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Heavy menstrual bleeding occurs in 80% of women with von Willebrand disease and is associated with iron deficiency and poor response to current therapies. International guidelines indicate low certainty regarding effectiveness of hormonal therapy and tranexamic acid. Although von Willebrand factor (VWF) concentrate is approved for bleeds, no prospective trials guide its use in heavy menstrual bleeding. We aimed to compare recombinant VWF with tranexamic acid for reducing heavy menstrual bleeding in patients with von Willebrand disease.

For all students, cognitive and social and emotional needs go hand in hand. Teachers of academically advanced students should address these intertwining needs in ways that are sensitive to what is unique about how these students think and feel. Over the years, my students have taught me several lessons about how to do just that. These lessons have prepared me to respond better to students’ perfectionist tendencies and their belief that school should be easy, to keep students engaged, to support the particular learning styles of my female students, and to help students be comfortable with their abilities. In this article, I explain how each of these lessons relates to students’ cognitive, social, and emotional needs and offer suggestions for helping students deal with each issue. In each explanation, I draw heavily on what many of my former students have shared with me.

Secondary analysis of the CONNECT nurse-led primary palliative care intervention found little effect on illness expectations in patients with advanced cancer at 3 months.

Introduction: US pneumococcal vaccination recommendations for adults aged 65 years or older recently changed, with options for either 20-valent pneumococcal conjugate vaccine (PCV20) or the combination of 15-valent conjugate vaccine (PCV15) followed by 23-valent polysaccharide vaccine (PPSV23) 1 year later. Underserved minority adults are at higher risk for pneumococcal disease. Methods: A Markov decision analysis model estimated the incremental cost-effectiveness of the newly adopted general population pneumococcal vaccination strategies in older underserved minority adults. The model examined hypothetical 65-year-old US Black cohorts (serving as a proxy for underserved minorities) and non-Black cohorts receiving PCV20 or PCV15/PPSV23, or no vaccination. Main outcome measures included incremental cost-effectiveness per quality-adjusted life year (QALY) gained and pneumococcal disease public health outcomes. Results: Black cohorts had a greater risk of pneumococcal disease hospitalization compared to non-Black cohorts. In Black cohorts, total per person PCV20 strategy costs, compared to no vaccination, were $124 higher while gaining 0.00073 QALY, or $169,540/QALY gained. PCV15/PPSV23 cost $535,797/QALY compared to PCV20. In the non-Black cohort, PCV20 cost $210,529/QALY gained compared to no vaccination and PCV15/PPSV23 cost $728,423/QALY. Plausible variation of vaccine effectiveness minimally affected PCV20 strategy results and made PCV15/PPSV23 more unfavorable. In scenarios where the simpler one-vaccine PCV20 strategy increased absolute vaccine uptake by 10%, PCV20 cost-effectiveness changed minimally while PCV15/PPSV23 cost in excess of $6 million/QALY in the Black cohort. In probabilistic sensitivity analyses that varied all parameters simultaneously, PCV15/PPSV23 was unlikely to be favored at thresholds less than $500,000/QALY gained. Conclusion: General population recommendations for PCV20 use are substantially more economically reasonable in Black and non-Black older adult populations than PCV15/PPSV23. If using a single vaccine increases uptake, which is potentially more likely in the underserved, then PCV20 use becomes even more favorable.

IMPORTANCE: Guidelines recommend early specialty palliative care for all patients with advanced cancer, but most patients lack access to such services. OBJECTIVE: To assess the effect of CONNECT (Care Management by Oncology Nurses to Address Supportive Care Needs), a primary palliative care intervention delivered by oncology nurses, on patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized clinical trial of the CONNECT intervention vs standard care was conducted from July 25, 2016, to October 6, 2020. Participants were adult patients with metastatic solid tumors who were undergoing oncological care and for whom an oncologist would agree with the statement “would not be surprised if the patient died in the next year.” The trial was conducted at 17 community oncology practices in western Pennsylvania. Data analyses adhered to the intention-to-treat principle. INTERVENTIONS: The CONNECT intervention included 3 monthly visits with an existing infusion room nurse who was trained to address symptoms, provide emotional support, engage in advance care planning, and coordinate care. MAIN OUTCOMES AND MEASURES: The primary outcome was quality of life. At baseline and 3 months, participants completed assessments of quality of life (Functional Assessment of Chronic Illness Therapy-Palliative care: score range, 0-184, with higher scores indicating better quality of life), symptom burden (Edmonton Symptom Assessment Scale: score range, 0-90, with higher scores indicating greater symptom burden), and mood symptoms (Hospital Anxiety and Depression Scale [HADS]: score range, 0-21, with higher scores indicating substantial anxiety and depression). Linear mixed-effects models were used to estimate adjusted mean differences in 3-month outcomes. Preplanned, intensity-adjusted analyses were conducted. RESULTS: A total of 672 patients were enrolled (mean [SD] age, 69.3 [10.2] years; 360 women [53.6%]). The mean (SD) number of CONNECT visits completed was 2.2 (1.0). At 3 months, no difference in mean (SD) quality-of-life score was found between the CONNECT and standard care groups (130.7 [28.2] vs 134.1 [28.1]; adjusted mean difference, 1.20; 95% CI, −2.75 to 5.15; P = .55). Similarly, there was no difference between groups in 3-month mean (SD) symptom burden (23.2 [16.6] vs 24.0 [16.1]; adjusted mean difference, −2.64; 95% CI, −5.85 to 0.58; P = .11) or mood symptoms (HADS depression subscale score: 5.1 [3.4] vs 4.8 [3.7], adjusted mean difference, −0.08 [95% CI, −0.71 to 0.57], P = .82; HADS anxiety subscale score: 5.7 [3.9] vs 5.4 [4.2], adjusted mean difference, −0.31 [95% CI, −0.96 to 0.33], P = .34). Intensity-adjusted analyses revealed a larger estimated treatment effect for patients who received a full dose (3 visits) of the CONNECT intervention. CONCLUSIONS AND RELEVANCE: This cluster randomized clinical trial found that a primary palliative care intervention that was delivered by oncology nurses did not improve patient-reported outcomes at 3 months. Primary palliative care interventions with a higher dose intensity may be beneficial for most patients with advanced cancer who lack access to palliative care specialists. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02712229

ObjectiveTo establish a rigorous, expert-led, evidence-based approach to the evaluation of licensed drugs for repurposing and testing in clinical trials of people with progressive multiple sclerosis (MS).MethodsWe long-listed licensed drugs with evidence of human safety, blood–brain barrier penetrance and demonstrable efficacy in at least one animal model, or mechanistic target, agreed by a panel of experts and people with MS to be relevant to the pathogenesis of progression. We systematically reviewed the preclinical and clinical literature for each compound, condensed this into a database of summary documents and short-listed drugs by scoring each one of them. Drugs were evaluated for immediate use in a clinical trial, and our selection was scrutinised by a final independent expert review.ResultsFrom a short list of 55 treatments, we recommended four treatments for immediate testing in progressive MS: R-α-lipoic acid, metformin, the combination treatment of R-α-lipoic acid and metformin, and niacin. We also prioritised clemastine, lamotrigine, oxcarbazepine, nimodipine and flunarizine.ConclusionsWe report a standardised approach for the identification of candidate drugs for repurposing in the treatment of progressive MS.

Subclinical rejection (SCR) screening in kidney transplantation (KT) using protocol biopsies and noninvasive biomarkers has not been evaluated from an economic perspective. We assessed cost‐effectiveness from the health sector perspective of SCR screening in the first year after KT using a Markov model that compared no screening with screening using protocol biopsy or biomarker at 3 months, 12 months, 3 and 12 months, or 3, 6, and 12 months. We used 12% subclinical cellular rejection and 3% subclinical antibody‐mediated rejection (SC‐ABMR) for the base‐case cohort. Results favored 1‐time screening at peak SCR incidence rather than repeated screening. Screening 2 or 3 times was favored only with age <35 years and with high SC‐ABMR incidence. Compared to biomarkers, protocol biopsy yielded more quality‐adjusted life years (QALYs) at lower cost. A 12‐month biopsy cost $13 318/QALY for the base‐case cohort. Screening for cellular rejection in the absence of SC‐ABMR was less cost effective with 12‐month biopsy costing $46 370/QALY. Screening was less cost effective in patients >60 years. Using biomarker twice or thrice was cost effective only if biomarker cost was <$700. In conclusion, in KT, screening for SCR more than once during the first year is not economically reasonable. Screening with protocol biopsy was favored over biomarkers. Economic analyses suggest that screening more than once for subclinical rejection during the first year after kidney transplant is generally not cost‐effective and that protocol biopsy is favored over biomarkers.

The reactions of furan and 2-methylfuran with methylidyne CH (X2Π) radical were investigated at 298 K using synchrotron radiation produced at the Advanced Light Source of the Lawrence Berkeley National Laboratory. Reaction products were observed by multiplexed photoionization mass spectrometry and characterized based on their photoionization spectra and kinetic time traces. Primary products observed in furan + CH are 2,4-cyclopentadien-1-one (m/z= 80), 2-penten-4-ynal (m/z= 80), and vinylacetylene (m/z= 52). From 2-methylfuran + CH, 2-4-cyclopentadien-1-carbaldehyde (m/z= 94), 2,3,4-hexatrienal (m/z= 94), 1,3 cyclopentadiene (m/z= 66), 3-penten-1-yne (Z) (m/z= 66), and vinylacetylene (m/z= 52) are the primary products observed. Using potential energy surface scans, thermodynamically favorable reaction pathways are proposed. CH addition to the π-bonds in furan and 2-methylfuran rings was found to be the entrance channel that led to formation of all identified primary products. Both reactions follow patterns of H loss and CHO loss, as well as formation of cyclic and acyclic isomers.

Novel anti-obesity medications, particularly glucagon-like peptide-1 receptor agonists (GLP-1RAs), have expanded weight loss (WL) options for kidney transplant (KT) candidates with obesity beyond lifestyle modifications and bariatric surgery. However, varying effectiveness, risk profiles, and costs make strategy choice challenging. To aid decision-making, we used a Markov model to examine the cost-effectiveness of different WL strategies over a 10-year horizon. A target WL of 15% of total body weight was used for the base-case scenario, and we compared these strategies to a ‘liberal’ KT strategy of transplanting candidates with obesity. Outcomes included costs (2023 US dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. In analysis, a liberal KT strategy was favored over lifestyle modifications and GLP-1RAs. Among WL strategies, bariatric surgery was most effective and cost the least, while lifestyle modification had the highest cumulative costs and was least effective. Compared to liberal KT, bariatric surgery cost $45,859 per QALY gained. GLP-1RAs were favored over bariatric surgery only when drug costs were below $5,000 per year (base cost $12,077). In conclusion, for KT candidates with obesity, a liberal KT strategy and bariatric surgery are preferred over lifestyle modifications alone and GLP-1RAs based on outcomes and cost-effectiveness.

ABSTRACTBackground: Broadly protective, long-lasting universal influenza vaccines are under development in response to low-moderate seasonal vaccine effectiveness, frequent genetic changes in circulating viruses and extended turnaround for vaccine manufacture. Because a long-lasting vaccine might be less effective than a seasonal vaccine that has been matched to current circulating strains, the public health impact of its introduction should be evaluated.Methods: A modified agent-based model (ABM) examined multi-year effects of a universal vaccine among 18 to 49-year-olds, given in Year 1 only. The proportion of vaccinated 18 to 49-year-olds who received universal vaccine was varied from 0% to 100%. Model parameters were drawn from US databases and the medical literature. Outcomes were 4-year cumulative and annual influenza cases as well as annual cases averted/100,000 population for 3 age groups, 0–17 years, 18–49 years and 50+ years.Results: In Year 1 when universal vaccine was given to 50% or 100% of all vaccinated 18 to 49-year-olds, more influenza cases occurred, compared to no universal vaccine, but fewer cases occurred in Years 2–4 as overall protection increased. Cumulative averted cases over 4 years in 18 to 49-year-olds were 892/100,000 and 1,687/100,000 population for the 50% and 100% universal vaccine for 18 to 49-year-olds scenarios, respectively, with additional benefits to children and older adults through indirect effects.Conclusions: In ABM, the universal vaccine with a conservative VE estimate given once to 18 to 49-year-olds reduced influenza cases among all age groups in Years 2–4 following its introduction. Reduced influenza burden may occur sooner if VE of universal vaccines exceeds that assumed in these models.

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Racial disparities in U.S. adult pneumococcal vaccination rates persist despite reduced barriers to access. Consequently, racial and ethnic minorities experience pneumococcal disease at higher rates than whites. This study examined prevalence of high-risk conditions and pneumococcal hospitalizations among U.S. black and non-black populations aged ≥50 years.

IMPORTANCE: The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings. OBJECTIVE: To estimate the financial and reproductive health implications for the VA of implementing a 12-month OCP dispensing option, with the goal of informing policy change. DESIGN, SETTING, AND PARTICIPANTS: A decision model from the VA payer perspective was developed to estimate incremental costs to the health care system of allowing the option to receive a 12-month supply of OCPs up front, compared with the standard 3-month maximum, during a 1-year time horizon. A model cohort of 24 309 reproductive-aged, heterosexually active, female VA enrollees who wish to avoid pregnancy for at least 1 year was assumed. Probabilities of continuation of OCP use, coverage gaps, pregnancy, and pregnancy outcomes were drawn from published data. Costs of OCP provision and pregnancy-related care and the number of women using OCPs were drawn from VA administrative data. One-way and probabilistic sensitivity analyses were performed to assess model robustness. MAIN OUTCOMES AND MEASURES: Incremental per-woman and total costs to the VA of allowing for 12-month dispensing of OCPs compared with standard 3-month dispensing. RESULTS: The 12-month OCP dispensing option, modeled from the VA health system perspective using a cohort of 24 309 women, resulted in anticipated VA annual cost savings of $87.12 per woman compared with the cost of 3-month dispensing, or an estimated total savings of $2 117 800 annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations. CONCLUSIONS AND RELEVANCE: Adoption of a 12-month OCP dispensing option is expected to produce substantial cost savings for the VA while better supporting reproductive autonomy and reducing unintended pregnancy among women veterans.

ABSTRACTIn the U.S., pneumococcal polysaccharide vaccine (PPSV23) uptake among high-risk adults aged <65 years is consistently low and improvement is needed. One barrier to improved vaccine coverage is the complexity of the adult vaccination schedule. This exploratory analysis compared the cost-effectiveness of strategies to increase pneumococcal vaccine uptake in high-risk adults aged 50–64 years. We used a Markov model to compare strategies for non-immunocompromised 50–64 year olds: 1) current pneumococcal polysaccharide vaccine (PPSV23) recommendations; 2) current recommendations enhanced by an intervention; 3) PPSV23 plus pneumococcal conjugate vaccine (PCV13) for high-risk patients with no intervention; or 4) both vaccines for all 50-year-olds with no intervention. Parameters included CDC data and other US data, varied extensively in sensitivity analyses. In the analysis, vaccinating high-risk individuals with PPSV23/PCV13 was the least costly strategy, with total costs of $424/person. Vaccinating all 50 year olds with PPSV23/PCV13 cost $40 more and gained 0.00068 quality-adjusted life years (QALY), or $57,786/QALY gained. Current recommendations with or without an intervention program were more expensive and less effective than other strategies. In multi-way sensitivity analyses, the current recommendations/intervention program strategy was favored at a $100,000/QALY threshold only if non-bacteremic pneumococcal pneumonia rate or PCV13 serotype coverage were substantially lower than base case values. Thus, an intervention program to improve pneumococcal vaccine uptake among high-risk 50–64 year-olds was not cost-effective in most scenarios. High-risk individuals receiving both PCV13 and PPSV23 could be economically favorable, and vaccinating all 50-year-olds with both vaccines could be considered.

In 2012 the American Urological Association released asymptomatic microhematuria guidelines that resulted in criticisms of overtreatment and improper risk stratification, particularly in women. Specifically, concerns have been raised regarding overtreatment in low risk female patients. Evaluating trade-offs between cost and effectiveness can provide valuable insight into the applicability of these guidelines in different patient populations.

Despite having the raw ability to pursue careers in science and engineering, gifted girls often shy away from such careers. Here, the authors explore two explanations for this puzzling phenomenon. Specifically, they argue that exposure to (a) negative stereotypes about women’s intellectual abilities and (b) stereotypes about scientists as “nerdy,” eccentric loners may undermine gifted girls’ confidence in their ability to succeed in science and engineering, their sense of belonging in these fields, and—ultimately—their interest. The authors also suggest evidence-based strategies for inoculating girls against these stereotypes and boosting their interest in science and engineering.

Traditional career education activities at the secondary level consist of academic, aptitude, skills, interests, and, less often, personality assessments that assist students in narrowing viable career options. Although this strategy is reasonable, its attempt to objectify the career decision-making process does not address two important components of career decision-making—personal values and social-emotional concerns. Because gifted students possess characteristics, such as heightened sensitivity, multipotentiality, and perfectionism, that might complicate this process, appropriately differentiated career education includes these dimensions, especially during times of transition. Due to gaps in preparation and training, school counselors may feel inadequate in meeting these students’ unique social-emotional needs. For gifted ruralstudents, career decision-making may be especially difficult as parents, school counselors, teachers, and other adults in the community encourage students to leave their small towns to realize their college and career dreams elsewhere. Rural students often experience deep connections to family and place, further complicating this developmental task of adolescence. This study highlights the voices of 19 gifted rural students as they share their thoughts and concerns regarding K-12 career education, values, and attachments to family and community. Considerations for school counselors and teachers who work in rural settings are included.

This article explores some of the common causes and solutions to perfectionism in gifted children. We highlight practical implications from studies examining perfectionism in gifted students, including how implicit theories of intelligence (e.g., mindset) relate to perfectionism. Specific strategies are shared to guide gifted children toward a mindful pursuit of excellence in which they are self-aware of how their thoughts, emotions, and beliefs about ability influence their behaviors in achieving a high standard.

Gifted individuals have unique social and emotional needs that often manifest as challenging interpersonal behavior. Chief among these needs are the fact that gifted students tend to be quite emotionally intense and that they tend to be quite cognitively rigid. Emotional intensity is defined as having stronger, more frequent, more complex, and more lasting emotional responses than would be considered typical. Cognitive rigidity is defined as difficulty in changing mental sets. The intersection of these two traits in the gifted population makes interventions challenging, but the impact of these traits can affect a person’s personal, social, and emotional growth. There are therapeutic techniques that can allow counselors, teachers, parents, and psychologists to positively impact these limiting traits. This article examines relevant literature on the subjects above, provides a case example from the author’s mental health practice, and explores potential interventions.

Gifted students can encounter anxiety-provoking stressors throughout their day. Developing effective anxiety management skills allows them to better navigate these challenges. Concepts from neuroscience help us better understand responses to anxiety and can assist gifted youth and those working with them in recognizing how and when to best apply anxiety management strategies. This article reviews these concepts and integrating them into the classroom environment to assist with this learning process. In addition, it examines an evidenced-based anxiety management intervention that has been found to be efficacious for gifted youth, Emotional Freedom Techniques (EFT). Results of recent EFT research are reviewed and the steps to learning EFT are outlined.

Occupational noise threatens U.S. worker health and safety and commands a significant financial burden on state and federal government worker compensation programs. Previous studies suggest that hearing conservation programs have contributed to reduced occupational hearing loss for noise-exposed workers. Many military personnel are overexposed to noise and are provided hearing conservation services. Select military branches require all active duty personnel to follow hearing conservation program guidelines, regardless of individual noise exposure. We evaluated the cost-effectiveness of a military hearing conservation program, relative to no intervention, in relation to cases of hearing loss prevented.

Gene therapy provides a potential phenotypic cure for hemophilia, yet the cost of this novel treatment is high, tempering enthusiasm and raising questions regarding cost vs benefit. To evaluate the cost-effectiveness of gene therapy treatment of severe hemophilia A compared with prophylaxis with factor VIII (FVIII), we developed a Markov state–transition model to estimate the costs and effectiveness of severe hemophilia A treatment strategies from a United States health care system perspective. Quality-adjusted life-years (QALYs) were the effectiveness measure. In the base case, hypothetical cohorts of 30-year-old patients received gene therapy or FVIII prophylaxis. We obtained model probabilities and utilities from the literature and costs from Medicare reimbursement data. One-way and probabilistic sensitivity analyses were performed to test the robustness of results. Over a 10-year time horizon, total per-person gene therapy strategy costs were $1.0M and resulted in 8.33 QALYs, whereas prophylaxis cost $1.7M and resulted in 6.62 QALYs. Thus, gene therapy dominated prophylaxis (costs less and was more effective). Gene therapy remained dominant unless initial costs exceeded $1.6M and were <$100 000 per 1 QALY gained compared with prophylaxis if initial costs were <$1.7M. Results were not sensitive to variation of all other parameters over clinically plausible ranges. In a probabilistic sensitivity analysis simultaneously varying all parameters 3000 times over parameter distributions, gene therapy was dominant in 92% of model iterations. Treatment of severe hemophilia A with gene therapy is likely to be cost-saving or cost-effective compared with FVIII prophylaxis.

Gene therapy provides a potential phenotypic cure for hemophilia, yet the cost of this novel treatment is high, tempering enthusiasm and raising questions regarding cost vs benefit. To evaluate the cost-effectiveness of gene therapy treatment of severe hemophilia A compared with prophylaxis with factor VIII (FVIII), we developed a Markov state–transition model to estimate the costs and effectiveness of severe hemophilia A treatment strategies from a United States health care system perspective. Quality-adjusted life-years (QALYs) were the effectiveness measure. In the base case, hypothetical cohorts of 30-year-old patients received gene therapy or FVIII prophylaxis. We obtained model probabilities and utilities from the literature and costs from Medicare reimbursement data. One-way and probabilistic sensitivity analyses were performed to test the robustness of results. Over a 10-year time horizon, total per-person gene therapy strategy costs were $1.0M and resulted in 8.33 QALYs, whereas prophylaxis cost $1.7M and resulted in 6.62 QALYs. Thus, gene therapy dominated prophylaxis (costs less and was more effective). Gene therapy remained dominant unless initial costs exceeded $1.6M and were <$100?000 per 1 QALY gained compared with prophylaxis if initial costs were <$1.7M. Results were not sensitive to variation of all other parameters over clinically plausible ranges. In a probabilistic sensitivity analysis simultaneously varying all parameters 3000 times over parameter distributions, gene therapy was dominant in 92% of model iterations. Treatment of severe hemophilia A with gene therapy is likely to be cost-saving or cost-effective compared with FVIII prophylaxis.

The goal of this study was to precisely and unambiguously identify foreign particles in human tissues using a combination of polarized light microscopy and Raman microscopy, which provides chemical composition and microstructural characterization of complex materials with submicrometer spatial resolution. This identification for patient care and research has been traditionally studied using polarized light microscopy, electron microscopy with X-ray analysis, and electron diffraction, all with some limitations. We designed a model system of stained and unstained cells that contained birefringent talc particles and systematically investigated the influence of slide and coverslip materials, laser wavelengths, and mounting media on the Raman spectra obtained. Hematoxylin and eosin stained slides did not produce useful results because of fluorescence interference from the stains. Unstained cell samples prepared with standard slides and coverslips produce high quality Raman spectra when excited at 532 nm; the spectra are uniquely assigned to talc. We also obtain high quality Raman spectra specific for talc in unstained tissue samples (pleural tissue following talc pleurodesis and ovarian tissue following long-term perineal talc exposure). Raman microscopy is sufficiently sensitive and compositionally selective to identify particles as small as one micrometer in diameter. Raman spectra have been catalogued for thousands of substances, which suggests that this approach is likely to be successful in identifying other particles of interest in tissues, potentially making Raman microscopy a powerful new tool in pathology.

Intervention fidelity is a critical component of behavioral research that has received inadequate attention in palliative care studies. With increasing focus on the need for palliative care models that can be widely disseminated and delivered by non-specialists, rigorous yet pragmatic strategies for training interventionists and maintaining intervention fidelity are needed.

IMPORTANCE: Little evidence exists to guide helicopter emergency medical services (HEMS) triage, and current practice is inefficient. The Air Medical Prehospital Triage (AMPT) score was developed to identify patients most likely to benefit from HEMS compared with ground EMS. To our knowledge, no studies have evaluated the potential effect on costs and outcomes of a more targeted HEMS triage strategy, such as the AMPT score. OBJECTIVE: To evaluate the cost-effectiveness of current practice compared with the AMPT score for HEMS scene triage of trauma patients. DESIGN, SETTING, AND PARTICIPANTS: A cost-effectiveness Markov model was developed for the US health care system to compare current practice with the AMPT score as HEMS scene triage strategies from the health care system perspective over a patient lifetime horizon. A base case was estimated using national data of patient characteristics from the National Trauma Databank from 2007 to 2012. Model inputs, including demographic information, health care costs, survival, and utility estimates, were derived from literature and national registries. Triage strategies were modeled as probability of HEMS transport. Multilevel logistic regression was used to evaluate survival probability between HEMS and ground EMS under the triage strategies. Costs considered included transport reimbursements, hospitalization, cost of health care in the first year postinjury, and annual cost of health care after the first year postinjury. Several sensitivity analyses were performed to evaluate robustness of model assumptions. MAIN OUTCOMES AND MEASURES: Incremental cost-effectiveness ratio, with a threshold of $100 000 or less per quality-adjusted life-year defining cost-effectiveness. RESULTS: The base case had an incremental cost-effectiveness ratio of $255 333 per quality-adjusted life-year for current practice compared with the AMPT score. Assuming 20% of patients have severe injuries and assuming HEMS only benefits these patients, current practice had an incremental cost-effectiveness ratio of $176 686 per quality-adjusted life-year. Probabilistic sensitivity analysis demonstrated that current practice is inferior in 85% of iterations, only becoming favored when the cost-effectiveness threshold is greater than $310 000 per quality-adjusted life-year. CONCLUSIONS AND RELEVANCE: Current practice is not cost-effective compared with the AMPT score for HEMS scene triage. The AMPT score was the preferred strategy across a range of model input values in sensitivity analyses. The AMPT score identifies patients most likely to benefit from HEMS while potentially reducing costs to the health care system and should be considered in air medical transport protocols for trauma patients.

ABSTRACTThe cost-effectiveness of the 4 Pillars™ Practice Transformation Program to improve vaccination rates in adults <65-years-old is unknown. Two vaccines, influenza and Tdap (tetanus, diphtheria, acellular pertussis), were targeted for this age group. Cost-effectiveness of the intervention compared with control, with a primary outcome of cost per quality adjusted life year (QALY) gained, was estimated from societal and third party payer perspectives over a 10-year time horizon using a decision analysis model. Vaccination rates and intervention costs were derived from an intervention trial, and vaccine effectiveness, illness rates, and costs with/without vaccination were obtained from US databases and literature data. Future costs and effectiveness were discounted at 3%/year. The intervention cost was $1.78 per eligible patient/year. From the societal perspective, per patient total vaccination and illness costs with the intervention were $27.43 higher than control while gaining 0.00087 QALYs, costing $31,700/QALY gained. The intervention, extrapolated to the US population, could prevent 4.2 million cases, 87,489 hospitalizations, and 5,680 deaths due to influenza over 10 y in adults <65-years-old. In a probabilistic sensitivity analysis, the intervention was favored in 68.2% of model runs at a $50,000/QALY level and in 94.3% at $100,000/QALY. In a separate scenario analysis, the intervention became cost saving if influenza economic burden was >$2,099 per case (societal base case $846). Thus, the 4 Pillars Practice Transformation Program is an economically reasonable intervention to improve vaccination rates in adults <65-years-old, and could have a substantial public health impact.

ABSTRACTBackground In an era when value-based care is paramount, teaching trainees to explicitly communicate the evidence behind recommendations fosters high-value care (HVC) in the consultation process.Objective To implement an HVC consult curriculum highlighting the need for clear consult questions, evidence-based recommendations to improve consult teaching, clinical decision-making, and the educational value of consults.Methods A pilot curriculum was implemented for residents on cardiology consult electives utilizing faculty and fellows as evidence-based medicine (EBM) coaches. The curriculum included an online module, an EBM teaching point template, EBM presentations on rounds, and “coach” feedback on notes.Results A total of 15 residents and 4 fellows on cardiology consults participated, and 87 (13 of 15) of residents on consults felt the curriculum was educationally valuable. A total of 80 (72 of 90) of residents on general medicine rotations responded to the survey, and 25 of 72 residents (35) had a consult with the EBM template. General medicine teams felt the EBM teaching points affected clinical decision-making (48, 12 of 25) and favored dissemination of the curriculum (90, 72 of 80). Checklist-guided chart review showed a 22 improvement in evidence-based summaries behind recommendations (7 of 36 precurriculum to 70 of 146 charts postcurriculum, P  .015).Conclusions The HVC consult curriculum during a cardiology elective was perceived by residents to influence clinical decision-making and evidence-based recommendations, and was found to be educationally valuable on both parties in the consult process.

Using cost-outcomes analysis, this analysis using data from a single regional organ procurement organization suggests that investment in donor registry promotion should continue because it offers positive return based on lower cost-per-registrant and cost-per-donor than willingness-to-pay by the society.

OBJECTIVEClostridium difficileinfection (CDI) places a high burden on the US healthcare system. Recurrent CDI (RCDI) occurs frequently. Recently proposed guidelines from the American College of Gastroenterology (ACG) and the American Gastroenterology Association (AGA) include fecal microbiota transplantation (FMT) as a therapeutic option for RCDI. The purpose of this study was to estimate the cost-effectiveness of FMT compared with vancomycin for the treatment of RCDI in adults, specifically following guidelines proposed by the ACG and AGA.DESIGNWe constructed a decision-analytic computer simulation using inputs from the published literature to compare the standard approach using tapered vancomycin to FMT for RCDI from the third-party payer perspective. Our effectiveness measure was quality-adjusted life years (QALYs). Because simulated patients were followed for 90 days, discounting was not necessary. One-way and probabilistic sensitivity analyses were performed.RESULTSBase-case analysis showed that FMT was less costly ($1,669 vs $3,788) and more effective (0.242 QALYs vs 0.235 QALYs) than vancomycin for RCDI. One-way sensitivity analyses showed that FMT was the dominant strategy (both less expensive and more effective) if cure rates for FMT and vancomycin were =70% and <91%, respectively, and if the cost of FMT was <$3,206. Probabilistic sensitivity analysis, varying all parameters simultaneously, showed that FMT was the dominant strategy over 10, 000 second-order Monte Carlo simulations.CONCLUSIONSOur results suggest that FMT may be a cost-saving intervention in managing RCDI. Implementation of FMT for RCDI may help decrease the economic burden to the healthcare system.Infect Control Hosp Epidemiol 2014;00(0): 1–7

We provide microarray data comparing genome-wide differential expression and pathology throughout life in four lines of “amyloid” transgenic mice (mutant human APP, PSEN1, or APP/PSEN1) and “TAU” transgenic mice (mutant human MAPTgene). Microarray data were validated by qPCR and by comparison to human studies, including genome-wide association study (GWAS) hits. Immune gene expression correlated tightly with plaques whereas synaptic genes correlated negatively with neurofibrillary tangles. Network analysis of immune gene modules revealed six hub genes in hippocampus of amyloid mice, four in common with cortex. The hippocampal network in TAU mice was similar except that Trem2had hub status only in amyloid mice. The cortical network of TAU mice was entirely different with more hub genes and few in common with the other networks, suggesting reasons for specificity of cortical dysfunction in FTDP17. This Resource opens up many areas for investigation. All data are available and searchable at http://www.mouseac.org.