Eltrombopag as frontline treatment of aplastic anaemia in routine practice: implications on cost and efficacy.

The thrombopoietin mimetic eltrombopag (EPAG) is efficacious in clinical trials of newly diagnosed moderate (M), severe (S) and very severe (vS) aplastic anaemia (AA). Its use in routine practice and resource-constrained settings is not well described. Twenty-five men and 38 women at a median age of 54 (18-86) years with newly diagnosed AA treated consecutively in a 7-year period with EPAG (N = 6), EPAG/cyclosporine (CsA) (N = 33) and EPAG/CsA/anti-thymocyte globulin (ATG) (N = 24) were analyzed. Because EPAG was not reimbursed, peak doses ranged from 25 to 200 mg/day depending on affordability. EPAG/CsA-treated patients were older (median age: 61 years) with less severe AA (MAA, N = 15; SAA, N = 14; vSAA, N = 4), whereas EPAG/CsA/ATG-treated patients were younger (median age: 44 years) with more severe AA (MAA, N = 2; SAA, N = 12, vSAA, N = 10). The overall/trilineage response rates were 83%/50% for EPAG-treated patients; 79%/42% for EPAG/CsA-treated patients and 75%/63% for EPAG/CsA/ATG-treated patients. Adverse events included grade 1 liver derangement (N = 7) and grade 1 dyspepsia (N = 3). The 5-year overall survivals/failure-free survivals were 62%/80% for the entire cohort; 55%/75% for EPAG/CsA-treated patients and 82%/78% for EPAG/CsA/ATG-treated patients. EPAG showed robust efficacy in AA in routine practice. However, EPAG dosage and combinations remain to be optimized for AA of different severities.

The Earliest Food Deserts: Availability of Infant and Follow-on Formula, and Lactation Support Products among Stores in Black and Non-Hispanic White Zip Codes in Los Angeles County.

OBJECTIVES: This study investigates the availability, accessibility, and product depth of in-store infant feeding and galactagogues products in majority Black and majority white zip codes in Los Angeles County. METHODS: A cross-sectional study was conducted to determine racial/ethnic neighborhood differences in the availability of infant and follow-on formula and galactagogues products in 47 retail stores in 21 zip codes. Store-level data were collected in June 2019 and an observational tool for galactagogues products and infant/follow-on formula (availability, accessibility, product depth) was employed at each store. RESULTS: Most of the stores were grocery stores (87.2%). Stores in majority Black zip codes had less availability of infant formula ready-to-use (p = 0.001), less accessibility of follow-on powder (p = 0.028), and availability of galactagogues beverages (p = 0.036) versus majority white zip codes. Product depth (number of brands sold) of stores with one or more brands of the aforementioned products was consistently higher in majority white zip codes compared to majority Black zip codes. Stores in majority Black zip codes were most likely to have lower availability of infant formula and galactagogues products, an important part of the food environment for infant feeding options, in particular, for lactation support. CONCLUSIONS FOR PRACTICE: Most studies investigating the association of the food environment and health outcomes have focused only on solid foods. However, additional food products (e.g., liquids, powders) may be contributors to extensive disparities in infant mortality between Black and white infants and may lead to health disparities beyond infant stage (e.g., children, adolescents, and adults). Lastly, for breastfeeding inequities to decrease, pregnant and postpartum Black persons need equitable access and education on safe and quality galactagogues products.

Cost-effectiveness of letermovir as cytomegalovirus prophylaxis in adult recipients of allogeneic hematopoietic stem cell transplantation in Hong Kong.

BACKGROUND: The cost-effectiveness of letermovir as cytomegalovirus (CMV) prophylaxis in adult seropositive patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT), compared with the conventional strategy of preemptive treatment, has not been evaluated in Asia. METHODS: A decision analytical model, simulating the clinical progression of CMV infection on a lifetime horizon, was developed to compare prophylactic strategy with letermovir with preemptive therapy alone as anti-CMV strategies. Prophylaxis comprised administering letermovir for 14 weeks, with clinical outcomes measured at 24 weeks, followed by preemptive therapy if CMV infection occurred. This approach was modeled on outcomes of the letermovir phase 3 clinical study. The model enumerated the cost of letermovir prophylaxis, quality-adjusted life years (QALYs), and incremental cost per QALYs gained with prophylaxis. The opposite arm involved regular monitoring and preemptive therapy for CMV reactivation. Real-world costs from the adult HSCT center at Queen Mary Hospital, Hong Kong, were adopted for analysis. Costs and clinical benefits, expressed as QALYs, were discounted at 3% per year. RESULTS: Letermovir prophylaxis compared with preemptive therapy only would lead to an increase of life-year and QALYs at increased costs. Incremental cost-effectiveness analysis showed that letermovir prophylaxis had an associated cost of HKD 193,580 for each life-year gained, and HKD 234,675 for each QALY gained. Probabilistic sensitivity analysis showed that the majority of incremental cost-effectiveness ratio fell below the cost-effectiveness threshold of HKD 382,046 (one gross domestic product per capita) per QALY gained. CONCLUSIONS: Letermovir prophylaxis would be cost-effective for preventing CMV infection in adult seropositive allogeneic HSCT recipients in Hong Kong.

Risk assessment of venous thromboembolism in hematological cancer patients: a review.

Introduction: Venous thromboembolism (VTE) is a frequent and serious complication in cancer patients. Nonetheless, patients with hematological cancers receive less attention as compared with their solid tumor counterparts regarding this potentially fatal complication.Areas covered: Risk factors that are associated with the development of VTE in hematological cancers are discussed, based on a PubMed literature search. Since different hematological malignancies carry different risks of VTE, risk assessment in individual types of hematological cancers, including acute leukemias, lymphomas, myeloma, and myeloproliferative neoplasms are examined separately. Clinical relevance of VTE assessment and current guidelines on thromboprophylaxis in patients with hematological malignancies are also briefly reviewed.Expert opinion: When assessing VTE risk in patients with hematological cancers, in addition to the non-cancer specific risk factors, individual cancer-type-specific and the therapy-related factors must be taken into consideration. Primary thromboprophylaxis should be considered in high-risk patients.

Engagement in Enriching Early-Life Activities Is Associated With Larger Hippocampal and Amygdala Volumes in Community-Dwelling Older Adults.

OBJECTIVES: Numerous studies show benefits of mid- and late-life activity on neurocognitive health. Yet, few studies have examined how engagement in enriching activities during childhood, when the brain is most plastic, may confer long-term neurocognitive benefits that may be especially important to individuals raised in low-income settings. We examined associations between enriching early-life activities (EELAs) and hippocampal and amygdala volumes in a sample of predominantly African-American, community-dwelling older adults. We further assessed whether these associations were independent of current activity engagement. METHODS: Ninety participants from the baseline Brain Health Substudy of the Baltimore Experience Corps Trial (mean age: 67.4) completed retrospective activity inventories and an magnetic resonance imaging scan. Volumes were segmented using FreeSurfer. RESULTS: Each additional EELA was associated with a 2.3% (66.6 mm3) greater amygdala volume after adjusting for covariates. For men, each additional EELA was associated with a 4.1% (278.9 mm3) greater hippocampal volume. Associations were specific to these regions when compared with the thalamus, used as a control region. DISCUSSION: Enriching lifestyle activities during an important window of childhood brain development may be a modifiable factor that impacts lifelong brain reserve, and results highlight the importance of providing access to such activities in historically underserved populations.

Impact of scribes on emergency medicine doctors' productivity and patient throughput: multicentre randomised trial.

OBJECTIVES: To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput. DESIGN: Randomised, multicentre clinical trial. SETTING: Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit. PARTICIPANTS: 88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site. INTERVENTIONS: Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018. MAIN OUTCOME MEASURES: Physicians' productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians' productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done. RESULTS: Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians' productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes. CONCLUSIONS: Scribes improved emergency physicians' productivity, particularly during primary consultations, and decreased patients' length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia's. TRIAL REGISTRATION: ACTRN12615000607572 (pilot site); ACTRN12616000618459.

Variety of Enriching Early-Life Activities Linked to Late-Life Cognitive Functioning in Urban Community-Dwelling African Americans.

OBJECTIVES: The early environment is thought to be a critical period in understanding the cognitive health disparities African Americans face today. Much is known about the positive role enriching environments have in mid- and late-life and the negative function adverse experiences have in childhood; however, little is known about the relationship between enriching childhood experiences and late-life cognition. The current study examines the link between a variety of enriching early-life activities and late-life cognitive functioning in a sample of sociodemographic at-risk older adults. METHOD: This study used data from African Americans from the Brain and Health Substudy of the Baltimore Experience Corps Trial (M = 67.2, SD = 5.9; N = 93). Participants completed a battery of neuropsychological assessments and a seven-item retrospective inventory of enriching activities before age 13. RESULTS: Findings revealed that a greater enriching early-life activity score was linked to favorable outcomes in educational attainment, processing speed, and executive functioning. DISCUSSION: Results provide promising evidence that enriching early environments are associated with late-life educational and cognitive outcomes. Findings support the cognitive reserve and engagement frameworks, and have implications to extend life-span prevention approaches when tackling age-related cognitive declines, diseases, and health disparities.

Naturally Occurring Mentorship in a National Sample of First-Generation College Goers: A Promising Portal for Academic and Developmental Success.

Attending college is increasingly important to compete in this global world; however, young people whose parents did not attend college are significantly less likely to enroll in and finish college. Formal programs to support first-generation college goers are common, but not scalable to provide support to all young people who need it. Instead, mentoring that naturally occurs on these students' journeys into and out of college may be a more practical avenue for supporting their success. This study investigated the role community members, relatives, and educators play in first-generation college goers' educational outcomes. Data from 4,181 participants of the National Longitudinal Study of Adolescent and Adult Health were used to test differences in supports received between first-generation, continuing-generation, and non-college goers. Results demonstrated that mentorship in adolescence moderated the relationship between parental college attendance and educational attainment in adulthood. Next, findings suggested that first-generation students received less support for identity development from their mentors than continuing-generation students. This study has program implications for facilitating college attendance and fostering the development and success of first-generation students. Moreover, this project continues to concretize an emerging taxonomy of mentoring functions for youth and emerging adults.

Posaconazole vs fluconazole or itraconazole for prevention of invasive fungal diseases in patients with acute myeloid leukemia or myelodysplastic syndrome: a cost-effectiveness analysis in an Asian teaching hospital.

BACKGROUND: Posaconazole is superior to fluconazole/itraconazole in preventing invasive fungal diseases (IFDs) in neutropenic patients. Whether the higher cost of posaconazole is offset by decreases in IFDs in a given institute requires cost-effective analysis encompassing the spectrum of IFDs and socioeconomic factors specific to that geographic area. METHODS: This study performed a cost-effective analysis of posaconazole prophylaxis for IFDs in an Asian teaching hospital, employing decision modeling and data of IFDs and medication costs specific to the institute, in neutropenic patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). RESULTS: In the cost-effectiveness analysis, the higher cost of posaconazole was partially offset by a reduction in the cost of treating IFDs that were prevented, resulting in an incremental cost of 125,954 Hong Kong dollars/16,148 USD per IFD avoided. Over a lifetime horizon, assuming same case fatality rate of IFDs in both groups, use of posaconazole results in 0.07 discounted life years saved. This corresponds to an incremental cost of 116,023 HKD/14,875 USD per life year saved. This incremental cost per life year saved in posaconazole prophylaxis fulfilled the World Health Organization defined threshold for cost-effectiveness. CONCLUSION: Posaconazole prophylaxis was cost-effective in Hong Kong.

Ciguatera fish poisoning in East Asia and southeast Asia.

In the coastal countries of East Asia and Southeast Asia, ciguatera should be common because of the extensive tropical and subtropical coral reefs along the coasts and in the neighboring seas with ciguatoxic fishes. An extensive search of journal databases, the Internet and the government websites was performed to identify all reports of ciguatera from the regions. Based on the official data and large published case series, the incidence of ciguatera was higher in the coastal cities (Hong Kong, Foshan, Zhongshan) of southern China than in Japan (Okinawa Prefecture). In Singapore, ciguatera appeared to be almost unknown. In other countries, only isolated cases or small case series were reported, but under-reporting was assumed to be common. Ciguatera may cause severe acute illness and prolonged neurological symptoms. Ciguatera represents an important public health issue for endemic regions, with significant socio-economic impact. Coordinated strategies to improve risk assessment, risk management and risk communication are required. The systematic collection of accurate data on the incidence and epidemiology of ciguatera should enable better assessment and management of its risk. Much more work needs to be done to define the size threshold for important coral reef fish species from different regions, above which the risk of ciguatera significantly increases.

A study of the health and economic effects of influenza-like illness on the working population under different working environments of a large corporation in Hong Kong.

OBJECTIVE: The incidence, health and economic impacts of influenza-like illness (ILI) among the working population in Hong Kong had never been studied. Due to the nature of the disease, ILIs can have a significant impact on the operation of a corporation in terms of loss of productivity and reduced work performance. The present study was undertaken to determine the health and economic impacts of ILIs under different environmental conditions on the working population of a large corporation. METHOD: Over 2,000 employees of a large corporation in the travelling and tourism industry were studied with three different types of working environment (confined, typical office and well ventilated) by two structured questionnaires. RESULTS: The most affected group in terms of productivity and health was the group working in a confined area, whilst those working in a well-ventilated area were least affected. However, symptoms of the confined area group seemed to disappear faster. The infection rate appeared to vary according to work environment for the studied population. CONCLUSION: Policies on preventive measures and early treatment are important for a corporation to reduce loss in productivity due to ILIs.

Economic evaluation of a clinical protocol for diagnosing emergency patients with suspected pulmonary embolism.

BACKGROUND: The objective of this paper is to estimate the amount of cost-savings to the Australian health care system from implementing an evidence-based clinical protocol for diagnosing emergency patients with suspected pulmonary embolism (PE) at the Emergency department of a Victorian public hospital with 50,000 presentations in 2001-2002. METHODS: A cost-minimisation study used the data collected in a controlled clinical trial of a clinical protocol for diagnosing patients with suspected PE. The number and type of diagnostic tests in a historic cohort of 185 randomly selected patients, who presented to the emergency department with suspected PE during an eight month period prior to the clinical trial (January 2002-August 2002) were compared with the number and type of diagnostic tests in 745 patients, who presented to the emergency department with suspected PE from November 2002 to August 2003. Current Medicare fees per test were used as unit costs to calculate the mean aggregated cost of diagnostic investigation per patient in both study groups. A t-test was used to estimate the statistical significance of the difference in the cost of resources used for diagnosing PE in the control and in the intervention group. RESULTS: The trial demonstrated that diagnosing PE using an evidence-based clinical protocol was as effective as the existing clinical practice. The clinical protocol offers the advantage of reducing the use of diagnostic imaging, resulting in an average cost savings of at least $59.30 per patient. CONCLUSION: Extrapolating the observed cost-savings of $59.30 per patient to the whole of Australia could potentially result in annual savings between $3.1 million to $3.7 million.

Reducing the use of diagnostic imaging in patients with suspected pulmonary embolism: validation of a risk assessment strategy.

OBJECTIVES: The aims of this study were to measure the: (i) effects of implementation of a new risk assessment strategy for patients with suspected pulmonary embolism (PE) on the use of imaging and D-dimer assay; (ii) negative predictive value for PE of a combination of low risk and negative D-dimer assay; and (iii) compliance of ED clinicians with the strategy. METHODS: A non-randomized clinical trial was conducted in the ED of a 720-bed teaching hospital between November 2002 and August 2003. Study subjects with suspected PE were compared with 191 randomly selected historical controls. The risk assessment strategy of Kline et al. was disseminated and implemented. RESULTS: The negative predictive value for PE was 99% (95% confidence interval [CI] = 97-100%) in 114 patients with low risk and negative D-dimer. There was a 21% absolute reduction in the rate of imaging following the implementation of the risk assessment strategy (56% vs 77%, P < 0.001). CONCLUSION: Low risk combined with a negative D-dimer result may allow exclusion of PE without imaging.

Cost-effectiveness analysis of high-dose omeprazole infusion as adjuvant therapy to endoscopic treatment of bleeding peptic ulcer.

BACKGROUND: Intravenous administration of proton pump inhibitors after endoscopic treatment of bleeding peptic ulcers has been shown to decrease the rate of recurrent bleeding and the need for subsequent surgery. Yet there is a relative lack of formal assessment of this practice. The aim of this study was to examine the cost-effectiveness of this therapy by using standard pharmacoeconomic methods. METHODS: The present study was performed in conjunction with a randomized controlled clinical trial that included 232 patients who received either omeprazole (80 mg intravenous bolus followed by infusion at 8 mg/hour for 72 hours) or placebo after hemostasis was achieved endoscopically. A cost-effectiveness analysis was performed to evaluate the different outcomes of the trial. All related direct medical costs were identified from patient records. Cost-effectiveness ratios were calculated. RESULTS: Analysis by the Kolmogorov-Smirnov test showed that the direct medical cost in the omeprazole group was lower than that for the placebo group. Cost-effectiveness ratios for omeprazole and placebo groups were, respectively, HK$ 28,764 (US$ 3688) and HK$ 36,992 (US$ 4743) in averting one episode of recurrent bleeding in one patient after initial hemostasis was achieved endoscopically. CONCLUSIONS: Intravenous administration of high-dose omeprazole appears to be a cost-effective therapy in reducing the recurrence of bleeding and need for surgery in patients with active bleeding ulcer after initial hemostasis is obtained endoscopically.