Ipilimumab in the real world: the UK expanded access programme experience in previously treated advanced melanoma patients.

Before licensing, ipilimumab was first made available to previously treated advanced melanoma patients through an expanded access programme (EAP) across Europe. We interrogated data from UK EAP patients to inform future clinical practice. Clinicians registered in the UK EAP provided anonymized patient data using a prespecified variable fields datasheet. Data collected were baseline patient characteristics, treatment delivered, toxicity, response, progression-free survival and overall survival (OS). Data were received for 193 previously treated metastatic melanoma patients, whose primary sites were cutaneous (82%), uveal (8%), mucosal (2%), acral (3%) or unknown (5%). At baseline, 88% of patients had a performance status (PS) of 0-1 and 20% had brain metastases. Of the patients, 53% received all four planned cycles of ipilimumab; the most common reason for stopping early was disease progression, including death from melanoma. Toxicity was recorded for 171 patients, 30% of whom experienced an adverse event of grade 3 or higher, the most common being diarrhoea (13%) and fatigue (9%). At a median follow-up of 23 months, the median progression-free survival and OS were 2.8 and 6.1 months, respectively; the 1-year and 2-year OS rates were 31 and 14.8%, respectively. The 2-year OS was significantly lower for patients with poorer PS (P<0.0001), low albumin concentrations (P<0.0001), the presence of brain metastases (P=0.007) and lactate dehydrogenase levels more than two times the upper limit of normal (P<0.0001) at baseline. These baseline characteristics are negative predictors of benefit from ipilimumab and should be taken into consideration before prescription.

Implementation of a level III trauma center in a rural community.

This evidence-based project was undertaken to implement research-based interventions in the care of the trauma patients in a Magnet-designated rural, community hospital. This article describes the importance of interfacility and interdisciplinary collaboration in the development of a level III trauma medical center in Wisconsin. Creative adaptations to optimize care for trauma patients were used during this journey.

A comparative assessment of West Virginia's financial incentive programs for rural physicians.

CONTEXT: Financial incentive programs are increasingly being used as a strategy to recruit physicians to underserved rural areas. Critical evaluation of state-supported programs is often lacking but is necessary to determine their efficacy and to improve outcomes. PURPOSE: The purpose of this study was to assess 4 service-contingent programs in West Virginia, a state with critical physician shortages. METHODS: Survey instruments were developed to evaluate the effectiveness of these programs and to document the practice environments and career paths of obligated allopathic and osteopathic physicians compared with a control group of nonobligated rural practitioners. Data were also collected from physicians who were recipients of multiple incentive programs and from obligated physicians who had defaulted. FINDINGS: Responses from more than 60% of surveyed physicians indicated that the typical respondent was a married white male who was a midcareer family practice physician. Obligated physicians were more likely than nonobligated physicians to have graduated from a West Virginia medical school and residency program, to be influenced by financial factors in their career decisions, to provide care to uninsured patients, and to work in offices that offered sliding fee scales. Both groups of physicians demonstrated similar retention patterns, reported a high degree of job satisfaction, and expressed a need for more practice management training. CONCLUSIONS: Although these financial incentive programs were found to be effective in recruiting primary care physicians to medically underserved areas of the state, the financial support of these programs was found to be too modest, and improved marketing of the programs was indicated.