Maternal and Child Health Pipeline Training Programs: A Description of Training Across 6 Funded Programs.

PURPOSE: The HRSA-funded maternal and child health pipeline training programs (MCHPTPs) are a response to the critical need to diversify the MCH workforce, as a strategy to reduce health disparities in MCH populations. These MCHPTPs support students from undergraduate to graduate education and ultimately into the MCH workforce. DESCRIPTION: The models and components of training across the six MCHPTPs funded in 2016-2021 are summarized, to examine the design and delivery of undergraduate pipeline training and the insights gained across programs. ASSESSMENT: Strategies that emerged across training programs were organized into three themes: recruitment, support for student persistence (in education), and pipeline-to-workforce intentionality. Support for student persistence included financial support, mentoring, creating opportunity for students to develop a sense of belonging, and the use of research as a tool to promote learning and competitiveness for graduate education. Finally, the link to Maternal and Child Health Bureau (MCHB) long-term training and other MCHB opportunities for professional development contributed significant nuance to the pipeline-to-workforce objectives of these programs. CONCLUSIONS: The MCHPTPs not only increase the diversity of the MCH workforce, they also actively prepare the next generation of MCH leaders. The intentional connection of undergraduates to the infrastructure and continuum of MCH training, underscores the comprehensive impact of this funding.

Work/study productivity gain and associated indirect cost savings with guselkumab compared with adalimumab in moderate-to-severe psoriasis: results from the VOYAGE 1 study.

BACKGROUND: Work productivity loss (WPL) is a major contributor to the indirect costs of psoriasis. Newer biologic therapies are effective at reducing disease symptoms and improving quality of life, but their impact on WPL and associated indirect cost savings compared to previously approved biologic therapies is largely unknown. OBJECTIVES: To compare the effects of guselkumab and adalimumab on WPL and associated indirect cost savings in patients with moderate-to-severe psoriasis. METHODS: Using data from the VOYAGE 1 (NCT02207231) trial, improvements from baseline in Dermatology Life Quality Index (DLQI) work/study domain scores were compared for patients receiving guselkumab or adalimumab at 24 and 48 weeks of treatment. Improvements in WPL and associated cost savings were calculated using a previously established DLQI-WPL algorithm. RESULTS: Among patients who could not work/study at baseline (DLQI work/study domain score = 3), a significantly greater proportion of guselkumab-treated patients could work/study without problems (DLQI work/study domain score = 0) than adalimumab-treated patients at Weeks 24 and 48. Improvements from baseline in WPL and associated cost savings were greater with guselkumab than with adalimumab at Week 48. CONCLUSIONS: Guselkumab was superior to adalimumab for improvement in WPL and associated indirect cost savings, and its use may reduce the economic burden of psoriasis.

Calcipotriol/betamethasone dipropionate foam demonstrates comparable efficacy to clinical trial data in the real world, improves patient satisfaction and is cost-effective.

Real-world evidence studies are becoming increasingly important in providing insight into clinical effectiveness and safety, economic outcomes, patient-reported outcomes and health-related quality of life of treatments in the clinical setting. These studies also help to complement data reported in clinical studies. Fixed-dose combination calcipotriol 50 µg/g plus betamethasone dipropionate 0.5 mg/g cutaneous foam (Cal/BD foam) is a topical agent used for the treatment of psoriasis vulgaris. In clinical studies, Cal/BD foam has demonstrated a significantly greater efficacy and rapid onset of action compared with both single and combination formulations such as ointments and gels. To date, three observational studies have examined the real-world efficacy and safety of Cal/BD foam in clinical practice in the United States, Germany and Spain. Data gathered from these studies reinforce the positive findings reported in clinical studies assessing Cal/BD foam for the treatment of psoriasis and demonstrate improved patient satisfaction with Cal/BD foam. Using Cal/BD foam has been shown to be cost-effective based on results from randomised clinical trials and cost-effective analysis. As such, Cal/BD foam has the potential to lower treatment costs by reducing the need for some patients to progress to more expensive treatments, such as phototherapy and biologics. Cal/BD foam is therefore a cost-effective solution for the treatment of psoriasis vulgaris that should be considered when prescribing topicals.

A plastic surgery service response to COVID-19 in one of the largest teaching hospitals in Europe.

COVID-19 is presenting a colossal challenge to frontline NHS staff. This paper highlights how plastic surgery teams can use their diverse skills and resources in times of crisis. Through effective strategy and leadership we present how we are adapting as a department to serve our plastic surgery patients, other hospital teams and the Trust.

Docetaxel chemotherapy in metastatic castration-resistant prostate cancer: cost of care in Medicare and commercial populations.

OBJECTIVE: To estimate the healthcare costs and characteristics of docetaxel chemotherapy episodes of care for men with metastatic castration-resistant prostate cancer (mCRPC). METHODS: This study used the Medicare 5% sample and MarketScan Commercial (2010-2013) claims data sets to identify men with mCRPC and initial episodes of docetaxel treatment. Docetaxel episodes included docetaxel claim costs from the first claim until 30 days after the last claim, with earlier termination for death, insurance disenrollment, or the end of a 24-month look-forward period from initial docetaxel index date. Docetaxel drug claim costs were adjusted for 2011 generic docetaxel introduction, while other costs were adjusted to 2015 values using the national average annual unit cost increase. RESULTS: This study identified 281 Medicare-insured and 155 commercially insured men, with 325 and 172 docetaxel episodes, respectively. The average number of cycles (unique docetaxel infusion days) per episode was 6.9 for Medicare and 6.3 for commercial cohorts. The average cost per episode was $28,792 for Medicare and $67,958 for commercial cohorts, with docetaxel drug costs contributing $2,588 and $13,169 per episode, respectively. The average cost per episode on docetaxel infusion days was $8,577 (30%) for Medicare and $28,412 (42%) for commercial. Non-docetaxel infusion day costs included $7,074 (25%) for infused or injected drugs for Medicare, $10,838 (16%) for commercial cohorts, and $6,875 (24%) and $9,324 (14%) for inpatient admissions, respectively. LIMITATIONS: The applicability is only to the metastatic castration-resistance clinical setting, rather than the metastatic hormone-sensitive setting, and the lack of data on the cost effectiveness of different sequencing strategies of a range of systemic therapies including enzalutamide, abiraterone, radium-223, and taxane chemotherapy. CONCLUSION: The majority of docetaxel episode costs in Medicare and commercial mCRPC populations were non-docetaxel drug costs. Future research should evaluate the total cost of care in mCPRC.

Impact of Oncotype DX breast Recurrence Score testing on adjuvant chemotherapy use in early breast cancer: Real world experience in Greater Manchester, UK.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) recommended the Oncotype DX® Breast Recurrence Score® (RS) assay as an option for informing adjuvant chemotherapy decisions in node-negative, oestrogen receptor (ER)+, human epidermal growth factor receptor 2 (HER2)-negative early breast cancer assessed to be at intermediate risk of recurrence based on clinicopathological factors. We evaluated the impact of RS testing on adjuvant chemotherapy decision-making in routine clinical practice in a UK Cancer Network. METHODS: RS testing was performed in 201 females with newly diagnosed, ER+, HER2-negative, invasive breast cancer who underwent breast surgery with curative intent, were calculated to have a >3% overall survival benefit at 10 years from adjuvant chemotherapy based on PREDICT, and were considered for adjuvant chemotherapy. The impact of RS testing on adjuvant treatment decisions/associated cost was assessed. RESULTS: In all patients, the multi-disciplinary team recommended chemotherapy but the RS result allowed 127/201 patients (63.2%) to avoid unnecessary adjuvant chemotherapy. Amongst ER+, HER2-negative, node-negative patients (eligible for Oncotype DX testing in UK guidelines), 60.3% were spared chemotherapy. In node-positive patients, the assay reduced the use of chemotherapy by 69.2%. The use of RS testing to guide treatment in these 201 patients was associated with significant cost saving (when considering the cost of RS testing for all patients plus chemotherapy and its associated cost for 74 patients). CONCLUSIONS: Incorporating RS testing into routine clinical practice for selected node-negative and node-positive breast cancer patients significantly reduces the use of chemotherapy (p < 0.001) with its associated morbidity and costs.

Financial impact of surgical training on hospital economics: an income analysis of 1184 out-patient clinic consultations.

INTRODUCTION: In many countries healthcare commissioning bodies (state or insurance-based) reimburse hospitals for their activity. The costs associated with post-graduate clinical training as part of this are poorly understood. This study quantified the financial revenue generated by surgical trainees in the out-patient clinic setting. METHODS: A retrospective analysis of surgical out-patient ambulatory care appointments under 6 full-time equivalent Consultants (Attendings) in one hospital over 2 months. Clinic attendance lists were generated from the Patient Access System. Appointments were categorised as: 'new', 'review' or 'procedure' as per the Department of Health Payment by Results (PbR) Outpatient Tariff (Outpatient Treatment Function Code 104; Outpatient Procedure Code OPRSI1). RESULTS: During the study period 78 clinics offered 1184 appointments; 133 of these were not attended (11.2%). Of those attended 1029 had sufficient detail for analysis (98%). 261 (25.4%) patients were seen by a trainee. Applying PbR reimbursement criteria to these gave a projected annual income of £GBP 218,712 (€EU 266,527; $USD 353,657) generated by 6 surgical trainees (Residents). This is equivalent to approximately £GBP 36,452 (€EU 44,415; $USD 58,943) per trainee annually compared to £GBP 48,732 (€EU 59,378; $USD 78,800) per Consultant. This projected yearly income off-set 95% of the trainee's basic salary. CONCLUSION: Surgical trainees generated a quarter of the out-patient clinic activity related income in this study, with each trainee producing three-quarters of that generated by a Consultant. This offers considerable commercial value to hospitals. Although this must offset productivity differences and overall running costs, training bodies should ensure hospitals offer an appropriate return. In a competitive market hospitals could be invited to compete for trainees, with preference given to those providing excellence in training.

Lapatinib and trastuzumab in combination with an aromatase inhibitor for the first-line treatment of metastatic hormone receptor-positive breast cancer which over-expresses human epidermal growth factor 2 (HER2): a systematic review and economic analysis.

BACKGROUND: Breast cancer is the uncontrolled, abnormal growth of malignant breast tissue affecting predominantly women. Metastatic breast cancer (mBC) is an advanced stage of the disease when the disease has spread beyond the original organ. Hormone receptor status and human epidermal growth factor 2 (HER2) status are two predictive factors that are taken into consideration when estimating the prognosis of patients with breast cancer. OBJECTIVES: To review the clinical effectiveness and cost-effectiveness evidence base for lapatinib (LAP) in combination with an aromatase inhibitor (AI) and trastuzumab (TRA) in combination with an AI for the first-line treatment of patients who have hormone receptor-positive (HR+)/human epidermal growth factor 2-positive (HER2+) mBC. DATA SOURCES: Relevant electronic databases and websites, including MEDLINE, EMBASE and the Cochrane Library, were searched until May 2010. Further data were derived from the manufacturers' submissions for LAP + AI and TRA + AI. REVIEW METHODS: A systematic review of the clinical effectiveness and cost-effectiveness of LAP + AI and TRA + AI was undertaken. As it was deemed inappropriate to compare LAP + AI with TRA + AI, two separate assessments of cost-effectiveness versus AIs alone were undertaken. RESULTS: Three trials were included in the systematic review [the patient populations of the efficacy and safety of lapatinib combined with letrozole (EGF30008) trial, the efficacy and safety of trastuzumab combined with anastrozole (TAnDEM) trial and the efficacy and safety of letrozole combined with trastuzumab (eLEcTRA) trial]. As a result of differences in the exclusion criteria and because one trial was halted prematurely, comparisons across trials were believed to be inappropriate and meta-analysis was not possible. Individually, however, the findings from the trials all suggest that LAP + AI or TRA + AI results in improved progression-free survival and/or time to progression when compared with AIs alone. The trials do not show a statistically significant benefit in terms of overall survival. Two separate economic analyses were conducted based on the completed trials; neither LAP + AI nor TRA + AI was found to be cost-effective when compared with AI monotherapy. LIMITATIONS: Because of differences in the EGF30008 and the TAnDEM trials, the Assessment Group believes the indirect comparisons analyses conducted by the manufacturers are inappropriate and, for the same reason, chooses not to compare LAP + AI with TRA + AI in an economic evaluation. CONCLUSIONS: LAP + AI and TRA + AI appear to be clinically more effective than AI monotherapy, but neither is cost-effective compared with AIs alone. It was not possible to compare LAP + AI with TRA + AI. Future research should include research into treating mBC in the HR+/HER2+ population who are not TRA (or LAP) naive and into comparing the clinical effectiveness of AIs as monotherapy in patients with HER2+ and human epidermal growth factor 2-negative breast cancer. FUNDING: The National Institute for Health Research Technology Assessment programme.

Technologies in dermatology: teledermatology review.

Many rural and underserved communities face a shortage of dermatologists and long patient wait times. Teledermatology systems have the potential to accommodate increasing demands for dermatologists. With the current shortage of dermatologists in many communities, teledermatology complements conventional face-to-face dermatologic care where access to specialty care is limited. Teledermatology involves the use of communications technology to remotely provide skin care, and it is an extensively investigated branch of telemedicine. The overall goal of this review is to discuss the current literature on: 1) teledermatology technology; 2) accuracy and reliability of teledermatology; 3) healthcare delivery models, clinical outcomes, and satisfaction data; 4) economic considerations; and 5) future research considerations and implications of teledermatology.

Seating and pressure support needs of people with cancer in the cervix or rectum: a case series on the clinical usefulness of pressure mapping assessment.

Pressure sores present a challenge to people with rectal and cervical cancers due to weight loss, compromised nutrition, chemotherapy and radiotherapy. Affected individuals often experience intense pain on sitting, and prefer to spend the majority of their time lying down. This pilot study, employing a case study design, investigated the pressure care needs of such persons using pressure mapping, a technology designed to measure pressures at the seating interface. Four participants were mapped on a selection of five cushions, three of which were developed to specifically reduce midline posterior pressure/pain relief. Participants rated the cushions for comfort. Findings demonstrated an inconsistent relationship between interface pressures and perceived cushion comfort, suggesting that patient-rated comfort is a poor indicator of high interface pressures. The specialized cushions did not always meet the needs of this target population and no one cushion suited all. This study demonstrated the precarious clinical balance needed between comfort and achieving optimal pressure reduction in cushion prescription for this client group, and suggested that comfort was more important than pressure reduction in terms of their seating needs.

Characterization and solubility measurements of uranium-contaminated soils to support risk assessment.

Remediation of uranium-contaminated soils is considered a high priority by the U.S. Department of Energy because these soils, if left untreated, represent a hazard to the environment and human health. Because the risk to human health is a function of the solubility of uranium in the soils, the objectives of this work are to measure the uranium solubility of two contaminated soils, before and after remedial treatment, and determine the health risk associated with these soils. Two carbonate-rich, uranium-contaminated soils from the U.S. Department of Energy Fernald Environmental Management Project facility near Cincinnati, Ohio, as well as two nearby background soils were characterized and their uranium solubility measured in a 75-d solubility experiment using acid rain, groundwater, lung serum, and stomach acid simulants. Results show that the soluble uranium levels of each soil by each simulant are greatly influenced by their contamination source term. Risk calculations and biokinetic modeling based on the solubility data show that the risks from the soil ingestion and groundwater ingestion pathways are the predominant contributors to the total carcinogenic risk, whereas the risk from the soil inhalation pathway is the smallest contributor to this risk. However, kidney toxicity was the greater health concern of the Fernald Environmental Management Project soils, primarily from undiluted ingestion of the groundwater solution following contact with the contaminated soils. Sensitivity analyses indicate that uranium solubility is a key parameter in defining kidney toxicity; therefore, without proper consideration of the solubility of radionuclides/metals in untreated and treated soils, important factors may be overlooked which may result in soil cleanup goals or limits which are not protective of human health and the environment. We recommend that characterization and measurement of target radionuclides/metals solubilities should also be required by the regulatory community to support the establishment of scientifically-sound, site-specific, soil cleanup goals or limits.

Women, customary law and equality: lessons from research in southern Africa.

PIP: The Women and Law in Southern Africa Research Project (WSLA) has concluded, after 6 years of study in Zimbabwe, Zambia, Swaziland, Mozambique, Lesotho, and Botswana, that the deconstruction of customary law rather than an emphasis on the concept of equality represents the most promising strategy for producing justice for women. An historical analysis indicates that customary law was, before colonialism, a family-centered, flexible system of law that favored the negotiation and settlement of disputes rather than a rigid state-centered application of a rule. Traditionally, the unifying value base of customary law was preservation of the family and protection of women and children. Marriage was viewed as a joint partnership rather than a guardian-minor relationship. Polygyny, which today constitutes a source of female subordination, was originally developed to provide the protection of marriage to women at a time when there were not enough men to go around and an unmarried woman was vulnerable. Moreover, under true customary law, family property was the norm and widows remained on the land. The responsiveness of true customary law to changing socioeconomic conditions is illustrated by the newly developed practice of Chiefs in Botswana to allow women to speak and represent themselves in court; another example is the Chief's modification of seduction damages law to stipulate payment directly to the young mother rather than to her parents. After the introduction of colonialism, customary law was reconstructed to serve the political interests of capital; even now, post-independence governments use the law as a tool to oppress women. WLSA research suggests that an emphasis on gender-neutral, equality-based laws and statutes can lead to the further oppression of women. For example, such laws have made unemployed divorced women responsible for the maintenance of their ex-husband, and could be used to promote women, as well as men, having several spouses. Needed instead is an emphasis on the concept of social justice, including assurance that a women's choices are informed and her interests are promoted.^ieng