bluuebunny/crossref_metadata_2025_split huggingface dataset:
Creating simple solutions for safe naloxone use.
Authors: Meadows Jason , McGee Kara , Goldberg Jessica , Stabler Stacy Marie 
Published: September 2018

e18185 Background: Naloxone is sometimes required to reverse acute intoxication from opioid pain medications. Although clinical guidelines exist, naloxone dosing is variable in practice. Higher doses can cause pain crisis, acute withdrawal, and possibly increased patient risk. We developed a multi-faceted intervention to increase guideline-concordant naloxone dosing. Methods: We surveyed medical staff and retrospectively collected 6 months of naloxone prescribing data to assess knowledge and frequency of guideline-concordant dosing. We reviewed the electronic order for naloxone and interviewed experienced nurses to facilitate mapping of the process of naloxone administration. We then designed 4 interventions aimed at adult inpatients on medical oncology, general medical and ICU services: 1. Simplify wording of naloxone guidelines; 2. Create naloxone kit containing all necessary equipment and instructions; 3. Auto-populate dose into electronic naloxone order; 4. Administer 5-minute educational inservice to staff (RN, NP, PA, MD). To assess rate of guideline concordance, naloxone prescribing data was collected for the pre-intervention (12 months), intervention (6 weeks), and post-intervention (8.5 months) groups. The survey was repeated after the intervention. For analysis, a generalized linear regression with logit link function and a generalized estimating equation method were used. Results: Over the 22-month study period, 137 patients received 148 naloxone doses. Patients were mean age 63.1 y/o, 54.7% female, and 75.9% white. Of the 90 naloxone doses given pre-intervention, only 24.4% were guideline-concordant. The 10 doses of naloxone given during the intervention period were guideline-concordant in 40% of the cases. Of the 48 naloxone doses given post-intervention, 62.5% were guideline-concordant, a significant increase compared to the pre-intervention group (p < 0.001). The improvement was most dramatic in the non-ICU services (26.4% to 73.5%, p < 0.001). Increases were maintained at 8 months (median concordant rate 53.5%/month (range: 33%-100%). Conclusions: A simple, inexpensive intervention can be used to increase guideline-concordant naloxone dosing and potentially avoid adverse effects of naloxone.
General medical oncologists assessment and use of targeted treatment for patients (pts) with metastatic nonsquamous non-small cell lung cancer (nsqNSCLC).
Authors: Love Neil , Oxnard Geoffrey R. , Sholl Lynette M. , Sequist Lecia V. , Harwin William N. , Kelly Gloria , Miller Kirsten , Paley Douglas , Moss Jonathan , Ziel Kathryn 
Published: September 2018

e18186 Background: Current guidelines endorse biomarker assessment for all pts with nsqNSCLC. However, variability in actualizing these recommendations may exist. This pilot project evaluated how MO in a large practice group approach mutation analysis and targeted treatment in nsqNSCLC, both hypothetically and in real pts. Methods: In fall 2016, 10 MO from Florida Cancer Specialists each provided information on biomarkers assessed and therapies administered for 10 nsqNSCLC pts(5 without an identified target and 5 with tumor driver mutations). A survey evaluating general practice patterns was also executed. IRB exemption was obtained and a modest honorarium was provided. Results: All MO reported that ideally all nsqNSCLC pts should be tested for EGFR mutations (EGFRm) and ALK rearrangement (ALKr) but only half stated that they would recommend next-generation sequencing (NGS). Of the 54 pts without a mutation, 52 (96%) had EGFRm and ALKr testing but only 12 (22%) had undergone NGS. Among the 45 pts with an actionable target, 41 (91%) had EGFRm and 4 (9%) had ALKr. 37 (80%) of these pts received first-line TKIs, and all MO agreed they would typically recommend this approach. 8 (20%) EGFRm pts initially received chemotherapy, 5 because the MO and/or pt preferred immediate treatment. All MO indicated that EGFRm pts progressing on first-line EGFR TKIs should be evaluated for T790M and indeed 9 pts with disease progression on an EGFR TKI since November 2015 had undergone plasma or tissue testing, and of these 5 are currently receiving osimertinib. Conclusions: The self-stated and actual practice patterns of MO related to nsqNSCLC biomarker assessment largely adhere to current guideline recommendations, but the limited use of NGS suggests that many pts with potentially targetable mutations other than EGFRm and ALKr are not being identified. These findings support growing evidence that interrogation of case-level data can elucidate practice gaps, and an integrated CME platform is being developed to assess whether discussion of documented deficiencies can enhance quality of care.
Children’s Oncology Group (COG) clinical trials as exemplars of pragmatism in clinical research.
Authors: Mittal Nupur , George Anil , Leanos Lizette , Kent Paul 
Published: September 2018

e18188 Background: In 2016, President Obama announced the “Moonshot Cancer Initiative” to advance cancer research. One of the key components of this initiative is promoting enrollment in pragmatic clinical trials and data sharing. As described in 2009 by Thorpe et al, using the 9-domian PRECIS-2 tool, a ‘pragmatic’ trial, as opposed to an ‘explanatory’ trial used to confirm a physiologic hypothesis, is one in which the intervention can be immediately applied into real-world clinical practice (J of Clin Epi:2009). In the US, 60%-90% children are enrolled on COG research trials. State-of-the-art treatment for a child is derived from superior therapy identified in prior trials which then serves as the standard arm of subsequent phase-III trials and becomes the de facto practice guideline and ‘standard of care’ .To accomplish this goal, COG shares its data among the 242 member institutions.Our objective is to assess “pragmatism” in COG trials. Methods: We analyzed the 158 COG phase III clinical trials between 2006-2016 for all 9 domains of the PRECIS-2 (Table 1) and graded them from 1-5 (most explanatory to most pragmatic). Results: Out of 152 phase III clinical trials on the COG website, 138 (91%) scored 5/5 for all 9 PRECIS pragmatic domains and 148 (98%) scored >4. The scoring for all 9 domains is in table 1. Conclusions: COG provides nearly all children in the United States access to pragmatic phase III research as outlined in the Moonshot Goals. Goal of merging evidence-based standard care accessible to all and conducting well- designed clinical research to identify the best therapies has been accomplished by COG and should serve as an example to other cancer organizations. 9 domains of PRECIS-2 to assess pragmatism in clinical trials. [Table: see text]
Using clinical pathways to understand biomarker testing patterns.
Authors: Ellis Peter G. , Lokay Kathleen , Barry Amanda 
Published: September 2018

e18189 Background: Via Pathways’ Disease Committees incorporate biomarker testing recommendations into the pathway decision support when the literature supports improved outcome. For several years, the non-small cell lung pathway (NSCLP) has recommended testing for ALK, EGFR, and, more recently ROS1 targeted therapies. The decision support software (VP) requires the practitioner to register testing and results, including the decision not to test. Methods: For the twenty months ending 10/31/16, we analyzed all NSCLP patients treated at UPMC CancerCenter locations for first line, metastatic, non-squamous lung cancer per the VP. Results were analyzed in total and by type of provider (83 community providers vs. 3 academic providers who specialize in lung cancer). Provider’s answers to the biomarker testing question included “positive” results, “negative” results, “test pending”, and “not tested”. Results: Of the 684 treatment starts in the 1stline non-squamous NSCLP, 100 were patients of academic providers (AP) and 584 were patients of community providers (CP). AP indicated testing for ALK and EGFR in 100% of patients (n=100). CP indicated testing for ALK in 91% (n=532) and for EGFR in 92% (n=538). AP indicated testing for ROS1 in 96% (n=93) and CP indicated testing for ROS1 in 81% (n=473). Results are summarized in the table. Conclusions: Data from clinical pathways software can be utilized to understand biomarker testing rates among providers. In this example, the three AP tested for actionable mutations more frequently than the 83 CP, although both rates of testing appeared to be high. This data can be used to generate hypothesis about patterns of care that may include patient parameters, size of network or other factors that can then further analyzed and tested. Pathways serves as an important tool in promoting and monitoring quality care. [Table: see text]
Current alignment between the practice patterns of gastrointestinal (GI) cancer clinical investigators (CI) and general medical oncologists (MO) in the treatment of metastatic GI cancers.
Authors: Miller Kirsten , Ziel Kathryn , Kelly Gloria , Paley Douglas , Moss Jonathan , Love Neil 
Published: September 2018

e18193 Background: CI with an interest in specific cancers amass a unique body of knowledge and relevant experiences that may make their practice patterns different from those of MO. This initiative sought to document and compare the stated management approaches of CI and MO. Methods: InMay 2016, as part of a continuing medical education (CME) project, 31 CI elected to complete a 78-item survey assessing their usual treatments for various metastatic colorectal, gastric and pancreatic cancer clinical scenarios. A stipend was provided for participation. On June 4, 2016, 13 clinical questions from the CI survey were posed to 140 MO, 103 US-based and 37 non-US-based, prior to a CME symposium on GI cancers. Responses of the groups were compared. Results: For 10 out of 13 questions, there was relative concordance between CI and MO responses. However,for 3 there was considerable variation (see table). Conclusions: Although CI and MO approach the care of many patients with GI cancers in a similar manner, important and noteworthy variations exist. These findings indicate that the documentation and comparison of treatment recommendations could be a novel strategy to elucidate misalignment between CI and MO and impel either or both to rethink current approaches. Additional work is needed to validate these findings and understand potential implications and applications. [Table: see text]
The morbidity and mortality conference (MMC) concept applied to contemporary oncology practice: Retrospective findings on management of 233 patients (pts) who died of ovarian cancer (OC), colorectal cancer (CRC) and wild-type (no identified targetable mutation) nonsquamous non-small cell lung cancer (WTLC).
Authors: Ziel Kathryn , Birrer Michael J. , Hecht J. Randolph , Wakelee Heather A. , Chen Gigi Qiqi , Deutsch Margaret Ann , Picton Maria Eugenia , Rodriguez Estelamari , Willmott Lyndsay , Kelly Gloria , Miller Kirsten , Moss Jonathan , Paley Douglas , Love Neil 
Published: September 2018

e18195 Background: MMC have traditionally evaluated pt management and potential areas for quality improvement. We hypothesized that this approach could be adapted and extrapolated to gain increased insight into how pts with common solid tumors are being treated in general oncology practice and how the approaches used align with evidence-based guidelines. Methods: 102 randomly recruited US-based general medical oncologists from a proprietary database of 4,019 agreed to consult their medical records and provide information on biomarkers assessed, systemic therapies administered and other treatment-related factors for the last pt in their practice to die from OC, CRC and/or WTLC. An IRB exemption was obtained and a modest honorarium was provided. Results: Pts with OC, CRC and WTLC received a median of 3, 3 and 2 lines of therapy, respectively, the majority of which were supported by guidelines, but in more than half of cases, the regimen administered required dose adjustment/discontinuation due to toxicity. Less than half of pts were offered trial participation and only 15 (6%) entered a trial. 19 pts with OC (25%), 25 pts with CRC (32%) and 58 pts with WTLC (73%) did not undergo BRCA, MSI and multiplex genomic testing, respectively, despite the recommendation of available guidelines. Conclusions: The MMC model may be an effective means to document variability as well as consistency in current oncologic care. Data generated via this assessment juxtaposed with current clinical evidence and available guideline recommendations could potentially serve as a powerful educational intervention. These findings require additional validation but provide initial support for future iterations of this exercise. [Table: see text]
A new pancreatojejunostomy of duct-to-mucosa combining back-to-back cross horizontal mattress anastomosisin pancreaticoduodenectomy.
Authors: Wu Wenchuan , Zhang Lei , Pu Ning 
Published: September 2018

e18216 Background: Postoperative pancreatic fistula(POPF) is always related to the morbidity and mortality. The objective of our study was to evaluate the safety and efficiency of the novel anastomotic method that termed duct-to-mucosa combining with “back-to-back” cross horizontal mattress inserting pancreatojejunostomy. In this technique, we used 4-0 Coated VICRYL to stitch the posterior of the stump of pancreas into the side of jejunum in the method of horizontal mattress suture. Then, we used 5-0 polypropylene to stitch the posterior of the pancreatic duct into the jejunum interruptedly. After that, a pancreatic duct stent was inputted. The anterior side of the pancreatic duct and the pancreas was stitched the same as the anastomosis of the posterior side. Methods: We investigated the postoperative recovery and complications of 49 patients who underwent pancreaticoduodenectomy from October 2015 to October 2016 retrospectively. The new technique was used in 24 patients, and was compared with the regular interrupted suturing anastomosis technique that was used in 25 patients as controls. We defined, diagnosed and graded POPF accroding to the International Study Group in Pancreatic Surgery criteria. Results: The anastomosis time in the conventional group was less than that in new technique group (21.52±2.26 min vs28.10±6.20 min, P=0.000), but we could find the POPF rate decreased significantly in the new technique group from the following data. There were 2 grade B POPF patients in the new technique group. Meanwhile, there were 8 grade B POPF and 1 grade C POPF patients in the control group (8.3% vs 36.0%, P=0.020). Conclusions: Duct-to-mucosa combining with “back-to-back” cross horizontal mattress inserting pancreatojejunostomy reduced the incidence of POPF effectively in our study. [Table: see text]
Utility of PET/CT in primary identification and management of cancers of unknown primary.
Authors: Cherniawsky Hannah Marie , Sawyer Michael B. , Ghosh Sunita , Cheung Winson Y. , Ho Maria Yi 
Published: September 2018

e18219 Background: The role of PET/CT in staging and management of cancers of unknown primary (CUP) is poorly defined. Our study sought to evaluate PET/CT versus standard CT in determining the primary site, lymph node status and solid organ metastases, and assess whether results of PET scans altered management of patients with CUP. Methods: We conducted a retrospective chart review of CUP patients to measure concordance of PET/CT and CT scans in patients diagnosed with CUP at two Western Canadian academic centres; the Cross Cancer Institute and BC Cancer Agencies from 2008 to 2015. Results: We identified 244 patients who had standard CT and PET/CT during their work-up. Of the 70 patients whose primary identification status was recorded, standard CT imaging detected 16.1% of primaries compared to 12.1% on PET/CT. 63.3% of primaries were concordantly identified on both modalities. PET/CT identified 2 primaries not seen on CT whereas standard CT identified 9 primaries not seen on PET/CT. Concordance rates between PET/CTs and standard CTs were 77.9% and 93.9% regarding lymph node status and extent of metastases, respectively. PET/CT identified a greater extent lymph node involvement in patients; 93.8% versus 79.0%. (CCOR = 2.92, 95% CI = 0.87-9.72) and identified a greater extent of solid organ involvement; 96.5% versus 92.4%. (CCOR = 45.25, 95% CI = 7.79-262.78). Data from the CCI of patients who had discordant imaging in either domain or identification of primary showed no cases in which PET/CT alone provided information that changed patient management. Conclusions: Our results suggest PET/CT scans do not provide additional diagnostic information with respect to identifying the primary site but may be superior in clarifying extent of metastases and nodal status though this did not alter therapy. Future studies investigating the impact of PET/CT scans on management and cost effectiveness in CUP are critical.
Thirty-day mortality following interventional line or drain placement among hospitalized cancer patients.
Authors: Kilbridge Kerry L. , Glotzbecker Brett , Stuver Sherri Oliver , Rosenbaum Cecilia H. , O'Horo Susan Kiernan , Day Angela , Jacobson Joseph O. 
Published: September 2018

e18222 Background: Percutaneous lines and drains provide a less invasive alternative to operative procedures for patients with cancer. We categorized outcomes for placements among solid tumor patients hospitalized on the medical oncology services of a tertiary care academic center. Methods: Consecutive cases (n=71, Mar-Sept 2016) were identified by electronic medical record orders for non-vascular lines and drains placed in solid tumor patients hospitalized on medical oncology services and confirmed by retrospective chart review. Percutaneous nephrostomy tubes, pleurx catheters (abdominal and thoracic), gastrojejunostomy/gastric tubes, biliary drains, and wound/abscess drains were included. Retrospective chart review was used to categorize 30-day outcomes including those deemed related or possibly related to the placement that resulted in a phone call, office visit, ED evaluation, or hospital readmission. Results: Mean age at placement was 62 years and 53% of patients were female. All patients had metastatic tumor. The majority of patients had an Eastern Cooperative Oncology Group Performance Status of 3-4 (63.4%). Patients with gastrointestinal, gynecological and genitourinary malignancies required more procedures than all other tumor types combined. The 30-day mortality rate following line and drain placement was 32.4%. Of these deaths, 43.5% occurred prior to discharge and 30.4% occurred within two weeks. 40.8% of patients required ED evaluation or hospital readmission and 29.6% of patients required an office visit or phone call within 30 days. Conclusions: Although percutaneous interventions are generally safe and minimally invasive, there is a high 30-day mortality rate associated with line and drain placement among hospitalized patients with advanced cancer. Among patients who expired, over forty percent of deaths occurred during the index hospitalization, suggesting placements are occurring at the end of life, may potentially reflect overuse and may represent a missed opportunity to address goals of care. [Table: see text]
The next generation of quality improvement at MSK: Turning chemotherapy process delays into chemo express.
Authors: Tota Jennifer , Levine Kathleen , Gordon Jeanine , Baldwin Abigail , Wald Jodi , Salvaggio Rori , Lee-Teh Melissa , Freeswick Scott , O'Cearbhaill Roisin , Reidy Diane Lauren 
Published: September 2018

e18230 Background: Chemotherapy wait times can dramatically affect patient experience. MSK’s largest outpatient facility has 76 infusion spaces and 250-300 daily visits. A retrospective review of the facility’s infusion area wait times suggested that the lab (where all patients go to get their vitals and blood drawn) was a major bottleneck leading to process delays in infusion. Methods: We conducted a pilot program using a multi-pronged approach. Our goal was to decrease wait time from 40 minutes to an average of 15 minutes. Our initiative was defined as follows: (1) to redefine lab parameters that are relevant for toxicity and to only consider drawing those necessary labs; additionally, we created guidelines for timing of the labs prior to infusion treatment, (2) to introduce a program known as “ChemoExpress” which offers patients the opportunity to get blood work done prior to the day of their infusion appointment. After the labs result, the outpatient RN calls the patient, assesses symptoms and “clears them” for treatment cueing the pharmacy to prepare and “premix” the drug on the day of treatment. Results: 150 patients have enrolled in ChemoExpress. Patient satisfaction was high based on patient satisfaction surveys (n = 20). Average wait time was 9 minutes (76% less) in ChemoExpress participants as compared to an average wait of 39 minutes for those who did not participate in ChemoExpress. Conclusions: Implementing a process that enables patients to have their bloodwork drawn prior to the day of treatment and drugs prepared in advance of their treatment appointment results in greater efficiency in the overall workflow. It also offers the patient a lower wait time and a more efficient and satisfying experience.
Development of a novel algorithm to identify staging and lines of therapy for bladder cancer.
Authors: Cary Clint , Roberts Anna , Church Abby K , Eckert George , Ouyang Fangqian , He Jinghua , Haggstrom David A 
Published: September 2018

e18235 Background: Large automated electronic medical record (EMR) databases have the potential to be valuable tools in studying the patterns and effectiveness of treatment. Therefore, the current study sought to develop novel tools to identify bladder cancer cases, their clinical stage, and the chemotherapy they receive in electronic medical records. Methods: EMR data were obtained from Indiana University Health hospitals from 2008 to 2015. We developed 2 novel algorithms using natural language processing on unstructured data to identify (a) bladder cancer cases and clinical stage, and (b) chemotherapy names and line of chemotherapy. Performance characteristics for each algorithm were assessed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Each algorithm’s performance for case ascertainment was measured against the gold standard of manual chart review. Results: A total of 2,559 unique bladder cancer patients were identified and stratified using the clinical staging algorithm, defined as metastatic, muscle invasive, or non-muscle invasive. We identified 657 metastatic cases, 567 muscle invasive cases, and 604 non-muscle invasive cases. Next, the treatment algorithm was applied to metastatic patients to identify the type of chemotherapy received and 1st or 2nd line of therapy. The sensitivity, specificity, PPV, and NPV for the clinical staging and treatment algorithm were calculated against the gold standard of manual chart review (Table). Conclusions: The performance of the staging algorithm demonstrates the strength of using innovative approaches. The poor performance of the treatment algorithm sets a framework from which to build upon in future work and suggests that structured approaches may still be the preferable approach. [Table: see text]