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author:("Kumar, akhal")
1.  Guideline-Based Peer-to-Peer Consultation Optimizes Pegfilgrastim Use With No Adverse Clinical Consequences 
Journal of Oncology Practice  2012;8(3 Suppl):e14s-e17s.
Active expert peer-to-peer consultation with prescribing oncologists can promote adherence to guidelines and lead to cost reductions without risk of neutropenic fever, with or without hospitalization, for patients with cancer.
Practice guidelines do not recommend the routine use of colony-stimulating factors when there is a low risk (< 10%) of febrile neutropenia (FN). We prospectively determined whether expert peer-to-peer consultation with prescribing oncologists would improve adherence to guidelines and whether there would be any adverse events associated with that adherence.
Commencing in March 2010, we reviewed requests for pegfilgrastim from 22 community oncology practices comprising 78 physicians providing service to approximately 97,000 Medicare members. Paid claims data on all chemotherapy and supportive care medications were reviewed from fourth quarter (Q4) 2009 through third quarter (Q3) 2010. In total, 82 patients received pegfilgrastim. If the prescribed chemotherapy was associated with a low risk (< 10%) for FN, then a peer review was initiated. The treating physician made the final decision to use, or not use, pegfilgrastim, and no denials were issued.
A total of 245 units (1 unit = 6 mg) of pegfilgrastim were administered during the four quarters analyzed. Use in the low-risk category decreased from 52 units in Q4 2009 to 15 units in Q3 2010. The per-member per-month (PMPM) cost of pegfilgrastim decreased across quarters, with an average cost of $1.07 PMPM for Q4 2009 and $0.57 PMPM for Q3 2010. No studied patient was admitted for neutropenic fever.
Active expert peer-to-peer consultation with prescribing oncologists can promote adherence to guidelines and potentially lead to significant cost reductions without significant risk of neutropenic fever, with or without hospitalization, for patients with cancer.
PMCID: PMC3348596  PMID: 22942828
2.  Countering the Misincentivization of Cancer Medicine by Real-Time Personal Professional Education 
In the United States, public and private payer misincentivization of medical care and the invisibility of costs to the consumers of that care have conspired to create unsustainable growth in health care expenditure that undermines our economy, diminishes our productivity, and limits our international competitiveness. Cancer medicine provides a small yet salient example. On average, Medicare reimburses oncologists 6% above the average acquisition price for essential anticancer agents and supportive therapies. The costs of these agents vary across a stunning five orders of magnitude, from a few dollars to more than $400,000 per course of treatment. The profitability to providers varies across approximately four orders of magnitude, from cents to thousands of dollars per treatment. National guidelines (National Comprehensive Cancer Network [NCCN], American Society of Clinical Oncology [ASCO]) help providers select the most effective therapies without regard for cost.
We created an oncologist-to-oncologist professional education program to help cancer physicians optimally use expensive long-acting white blood cell growth factors, in accordance with these national guidelines. We then compared their use across a population of approximately 97,000 Medicare members before and after our intervention. Baseline use was recorded over two consecutive quarters (2009 to 2010). In March 2010, our oncologists initiated real-time discussions with the oncologists of 22 separate groups if these agents were ordered for use with regimens that placed patients at less than 10% risk of febrile neutropenia, according to NCCN guidelines. Neither NCCN nor ASCO recommend the routine use of these agents in this low-risk group. The care of 82 such patients was thoroughly discussed in the following 6 months.
The monthly costs for these agents decreased by more than 50% by the final month of our intervention, although savings began immediately, reducing costs by more than $150,000 per quarter. No episode of febrile neutropenia was recorded in any patient in the intervention group. These savings generalize to the entire Medicare population at $30 million each month.
We conclude that personal, oncologist-to-oncologist, real-time professional education will favorably modify oncologic prescribing behavior and can do so with significant immediate savings at no risk to patients with cancer.
PMCID: PMC3457828
3.  MetRxn: a knowledgebase of metabolites and reactions spanning metabolic models and databases 
BMC Bioinformatics  2012;13:6.
Increasingly, metabolite and reaction information is organized in the form of genome-scale metabolic reconstructions that describe the reaction stoichiometry, directionality, and gene to protein to reaction associations. A key bottleneck in the pace of reconstruction of new, high-quality metabolic models is the inability to directly make use of metabolite/reaction information from biological databases or other models due to incompatibilities in content representation (i.e., metabolites with multiple names across databases and models), stoichiometric errors such as elemental or charge imbalances, and incomplete atomistic detail (e.g., use of generic R-group or non-explicit specification of stereo-specificity).
MetRxn is a knowledgebase that includes standardized metabolite and reaction descriptions by integrating information from BRENDA, KEGG, MetaCyc, and 44 metabolic models into a single unified data set. All metabolite entries have matched synonyms, resolved protonation states, and are linked to unique structures. All reaction entries are elementally and charge balanced. This is accomplished through the use of a workflow of lexicographic, phonetic, and structural comparison algorithms. MetRxn allows for the download of standardized versions of existing genome-scale metabolic models and the use of metabolic information for the rapid reconstruction of new ones.
The standardization in description allows for the direct comparison of the metabolite and reaction content between metabolic models and databases and the exhaustive prospecting of pathways for biotechnological production. This ever-growing dataset currently consists of over 76,000 metabolites participating in more than 72,000 reactions (including unresolved entries). MetRxn is hosted on a web-based platform that uses relational database models (MySQL).
PMCID: PMC3277463  PMID: 22233419
4.  Tube Migration During Laparoscopic Gynecological Surgery 
The positioning (trendelenburg) and pneumoperitoneum during laparoscopic gynecological surgeries may cause cephalad movement of diaphragm and subsequent endobronchial intubation.
Patients & Methods:
50 ASA I/II patients posted for laparoscopic ligation were included in the study. Standardized anaesthesia technique was employed in all the patients. The distance of endotracheal tube to carina was measured in supine position, trendelenberg position, 5 min and 25 minutes post pneumoperitoneum and after deflation of pneumo-peritoneum.
The mean distance from the tip of the ETT to the carina was 3.41± 1.3 cm, 2.96 ± 1.4, 2.0 ± 1.5 and 1.7 ± 1.6 in supine position, trendelenburg position and 5min and 25 min post pneumoperitoneum. (P<0.01) Following deflation the carina moved back to its position to some extent and was 2.5 ± 1.5 from the tip of endotracheal tube.( P< 0.05)
We conclude that pneumoperitoneum and trendelenburg position during laparoscopic surgeries may lead to cephalad migration of carina.
PMCID: PMC3087276  PMID: 21547186
Tube Migration; Laparoscopic Gynaecological Surgery

Results 1-4 (4)