Effectiveness of a Bundled Payments for Care Improvement Program for Chronic Obstructive Pulmonary Disease.

BACKGROUND: The Medicare Bundled Payments for Care Improvement (BPCI) program reimburses 90-day care episodes post-hospitalization. COPD is a leading cause of early readmissions making it a target for value-based payment reform. OBJECTIVE: Evaluate the financial impact of a COPD BPCI program. DESIGN, PARTICIPANTS, INTERVENTIONS: A single-site retrospective observational study evaluated the impact of an evidence-based transitions of care program on episode costs and readmission rates, comparing patients hospitalized for COPD exacerbations who received versus those who did not receive the intervention. MAIN MEASURES: Mean episode costs and readmissions. KEY RESULTS: Between October 2015 and September 2018, 132 received and 161 did not receive the program, respectively. Mean episode costs were below target for six out of eleven quarters for the intervention group, as opposed to only one out of twelve quarters for the control group. Overall, there were non-significant mean savings of $2551 (95% CI: - $811 to $5795) in episode costs relative to target costs for the intervention group, though results varied by index admission diagnosis-related group (DRG); there were additional costs of $4184 per episode for the least-complicated cohort (DRG 192), but savings of $1897 and $1753 for the most complicated index admissions (DRGs 191 and 190, respectively). A significant mean decrease of 0.24 readmissions per episode was observed in 90-day readmission rates for intervention relative to control. Readmissions and hospital discharges to skilled nursing facilities were factors of higher costs (mean increases of $9098 and $17,095 per episode respectively). CONCLUSIONS: Our COPD BPCI program had a non-significant cost-saving effect, although sample size limited study power. The differential impact of the intervention by DRG suggests that targeting interventions to more clinically complex patients could increase the financial impact of the program. Further evaluations are needed to determine if our BPCI program decreased care variation and improved quality of care. PRIMARY SOURCE OF FUNDING: This research was supported by NIH NIA grant #5T35AG029795-12.

Fatal Sarcocystis falcatula Infection in Three Penguins.

Sarcocystis falcatula is a well-known cause of fatal pneumonia in some birds, particularly Old World psittacines. Here we describe fatal sarcosystosis due to S. falcatula in 3 penguins (Family Spheniscidae) under managed care, including one African penguin (Spheniscus demersus), and two Southern rockhopper penguins (Eudyptes chrysocome). Randomly distributed foci of necrosis, inflammatory cell infiltrates, edema, and variable numbers of round to elongated protozoal schizonts were observed in sections of lung. Protozoal organisms exhibited strong immunoreactivity for Sarcocystis sp. antigen by immunohistochemistry. Apicomplexan and Sarcocystis genus-specific PCR assays and sequence analysis confirmed S. falcatula as the etiologic agent. These cases of fatal pneumonia attributed to S. falcatula expand the list of aberrant intermediate avian hosts, with particular implications for penguins.

Venetoclax Synergizes with Radiotherapy for Treatment of B-cell Lymphomas.

Constitutive B-cell receptor signaling leads to overexpression of the antiapoptotic BCL-2 protein and is implicated in the pathogenesis of many types of B-cell non-Hodgkin lymphoma (B-NHL). The BCL-2 small-molecule inhibitor venetoclax shows promising clinical response rates in several lymphomas, but is not curative as monotherapy. Radiotherapy is a rational candidate for combining with BCL-2 inhibition, as DNA damage caused by radiotherapy increases the activity of pro-apoptotic BCL-2 pathway proteins, and lymphomas are exquisitely sensitive to radiation. We tested B-NHL responses to venetoclax combined with either external beam radiotherapy or radioimmunotherapy (RIT), which joins the selectivity of antibody targeting with the effectiveness of irradiation. We first tested cytotoxicity of cesium-137 irradiation plus venetoclax in 14 B-NHL cell lines representing five lymphoma subtypes. Combination treatment synergistically increased cell death in 10 of 14 lines. Lack of synergy was predicted by resistance to single-agent venetoclax and high BCL-XL expression. We then assessed the efficacy of external beam radiotherapy plus venetoclax in murine xenograft models of mantle cell (MCL), germinal-center diffuse large B-cell (GCB-DLBCL), and activated B-cell (ABC-DLBCL) lymphomas. In each model, external beam radiotherapy plus venetoclax synergistically increased mouse survival time, curing up to 10%. We finally combined venetoclax treatment of MCL and ABC-DLBCL xenografts with a pretargeted RIT (PRIT) system directed against the CD20 antigen. Optimal dosing of PRIT plus venetoclax cured 100% of mice with no detectable toxicity. Venetoclax combined with radiotherapy may be a promising treatment for a wide range of lymphomas Cancer Res; 77(14); 3885-93. ©2017 AACR.

Switching the Immunogenicity of Peptide Assemblies Using Surface Properties.

Biomaterials created from supramolecular peptides, proteins, and their derivatives have been receiving increasing interest for both immunological applications, such as vaccines and immunotherapies, as well as ostensibly nonimmunological applications, such as therapeutic delivery or tissue engineering. However, simple rules for either maximizing immunogenicity or abolishing it have yet to be elucidated, even though immunogenicity is a prime consideration for the design of any supramolecular biomaterial intended for use in vivo. Here, we investigated a range of physicochemical properties of fibrillized peptide biomaterials, identifying negative surface charge as a means for completely abolishing antibody and T cell responses against them in mice, even when they display a competent epitope. The work was facilitated by the modularity of the materials, which enabled the generation of a set of co-assembled fibrillar peptide materials with broad ranges of surface properties. It was found that negative surface charge, provided via negatively charged amino acid residues, prevented T cell and antibody responses to antigen-carrying assemblies because it prevented uptake of the materials by antigen-presenting cells (APCs), which in turn prevented presentation of the epitope peptide in the APCs' major histocompatibility class II molecules. Conversely, positive surface charge augmented the uptake of fibrillized peptides by APCs. These findings suggest that some surface characteristics, such as extensive negative charge, should be avoided in vaccine design using supramolecular peptide assemblies. More importantly, it provides a strategy to switch off potentially problematic immunogenicity for using these materials in nonimmunological applications.