213 A Novel, Cost-Effective and Convenient Model for Simulating Facial Wound Repair

Introduction

We describe the use of a novel synthetic simulation pad for learning complex facial wound management including local flaps. The simulation pad is a cost effective and convenient model of facial wounds. We have compared the use of animal tissue to the simulation pad in the context of a workshop for surgical trainees and collected feedback from delegates.

Methods

Feedback was collected from 14 of 16 attending delegates.

Results

It was clear from feedback that animal tissue is not an ideal model of facial wounds with 71% of delegates stating that they did not consider it to be high-fidelity. The synthetic pad was rated more favourably with 100% of delegates reporting that it was a valuable exercise and well designed for local flaps.

Conclusions

It is imperative that training opportunities are high quality and useful to clinical practice. Techniques learnt in the context of a course or workshop are more valuable where targeted practice may occur following learning. The use of a synthetic pad is more amenable to continued practice where it may be taken home following a workshop. Feedback from this event suggests a well-designed synthetic pad is more useful than animal tissue in learning local flaps.

The effect of pituitary adenylate cyclase-activating peptide-38 and vasoactive intestinal peptide in cluster headache

BACKGROUND

Previously reported increases in serum levels of vasodilating neuropeptides pituitary adenylate cyclase-activating peptide-38 (PACAP38) and vasoactive intestinal peptide (VIP) during attacks of cluster headache could indicate their involvement in cluster headache attack initiation. We investigated the attack-inducing effects of PACAP38 and vasoactive intestinal peptide in cluster headache, hypothesising that PACAP38, but not vasoactive intestinal peptide, would induce cluster-like attacks in episodic active phase and chronic cluster headache patients.

METHODS

In a double-blind crossover study, 14 episodic cluster headache patients in active phase, 15 episodic cluster headache patients in remission phase and 15 chronic cluster headache patients were randomly allocated to receive intravenous infusion of PACAP38 (10 pmol/kg/min) or vasoactive intestinal peptide (8 pmol/kg/min) over 20 min on two study days separated by at least 7 days. We recorded headache intensity, incidence of cluster-like attacks, cranial autonomic symptoms and vital signs using a questionnaire (0-90 min).

RESULTS

In episodic cluster headache active phase, PACAP38 induced cluster-like attacks in 6/14 patients and vasoactive intestinal peptide induced cluster-like attacks in 5/14 patients (p = 1.000). In chronic cluster headache, PACAP38 and vasoactive intestinal peptide both induced cluster-like attacks in 7/15 patients (p = 0.765). In episodic cluster headache remission phase, neither PACAP38 nor vasoactive intestinal peptide induced cluster-like attacks.

CONCLUSIONS

Contrary to our hypothesis, attack induction was lower than expected and roughly equal by PACAP38 and vasoactive intestinal peptide in episodic active phase and chronic cluster headache patients, which contradicts the PAC₁-receptor as being solely responsible for attack induction.Trial registration: clinicaltrials.gov (identifier NCT03814226).

Dizziness and vertigo during the prodromal phase and headache phase of migraine: A systematic review and meta-analysis

OBJECTIVE

To assess the proportion of individuals who report dizziness and/or vertigo during the prodromal phase or headache phase of migraine.

METHODS

The databases of MEDLINE and EMBASE were searched for studies on dizziness and/or vertigo during the prodromal phase or headache phase of migraine. Pooled relative frequencies were estimated using a random-effects meta-analysis.

RESULTS

We identified nine articles eligible for inclusion. Of these, one study reported results for the prodromal phase, seven studies for the headache phase and one study for both the prodromal and headache phase. In the prodromal phase, 9.0% of individuals with migraine reported dizziness, while 3.3% reported vertigo. During the headache phase, relative frequency of dizziness ranged from 6.7% to 59.6%, while vertigo ranged from 6.4% to 44.7%. The meta-analysis showed a relative frequency of 35.7% for dizziness (95% CI = 13.7-61.5%, I2 = 99%) and 33.9% for vertigo (95% CI = 26.7-41.5%, I2 = 87%). Study quality was rated 5/9 or below for seven studies and 6/9 or above for two studies.

CONCLUSION

We found that there is a scarcity of literature on dizziness and vertigo as prodromal- and headache-associated symptoms in individuals with migraine. Methodological variations confound comparisons of epidemiological patterns, although it appears that dizziness and vertigo are more frequent during the headache phase of migraine, compared with the prodromal phase. Future studies should ensure use of standardized definitions and rigorous methodology to enable accurate measurements of dizziness and vertigo in migraine.

Efficacy, tolerability, and safety of erenumab for the preventive treatment of persistent post-traumatic headache attributed to mild traumatic brain injury: an open-label study

BACKGROUND

Calcitonin gene-related peptide (CGRP) has recently been implicated in the pathogenesis of post-traumatic headache (PTH), which raises the prospect for therapeutic use of monoclonal antibodies targeting CGRP or its receptor. Therefore, we decided to assess the efficacy, tolerability, and safety of erenumab for prevention of persistent PTH attributed to mild traumatic brain injury.

METHODS

A single-center, non-randomized, single-arm, open-label study of erenumab for adults aged 18-65 years with persistent PTH. Patients were assigned to receive 140-mg erenumab monthly by two subcutaneous 1-mL injections, given every 4 weeks for 12 weeks. The primary outcome measure was the mean change in number of monthly headache days of moderate to severe intensity from baseline (4-week pretreatment period) to week 9 through 12. Tolerability and safety endpoints were adverse events (i.e. number and type).

RESULTS

Eighty-nine of 100 patients completed the open-label trial. At baseline, the mean monthly number of headache days of moderate to severe intensity was 15.7. By week 9 through 12, the number was reduced by 2.8 days. The most common adverse events were constipation (n = 30) and injection-site reactions (n = 15). Of 100 patients who received at least one dose of erenumab, two patients discontinued the treatment regimen due to adverse events.

CONCLUSIONS

Among patients with persistent PTH, erenumab resulted in a lower frequency of moderate to severe headache days in this 12-week open-label trial. In addition, erenumab was well-tolerated as discontinuations due to adverse events were low. Placebo-controlled randomized clinical trials are needed to adequately evaluate the efficacy and safety of erenumab in patients with persistent PTH.

TRIAL REGISTRATION

ClinicalTrials.Gov, NCT03974360. Registered on April 17, 2019 - Retrospectively registered.

Risk Factors for the Development of Post-Traumatic Headache Attributed to Traumatic Brain Injury: A Systematic Review

OBJECTIVE

To systematically identify risk factors for the development of post-traumatic headache (PTH) attributed to traumatic brain injury (TBI) as defined in the International Classification of Headache Disorders (ICHD).

BACKGROUND

PTH is a common sequela of TBI and a leading cause of injury-related disability worldwide. However, little is known about risk factors for the development of PTH attributed to TBI.

METHODS

We searched PubMed and Embase for literature on risk factors for the development of acute and/or persistent PTH attributed to TBI in accordance with any version of the ICHD. Original studies published in English and of prospective, cross-sectional or retrospective design were considered for the review. Data extraction was performed independently by 2 investigators.

RESULTS

Of 1993 potentially relevant articles identified, 3 articles met the inclusion criteria. The following risk factors were assessed for the development of acute PTH: age, sex, type of injury, loss of consciousness, previous TBIs, history of primary headache disorders, history of chronic pain condition other than headache, current treatment for depression/anxiety, attention or learning disorders, body mass index, and other diseases (not further specified). None of the included studies assessed risk factors for the development of persistent PTH.

CONCLUSIONS

We found that there is little evidence for any risk factors involved in the development of acute PTH, whereas no study had assessed risk factors for the development of persistent PTH. Further studies are warranted and should be powered to examine possible risk factors for the development of PTH. Rigorous methodology and standardized monitoring should be prioritized to support high-quality research and validate potential findings.

Effects of rising drug costs on efforts to control overall cost at a large academic cancer center

2

Background: Value-based payment programs like the Oncology Care Model (OCM) have focused efforts to reduce costly acute care use through improvements in access and coordination rather than targeting the exponential rise in pharmaceutical pricing. We assessed how participation in OCM affected total cost of cancer care at a large academic cancer center. Methods: Using Medicare claims for Yale-Smilow Cancer Hospital, an NCI-designated cancer center with an academic hub and 10 community practices, we identified episodes for chemotherapy initiated during a historical period (pre-OCM, 2012-2015) and performance period (post-OCM, 2016-2017) following OCM criteria to identify total cost of care. We reported frequency of utilization categories, the mean cost per episode, the proportion of total cost attributed to each utilization category and compared pre- and post-participation periods. Results: There were 8,843 episodes during the historical period and 6,679 episodes during the performance period. The mean total cost per episode increased from $28,645 to $32,666, but this was less than the Medicare-defined expected increase (target price). Between the two periods, the percentage of total episodes decreased for emergency department (ED) use from 36% to 33%, inpatient care from 33% to 29%, and post-acute care from 28% to 25% (p < 0.01). Mean costs of drugs per episode increased by 27% between periods, and from 52% to 58% of total cost of care (p < 0.01). While mean cost per episode for ED, inpatient, and post-acute care remained stable, the mean cost per episode for antineoplastics increased 39% from $10,676 to $14,843. Conclusions: After implementing OCM, we beat the Medicare target largely by decreasing acute care use and stabilizing the cost of hospitalizations and ED; however, actual cost increased largely due to pharmaceutical spending. Because drug costs were the largest proportion of overall cost of care, future value-based models must address the rising cost of pharmaceuticals.

[Table: see text]

The effect of guideline-concordant novel therapy use on meeting cost targets in OCM: Results from a large community oncology network

6635

Background: The Oncology Care Model (OCM) is intended to incentivize physicians to improve the quality and reduce the cost of cancer care. In OCM, providers are accountable for all costs during six month episodes of care relative to target costs (TC) derived from a baseline spending period (BSP; 2013-2015). This accountability is intended to foster care coordination to reduce preventable emergency department visits and hospitalizations (EDH). Benefits of reducing EDH may be diluted when new treatment indications for costly immunotherapies (IO) are introduced into clinical practice after BSP. Methods: We identified all non-small cell lung cancer (NSCLC) and bladder cancer (BC) OCM episodes attributed to Tennessee Oncology (TO), a large community oncology network of over 90 oncologists, during performance period 2 (PP2; the most recent PP with available data). We selected NSCLC and BC because both diseases have IO indications that became standard of care after BSP. Using claims data analytics software, we identified all NSCLC and BC episodes with spending above TC, and found a subset of these above target episodes (ATEs) without any EDH that remained above TC due to IO use. Two medical oncologists reviewed these cases in duplicate to assess guideline concordance of IO. Results: During PP2 there were 2,623 OCM episodes attributed to TO, including 240 NSCLC and 31 BC episodes. Spending was above TC in 118 (49%) and 13 (42%) of NSCLC and BC episodes, respectively. For these NSCLC and BC ATEs, EDH was prevented in 62 (53%) and 5 (38%) of cases, respectively. In NSCLC and BC ATEs without EDH, 43 (69%) and 5 (100%) of episodes included IO, respectively. Clinician review in duplicate (S.M.S.; C.A.W.) found that the use of IO was NCCN guideline concordant in 33 (77%) and 4 (80%) of these NSCLC and BC cases, respectively (K = 0.87). Conclusions: Guideline-concordant use of expensive IO as its treatment indications expand poses substantial challenges to meeting cost targets in OCM, even when practices prevent EDH. [Table: see text]

Abstract P1-11-22: Aromatase inhibitors are significantly better tolerated by early stage breast cancer patients 75 or older and with significantly lower early discontinuation rate

Introduction:

Breast cancer is the most common cancer in women. In postmenopausal women with early stage estrogen receptor positive breast cancer, aromatase inhibitors (AI) are a common treatment option. AI's are reported to lead to a high early discontinuation rate in younger post-menopausal women due to poor tolerance. The most common side effects reported to lead to early discontinuation are arthralgia, hot flashes, fatigue, and night sweats. The reported tolerance to AI therapy in women age 75 or older is not well documented. Our study looks at women, ages 75 and older, diagnosed with early stage breast cancer who were placed on adjuvant AI therapy and focuses on tolerability, incidence of common side effects, rate of treatment changes, and on discontinuation rates.

Objective:

This study evaluates the tolerability, treatment side effects and the discontinuation rate of AI in women over the age of 75 with early stage breast cancer.

Methods:

Our study is a retrospective chart review of 58 patients' ages 75 to 95 with early stage breast cancer treated with adjuvant AI. Charts of patients were reviewed and duration of treatment, patient reported side effects, treatment changes, and discontinuation rate were recorded.

Results:

Data analysis showed that 36/55 (65.5%) of patients did not report significant side effects to AI. 6/55 (10.9%) patients required therapy changes due to side effects. 5/6 required one treatment change and 1/6 required multiple treatment changes. In 5/6 therapy was changed to another AI. Only 2/55 (3.6%) of patients discontinued therapy. In both patients who discontinued AI, therapy was discontinued due to medical complications unrelated to AI therapy. Average time to discontinuation was 11 months. The most common reported side effects were arthralgia 9/55 (16.4%), fatigue 3/55 (5.5%), hot flashes 4/55 (7.3%), rash 3/55 (5.5%) and hair thinning 3/55 (5.5%). The most common reported side effect which led to treatment change was arthralgia 4/6 (66.7%). With a median follow up time of 24 months, breast cancer specific mortality was 1/55 (1.8%).

Reported Side Effects on AIn=55 patientsPatients who noted symptomsPatients who changed therapy due to symptomsFatigue30Arthralgia94Hot flashes40Rash31Vaginal dryness10Hair thinning31

Conclusion:

Our study evaluated the tolerance of AI in older women diagnosed with early stage breast cancer. 36/55 (65.5%) of elderly patients reported no significant side effects suggesting that AI's are well tolerated in this population and the known side effects are significantly less common than previously reported in a younger cohort in whom arthralgia as well as vasomotor symptoms affect as many as 30% of women. This improved tolerance led to a significantly lower early discontinuation rate than previously reported in the younger cohort: discontinuation rate of 3.6% by 24 months in the 75 or older population versus 20% by 24 months in the younger cohort of post-menopausal women treated with AI.

Reference:

1 Wagner, L.I., Zhao, F., Goss, P.E. et al. Breast Cancer Res Treat (2018) 169: 537. https://doi-org.proxy.library.stonybrook.edu/10.1007/s10549-018-4713-2

Citation Format: Chaudhry B, Baer L, Kudelka A, Cohen J, Stopeck AT. Aromatase inhibitors are significantly better tolerated by early stage breast cancer patients 75 or older and with significantly lower early discontinuation rate [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-22.

Abstract P1-11-24: Aromatase inhibitors and bone health in women 75 and older treated for early stage breast cancer

Introduction:

Breast cancer is the most common cancer in women. In estrogen receptor positive breast cancers aromatase inhibitors (AI) are a common treatment option. AIs are associated with a reduction in bone mineral density, and patients with osteopenia at baseline have a higher risk of developing subsequent osteoporosis while on AI therapy. Women age 75 and older are a fast growing subset of breast cancer patients and commonly have osteopenia or osteoporosis at time of breast cancer diagnosis. Studies of long-term effects of AI on bone density in these older women who are at higher risk of osteoporosis and musculoskeletal events are lacking at this time.

Objective:

To evaluate the objective change in bone density in women over the age of 75 diagnosed with early stage breast cancer and treated with AI.

Methods:

A retrospective chart review of 49 patients ages 75 to 95 diagnosed with early stage breast cancer and treated with AI. Pretreatment DEXA scan results were recorded as well as prevalence of bone targeted therapy at the time of breast cancer diagnosis. Incidence of bone targeted therapy initiated subsequent to cancer diagnosis and changes in T score on follow up DEXA scans were collected as well. Incidence of musculoskeletal events and osteonecrosis of the jaw were recorded.

Results:

40/49 (81.6%) of study women were found to have osteopenia (23/49 [46.9%]) or osteoporosis (17/49 [34.7%]) on pre-treatment DEXA scans. Only 16/49 (32.7%) of patients were on bone-targeted treatment prior to breast cancer diagnosis. Of the patient with baseline osteoporosis, only 4/17 (23.5%) were on bone targeted treatment prior to breast cancer diagnosis. 25/49 (51%) of women were initiated on bone targeted therapy subsequent to breast cancer diagnosis and following review of pretreatment DEXA scan results. 5/49 (10.2%) of women were started on bisphosphonates and 7/49 (14.3%) were started on Denosumab. On the first subsequent DEXA scan at a median follow up of 2 years, 14/21(66.7%) of women were noted to have stable DEXA findings (defined as change in T score less than 0.5). 7/21 (33.3%) had a worsening T score on repeat DEXA. Of those patients with worsening T score, 3/7 (42.9%) changed categories (either from normal density to osteopenia or from osteopenia to osteoporosis. 3/49 (6%) of patients sustained a fracture while on AI therapy. There were no reported events of osteonecrosis of the jaw.

 Subsequent DEXA showing stabilitySubsequent DEXA showing worsening T scoreFractureBaseline Normal bone density1 (n=3)2 (n=3)1 (n=9)Baseline Osteopenia9 (n=12)3 (n=12)0 (n=12)Baseline Osteoporosis4 (n=6)2 (n=6)2 (n=17)

Conclusion:

Many elderly women are found to have osteopenia or osteoporosis at the time of breast cancer diagnosis and AI initiation. Most elderly patients had stable findings on subsequent bone density testing. Women with known osteoporosis initiated on bone-targeted therapy and AI did not have significant worsening in bone health. With appropriate treatment and monitoring elderly women with baseline decreased bone density can be treated safely with aromatase inhibitors.

Citation Format: Baer L, Chaudhry B, Kudelka A, Cohen J, Stopeck AT. Aromatase inhibitors and bone health in women 75 and older treated for early stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-24.

Harnessing autophagy to overcome mitogen-activated protein kinase kinase inhibitor-induced resistance in metastatic melanoma

BACKGROUND

Patients with malignant melanoma often relapse after treatment with BRAF and/or mitogen-activated protein kinase kinase (MEK) inhibitors (MEKi) owing to development of drug resistance.

OBJECTIVES

To establish the temporal pattern of CD271 regulation during development of resistance by melanoma to trametinib, and determine the association between development of resistance to trametinib and induction of prosurvival autophagy.

METHODS

Immunohistochemistry for CD271 and p62 was performed on human naevi and primary malignant melanoma tumours. Western blotting was used to analyse expression of CD271, p62 and LC3 in melanoma subpopulations. Flow cytometry and immunofluorescence microscopy was used to evaluate trametinib-induced cell death and CD271 expression. MTS viability assays and zebrafish xenografts were used to evaluate the effect of CD271 and autophagy modulation on trametinib-resistant melanoma cell survival and invasion, respectively.

RESULTS

CD271 and autophagic signalling are increased in stage III primary melanomas vs. benign naevi. In vitro studies demonstrate MEKi of BRAF-mutant melanoma induced cytotoxic autophagy, followed by the emergence of CD271-expressing subpopulations. Trametinib-induced CD271 reduced autophagic flux, leading to activation of prosurvival autophagy and development of MEKi resistance. Treatment of CD271-expressing melanoma subpopulations with RNA interference and small-molecule inhibitors to CD271 reduced the development of MEKi resistance, while clinically applicable autophagy modulatory agents - including Δ9-tetrahydrocannabinol and Vps34 - reduced survival of MEKi-resistant melanoma cells. Combined MEK/autophagy inhibition also reduced the invasive and metastatic potential of MEKi-resistant cells in an in vivo zebrafish xenograft.

CONCLUSIONS

These results highlight a novel mechanism of MEKi-induced drug resistance and suggest that targeting autophagy may be a translatable approach to resensitize drug-resistant melanoma cells to the cytotoxic effects of MEKi.

Re-evaluation of hypoplastic left heart syndrome from a developmental and morphological perspective

Background

Hypoplastic left heart syndrome (HLHS) covers a spectrum of rare congenital anomalies characterised by a non-apex forming left ventricle and stenosis/atresia of the mitral and aortic valves. Despite many studies, the causes of HLHS remain unclear and there are conflicting views regarding the role of flow, valvar or myocardial abnormalities in its pathogenesis, all of which were proposed prior to the description of the second heart field. Our aim was to re-evaluate the patterns of malformation in HLHS in relation to recognised cardiac progenitor populations, with a view to providing aetiologically useful sub-groupings for genomic studies.

Results

We examined 78 hearts previously classified as HLHS, with subtypes based on valve patency, and re-categorised them based on their objective ventricular phenotype. Three distinct subgroups could be identified: slit-like left ventricle (24%); miniaturised left ventricle (6%); and thickened left ventricle with endocardial fibroelastosis (EFE; 70%). Slit-like ventricles were always found in combination with aortic atresia and mitral atresia. Miniaturised left ventricles all had normally formed, though smaller aortic and mitral valves. The remaining group were found to have a range of aortic valve malformations associated with thickened left ventricular walls despite being described as either atresia or stenosis. The degree of myocardial thickening was not correlated to the degree of valvar stenosis. Lineage tracing in mice to investigate the progenitor populations that form the parts of the heart disrupted by HLHS showed that whereas Nkx2–5-Cre labelled myocardial and endothelial cells within the left and right ventricles, Mef2c-AHF-Cre, which labels second heart field-derived cells only, was largely restricted to the endocardium and myocardium of the right ventricle. However, like Nkx2–5-Cre, Mef2c-AHF-Cre lineage cells made a significant contribution to the aortic and mitral valves. In contrast, Wnt1-Cre made a major contribution only to the aortic valve. This suggests that discrete cardiac progenitors might be responsible for the patterns of defects observed in the distinct ventricular sub-groups.

Conclusions

Only the slit-like ventricle grouping was found to map to the current nomenclature: the combination of mitral atresia with aortic atresia. It appears that slit-like and miniature ventricles also form discrete sub-groups. Thus, reclassification of HLHS into subgroups based on ventricular phenotype, might be useful in genetic and developmental studies in investigating the aetiology of this severe malformation syndrome.

Shear stress-induced angiogenesis in mouse muscle is independent of the vasodilator mechanism and quickly reversible

AIM

Is modulation of skeletal muscle capillary supply by altering blood flow due to a presumptive shear stress response per se, or dependent on the vasodilator mechanism?

METHODS

The response to four different vasodilators, and cotreatment with blockers of NO and prostaglandin synthesis, was compared. Femoral artery blood flow was correlated with capillary-to-fibre ratio (C:F) and protein levels of putative angiogenic compounds.

RESULTS

All vasodilators induced a similar increase in blood flow after 14 days, with a similar effect on C:F (1.62 ± 0.05, 1.60 ± 0.01, 1.57 ± 0.06, 1.57 ± 0.07, respectively, all P < 0.05 vs. control 1.20 ± 0.01). Concomitant inhibitors revealed differential effects on blood flow and angiogenesis, demonstrating that a similar response may have different signalling origins. The time course of this response with the most commonly used vasodilator, prazosin, showed that blood flow increased from 0.40 mL min^-1 to 0.61 mL min^-1 by 28 days (P < 0.05), dropped within 1 week after the cessation of treatment (0.54 mL min^-1 ; P < 0.05) and returned to control levels by 6 weeks. In parallel with FBF, capillary rarefaction began within 1 week (P < 0.05), giving C:F values similar to control by 2 weeks. Of the dominant signalling pathways, prazosin decreased muscle VEGF, but increased its cognate receptor Flk-1 (both P < 0.01); levels of eNOS varied with blood flow (P < 0.05), and Ang-1 initially increased, while its receptor Tie-2 was unchanged, with only modest changes in the antiangiogenic factor TSP-1.

CONCLUSION

Hyperaemia-induced angiogenesis, likely in response to elevated shear stress, is independent of the vasodilator involved, with a rapid induction and quick regression following the stimulus withdrawal.

Preparing for Value-Based Payment: A Stepwise Approach for Cancer Centers

Most cancer centers are ill-equipped to pursue value-based payment (VBP) because of limited information on their population’s cost of care. Herein, we outline the stepwise approach used by Smilow Cancer Hospital at Yale-New Haven in our pursuit of better value care. First, we addressed institutional barriers. A move toward value required demonstration to Yale-New Haven Health System leadership that OCM would improve patient care, fund new infrastructure, and provide the opportunity to gain experience with VBP without a major threat to the financial stability of the health system. We evaluated patterns of care and found that of patients presenting to the emergency department (ED), 88% were admitted, 62% arrived during the workday, and 50% could have been stabilized with urgent care services. Within 30 days of death, 27% were admitted to the intensive care unit, 38% presented to the ED, and 52% were admitted. To quantify total cost of care, we accessed the 5% Medicare Limited Data Set to map out total cost of care for patients receiving chemotherapy at Smilow Cancer Hospital. Costs increased as patients moved through 6-month episodes, used the ED (patients with two or more visits were twice as expensive as those with one or fewer), or died during an episode (costs were twice as high as episodes in which the patient lived). To determine strategic interventions to improve value, we targeted investments in urgent care to reduce ED utilization, care management to prevent hospital admissions, and referral to palliative care for clarification of goals of care and avoidance of costly futile treatment. Developing internal metrics to evaluate success will require monitoring our interventions by having utilization measures for each site of care and individual provider.

Understanding total cost of cancer care to determine strategic interventions to improve value

3

Background: Cancer centers across the country are largely unprepared to move toward value-based payment. Total cost of care data is not readily available and centers do not know how much of their patients’ care is received at other hospitals, when in the trajectory of illness greatest cost is incurred, or the elements of care that present the greatest opportunity for savings. A previous examination of practice patterns Smilow Cancer Hospital (SCH) demonstrated that our patients had high rates of ED visits, hospital admissions and ICU use in their last month of life. While this data is consistent with other large academic cancer centers (AMCs), there is a clear opportunity to improve our end-of-life planning and reduce futile care. Cost data supplemented the overutilization analysis, informing the infrastructure investments to prepare us for value-based payment models. Methods: We accessed the 5% Medicare Limited Dataset (2012-2013) to map out cost of care in 6-month episodes for all Medicare patients receiving chemotherapy. Patients who had received chemotherapy at a SCH site were flagged and the analysis included all cost of care, regardless of the site of service or type of professional delivering the service. Results: On average, a first episode of care at SCH cost $26,500, a second episode $38,000 and a third $45,600. Our analysis demonstrated important associations between increases in spending and ED utilization. Patients who had 1 or fewer ED visits during an episode, averaged $21,000 vs. $49,000 for those with 2 or more. Patients who died during an episode cost $53,000 compared to $25,600 for patients who lived. SCH episodes were significantly more expensive than CT, and slightly more than a comparable east coast Academic Medical Center. Conclusions: The above demonstrates that aggressive treatments, ED visits and hospital admissions at the end-of-life are major cost drivers. We used the analysis to target infrastructure investments in Urgent Care to reduce ED utilization, Care Management to prevent hospital admissions/readmissions and early referral to Palliative Care for clarification of goals of care. We believe these investments will lead to significant cost reductions.

Systematic review: impact of health information technology on quality, efficiency, and costs of medical care

BACKGROUND

Experts consider health information technology key to improving efficiency and quality of health care.

PURPOSE

To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care.

DATA SOURCES

The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005.

STUDY SELECTION

Descriptive and comparative studies and systematic reviews of health information technology.

DATA EXTRACTION

Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs.

DATA SYNTHESIS

257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited.

LIMITATIONS

Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited.

CONCLUSIONS

Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.

The barley 60 kDa jasmonate-induced protein (JIP60) is a novel ribosome-inactivating protein

The N-terminal region of a 60 kDa, jasmonate-induced protein of barley leaves (JIP60) is shown to be homologous to the catalytic domains of plant ribosome-inactivating proteins (RIP). Western blotting of leaf extracts and in vitro reconstitution experiments indicate that JIP60 is synthesized as a precursor which is processed in vivo. This is in keeping with in vitro translation experiments indicating that a deletion derivative of the N-terminal region, but not the putative precursor, strongly inhibits protein synthesis on reticulocyte ribosomes. The inhibition of ribosome function is associated with depurination of 26S rRNA, characteristic of plant RIPs. This indicates that JIP60 is a novel ribosome-inactivating protein requiring at least two processing events for full activation. JIP60 derivatives do not significantly inhibit in vitro protein synthesis on wheat germ ribosomes. These and other results suggest that JIP60 may be involved in plant defence.

Expression and mutagenesis of human poly(ADP-ribose) polymerase as a ubiquitin fusion protein from Escherichia coli

The cDNA of human poly(ADP-ribose) polymerase (pADPRP), encoding the entire protein, was subcloned into the Escherichia coli expression plasmid pYUb. In this expression system, the carboxyl terminus of ubiquitin is fused to the amino terminus of a target protein, in this case pADPRP, stabilizing the accumulation of the cloned gene product. Following induction of the transformed cells, the sonicated extract contained a unique protein immunoreactive with both pADPRP and ubiquitin antibodies and corresponding to the predicted mobility of the fusion protein in SDS-PAGE. Fusion of ubiquitin to pADPRP increased the yield of pADPRP approximately 10-fold compared to that of the unfused enzyme. The resulting recombinant fusion protein had catalytic properties which were nearly identical to those of native pADPRP obtained from mammalian tissues. These properties included specific activity, Km for NAD, response to DNA strand breaks, response to Mg2+, inhibition by 3-aminobenzamide, and activity in activity gel analysis. An initial analysis by deletion mutagenesis of pADPRP's functional domains revealed that deletions in the NAD binding domain eliminated all activity; however, partial polymerase activity resulted from deletion in the DNA binding or automodification domains. The activities were not enhanced by breaks in DNA. We further report a colony filter screening procedure designed to identify functional polymerase molecules which will facilitate structure/function studies of the polymerase.