50% of patients in studies recall discussion of fertility issues prior to chemotherapy. Methods: A retrospective review was conducted to evaluate discussion of fertility in patients ages 19-35 seen at the University of Alabama at Birmingham Hematology/Oncology clinic from 1/1/15-12/31/15. Patients who never received therapy that could alter their childbearing potential were excluded. Patients’ sex, age at diagnosis, type of cancer, documented discussion of fertility implications prior to therapy, and referral to Reproductive Endocrinology (REI) were documented. Rates of discussion of fertility risks and rate of referral were determined. Results: Fifty-four patients met inclusion criteria for the study. 46.3% were female. 30 patients (55.6%) had a hematologic malignancy and 24 patients (44.4%) had a solid tumor malignancy. Documentation of fertility risk was seen in 33.3% of patients with 29.2% referred to REI. Seven (24.1%) patients had hematologic malignancies and eight (33.3%) had solid tumors were referred to REI. Of the 25 female patients, only five (16.7%) were referred to REI, whereas another five patients could have been deemed not suitable for referral due to previous surgery or metastatic disease making the appropriate referral rate of 25%. Of the 29 male patients, nine were referred to REI, one had semen analysis without REI referral, and one refused REI evaluation making overall referral rate 34.5%. 35 of the 54 patients received their initial chemotherapy at our facility, and of those 34.3% were referred to REI. Conclusions: Despite guidelines recommending discussion of fertility risks with all patients of child-bearing age prior to chemotherapy, less than half of patients at our institution are referred to REI. [Table: see text]
Inpatient care use among Californian patients with cancer in the year after diagnosis.
Authors: Whitney Robin L. , Bell Janice , Tancredi Daniel J , Romano Patrick S. , Bold Richard J. , Joseph Jill
Published: April 2017

235

Background: Inpatient care use is the chief driver of regional spending variation among some cancer patients and contributes more to cancer-related healthcare spending than does any other service category– including costly chemotherapy drugs. However, few studies are available to describe population rates of and reasons for hospitalization. Methods: California Cancer Registry (CCR) data linked with administrative claims data were used to quantify and describe inpatient care use among individuals diagnosed with cancer in California between 2009-2012 (n = 412, 850). Multistate models were used to estimate age-adjusted hospitalization rates, accounting for survival. Characteristics of hospitalizations were described and tabulated, including reasons for admission, procedures, and emergency department (ED) origin. Results: Among individuals with cancer, 62% had at least one hospitalization in the year after diagnosis, nearly half of which originated in the ED (45%). Among individuals with late stage cancers, 73-77% had an admission, 42-66% of which originated in the ED. Many hospitalizations included at least one surgical procedure (54%), diagnostic procedure (24%), or chemotherapy (11%). The most frequent principal diagnoses (other than malignancy) were infection-related (11%), cardiovascular (4%) and complications of a medical device or care (4%). Estimated hospitalization rates were highest for individuals with hepatobiliary/pancreatic cancers (2.5 hospitalizations), bone/soft tissue cancers (2.1 hospitalizations), and digestive system cancers (2.0 hospitalizations), and lowest for individuals with melanoma (0.3 hospitalizations), and breast or prostate cancer (0.6 hospitalizations). Conclusions: The population burden of inpatient care use among individuals with newly diagnosed cancer is substantial. Many hospitalizations originate in the emergency room, suggesting that they are unplanned. Oncology care providers’ efforts to reduce acute care use might target subgroups with higher rates, including hepatobiliary/pancreatic, bone/soft tissue, digestive, and late-stage cancers. Further research is warranted that examines the extent to which such visits are avoidable.
Experience and impact of alopecia in patients (pts) with HER2+ metastatic breast cancer (MBC) in the SystHERs registry.
Authors: Mason Ginny , Mayer Musa , Swain Sandra M. , Kaufman Peter , Tripathy Debu , Hurvitz Sara A. , O'Shaughnessy Joyce , Yardley Denise A. , Brufsky Adam , Rugo Hope S. , Cobleigh Melody A. , Chu Laura Kay , Antao Vincent P. , Morris Anne , Yoo Bongin , Jahanzeb Mohammad
Published: April 2017

239

Background: Although alopecia is common with systemic chemotherapy, its psychological impact is often overlooked in treatment (tx) decisions. We sought to better understand the impact of alopecia using data from SystHERs, an observational registry of pts with HER2+ MBC. Methods: SystHERs enrolled pts ≥ 18 years within 6 mos of an MBC diagnosis. Pt-reported outcomes are assessed quarterly. The Alopecia Patient Assessment (APA, Genentech) is a validated instrument measuring the incidence of hair loss in the prior 3 mos and the impact of hair loss in the prior 7 days. The APA includes 5 items scored on a 5-point scale (total range: 1–25). Higher scores indicate greater impact. Pts completed the APA within 30–90 days of initial MBC tx. Subgroups with no hair loss, hair loss without impact, or impactful hair loss were compared descriptively. Results: As of June 3, 2016, 591 of 976 pts were eligible for this analysis. Of these, 175 (30%) reported no hair loss, 123 (21%) reported hair loss without impact, and 293 (50%) reported impactful hair loss within 30–90 days of initial MBC tx. Respectively, 23% (41/175), 82% (101/123), and 79% (231/293) were on active chemotherapy, most commonly docetaxel (39% [16/41], 66% [67/101], and 62% [144/231]) and paclitaxel (5% [2/41], 27% [27/101], and 23% [54/231]). Median time from initial chemotherapy tx to APA was 55, 70, and 64 days. Of all pts with no hair loss, 39% had de novo MBC vs 56% of pts with hair loss but no impact and 55% with impactful hair loss. Relative to the no-hair-loss and hair-loss-but-no-impact subgroups, the subgroup with impactful hair loss was younger (median 57 and 59 vs 54 years, respectively) and had more pts with ≥ 2 metastatic sites (51% and 54% vs 63%) and visceral metastases (59% and 63% vs 69%). The median total APA score for pts with impactful hair loss was 8.8 (IQR 7.0–12.5). Conclusions: Of pts reporting hair loss, 79–82% were receiving systemic chemotherapy. Pts with impactful hair loss may have had greater disease burden. Alopecia impacted self-image and embarrassment more than work or social functioning. Clinical trial information: NCT01615068. [Table: see text]
Outpatient management of pediatric oncology patients with low-risk fever and neutropenia: Implementation of new clinical practice guideline at Texas Children's Hospital.
Authors: Bavle Abhishek Amar , Grimes Amanda Bell , Zhao Sibo , Zinn Daniel Joseph , Jackson Andrea , Porea Timothy , Dutta Ankhi , Heczey Andras
Published: April 2017

26

Background: Traditionally, pediatric oncology patients with fever and severe neutropenia (absolute neutrophil count [ANC] <500) are admitted on empiric intravenous (IV) antibiotics pending blood cultures, fever resolution, and a rising ANC. Based on significant evidence that risk-stratification of these patients with fever and neutropenia (FN) and outpatient management of “low-risk” FN (LRFN) patients with oral antibiotics can be safe and effective, we implemented an institutional clinical practice guideline (CPG) to provide outpatient care for children with LRFN. Methods: A validated “Alexander” clinical decision rule was adopted to risk stratify pediatric oncology patients with FN. A new CPG was formulated for the outpatient management of LRFN patients, with either discharge on presentation or at 24-48 hours after admission, with levofloxacin and close follow-up. All stakeholders were educated regarding the new guidelines and process prior to implementation, and the guidelines were approved by the institutional Evidence Based Outcomes Center. Results: In 9 months since guideline implementation, 10/11 (91%) of the eligible patients have been managed outpatient for LRFN (mean ANC 160, range 0 - 480). Seven patients were discharged home from the ER or oncology clinic. Three patients were discharged early at 24 – 48 hours after admission. Outpatient management was safe, and all but one patient had resolution of fever within 48 hours and negative blood cultures. One patient had a positive blood culture with Staphylococcus epidermidis and was admitted for IV antibiotics with no complications. Parents of 9/10 patients responded to surveys. All 9 families found outpatient management to be a good experience, follow-up easy, and reported no adverse effects with levofloxacin. One family preferred inpatient care due to anxiety, while importantly 8/9 (89%) parents said they preferred outpatient care compared to inpatient observation. Conclusions: Pediatric oncology patients with low-risk fever and neutropenia were successfully idenitified and managed in the outpatient setting without adverse events with a high level of parent satisfaction.
Utilizing patient navigators to enhance oral chemotherapy education and safety for at-risk patients.
Authors: Lin Mingqian , Hackenyos Douglas W , Mao Daqin , Wang Feng Qing , Erban John Kalil , Parsons Susan K.
Published: April 2017

43

Background: Oral anticancer drugs are increasingly being used as standard therapy. At Tufts Medical Center Cancer Center, 10% of patients on active cancer treatment are receiving oral chemotherapy. To address barriers to medication education and timely management of treatment effects, we began an initiative involving our pharmacy specialist who reviews newly-started oral chemotherapy treatments for safety concerns, dose appropriateness, and drug interactions. In response to the cultural-linguistic needs of our Chinese patients (20% of our patients, largest minority group) and unique challenges of our patients of lower SES (40% of our patients), we are also leveraging patient navigators (PN) to improve timely care and understanding of and adherence to oral cancer medications for our most vulnerable patients. Methods: PN regularly interact with patients and work closely with the care team to address patients’ concerns. Formal PN visits with patients in clinic are documented in the EMR. To assess the scope of issues related to oral chemotherapy and/or supportive care drugs (e.g. anti-nausea, anti-constipation) and the potential impact in using PN, we reviewed PN encounter notes from the first 6 months of 2016 to identify patient-reported issues. Results: In reviewing 492 PN encounter notes from the first 6 months of 2016 (111 patients were navigated), 138 (28%) of all patient encounters involved assistance related to oral chemotherapy, supportive care drugs, and/or comorbidities medications. Examples of patient-reported issues include confusion about purpose and/or type of drug, dosing scheduling, side effects management, and logistical challenges (e.g. refills, copays, specialty pharmacy orders). Conclusions: From the PN encounter notes, we identified a need for more formalized patient-centered interventions to enhance education, monitoring, and patient-provider communication about oral chemotherapy to proactively resolve medication-related issues. We are piloting an evidence-based approach involving pharmacist-PN-patient teaching sessions, tailored patient education tools, and scheduled check-ins between PN and patients adapted from the MASCC Oral Agent Teaching Tool model.
Written care plan and patient enablement: Pre-implementation data from the 4R in Oncology Project.
Authors: Trosman Julia Rachel , Weldon Christine B. , Perez Claudia B. , Kulkarni Swati , Khan Seema Ahsan , Hansen Nora , Nelson Valerie , Stein Jennifer , Simon Melissa A. , Strauss Jonathan Blake , Espino Sasa M. , Bunce Mikele , Pan Wayne , Friedewald Sarah M. , Gradishar William John
Published: April 2017

55

Background: The IOM ’11 and ’13 reports recommend a written care plan (WCP) at cancer diagnosisto enable teamwork and patient (pt) engagement. Standardized multimodality WCP is a key part of the 4R model of care planning and pt engagement proposed under “NCI ASCO Teams” Project (Trosman JOP 2016). 4R (Right Information / Care / Patient / Time) is under implementation at three centers: academic, community and safety net. As current state assessment prior to implementing 4R and standard multimodality WCP, we surveyed pts not impacted by 4R on care planning, enablement and whether they received any WCP. Methods: Survey of breast cancer stage I-III pts who received care at the three sites Jan ’15 - Mar ’16, prior to 4R. We used simple frequencies and Fisher’s exact test in analysis. Results: Survey response rate: 48%, 197/410. Gaps of > 30% were reported in 6 of 8 aspects of care planning and pt enablement - Table. A non standard WCP was received by 45% of pts. Receiving a WCP impacted whether pts were clear about care (90% with WCP vs 50% without, p < .0001), able to manage own care (81% with WCP vs 59% without, p = .001) and overwhelmed (49% with WCP vs 68% without, p = .006). Care complexity was a significant factor for feeling overwhelmed by pts without WCP (60% of pts receiving > 6 care services felt overwhelmed vs. 39% of pts receiving < = 6 services, p = .04), but not a significant factor in pts with WCP (38% vs 44%, p = .7). More pts with WCP reported well managed care by providers than pts without WCP (78%, 64%, P = .04). Conclusions: Serious gaps found in care planning and pt enablement at our sites support the need for 4R implementation. Even pre-4R, non standard WCPs improve pt understanding of care and ability to manage it, and reduce the impact of care complexity on pts. Providers using WCP appear to also coordinate care, but WCP itself may be an important factor of patient enablement. [Table: see text]
Off-label immunotherapy prescription: Financial implications for payers and patients.
Authors: De Souza Jonas A. , Duong Yen Yvonne
Published: April 2017

6

Background: Pembrolizumab (PEM) and nivolumab (NIV) are FDA-approved immunotherapy agents for specific indications. These drugs are extremely costly to the health care system, payers, and ultimately, patients, and little is known about their utilization for non-FDA labeled indications (off-label). Methods: We reviewed claims for PEM and NIV using the focalPoint database by onPoint oncology, which provides access to clearinghouse data for 168 community oncology practices and 2000+ providers throughout the US. Clearinghouse data is unique as it links claims data with remittance (payer response) data. ICD codes representing malignancies other than head and neck cancer, melanoma, non-small cell lung cancer ,and claims for 3 indications prior to their FDA-approval were considered off-label. Primary insurance for the patients, as well as patients’ financial responsibility and amounts paid by the insurance were evaluated. Results: A total of 1,570 patients received PEM or NIV from January 1st 2015 to September 1st 2016 for a cumulative total of 7,687 distinct claims. Of these patients, 285 (18%) received these agents for off-label indications for a total of 978 distinct claims. The total cost for the insurance for off-label claims was $13.36 million with the following breakdown: $7.74 million for 111 patients with commercial insurance, $125 thousand for 5 patients with Medicaid, $3.85 million for 126 patients with Original Medicare, and $1.90 million for 43 patients with Medicare Advantage. The patient responsibility for the off-label immunotherapy agents, which included the co-insurance and co-pay, totaled to $1.06 million or $3,731 per patient. Patient responsibility for off-label therapy per payer was as follows: $657 per patient for commercial insurance, $0 for Medicaid, $7,436 for Original Medicare, and $1,248 for Medicare Advantage. Conclusions: A substantial number of patients received unsupported off-label immunotherapy treatment. The costs of these therapies to the health care system, payers, and patients warrant increased efforts to regulate their use in off-label settings lacking sufficient scientific evidence or while clinical trials are in progress.
Monitoring and developing volunteer patient navigation intervention to improve mammography compliance in a safety net hospital.
Authors: Srinivasan Anitha , Zwillenberg Judith , Chadda Anisha , Gissel Hannah , Lettera Michael , Bender Sarah , Wallack Marc K. , Greene Margulies Ilana
Published: April 2017

62

Background: Mammography screening is crucial for cancer detection. Screening rates have been declining in patients of low socioeconomic status and minorities, supporting the need for intervention at our safety-net hospital. Methods: Patients with a primary care provider order for screening mammograms over a one month period were monitored for 90 day compliance. This analysis determined compliance rate and optimal intervention period. A prospective randomized trial was done to improve compliance using a volunteer patient navigator. All patients received educational material and were randomly assigned to the control or intervention group. The latter were further educated on breast cancer and mammograms and, if amenable, were escorted to a walk-in mammogram. The study period was 3 weeks with 49 participants-24 patients in the control and 25 patients in the intervention group. The principal outcome was the 14 day mammography compliance rate. Secondary analysis examined efficacy of the study with respect to patient demographics, prior mammography compliance, family history of cancer, beliefs on mammography and past medical history and analyzed using GraphPad Prism 7. Results: Analysis revealed a noncompliance rate of 52% with majority compliance occurring within two weeks of order placement. The patient navigation intervention significantly improved compliance by 34% (42% in the control group, 76% in the intervention group, p < 0.05 Fisher exact test). Intervention significantly improved compliance in patients with low susceptibility to cancer belief, who understood benefits of mammography and early diagnosis (p < 0.05 Fisher exact test), had a prior mammogram (p < 0.05 Fisher exact test), a family history of cancer (p < 0.01 Fisher exact test), hyperlipidemia (p < 0.05 Fisher exact test), and those employed (p < 0.05 Fisher exact test). Conclusions: A system to monitor compliance and intervene using patient navigation significantly improved mammography compliance of patients in a safety net urban hospital. The relatively straightforward design of the volunteer based intervention makes it affordable, easily replicable and perhaps beneficial at other institutions.
Impact of genomic profiling on treatment decisions for patients with melanoma and colorectal cancer cohorts.
Authors: Biltaji Eman , Au Trang H. , Gligorich Keith , Bronner Mary P. , Stenehjem David D. , Brixner Diana I.
Published: April 2017

66

Background: Clinical guidelines recommend RAS testing and BRAF testing in CRC and melanoma, respectively, to guide treatment (tx) decisions. However, there are limited data to support routine multi-gene profiling. This study evaluated the impact of multi-gene profiling on genomically-guided tx decisions in patients with CRC or melanoma. Methods: A retrospective cohort study using combined data from UUHC Electronic Warehouse, Huntsman Cancer Institute (HCI) tumor registry, ARUP laboratories, and Foundation Medicine. Included patients were treated at HCI for CRC or melanoma and had genomic profiling (2012-2016). The index date was date of first genomic profiling result and impact on practice was measured by rate of genomically-guided therapy use. Results: Among 127 genomically-profiled patients with CRC, 66 (52%) received therapy. Patients were predominantly male (64%), aged 57 years (median) at diagnosis, had advanced disease (52%), received three tx lines (mean) at baseline, and had three mutations (mean) detected. Actionable mutations, other than RAS,occurred in 43.9% of tested patients; and only 10.1% of these patients received genetically-guided tx. In the CRC cohort 55% are still receiving standard of care tx, and may benefit from testing results in the future. Among 186 genomically-profiled patients with melanoma, 123 (66.1%) received therapy. Patients were predominantly male (63%), aged 60 years (median) at diagnosis, diagnosed at earlier stages (68%), received two tx lines (mean) at baseline, and had two mutations (mean) detected. Actionable mutations, other than BRAF V600E/K, occurred in 14.6 % of tested patients; and only 5.6% of these patients received genetically-guided tx. In the Melanoma cohort 77% are still receiving standard tx. Actionable mutations and genomically guided tx decisions will be presented. Conclusions: Genomic profiling lead to modest increase in genetically-guided therapy. The incremental clinical and economic benefit of guideline-recommended testing needs further investigation by cancer type.
Impact of a nurse-calling program on retaining patients with a new diagnosis of cancer.
Authors: Gross Anne , Leib Ryan , Hilton Nancy , Bagley Janet , Burnard Rachel A. , Hirshfield-Bartek Judith , Dorenzo Eric , Keavany Kathleen , Read David C , Bunnell Craig A.
Published: April 2017

69

Background: In 2013, Dana-Farber Cancer Institute began an initiative to improve the new patient experience. Our goal was to remove barriers to access and, as much a possible, begin to care for individuals even before they step foot through our door. A key component of this initiative was for each patient to receive a phone call from an oncology nurse shortly after speaking to a new patient coordinator to schedule their first appointment. The purpose of the call was to answer questions about their diagnosis, the care they will receive and to begin the process of assessing their individual needs. Methods: The program was supported by over 40 full and part-time oncology nurses who devote a portion of their time each day to calling new patients prior to their first visit. In total nurses made over 10,000 phone calls per year. Through a survey given to patients after the intake process, we gathered feedback from over 1,200 patients, which overwhelmingly demonstrated a positive response to receiving a phone call from a nurse. We also investigated if receiving a phone call from a nurse prior to the first visit impacted the likelihood of retaining the patient for their treatment. Results: Comparing 9,000 new patients over one year, we found that patients who spoke to a nurse prior to their first appointment had a 13.5% higher relative retention rate compared to patients who did not speak to a nurse (see figure 1, absolute difference is 42.9% vs. 37.8%, odds ratio = 1.24, confidence interval 1.10-1.39, P < 0.0005). Controlling for confounding variables, a logistical regression with 15 variables was performed (e.g. time to first appointment, age,). Receiving a call from a nurse was one of the most predictive, statistically significant variables for patient retention. Conclusions: Given the positive qualitative response from patients and the quantitative impact on retention, we continue to build the program to ensure all patients receive a phone call from a nurse prior to their first visit. [Table: see text]
Learning from near misses: Addressing nursing chemotherapy verification fatigue.
Authors: Shea Meghan , Sato-DiLorenzo Aya , Wright Danielle , Coletti Erika , Carvalho Michael , Zerillo Jessica A.
Published: April 2017

70

Background: Administration of chemotherapy is high-risk, requiring multiple safety checks, including pre-treatment laboratory value verification by nursing. A recent series of near misses in our event reporting system highlighted that nurses verified chemotherapy orders with pending pre-treatment or abnormal labs, such as grade 2 hyperbilirubinemia and grade 4 neutropenia. Such laboratory results would normally require holding or modifying planned treatment doses. Methods: Nurses treating patients in the outpatient chemotherapy infusion units were surveyed regarding barriers to pre-treatment lab verification. A team of clinicians, nurses, and pharmacists outlined a process map of the order verification process from acknowledging patient assignment and looking at patient oncologic history to sending the physician order to pharmacy. Pharmacists collected baseline data by tracking near-miss incidents. Results: The survey response rate of outpatient treatment nurses was 18 of 32 (56%). Nurses ranked inconsistent notation of treatment criteria in orders, long lab processing time, and patient frustration with a long wait as the most common barriers to lab verification. At baseline, in six non-consecutive weeks from August-October 2016, 31 of 947 (3%) orders were inappropriately verified by nursing in which pre-treatment lab results were pending or lab results did not meet parameters in the chemotherapy order. The team’s aim is by February 1, 2017, to reduce the number of chemotherapy orders sent to pharmacy without proper lab verification by 50%. Conclusions: Chemotherapy verification fatigue, specifically pre-treatment lab near misses, was identified as an area for improvement from recent patient safety reports. Barriers for nurses include inconsistent notation of treatment criteria in orders, long lab processing time, and patient frustration with a long wait. Interventions are underway to improve nursing adherence to pre-treatment lab verification.
Improving oral chemotherapy documentation in a breast medical oncology outpatient practice.
Authors: Bhardwaj Aarti Sonia , FitzPatrick Katherine , Hynes Kathleen , Bivens David , McLean Micheal , Enson Jenna , Hammer Marilyn J. , Holcombe Randall F.
Published: April 2017

71

Background: The safe administration of oral chemotherapy is a challenging yet important process to ensure patient safety. Comprehensive initial and subsequent documentation especially regarding dosage and toxicities in the plan of care for patients receiving oral chemotherapy can be instrumental in improving patient safety by ensuring comprehensive health information is available to all health team members. Methods: We are undertaking a rapid cycle improvement project to improve initial and subsequent documentation of new oral chemotherapy care plans by increasing our compliance with the number of components of an oral chemotherapy care plan (as outlined by QOPI’s 13 standards). We performed a baseline chart audit to confirm our current low level of compliance. We then created a process to use smart phrases that include necessary QOPI elements for progress notes upon new prescription of oral chemotherapy as well as smart phrases for subsequent patient initiated telephone encounters regarding oral chemotherapy, that feed into a universal “med note” location. Post implementation, we will perform a chart audit to determine our updated compliance. Staff satisfaction with the old vs the new process will be compared to verify that we have created a more efficient system to answer patient questions regarding oral chemotherapy. Results: Baseline chart audit revealed the number of components of an oral chemotherapy care plan (as per QOPI standards) documented in the EMR was 43% (i.e contained 5/13 components). A Pareto chart confirmed that underutilization of current EMR resources and lack of knowledge regarding QOPI standards were common reasons for poor oral chemotherapy documentation. Implementation of smart phrases for documentation for initial patient encounters and subsequent telephone encounters is currently in process to determine our new level of compliance with QOPI standards for a sustained and meaningful improvement. Conclusions: This quality improvement initiative was designed to improve patient safety by enhancing documentation of an oral chemotherapy care plan in the EMR and also to create a more efficient system to answer and document patient phone calls regarding oral chemotherapy.
Post-discharge venous thromboembolism prophylaxis for surgical oncology patients.
Authors: Nadler Ashlie , Morba Mary Ellen , Pezzella Jesse , Farma Jeffrey M.
Published: April 2017

79

Background: A number of guidelines have been proposed for prolonged venous thromboembolism (VTE) prophylaxis following hospital discharge for cancer patients undergoing major abdominal or pelvic surgery. However, there is disparity in how closely these guidelines are followed. The purpose of this study was to examine the administration and complications of post-discharge chemical VTE prophylaxis (pdVTE) at an institutional level among surgical oncology patients to help inform policy creation. Methods: A retrospective study at a tertiary referral cancer center was performed. Data was analyzed for patients undergoing surgery in 2015. Chi-square tests were performed. Results: Of 566 colorectal, urologic, and gynecologic surgical oncology procedures performed in 2015, 24% (137) were discharged with a prescription for enoxaparin for pdVTE. An additional 24 patients were already on another form of anticoagulation at the time of discharge. Of the patients discharged on pdVTE, 77% (105) had the prescriptions filled. The compliance rate of those patients was 96% (101). The rate of VTE was 3.5% for all patients. There was a significantly greater rate of VTE amongst patients that received pdVTE (10.4%) compared to those who did not (1.6%) (OR 7.20, CI 2.80-18.46, p < 0.001). For each subspecialty, there was also a significantly greater rate of VTE amongst patients that received pdVTE (p < 0.001). Conclusions: There is a very low rate of pdVTE administration despite current guidelines. Identifying patients who received pdVTE appears to identify patients at high risk for VTE rather than the benefits of pdVTE. Institutional policies regarding prolonged VTE prophylaxis should be implemented to target high-risk patients and to ensure appropriate prescribing practices. [Table: see text]
Interventions to improve oral chemotherapy safety and quality: A systematic and grey literature review.
Authors: Zerillo Jessica A. , Goldenberg Benjamin Adam , Kotecha Ritesh R. , Tewari Alok , Krzyzanowska Monika K. , Jacobson Joseph O.
Published: April 2017

97

Background: With the growing use of oral chemotherapy, there is an urgent need to develop safe and effective systems to administer and manage these agents. A comprehensive synthesis of literature on oral chemotherapy care delivery programs to which clinicians can look for best practices is lacking. Methods: We performed a systematic review of PubMed, EMBASE and CINAHL from 1/1995- 5/2016 and the grey literature to identify publications describing oral chemotherapy care delivery programs. Our population of interest was cancer patients of all ages prescribed cytotoxic or targeted anti-cancer oral agents. Interventions could address any part of the oral chemotherapy delivery process from prescribing through disposal but had to report outcomes (adherence and/or safety or toxicity) in relation to a control group. Results: From 7,984 abstracts in the peer-reviewed and 9 from the grey literature, 16 studies met inclusion criteria (7 of these randomized) with 3,612 patients represented. Interventions focused on prescribing (n = 1), preparation/dispensing (n = 2), education (n = 11), administration (n = 5), monitoring (n = 14), and storage/disposal (n = 1). Of the 10 articles with adherence as an outcome, four different measurement methods were used. Many articles lacked formal statistical testing. In the 6 studies with statistically significant improvement in outcomes, 3 utilized nursing phone calls to patients within the first few days of treatment initiation, which resulted in less toxicity (n = 2) or better adherence (n = 1). None of the four studies that evaluated eHealth strategies to increase patient to care team contact demonstrated a statistically significant improvement in outcomes. Conclusions: Limitations in study design impair our ability to draw definitive conclusions on best practices for oral chemotherapy care delivery. A framework for conducting research in this area that defines the processes of oral chemotherapy delivery and standardizes outcomes of success is needed to address this gap. Existing studies suggest that interventions focusing on education and remote phone-based monitoring of patients at therapy initiation may decrease toxicity, and possibly improve adherence.
Down Syndrome-Associated Diabetes Is Not Due To a Congenital Deficiency in β Cells
Authors: Butler Alexandra E. , Sacks Wendy , Rizza Robert A. , Butler Peter C.
Published: April 2017

Aims/Hypothesis:

We sought to establish whether the increased incidence of diabetes associated with Down syndrome was due to a congenital deficit in β cells.

Methods:

The pancreas was obtained at autopsy from nondiabetic subjects with Down syndrome (n = 29) and age-matched nondiabetic control subjects without Down syndrome (n = 28). The pancreas sections were evaluated for the fractional β-cell area.

Results:

No difference was found in the fractional β-cell area between the subjects with Down syndrome and the control subjects.

Conclusions/Interpretations:

The increased incidence and prevalence of diabetes in individuals with Down syndrome is not due to an underlying congenital deficiency of β cells.
Use of the Electronic Health Record for Coding in Outpatient Neurology
Authors: Weathers Allison L.
Published: April 2017

Diagnostic coding now factors into reimbursement, quality assessments, reputational metrics, and epidemiologic analysis; therefore, it is more critical than ever that neurologists are accurate and precise in their coding. In addition to being the means though which most neurologists are capturing this information, the electronic health record can offer multiple tools to assist in these efforts. With conscientious design, build, and implementation of the electronic health record, diagnostic coding can be effortless, even for the most complex and varied of conditions seen in an outpatient neurology visit.
Urogenital Symptoms in Neurologic Patients
Authors: Panicker Jalesh N.
Published: April 2017

Purpose of Review: Lower urinary tract and sexual dysfunction are commonly reported sequelae of neurologic disease and have a significant impact on quality of life. This article presents an up-to-date summary of the clinical presentation, investigations, and treatment options for urogenital dysfunction in patients with neurologic disease.

Recent Findings: The pattern of lower urinary tract dysfunction is influenced by the site of the neurologic lesion. The risk for developing upper urinary tract damage is considerably less in patients with slowly progressive nontraumatic neurologic disorders, as compared to those with spinal cord injury or spina bifida. Investigations such as urinalysis, ultrasonography, and urodynamics provide further information about the cause and nature of lower urinary tract dysfunction. Antimuscarinic agents are the first-line management of urinary incontinence; however, side effect profile and anticholinergic burden should be considered when prescribing medications. β3-Adrenergic receptor agonists are a promising alternative oral medication. Tibial and sacral neuromodulation have been shown to be effective for managing incontinence, as well as urinary retention due to Fowler syndrome. Intradetrusor injections of onabotulinumtoxinA have revolutionized the management of neurogenic detrusor overactivity.

Summary: Neurologic patients reporting urogenital symptoms require a comprehensive evaluation for planning a patient-tailored approach to management. Neurologists are increasingly inquiring about lower urinary tract and sexual functions and becoming involved in the management of these disorders.
Low Back Pain
Authors: Tavee Jinny O. , Levin Kerry H.
Published: April 2017

Purpose of Review: This article provides an overview of evaluating and treating low back pain in the outpatient setting.

Recent Findings: As most cases of acute low back pain have a favorable prognosis, current guidelines on imaging studies recommend conservative treatment for 6 weeks prior to obtaining an MRI if no red flags are present. Of these red flags, a prior history of cancer is the strongest risk factor for a malignant etiology and requires urgent evaluation with MRI. Management of acute low back pain is mainly conservative with oral non-narcotic analgesics and mobilization as the initial recommendations. For patients with radiculopathy, epidural steroids may result in short-term pain relief, but long-term effects are still unclear.

Summary: A systematic, evidence-based approach to the patient with low back pain is key to providing safe and cost-efficient care.
Dizziness in the Outpatient Care Setting
Authors: Fife Terry D.
Published: April 2017

Purpose of Review: This article summarizes an approach to evaluating dizziness for the general neurologist and reviews common and important causes of dizziness and vertigo.

Recent Findings: Improved methods of diagnosing patients with vertigo and dizziness have been evolving, including additional diagnostic criteria and characterization of some common conditions that cause dizziness (eg, vestibular migraine, benign paroxysmal positional vertigo, chronic subjective dizziness). Other uncommon causes of dizziness (eg, superior canal dehiscence syndrome, episodic ataxia type 2) have also been better clarified. Distinguishing between central and peripheral causes of vertigo can be accomplished reliably through history and examination, but imaging techniques have further added to accuracy. What has not changed is the necessity of obtaining a basic history of the patient’s symptoms to narrow the list of possible causes.

Summary: Dizziness and vertigo are extremely common symptoms that also affect function at home and at work. Improvements in the diagnosis and management of the syndromes that cause dizziness and vertigo will enhance patient care and cost efficiencies in a health care system with limited resources. Clinicians who evaluate patients with dizziness will serve their patient population well by continuing to manage patients with well-focused workup and attentive care.
Practical Considerations in Addressing Physician Burnout
Authors: Deb Anindita
Published: April 2017

Physician burnout is an epidemic impacting patient care, career satisfaction, and physician health and well-being. Symptoms may result in potentially damaging consequences for physicians’ professional and personal lives. Neurologists are experiencing burnout at higher rates than most medical and surgical specialties. Empowering physicians to identify symptoms of burnout and engage with their organization to reduce triggers will lead to healthier physician-organization and physician-patient relationships. It is imperative that the medical community continue to raise awareness, recognize symptoms early, and provide techniques and resources to address physician burnout.
In vivomodels in breast cancer research: progress, challenges and future directions
Authors: Holen Ingunn , Speirs Valerie , Morrissey Bethny , Blyth Karen
Published: April 2017

Research using animal model systems has been instrumental in delivering improved therapies for breast cancer, as well as in generating new insights into the mechanisms that underpin development of the disease. A large number of different models are now available, reflecting different types and stages of the disease; choosing which one to use depends on the specific research question(s) to be investigated. Based on presentations and discussions from leading experts who attended a recent workshop focused on in vivo models of breast cancer, this article provides a perspective on the many varied uses of these models in breast cancer research, their strengths, associated challenges and future directions. Among the questions discussed were: how well do models represent the different stages of human disease; how can we model the involvement of the human immune system and microenvironment in breast cancer; what are the appropriate models of metastatic disease; can we use models to carry out preclinical drug trials and identify pathways responsible for drug resistance; and what are the limitations of patient-derived xenograft models? We briefly outline the areas where the existing breast cancer models require improvement in light of the increased understanding of the disease process, reflecting the drive towards more personalised therapies and identification of mechanisms of drug resistance.
Job Ladders and Earnings of Displaced Workers
Authors: Krolikowski Pawel
Published: April 2017

Workers who suffer job displacement experience surprisingly large and persistent earnings losses. This paper proposes an explanation for this robust empirical puzzle in a model of search with a significant job ladder and increased separation rates for the recently hired. In addition to capturing the depth and persistence of displaced worker earnings losses, the model matches: employment-to-nonemployment and employer-to-employer probabilities by tenure; the empirical decomposition of earnings losses into reduced wages and employment; observed wage dispersion; and the distribution of wage changes around a nonemployment event. (JEL J31, J63, J64)
PSFC: a Pathway Signal Flow Calculator App for Cytoscape
Authors: Nersisyan Lilit , Johnson Graham , Riel-Mehan Megan , Pico Alexander R , Arakelyan Arsen
Published: April 2017

Cell signaling pathways are sequences of biochemical reactions that propagate an input signal, such as a hormone binding to a cell-surface receptor, into the cell to trigger a reactive process. Assessment of pathway activities is crucial for determining which pathways play roles in disease versus normal conditions. To date various pathway flow/perturbation assessment tools are available, however they are constrained to specific algorithms and specific data types. There are no accepted standards for evaluation of pathway activities or simulation of flow propagation events in pathways, and the results of different software are difficult to compare. Here we present Pathway Signal Flow Calculator (PSFC), a Cytoscape app for calculation of a pathway signal flow based on the pathway topology and node input data. The app provides a rich framework for customization of different signal flow algorithms to allow users to apply various approaches within a single computational framework.
It Is Not My Place! Psychological Standing and Men’s Voice and Participation in Gender-Parity Initiatives
Authors: Sherf Elad N. , Tangirala Subrahmaniam , Weber Katy Connealy
Published: April 2017

Attempts to improve gender parity at workplaces are more effective when organizations mobilize their entire workforce, including men, to participate (i.e., speak up with ideas, volunteer, or serve as champions) in gender-parity initiatives. Yet, frequently, men are hesitant to participate in such initiatives. We explicate one reason for such hesitation on the part of men and suggest ways organizations can address this challenge. Using four studies (correlational as well as experimental), we demonstrate that men experience lower psychological standing (i.e., a subjective judgment of legitimacy to perform an action) with respect to gender-parity initiatives that leads them to participate less in such initiatives. We explain how psychological standing provides a complementary explanation to the current narrative in the literature suggesting that men’s poor participation results from sexist or discriminatory attitudes toward gender parity. We also establish that psychological standing influences participation over and above efficacy, instrumentality, and psychological safety and highlight how organizations can increase men’s participation by providing them with psychological standing when soliciting their participation in gender-parity initiatives. We discuss the implications of our findings for the literatures on gender parity, change management, and employee voice and participation.

The online appendix is available at https://doi.org/10.1287/orsc.2017.1118 .
Albumin reduces the antibacterial efficacy of wound antiseptics against Staphylococcus aureus
Authors: Kapalschinski N. , Seipp H.M. , Kückelhaus M. , Harati K.K. , Kolbenschlag J.J. , Daigeler A. , Jacobsen F. , Lehnhardt M. , Hirsch T.
Published: April 2017

Objective:

The influence of proteins on the efficacy of antiseptic solutions has been rarely investigated even though exudate can contain high levels of protien. The aim of this study was to analyse the antibacterial efficacy of commonly used solutions in the presence of albumin protein.

Method:

Using Staphylococcus aureus in a standardised quantitative suspension assay, the antibacterial effects of poly (1-(2-oxo-1-pyrrolidinyl) ethylene)-iodine (PVP-I) and octenidin-dihydrochloride/phenoxyethanol (OCT/PE) were analysed in the presence of 0–3% bovine serum albumin (BSA). These were compared with previous results obtained with polyhexamethylene biguanide hydrochloride (PHMB).

Results:

Presence of albumin caused a significant (p<0.001) decrease in antibacterial effect in the analysed solutions. The concentrations of albumin that provoked highly significant decreases in the bacterial reduction factors of the study agents were: 0.01875 % for PVP-I, followed by 0.75 % for OCT/PE. After addition of 3 % albumin, adequate antimicrobial effects were ensured for titrations to 5 % PVP-I and 8 % OCT/PE. As we could show before, it is not possible to titrate PHMB in order to assure adequate potency.

Conclusion:

This study demonstrates that albumin induces a significant decrease of the antibacterial potency of the analysed solutions.
Quantifying the Release of Biomarkers of Myocardial Necrosis from Cardiac Myocytes and Intact Myocardium
Authors: Marjot Jack , Kaier Thomas E , Martin Eva D , Reji Shiney S , Copeland O'Neal , Iqbal Mohammed , Goodson Bob , Hamren Sarah , Harding Sian E , Marber Michael S
Published: April 2017

BACKGROUND

Myocardial infarction is diagnosed when biomarkers of cardiac necrosis exceed the 99th centile, although guidelines advocate even lower concentrations for early rule-out. We examined how many myocytes and how much myocardium these concentrations represent. We also examined if dietary troponin can confound the rule-out algorithm.

METHODS

Individual rat cardiac myocytes, rat myocardium, ovine myocardium, or human myocardium were spiked into 400-μL aliquots of human serum. Blood was drawn from a volunteer after ingestion of ovine myocardium. High-sensitivity assays were used to measure cardiac troponin T (cTnT; Roche, Elecsys), cTnI (Abbott, Architect), and cardiac myosin-binding protein C (cMyC; EMD Millipore, Erenna®).

RESULTS

The cMyC assay could only detect the human protein. For each rat cardiac myocyte added to 400 μL of human serum, cTnT and cTnI increased by 19.0 ng/L (95% CI, 16.8–21.2) and 18.9 ng/L (95% CI, 14.7–23.1), respectively. Under identical conditions cTnT, cTnI, and cMyC increased by 3.9 ng/L (95% CI, 3.6–4.3), 4.3 ng/L (95% CI, 3.8–4.7), and 41.0 ng/L (95% CI, 38.0–44.0) per μg of human myocardium. There was no detectable change in cTnI or cTnT concentration after ingestion of sufficient ovine myocardium to increase cTnT and cTnI to approximately 1 × 108 times their lower limits of quantification.

CONCLUSIONS

Based on pragmatic assumptions regarding cTn and cMyC release efficiency, circulating species, and volume of distribution, 99th centile concentrations may be exceeded by necrosis of 40 mg of myocardium. This volume is much too small to detect by noninvasive imaging.