Successful creation of an outpatient team-based model for traditionally inpatient chemotherapy

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Background: In 2014, due to increased demand for inpatient hospital beds and subsequent patient dissatisfaction due to delays for patients receiving scheduled chemotherapy, Moffitt Cancer Center created a multi-disciplinary team to transition traditionally inpatient chemotherapy regimens into the outpatient setting. Methods: A Team composed of Physicians, Pharmacists, PA’s/ARNP’s, Social work, Infusion Nursing and IT drove initiation and implementation of new processes from 2014-Current with gradual increases in patient volumes and continued high quality and patient safety. Results: Over the examined 5 year time period, HyperCVAD Arm A, DA-EPOCH, Blinatumomab and Liposomal Daunorubicin and Cytarabine (Vyxeos) were transitioned into the outpatient setting. 667 total cycles of chemotherapy were transitioned into the outpatient setting, saving 4,386 inpatient days over the examined time period. Hospitalization was required in 22 of 667 cycles (3.3%) with no attributable mortality due to outpatient administration. Examination of potential financial impact was consistent with an estimated favorable impact to overall margin of $3,153,534 due to backfill of inpatient beds. Conclusions: Outpatient delivery of traditionally inpatient chemotherapy is safe and effective with the potential for reduction in delays for scheduled chemotherapy patients and favorable financial impact. Critical to success is the creation of an empowered, cross functional leadership team and a gradual and sequential approach to implementation.

Building a specialty accountable care organization (ACO) for cancer: Using cost groupers in breast cancer (BC) and malignant hematology (MH)

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Background: New payment models, such as accountable care organizations (ACOs), bundled payments and global budgets will shift some financial risk from payers to providers. The first step in creating a cancer ACO will be to partner with payers to understand aggregate costs over time. Methods: Moffitt Cancer Center (MCC) is partnering with Florida Blue in (BCBS of FL) in developing a specialty ACO strategy for cancer. As an initial step, we created an analytical framework to group and estimate the total costs of cancer care for newly diagnosed breast cancer (BC) and malignant hematology (MH) patients. We used HIPPA-compliant Florida Blue claims billings from 2010-2012 to capture all episodes of care within each calendar year. BC and MH patients were attributed to MCC if they had at least 3 annual visits. Claims from attributed patients were grouped into 7 categories. We calculated the annual costs and the costs by category to generate a Per Member Per Year (PMPY) cost and determine the stability and/or trends in these costs. Results: The PMPY data for the three years (2010, 2011, 2012) were stable over time. Important trends, however, were noted: outpatient (OP) costs, which include infusion chemotherapy, rose similarly (16 and 13%, respectively), inpatient (IP) costs for BC increased 10%, compared to an 8% decrease in IP cost for MH over the 3 years. Physician costs remained stable, consistent with other reports. Conclusions: Moving away from volume-based reimbursement requires building partnerships between payers and providers. We created disease-based cost groupers for two cancer conditions as a first step. Cost trends were stable over time. These findings will give payers and partners confidence to explore ways to improve quality and reducing cost as they consider new arrangements such as a specialty ACO. [Table: see text]

Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

The inner core region of Yersinia enterocolitica Ye75R (0:3) lipopolysaccharide

The inner-core region of the lipopolysaccharide of an UDPGalNAc-4-epimerase-deficient mutant of Yersinia enterocolitica 0:3, designated as Ye75R, was investigated using methylation analysis, 1D-13C-NMR and 2D-13C-NMR and 1H-NMR, as well as 31P-NMR, fast-atom-bombardment mass spectrometry (FAB MS) and FAB MS/MS in positive and negative modes. The isolated core heptasaccharide (OS) was composed of 2 units D-glucose, 3 units LD-heptose and 1 unit each of DD-heptose and 3-deoxy-D-manno-octulosonic acid. Methylation analysis indicated that OS was highly branched with terminal location of the two glucoses and the DD-heptose unit, which was partially (to about 40%) phosphorylated at C7. These combined studies allowed us to formulate the structure of the inner core region as shown in Scheme 1. The substitution of the 7-position of the terminally linked DD-heptose unit by phosphate could be recognized by MS characterization of permethylated DD-heptose-7-phosphate (alditol acetate) and the extent of the substitution by the ratio of the two well separated 1H signals of DD-heptose in 500-MHz 1H-NMR. Negative FAB MS of OS also indicated the presence of smaller amounts of two hexasaccharides, differing from OS in lacking either one terminal unit of D-glucose or of the terminal DD-heptose, and additionally of a pentasaccharide lacking two heptosyl units, namely the terminal DD-heptose and and the subterminal LD-heptose. The presence of the smaller oligosaccharides in the OS fraction was also recognized by the methylation analysis.

Differentiation of serological responses to Yersinia enterocolitica serotype O9 and Brucella species by immunoblot or enzyme-linked immunosorbent assay using whole bacteria and Yersinia outer membrane proteins

Serum samples from 134 patients showing by the microagglutination test serological cross-reactivity between Yersinia enterocolitica serotype O9 and Brucella spp. were analyzed by immunoblot and enzyme-linked immunosorbent assay techniques for the presence of antibodies directed against plasmid-encoded, yersinia-associated outer membrane proteins (OMPs). Since these OMPs are exclusively expressed in pathogenic strains of Yersinia spp., this characteristic was chosen for serological differentiation of infections caused by these bacteria. The presence of antibodies against plasmid-encoded OMPs of pathogenic Yersinia spp. in patient sera appeared to be a suitable means to identify acute or recent infection with Y. enterocolitica serotype O9, whereas the failure to detect such antibodies indicated an acute or recent infection with Brucella spp.

Detection of cross-reacting epitopes on plasmid-encoded outer membrane proteins of enteropathogenic Yersinia by monoclonal antibodies

Plasmid-positive Yersinia bacteria of different species and different serotypes were analysed with respect to the immunological relationship of two of their plasmid-encoded outer membrane proteins (OMPs) by the immunoblot technique using three monoclonal antibodies (mAb), which were induced against OMPs of Yersinia enterocolitica serotype O:9 bacteria. Evidence is presented that these OMPs display discrete epitopes, which are common to all plasmid-positive Yersinia strains tested, with only one exception, indicating a close structural relationship of the OMPs analysed.

Temperature-dependent incorporation of 4-amino-L-arabinose in lipid A of distinct gram-negative bacteria

The presence and the relative amount of 4-amino-L-arabinose in lipopolysaccharides of members of the Enterobacteriaceae family and in a single strain of Chromobacterium violaceum has been studied with regard to growth-temperature dependent variations. Changes in the presence and the amount of 4-amino-L-arabinose (4-AA) were observed in almost all cases, but the variations observed were not consistent among different species. While Salmonella minnesota and Proteus mirabilis showed higher levels of incorporation at higher temperatures, the S- and R-forms of Yersinia enterocolitica showed the opposite effect, i.e. only marginal incorporation by growth at 10 degrees C. Chromobacterium violaceum, however, showed no significant alteration in the 4-amino-L-arabinose content when growth either at 14 or at 37 degrees C. DOC-PAGE pattern of isolated lipopolysaccharides showed characteristic profiles indicating that the O-chain-synthesis of distinct Enterobacteriaceae is also differently influenced by changes in growth temperature.

Immunological characterization of Yersinia enterocolitica O:9 and O:3 LPS antigens by monoclonal antibodies

LPS-specific monoclonal antibodies induced against Y. enterocolitica serotype O:9 bacteria and against Y. enterocolitica O:3 were used in a comparative study to characterize the O:9 and O:3 LPS. Yersinia bacteria grown at 22 degrees C and 37 degrees C and LPS preparations thereof were tested. SDS-PAGE, Western blot analysis and adsorption procedures revealed that LPS of Y. enterocolitica O:9 differed from that of Y. enterocolitica O:3 in: (i) its repeating LPS O-side-chain sugar, (ii) its shorter length of the LPS O-side-chain and (iii) its failure to show temperature-dependent variation in the length of O-side-chains.

Plasmids of Yersinia enterocolitica and Yersinia pseudotuberculosis: analysis with restriction endonucleases

The plasmids of Yersinia enterocolitica and Yersinia pseudotuberculosis tested differed in regard to the following aspect: there were some of a molecular size of 41 to 47 Mdal which could be correlated with autoagglutination of the host bacteria, and the others with a smaller size of 19 to 34 Mdal that lacked the capacity to code for autoagglutination. Analysis of both types of plasmids with the restriction endonucleases Bam HI, Eco RI and Hind III besides of some similarities revealed also considerable serogroup-specific differences in their DNA fragmentation pattern.

Lung tissue concentrations of cefoperazone

The following lung tissue concentrations of cefoperazone were found in 20 patients after a 2 g single dose: 45.3-113.3 mg/kg after one hour and 20.5-68.1 mg/kg after two hours. The respective serum levels were measured in parallel determinations for comparison purposes. All determinations were carried out by means of high pressure liquid chromatography. The results suggest that cefoperazone has a rapid and sustained concentration ability in the lung tissue. The drug is therefore suitable for perioperative prophylaxis in lung surgery.

Temperature-dependent changes in the sugar and fatty acid composition of lipopolysaccharides from Yersinia enterocolitica strains

Yersinia enterocolitica S and R strains change the pattern and the amount of their lipopolysaccharide-linked fatty acids with the respective growth temperature. As described also for other enterobacterial strains, saturated fatty acids are decreased, especially the amount of C14:0, when growth was done at 10 degrees C and unsaturated fatty acids, notably C16:1 (palmitoleic acid), appear, which are present in trace amounts only when bacteria are grown at 40 degrees C. In addition to these changes in the fatty acids, also the amount of O-specific sugars is temperature-dependent. 6-Deoxy-L-altrose which is the only main O-specific sugar in the LPS investigated, amounts to 30-40% (based on LPS dry weight) when grown at 10 degrees C, but only to 13-20% when growth was done at 40 degrees C. The decrease in O-specific material at 40 degrees C can at least partly be explained by the finding of a high number of unsubstituted R core stubs in polyacryl gel-electrophoresis.

Localization of enterobacterial common antigen in Yersinia enterocolitica by the immunoferritin technique

Rabbits were immunized with the enterobacterial common antigen (ECA)-immunogenic strain Escherichia coli F470. ECA-specific antiserum was obtained by absorbing the resulting antisera with the genetically closely related ECA-negative strain E. coli F1283. These two strains also served as positive and negative controls in the localization study of ECA in Yersinia enterocolitica strain 75, smooth and rough forms (Ye75S and Ye75R), by the indirect immunoferritin technique. Cells of Ye75S grown at 22 degrees C showed no labeling with ferritin after treatment with the ECA-specific antiserum and subsequent ferritin-conjugated goat anti-rabbit antibodies. If the cells were grown at 40 degrees C, however, most of the cells showed weak ferritin labeling. At this higher growth temperature, the lipopolysaccharide of this strain contains less O-specific chains (6-deoxy-L-altrose), as was shown in a previous study. The rough mutant Ye75R, which lacks O-specific chains completely, showed denser labeling with ferritin. These results indicate that ECA on the cell surface of Ye75S is covered by O-specific chains of the lipopolysaccharide if grown at 22 degrees C and is therefore not accessible to ECA antibodies. It becomes accessible, however, when O-chains are lacking (R mutants) or when they are reduced in size or amount (growth at 40 degrees C).

Ultrastructure of lipopolysaccharides of Yersinia enterocolitica, Salmonella typhimurium and Escherichia coli

The fine structure of isolated lipopolysaccharides (LPS) from the rough and smooth form of an Yersinia enterocolitica strain (Ye 75 R/Ye 75 S) and from smooth forms of Salmonella typhimurium (S 1010) and Escherichia coli (Essen) were examined electron-microscopically by negative staining. Partial denaturation of LPS in Tris-buffer with acid and/or polymyxin B treatment revealed a common structure of strandlike LPS. Electron-microscopically, LPS-strands were found to consist of two identical sub-strands which form a double helix. High resolution electron microscopy permitted the identification of a total of four longitudinal fibrils (diameter approximately 20 A); therefore, each sub-strand consists of two longitudinal fibrils. These results were correlated with those obtained with positive staining procedure and chemical fixation technique. The development of the "double-track"-profile of the outer membrane was interpreted to result from the projection of the helical longitudinal fibrils into the image plane.