Implementation of an Outpatient HD-MTX Initiative.

INTRODUCTION: Methotrexate (MTX) a folate antagonist is often given in high doses (≥500 mg/m2) to treat a variety of disease processes. While inpatient administration has been the norm, outpatient administration, has been shown to be safe, effective, and patient centered. Here in we describe development of an outpatient HDMTX protocol and our initial experience. METHODS: All patients were to receive their first cycle of HDMTX in the hospital to ensure they tolerate it well and also to use this time to assist in training for home administration. The outpatient protocol involved continuous IV sodium bicarbonate, along with oral leucovorin and acetazolamide. Patients were required to visit the infusion center daily for labs and methotrexate levels. Clear criteria for admission were developed in the case of delayed clearance or methotrexate toxicity. RESULTS: Two patients completed the safety run-in phase. Both patients tolerated treatment well. There were no associated toxicity. Methotrexate cleared within 3 days for all cycles. Both patients were able to follow the preadmission instructions for sodium bicarbonate and acetazolamide. The patients reported adequate teaching on the protocol and were able to maintain frequency of urine dipstick checks. CONCLUSION: We developed and implemented an outpatient protocol for high dose methotrexate. This study largely details the development of this protocol and its initial safety evaluation. More work needs to be done to assess its feasibility on a larger number of patients who receive more cycles in the outpatient setting.

Decreasing Cost and Decreasing Length of Stay After Implementation of Updated High-Dose Methotrexate Discharge Criteria.

PURPOSE: High-dose methotrexate (HD-MTX) is commonly used for the treatment of osteosarcoma or for CNS involvement in lymphoproliferative neoplasms. It is often given in the inpatient setting because of monitoring requirements after administration. We conducted a process improvement initiative to change our institutional discharge criteria for HD-MTX from 0.05 µmol/L to ≤ 0.1 µmol/L to reduce cost and length of stay (LOS) for this patient population. METHODS: After an assessment of drivers of LOS among patients receiving HD-MTX, we identified discharge criteria as an actionable factor. We developed a workflow to discharge patients with 3 days of oral leucovorin and sodium bicarbonate when the methotrexate level reached ≤ 0.1 µmol/L. Patient demographics, chemotherapy regimen, cycle, dose, and LOS data were collected for a 7-month period before and a 4-month period after the intervention. Cost savings were estimated on the basis of the daily cost of a hospital bed at the institution. RESULTS: Mean LOS for the pre-intervention and postintervention group was 4.84 days (n = 49) and 3.67 days (n = 42), respectively, resulting in a 24.4% reduction in LOS, with a mean ratio of 0.756 (95% CI, 0.615 to 0.927; P = .007). Reduced LOS resulted in a decrease in cost of $1,828.73 per admission, with a 4-month savings of $76, 806.56 and projected annualized savings of $230,419.67. No patient experienced complications because of the change in discharge criteria. CONCLUSION: Liberalizing discharge criteria for HD-MTX was feasible and safe and reduced cost. Additional efforts to reduce LOS for elective chemotherapy admissions or to safely transition some of these complex regimens to the home setting are currently underway at our institution.

Optimizing Drug Delivery of Small-Volume Infusions.

When administering intermittent secondary intravenous infusions, commonly referred to as intravenous piggyback (IVPB) infusions, residual medication remains in the administration set and bag. No previous studies exist examining the optimal technique to infuse the residual medication. The aims of this study were to identify various IVPB ancillary techniques used to administer medication residing in the secondary administration set and bag following an infusion, evaluate the potential drug loss associated with each technique, and recommend a standard ancillary technique for administration of select small-volume IVPB infusions. Qualitative and quantitative tests were performed, leading to a recommendation for a standard ancillary technique for select small-volume IVPB infusions.

Hybrid fibers transform into distinct fiber types in maturing mouse muscles.

The role of hybrid fibers as intermediates in fiber type transformations is not completely understood. In some cases hybrids are clearly transitional fibers changing from one type to another, but in others they represent phenotypically stable fibers in normal muscles. In the current study, our goal was to understand the fate of hybrid fibers in fiber type transitions that take place during muscle maturation. Previous studies have reported high proportions of hybrid fibers during postnatal development, but few have followed the fate of these fibers past the time of weaning. We quantified proportions of hybrid fibers in three different mouse skeletal muscles from newly weaned to 6-month-old mice. Hybrid fibers were very prevalent in the brachioradialis (BR) and tibialis anterior (TA) muscles from newly weaned mice, where they constituted 50 and 40% of the fibers, respectively. These hybrids declined steadily to about 15-30% over the next several months. In the soleus muscle the proportion of hybrids did not change, but constituted approximately 20% of fibers. The reduction in IIX/IIB hybrids resulted from different processes in the BR and the TA. In the BR, the reduction was coincident with an increase in type IIX fibers. In the TA, the number of IIX/IIB hybrids was inversely correlated with the proportion of IIB fibers. These patterns reveal that the role of hybrid fibers as intermediates in muscle development is complex. Some hybrid fibers in maturing muscles represent transitional fiber types, while others are phenotypically stable. Moreover, the fate of transitional fibers may be distinct among similar fiber types within different muscles.