Dynamic CDM strategies in an EHR environment.

A dynamic charge description master (CDM) integrates information from clinical ancillary systems into the charge-capture process, so an organization can reduce its reliance on the patient accounting system as the sole source of billing information. By leveraging the information from electronic ancillary systems, providers can eliminate the need for paper charge-capture forms and see increased accuracy and efficiency in the maintenance of billing information. Before embarking on a dynamic CDM strategy, organizations should first determine their goals for implementing an EHR system, include revenue cycle leaders on the EHR implementation team, and carefully weigh the pros and cons of CDM design decisions.

RapidArc planning and delivery in patients with locally advanced head-and-neck cancer undergoing chemoradiotherapy.

PURPOSE: Volumetric modulated arc therapy (RapidArc, Varian Medical Systems) permits the delivery of highly conformal dose distributions. We studied planning and delivery in patients who underwent RapidArc for locally advanced head-and-neck cancer (HNC). METHODS AND MATERIALS: A total of 35 consecutive patients who completed RapidArc with concurrent chemotherapy for Stages III-IV tumors of the oro- and hypopharynx/larynx in our center were identified. All underwent bilateral neck irradiation and 21 patients had at least N2 disease. A simultaneous integrated boost (SIB) delivered 70 Gy (in 2 Gy/fraction) to the planning target volume (PTV)(boost) and elective nodal regions (PTV(elect)) received 57.75 Gy. A standard planning constraint set was used and constraints for parotid glands were individually adapted. Treatments were delivered using two arcs after all plans were verified in a solid water phantom using GafChromic External Beam Therapy films. RESULTS: RapidArc planning generally took 1.5-2 h, which was faster than with our previous seven-field intensity-modulated radiotherapy sliding window technique. Film dosimetry revealed that 0.6% of films exceeded a combination of dose differences ≥3% or distance to agreement ≥2 mm. More than 99% of both PTVs received ≥95% of the prescription dose. Average plan conformity index was 1.13 and mean dose to ipsilateral and contralateral parotid glands were 31.4 Gy and 26.1 Gy, respectively. The mean beam-on time was <3 min and mean number of monitor units was 426. CONCLUSIONS: RapidArc achieved excellent target coverage and normal tissue sparing, with delivery completed in less than 3 min. RA is currently our standard intensity-modulated radiotherapy approach for advanced HNC.

Volumetric intensity-modulated arc therapy vs. conventional IMRT in head-and-neck cancer: a comparative planning and dosimetric study.

PURPOSE: Volumetric intensity-modulated arc therapy (RA) allows for rapid delivery of highly conformal dose distributions. In this study, planning and dosimetry of RA were compared with conventional intensity-modulated radiation therapy (IMRT) plans of head-and-neck cancer patients. MATERIALS AND METHODS: Computed tomography scans of 12 patients who had completed IMRT for advanced tumors of the naso-, oro- and hypopharynx were replanned using RA using either one or two arcs. Calculated doses to planning target volume (PTV) and organs at risk (OAR) were compared between IMRT and RA plans. Dose distributions for single arc (n = 8) and double arc (n = 4) plans were verified using film dosimetry in three to five coronal planes using a quality assurance phantom. RESULTS: RA plans allowed for a mean reduction in number of monitor units (MU) by nearly 60%, relative to seven field sliding window IMRT plans. RA plans achieved similar sparing of all OAR as IMRT. Double arc RA provided the best dose homogeneity to PTV with a lower standard deviation of PTV dose (1.4 Gy), vs. single arc plans (2.0 Gy) and IMRT (1.7 Gy). Film measurements showed good correspondence with calculated doses; the mean gamma value was 0.30 (double arc) and area of the film with a gamma exceeding 1 was 0.82%. CONCLUSIONS: RA is a fast, safe, and accurate technique that uses lower MUs than conventional IMRT. Double arc plans provided at least similar sparing of OAR and better PTV dose homogeneity than single arc or IMRT.

Botulinum toxin prevents radiotherapy-induced salivary gland damage.

Radiotherapy of head and neck malignancies results in severe damage to salivary glands. Irradiation-induced sialadenitis with xerostomia leads to a significant deterioration of the quality of life which lasts life-long. Here we show in a preliminary study that intraglandular application of botulinum toxin performed prior to radiation reduces significantly the radiation induced toxicity of the glandular tissue in rats.

End-of-life care for terminal head and neck cancer patients.

The objective of this study was to describe end-stage disease in patients suffering from advanced head and neck cancer (hnc). It is one of the most unpleasant and agonizing way a person may die and is a challenging problem for all involved with its treatment. Until today, only few detailed information about the final phase of life of hnc patients in a hospice setting are available. The design of this study was a cohort sample. The course of disease until death was thoroughly analyzed. In addition, hospice staff was interviewed. The study was conducted in a hospice setting (University Hospital). The charts of 16 patients suffering from end-stage hnc were evaluated. The median survival time in the hospice was 19.5 days. There, a more or less rapid deterioration of disease was evident. Several nurses sometimes felt extremely distressed after confrontation with the advanced disease stages. Partially, the situations for the nursing staff were unbearable because of visible, odorous, and fungating tumors or metastasis. The final days were characterized by restlessness followed by somnolence and resulting in an irreversible coma. The goal of palliative treatment of terminal hnc patients is offering the most convenient way to "live" the final days of their lives in dignity. The short survival time in hospice indicates that incurable patients may be referred to terminal care institutions too late in their dying trajectory. Physicians should be encouraged to talk to their terminally ill patients about the status and incurability of the disease as early as possible to facilitate patient and family decision making on how to prepare for the impending end of life.

Increased expression of EphA2 correlates with adverse outcome in primary and recurrent glioblastoma multiforme patients.

Glioblastoma multiforme (GBM) is the most aggressive form of brain tumor characterized by excessive angiogenesis. The dismal prognosis of patients with GBM warrants the development of new targeting therapies based on novel molecular markers. The EphA2 receptor tyrosine kinase plays a pivotal role in tumor angiogenesis and an increased expression in glioma patients has recently been reported. In this study, we investigated the expression of EphA2 in human normal brain, primary and recurrent GBM and correlated it with clinical pathological parameters and patient's outcome. In addition, intratumor microvascular density was quantified by immunostaining for the endothelial cell marker, von Willebrand factor. A different intensity of the membranous and cytoplastic expression of EphA2 was observed in the 40 primary and recurrent samples of GBM analyzed but not in the normal brain. A high level expression of EphA2 was demonstrated in 24 (60%) of the primary and recurrent GBM analyzed. The increased expression of the EphA2 protein was significantly associated with the adverse outcome of GBM patients (p<0.01 for overall survival). The data presented in this study define the expression pattern of EphA2 in both primary and recurrent glioblastoma and suggest an important role of EphA2 in the pathogenesis of GBM. The EphA2 may be used as a surrogate marker to screen patients for tyrosine kinase inhibitor therapy.

Super standardization: one health system, one chargemaster.

The task of standardizing chargemasters is huge, but so is the payoff. A standard chargemaster means improved charge capture and collections, uniform price and volume analysis, and reduced risk of payer audits and penalties, among other things. Having a central chargemaster team and adequate time and resources are essential to success.

Getting a charge out of emergency care.

To help emergency department (ED) nurses effectively capture charge information, hospitals should create a one-page form that contains a list of possible charges for selection. Hospitals should use and maintain a formal protocol for ED visit charges so they can be consistently assigned. Hospitals that use coders to enter ED charges should give them workspace in the department so they can answer questions for the clinical staff and provide documentation training as needs arise.

Multicenter phase II trial of chemoradiation with oxaliplatin for rectal cancer.

PURPOSE: To evaluate the activity and safety of preoperative radiotherapy (RT) and concurrent capecitabine and oxaliplatin (XELOX-RT) plus four cycles of adjuvant XELOX in patients with rectal cancer. PATIENTS AND METHODS: One hundred ten patients with T3/T4 or N+ rectal cancer were entered onto the trial in 11 investigator sites and received preoperative RT (50.4 Gy in 28 fractions). Capecitabine was administered concurrently at 1,650 mg/m2 on days 1 to 14 and 22 to 35, and oxaliplatin was administered at 50 mg/m2 on days 1, 8, 22, and 29. Surgery was scheduled 4 to 6 weeks after completion of XELOX-RT. Four cycles of adjuvant XELOX (capecitabine 1,000 mg/m2 bid on days 1 to 14; oxaliplatin 130 mg/m2 on day 1) were administered. The main end points were activity as assessed by the pathologic complete response (pCR) rate and the feasibility of postoperative XELOX chemotherapy. RESULTS: After XELOX-RT, 103 of 104 eligible patients underwent surgery; pCR was achieved in 17 patients (16%), one patient had ypT0N1 disease, and 53 patients showed tumor regression of more than 50% of the tumor mass. R0 resections were achieved in 95% of patients, and sphincter preservation was accomplished in 77%. Full-dose preoperative XELOX-RT was administered in 96%. Grade 3 or 4 diarrhea occurred in 12% of patients. Postoperative complication occurred in 43% of patients. Sixty percent of patients received all four cycles of adjuvant XELOX, with sensory neuropathy (18%) and diarrhea (12%) being the main grade 3 or 4 toxicities. CONCLUSION: Preoperative XELOX-RT plus four cycles of adjuvant XELOX is an active and feasible treatment. This regimen is proposed for phase III evaluation comparing standard fluorouracil-based treatment with XELOX- based multimodality treatment.