Barriers to patient-centered oncology care: Pilot study of home infusion of anticancer immunotherapy

36

Background: ASCO published a position statement regarding home infusion of anticancer therapy in June 2020. This statement recommends independent research to evaluate the safety and effectiveness of home infusions. Intermountain Healthcare (IM) incorporated this statement into its oncology care with an IRB-approved, prospective single-arm pilot study to determine the safety and feasibility of home administration of checkpoint inhibitor (CPI) immunotherapy with synchronous telemedicine visits. Methods: Patients with cancer receiving treatment at Intermountain Medical Center and Intermountain Cancer Center St. George were screened for enrollment into an IRB-approved, non-randomized pilot study of 20 patients. Eligibility criteria required patients to receive a CPI for an FDA-approved indication, live in Washington County or Salt Lake County, Utah, and have commercial payer coverage of CPI home infusion. Eligible patients were required to receive 2 doses of CPI at an infusion center, and patients who experienced an infusion reaction were excluded from receiving home infusion. Home infusion nurses are trained in oncology, CPIs, and home infusion reaction protocol. During synchronous video visits, infusion nurses are trained to perform the hands-on portions of the physical exam. A financial analysis estimated cost to IM and commercial payers for routine and home CPI infusions. Results: 622 patients were screened, of which 104 were receiving a CPI. 64 patients lived in an eligible county and 19 patients had commercial payer coverage. Of patients on CPIs, 8.7% (9/104) met all eligibility criteria accounting for 1.4% (9/622) of all patients with cancer screened (Table). Financial analysis estimated $829 cost (excluding drug cost) to IM for standard infusion reimbursement compared to $599 for in-home CPI infusions, accounting for savings of $230 per infusion. Majority of cost savings are from elimination of infusion center facilities fee ($495). Analysis includes $269 for home infusion nurse wages. Subsequent analysis for commercial payer SelectHealth estimates $270 reimbursement savings for the payer. Conclusions: Home immunotherapy infusions are estimated to be cost effective for both IM and commercial payers. However, lack of drug coverage and the rural demographics of Utahns with cancer are barriers to home CPI infusions. The pilot study was discontinued per infeasibility stopping criteria.[Table: see text]

Adhaeribacter aquaticus gen. nov., sp. nov., a Gram-negative isolate from a potable water biofilm

A Gram-negative bacterium was isolated from a freshwater biofilm developed on a stainless steel surface under a fluid velocity of 0·26 m s−1. The strain, MBRG1.5T, was cultivated on R2A agar and formed pink colonies. Light microscopy and negative staining in a transmission electron microscope showed that the cells were rod-shaped, approximately 2·8–4·1 μm long by 0·9–1·7 μm wide in size and produced large quantities of extracellular fibrillar material. Additionally, following growth in batch culture, transmission electron microscopy showed that many cells plasmolysed. Stationary-phase cells were more variable in size and shape. The DNA G+C content was 40·0 mol%. The most abundant fatty acids were 15 : 0 iso (22·5 %), followed by 16 : 1ω5c (16·9 %) and 15 : 0 iso 2-OH (16·5 %). Phylogenetic analysis of the 16S rRNA gene showed that the strain was a member of the family ‘Flexibacteraceae’ of the Cytophaga–Flavobacterium–Bacteroides group. Phenotypic and genotypic analyses indicated that the strain could not be assigned to any recognized genus; therefore a novel genus and species, Adhaeribacter aquaticus gen. nov., sp. nov., is proposed, with MBRG1.5T (=DSM 16391T=NCIMB 14008T) as the type strain.

Quantitation of the water channel protein aquaporin (CHIP28) from red blood cell membranes by densitometry of silver stained polyacrylamide gels

A protein determination procedure which involves the densitometry of silver stained polyacrylamide gels is described. It involves calibration with bovine serum albumin and molecular weight markers on the same gel with the protein to be quantitated. The procedure is simple, rapid, reproducible and accurate and is more sensitive than other procedures for protein determination. The procedure is particularly useful in quantitating proteins purified in small amounts since the determination can be performed on the same gel used to check the purification. It avoids interference by detergents and other substances usually present in solutions of purified proteins. The procedure has been applied to the quantitation of a recently identified protein, aquaporin (CHIP28), assumed to be a major water channel in the red blood cell membrane. A quantitative analysis of a purified fraction of this protein shows that the 28 kDa component represents approximately two thirds of the protein content of the sample, with the remainder comprising a glycosylated, high molecular mass component. The procedure may be useful for quantitating proteins revealed on silver stained gels and could be included as a standard part of any protocol for protein purification.

Transcervical fallopian tube recanalization: a safe and effective therapy for patients with proximal tubal obstruction

Over a 13-month period, 14 patients with proximal tubal obstruction underwent transcervical fallopian tube recanalization under fluoroscopic guidance in an outpatient setting at the hospital of the University of Pennsylvania. Twenty-one of 24 attempted tubal dilations (87.5%) were successful, as demonstrated by tubal opacification and contrast spillage into the peritoneal cavity at the conclusion of the procedure. Four intrauterine pregnancies, and no ectopic pregnancies, have followed the recanalization. One pregnancy ended in an early miscarriage, one patient delivered a healthy term female, and two pregnancies are ongoing at greater than twenty weeks' gestation. Two procedure-related complications occurred: in one patient, the isthmic segment of a fallopian tube was perforated, but healed without incident, and another patient experienced a low-grade fever, which resolved with p.o. antibiotics. We therefore conclude that fallopian tube recanalization is a well-tolerated, safe, and effective procedure for the treatment of proximal tubal occlusion.

Contrast medium pooling in cystic renal carcinoma: CT findings

This case report describes a serendipitously diagnosed renal carcinoma in a transplant donor. Computed tomography was instrumental in establishing the true nature of this mass based on its ability to demonstrate pooling of contrast material and staining of discrete septae on dynamic postcontrast scans.

Prospective analysis of the value of scrotal ultrasound

Ultrasound was evaluated in 69 patients for its usefulness in distinguishing scrotal abnormalities requiring surgery from those that may have clinical follow-up only. Distinction was possible in the majority of cases. On imaging, tumor showed decreased echogenicity within the testicle, which was usually enlarged. Epididymal enlargement, marked increase in peritesticular fluid, and skin thickening suggest a non tumorous condition. The ultrasound characteristics of various scrotal abnormalities are described.

The effects of N-alkylmaleimides on the activity of rat liver glucose 6-phosphatase

A series of N-alkylmaleimides has been synthesized and used to investigate the thiol groups that are essential for the activity of rat liver microsomal glucose 6-phosphatase. All of the N-alkylmaleimides inactivated glucose 6-phosphatase when preincubated with microsomes (microsomal fractions) at pH 6.5 and 30 degrees C. When enzyme activity was assayed in intact microsomes, the inactivation was non-linear with respect time, showing an initial rapid phase followed by a slower secondary phase. During the initial rapid phase the inactivation may apparently be completely reversed by disrupting the microsomal membrane with detergent. However, after longer exposure to N-alkylmaleimides the reversal is no longer complete. This observation was explained by the results obtained from studying the inactivation in detergent-disrupted microsomes. In this case glucose 6-phosphatase was also completely inactivated, but much more slowly than was seen in intact microsomes, and the process was linear with respect to time. When assayed in both intact and detergent-disrupted microsomes, glucose 6-phosphatase inactivation was dependent on the number of carbon atoms in the alkyl side chain of the N-alkylmaleimides; this dependence was much more marked in disrupted microsomes. Analysis of the data showed that in neither case was there a saturating effect at high concentrations of maleimide. The data have been interpreted to suggest that there are are least two thiol groups essential for activity located in two separate non-polar regions of the membrane-enzyme system. The conclusions are discussed in the light of the current model for the microsomal glucose 6-phosphatase system.

Nursing assessment of intermittent mandatory ventilation

IMV provides the ICU nurse responsible for total multifunctional patient care with many advantages. First of all, it allows more time to perform other needed tasks. Time is made available for counseling the patient and family; consulting with the social worker, occupational therapist, and other staff members; and participating actively on team patient care conferences. IMV permits the patient to perform at an optimal level throughout the ICU stay and to participate in the treatment program. This is perhaps the greatest advantage of IMV for both the nurse and the patient. The patient's comprehension and ability to communicate are not limited by sedation or anxiety, the patient is more responsive when at least some control is retained over the environment. This reassures the family. Allowing the patient to be as awake and alert as possible not only assists the staff in assessment but allows positive feedback to the patient. It is difficult for a nurse to argue with the advantages of this method in contrast to the difficulty of caring for a sedated patient receiving controlled ventilation. Incrementally decreased ventilatory support lessens anxiety during weaning, thereby minimizing one of the negative aspects of critical illness. Because less sedation is required, the patient's overall safety is improved. The ICU team can more easily find out about such problems as abdominal pain and difficulty in breathing. An alarm aids the nurse in discriminating anxiety from hypoxia/hypercapnia. With definitive guidelines for its use and careful delineation of team members' responsibilities, IMV provides the nurse with a simple, flexible, and innovative tool for patient care.