RESUMO
Public health policy interventions are associated with many important public health achievements. To provide public health practitioners and decision makers with practical approaches for examining and employing evidence-based public health (EBPH) policy interventions, we describe the characteristics and benefits that distinguish EBPH policy interventions from programmatic interventions. These characteristics include focusing on health at a population level, focusing on upstream drivers of health, and involving less individual action than programmatic interventions. The benefits of EBPH policy interventions include more sustained effects on health than many programs and an enhanced ability to address health inequities. Early childhood education and universal preschool provide a case example that illustrates the distinction between EBPH policy and programmatic interventions. This review serves as the foundation for 3 concepts that support the effective use of public health policy interventions: applying core component thinking to understand the population health effects of EBPH policy interventions; understanding the influence of existing policies, policy supports, and the context in which a particular policy is implemented on the effectiveness of that policy; and employing a systems thinking approach to identify leverage points where policy implementation can have a meaningful effect.
RESUMO
A growing body of literature uses the concept of core components to better understand small-scale programmatic interventions. Instead of interventions being viewed as unitary "black boxes," interventions are viewed as configurations of core components, which are the parts of interventions that carry their causal potential and therefore need to be reproduced with fidelity to produce the intended effect. To date, the concept of core components has not been as widely applied to public health policy interventions as it has to programmatic interventions. The purpose of this topical review is to familiarize public health practitioners and policy makers with the concept of core components as applied to public health policy interventions. Raising the profile of core component thinking can foster mindful adaptation and implementation of public health policy interventions while encouraging further research to enhance the supporting evidence base. We present 3 types of multilevel interactions in which the core components of a public health policy intervention produce effects at the population level by (1) seeking to directly affect individual behavior, (2) facilitating adoption of programmatic interventions by intermediaries, and (3) encouraging intermediaries to take action that can shape changes in upstream drivers of population health. Changing the unit of analysis from whole policies to core components can provide a basis for understanding how policies work and for facilitating novel evidence-generating strategies and rapid evidence reviews that can inform future adaptation efforts.
RESUMO
Objective: We sought to characterize patterns of utilization of telemental health among commercially insured individuals over the decade preceding COVID-19.Methods: We developed telemental health service groups from the US PharMetrics Plus database, using diagnostic codes to identify those diagnosed with mental health conditions and procedure codes to capture mental health visits delivered via telehealth sessions. We analyzed 2 indicators of utilization between January 1, 2010, and December 31, 2019: (1) the percentage of patients with mental health needs who used telemental health services and (2) the percentage of all mental health services provided via telehealth. We stratified our analyses by year, patient gender, patient age, and geographic region.Results: The proportion of mental health visits delivered via telemental health increased from 0.002% to 0.162% between 2010 and 2019. A larger proportion of males received telemental health services as compared to females; however, the proportion of mental health visits delivered via telehealth was higher for females than for males. Patients aged 18 to 34 years and those in the western US had the highest utilization compared to other age groups and geographic regions.Conclusions: Telemental health utilization comprised a small fraction of overall mental health services and beneficiaries in the IQVIA PharMetrics Plus claims data, but increased over time, with differences documented in utilization based on patient gender, patient age, geographic region, and type of telemental health claim. Evidence from this study may serve as a pre-pandemic baseline for comparison against future evaluations of telehealth expansion policies.
Assuntos
Transtornos Mentais , Serviços de Saúde Mental , Telemedicina , Masculino , Feminino , Humanos , Estados Unidos/epidemiologia , Seguro Saúde , Saúde Mental , Transtornos Mentais/diagnóstico , Transtornos Mentais/epidemiologia , Transtornos Mentais/terapia , Telemedicina/métodosRESUMO
There is a global rise in skin cancer incidence, resulting in an increase in patient care needs and healthcare costs. To optimize health care planning, costs, and patient care, Ontario Health developed a provincial skin cancer plan to streamline the quality of care. We conducted a systematic review and a grey literature search to evaluate the definitions and management of skin cancer within other jurisdictions, as well as a provincial survey of skin cancer care practices, to identify care gaps. The systematic review did not identify any published comprehensive skin cancer management plans. The grey literature search revealed skin cancer plans in isolated regions of the United Kingdom (U.K.), National Institute for Health and Care Excellence (NICE) guidelines for skin cancer quality indicators and regional skin cancer biopsy clinics, and wait time guidelines in Australia and the U.K. With the input of the Ontario Cancer Advisory Committee (CAC), unique definitions for complex and non-complex skin cancers and the appropriate cancer services were created. A provincial survey of skin cancer care yielded 44 responses and demonstrated gaps in biopsy access. A skin cancer pathway map was created and a recommendation was made for regional skin cancer biopsy clinics. We have created unique definitions for complex and non-complex skin cancer and a skin cancer pathways map, which will allow for the implementation of both process and performance metrics to address identified gaps in care.
Assuntos
Neoplasias Cutâneas , Humanos , Incidência , Ontário/epidemiologia , Neoplasias Cutâneas/epidemiologia , Neoplasias Cutâneas/terapiaRESUMO
BACKGROUND: Treatment practices vary for lentigo maligna (LM). Staged excision with circumferential margin control (SECMC) has the potential to achieve low recurrence rates. OBJECTIVES: To evaluate the clinical outcomes of SECMC using permanent, paraffin-embedded sections and delayed reconstruction. METHODS: We conducted a retrospective, uncontrolled, observational cohort study involving patients who underwent staged excision for LM of the head and neck at Women's College Hospital in Toronto, Canada, from September 2010 to March 2013. Recurrence and infection rates were ascertained from patient charts and postal surveys. RESULTS: One hundred and two patients (45 female, 57 male) were included with a median follow-up time of 1410.5 (IQR 260-1756) days. The median age was 69 (IQR 61-79) years. Approximately one-fifth (21%, 21/102) of patients required greater than 0.5 cm margins to achieve histological clearance. One patient (1/102) upstaged to invasive melanoma based on the initial stage of excision. The infection rate was 6% (6/102) and the 5-year cumulative recurrence rate was 1.4% (95% CI 0.2-9.6%). CONCLUSION: SECMC using permanent sections and delayed reconstruction appears to be a safe and effective treatment method for LM on the head and neck. Randomized trials are needed to help define the optimal treatment.
Assuntos
Neoplasias Faciais/cirurgia , Sarda Melanótica de Hutchinson/cirurgia , Margens de Excisão , Recidiva Local de Neoplasia , Couro Cabeludo , Neoplasias Cutâneas/cirurgia , Idoso , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Procedimentos Cirúrgicos Dermatológicos/métodos , Neoplasias Faciais/patologia , Feminino , Seguimentos , Humanos , Sarda Melanótica de Hutchinson/patologia , Masculino , Pessoa de Meia-Idade , Pescoço , Estadiamento de Neoplasias , Estudos Retrospectivos , Neoplasias Cutâneas/patologia , Infecção da Ferida Cirúrgica/etiologia , Resultado do TratamentoRESUMO
In a qualitative study with both MSM and TW living with HIV in Guatemala City, Barrington et al (2016) again found that intersecting stigma and discrimination created fear of HIV testing and linkage to HIV care and barriers to knowledge about HIV. Retention-specific determinants included HIV clinic dynamics and limited employment opportunities, which affected economic stability. These multiple levels of factors driving linkage and retention in care and treatment require multi-level, integrated responses (AU)
Assuntos
Humanos , Masculino , Feminino , Adulto , Infecções por HIV/diagnóstico , HIV , Fármacos Anti-HIV/uso terapêutico , Saúde Sexual , Apoio Social , Aplicações da Informática Médica , Estudos Prospectivos , Medo/psicologia , Estigma Social , Guatemala/epidemiologiaRESUMO
BACKGROUND AND OBJECTIVES: Although acute respiratory illness (ARI) is a leading cause of hospitalization among young children, few data are available about cost of hospitalization in middle-income countries. We estimated direct and indirect costs associated with severe ARI resulting in hospitalization among children aged <10 years in El Salvador and Panama through the societal perspective. METHODS: During 2012 and 2013, we surveyed caregivers of children hospitalized with ARI about their direct medical (i.e., outpatient consultation, medications, hospital fees), non-medical (transportation, childcare), and indirect costs (lost wages) at discharge and 7 days after discharge. We multiplied subsidized hospital bed costs derived from administrative data by hospitalization days to estimate provider costs. RESULTS: Overall, 638 children were enrolled with a median age of 12 months (IQR 6-23). Their median length of hospitalization was 4 days (IQR 3-6). In El Salvador, caregivers incurred a median of US$38 (IQR 22-72) in direct and indirect costs per illness episode, while the median government-paid hospitalization cost was US$118 (IQR 59-384) generating an overall societal cost of US$219 (IQR 101-416) per severe ARI episode. In Panama, caregivers incurred a median of US$75 (IQR 39-135) in direct and indirect costs, and the health-care system paid US$280 (IQR 150-420) per hospitalization producing an overall societal cost of US$393 (IQR 258-552). CONCLUSIONS: The cost of severe ARI to caregivers and the health care system was substantive. Our estimates will inform models to estimate national costs of severe ARI and cost-benefit of prevention and treatment strategies.
Assuntos
Efeitos Psicossociais da Doença , Hospitalização , Infecções Respiratórias/epidemiologia , Viroses/epidemiologia , Doença Aguda , Fatores Etários , Criança , Pré-Escolar , Análise Custo-Benefício , El Salvador/epidemiologia , Feminino , Gastos em Saúde , Humanos , Lactente , Recém-Nascido , Masculino , Panamá/epidemiologia , Aceitação pelo Paciente de Cuidados de Saúde , Vigilância em Saúde Pública , Fatores SocioeconômicosRESUMO
The purpose of the present review was to describe evidence-based indications for Mohs micrographic surgery (MMS) in patients with a diagnosis of skin cancer. Relevant studies were identified from a systematic MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews search of studies published from 1970 to 2017. Randomized controlled trials (RCTs), prospective and retrospective comparative studies with greater than 30 patients, and single-arm retrospective studies with multivariate analyses were included. A total of 2 RCTs, 3 prospective studies, and 16 retrospective studies (14 comparative and 2 single-arm) were included. Data on recurrence rate, cure rate, complications, cosmesis, and quality of life were extracted. Surgery (with postoperative or intraoperative marginal assessment) or radiation for those who are ineligible for surgery should remain the standard of care for patients with skin cancer given the lack of high-quality, comparative evidence. MMS is recommended for those with histologically confirmed recurrent basal cell carcinoma (BCC) of the face and is appropriate for primary BCCs of the face that are >1 cm, have aggressive histology, or are located on the H zone of the face. The available evidence is difficult to generalize to all patients with skin cancer because the evidence did not adequately cover non-BCC skin cancers; however, those skin cancers can be considered on a case-by-case basis for MMS. MMS should be performed by physicians who have completed a degree in medicine or equivalent, including a Royal College of Physicians and Surgeons of Canada Specialist Certificate or equivalent, and have received advanced training in MMS.
Assuntos
Cirurgia de Mohs , Neoplasias Cutâneas , Medicina Baseada em Evidências , Humanos , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Lentigo maligna is an in situ form of cutaneous melanoma that commonly arises on the head and neck. Various surgical and nonsurgical treatment options are available but no randomized trials exist to guide practice. OBJECTIVE: To determine the current treatment practices for lentigo maligna of the head and neck in Ontario, Canada. MATERIALS AND METHODS: Cross-sectional survey of dermatologists, plastic surgeons, and head and neck surgeons. RESULTS: The response rate was 35% (190/542). Wide excision with immediate reconstruction was the most commonly recommended treatment for tumors on the cheek (69%), whereas staged excision with margin control was recommended most often for tumors on the nasal ala (60%). Overall, 5 mm was the most frequently recommended initial surgical margin (69%); 26.5% of respondents recommended margins wider than 5 mm. For tumors on the nasal ala, eyelid, and ear helix, more than 30% of respondents recommended an initial margin narrower than 5 mm. CONCLUSION: Although surgical excision is the predominant treatment modality for lentigo maligna on the head and neck, practices vary considerably in terms of the type of excision and the initial margin used. Potential response bias and the geographic restriction of our sample may limit the generalizability of our results.
Assuntos
Neoplasias de Cabeça e Pescoço/cirurgia , Sarda Melanótica de Hutchinson/cirurgia , Padrões de Prática Médica , Neoplasias Cutâneas/cirurgia , Estudos Transversais , Secções Congeladas , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Sarda Melanótica de Hutchinson/patologia , Margens de Excisão , Cirurgia de Mohs , Ontário , Neoplasias Cutâneas/patologia , Inquéritos e QuestionáriosRESUMO
BACKGROUND: In many Latin American countries, official influenza reports are neither timely nor complete, and surveillance of influenza-like illness (ILI) remains thin in consistency and precision. Public participation with mobile technology may offer new ways of identifying nonmedically attended cases and reduce reporting delays, but no published studies to date have assessed the viability of ILI surveillance with mobile tools in Latin America. We implemented and assessed an ILI-tailored mobile health (mHealth) participatory reporting system. OBJECTIVE: The objectives of this study were to evaluate the quality and characteristics of electronically collected data, the user acceptability of the symptom reporting platform, and the costs of running the system and of identifying ILI cases, and to use the collected data to characterize cases of reported ILI. METHODS: We recruited the heads of 189 households comprising 584 persons during randomly selected home visits in Guatemala. From August 2016 to March 2017, participants used text messages or an app to report symptoms of ILI at home, the ages of the ILI cases, if medical attention was sought, and if medicines were bought in pharmacies. We sent weekly reminders to participants and compensated those who sent reports with phone credit. We assessed the simplicity, flexibility, acceptability, stability, timeliness, and data quality of the system. RESULTS: Nearly half of the participants (47.1%, 89/189) sent one or more reports. We received 468 reports, 83.5% (391/468) via text message and 16.4% (77/468) via app. Nine-tenths of the reports (93.6%, 438/468) were received within 48 hours of the transmission of reminders. Over a quarter of the reports (26.5%, 124/468) indicated that at least someone at home had ILI symptoms. We identified 202 ILI cases and collected age information from almost three-fifths (58.4%, 118/202): 20 were aged between 0 and 5 years, 95 were aged between 6 and 64 years, and three were aged 65 years or older. Medications were purchased from pharmacies, without medical consultation, in 33.1% (41/124) of reported cases. Medical attention was sought in 27.4% (34/124) of reported cases. The cost of identifying an ILI case was US $6.00. We found a positive correlation (Pearson correlation coefficient=.8) between reported ILI and official surveillance data for noninfluenza viruses from weeks 41 (2016) to 13 (2017). CONCLUSIONS: Our system has the potential to serve as a practical complement to respiratory virus surveillance in Guatemala. Its strongest attributes are simplicity, flexibility, and timeliness. The biggest challenge was low enrollment caused by people's fear of victimization and lack of phone credit. Authorities in Central America could test similar methods to improve the timeliness, and extend the breadth, of disease surveillance. It may allow them to rapidly detect localized or unusual circulation of acute respiratory illness and trigger appropriate public health actions.
RESUMO
Cutaneous surgery requires a precise understanding of anatomy. This review describes the clinically relevant anatomy of the hand and relates it to the most common methods of digital anaesthesia.
Assuntos
Procedimentos Cirúrgicos Dermatológicos , Dedos/irrigação sanguínea , Dedos/inervação , Bloqueio Nervoso/métodos , Dedos/cirurgia , HumanosRESUMO
Plant cell walls are extracellular matrices that surround plant cells and critically influence basic cellular processes, such as cell division and expansion. Cellulose is a major constituent of plant cell walls, and this paracrystalline polysaccharide is synthesized at the plasma membrane by a large protein complex known as the cellulose synthase complex (CSC). Recent efforts have identified numerous protein components of the CSC, but relatively little is known about regulation of cellulose biosynthesis. Numerous phosphoproteomic surveys have identified phosphorylation events in CSC associated proteins, suggesting that protein phosphorylation may represent an important regulatory control of CSC activity. In this review, we discuss the composition and dynamics of the CSC in vivo, the catalog of CSC phosphorylation sites that have been identified, the function of experimentally examined phosphorylation events, and potential kinases responsible for these phosphorylation events. Additionally, we discuss future directions in cellulose synthase kinase identification and functional analyses of CSC phosphorylation sites.
RESUMO
Expert diagnosis of cutaneous pathology requires precise anatomic description. In this brief report the authors review the clinically relevant surface anatomy of the nail and relate it to a case of squamous cell carcinoma.
Assuntos
Carcinoma de Células Escamosas/patologia , Doenças da Unha/patologia , Unhas/anatomia & histologia , Neoplasias Cutâneas/patologia , Carcinoma de Células Escamosas/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Doenças da Unha/diagnóstico , Neoplasias Cutâneas/diagnóstico , PolegarRESUMO
BACKGROUND: Facial reconstruction requires the use of various techniques to repair cutaneous defects. Sliding flaps, such as advancement and rotation flaps, typically result in tension alterations and skin redundancy, necessitating a secondary defect. OBJECTIVE: We describe a back cut technique that allows minimization of the scar line and appropriate placement of tension vectors in certain locations, which we call the crescentic back cut. METHODS: A patient with a surgical defect on his preauricular cheek is repaired by use of a rotation flap modified with a crescentic back cut. We briefly review the alternative methods for management of flap/defect discrepancies in rotation flaps. RESULTS: The crescentic back cut is simple to suture, can be adjusted in length and thickness to minimize pedicle transection, and keeps the scar short and within the relaxed skin tension lines. CONCLUSION: The crescentic back cut is a useful option to manage flap/defect discrepancies in rotation flaps.
Assuntos
Carcinoma Basocelular/cirurgia , Neoplasias Faciais/cirurgia , Procedimentos de Cirurgia Plástica , Neoplasias Cutâneas/cirurgia , Retalhos Cirúrgicos , Carcinoma Basocelular/patologia , Neoplasias Faciais/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Cirurgia de Mohs , Neoplasias Cutâneas/patologiaRESUMO
Dermatologic surgery procedures can sometimes be time consuming in an office setting. We present a series of tips for dermatologists and dermatologic surgeons that will enhance the efficiency of simple procedures.
Assuntos
Procedimentos Cirúrgicos Dermatológicos/métodos , Técnicas de Sutura , HumanosRESUMO
Dermatologic surgery procedures can sometimes be time consuming in an office setting. We present a series of tips for dermatologists and dermatologic surgeons that will enhance the efficiency of skin graft procedures.
Assuntos
Procedimentos Cirúrgicos Dermatológicos/métodos , Transplante de Pele/métodos , HumanosRESUMO
Dermatologic surgery procedures can sometimes be time consuming in an office setting. We present two tips for dermatologists and dermatologic surgeons that will enhance the efficiency of procedures around the lip.
Assuntos
Procedimentos Cirúrgicos Dermatológicos/métodos , Lábio/cirurgia , Humanos , Procedimentos de Cirurgia Plástica/métodosRESUMO
Dermatologic surgery procedures can sometimes be time consuming in an office setting. We present a series of tips for dermatologists and dermatologic surgeons that will enhance the efficiency of simple procedures. This article reviews three methods to aid in the closure of defects under tension.
Assuntos
Procedimentos Cirúrgicos Dermatológicos/métodos , Técnicas de Sutura , HumanosRESUMO
Palmar and plantar hyperhidrosis is relatively common and can have severe psychological and medical consequences for those afflicted. A multitude of treatments exist but are often inadequate especially for those with significant disease. In these cases botulinum neurotoxin provides a reliable method for reducing the symptoms and improving quality of life. Although actual administration is relatively straightforward, pain management is a crucial component that requires a mastery of several techniques. Patients have a high degree of satisfaction with botulinum neurotoxin treatment and are motivated to come back for repeat treatments, usually every 6 months.