Predictive markers for pathological complete response (pCR) after neo-adjuvant chemotherapy in HER2-positive breast carcinoma.

OBJECTIVES: Patients with HER2-positive invasive breast cancer that is node-positive and/or larger than 3 cm are generally treated with neoadjuvant chemotherapy (NAC). We aimed to identify predictive markers for pathological complete response (pCR) after NAC in HER2-positive breast carcinoma. METHODS: Hematoxylin/eosin-stained slides of 43 HER2-positive breast carcinoma biopsies were histopathologically reviewed. Immunohistochemistry (IHC) was performed on pre-NAC biopsies, comprising HER2, estrogen receptor (ER), progesterone receptor (PR), Ki-67, epidermal growth factor receptor (EGFR), mucin-4 (MUC4), p53 and p63. Dual-probe HER2 in situ hybridization (ISH) was performed to study the mean HER2 and CEP17 copy numbers. ISH and IHC data were retrospectively collected for a validation cohort, comprising 33 patients. RESULTS: Younger age at diagnosis, 3+ HER2 IHC scores, high mean HER2 copy numbers and high mean HER2/CEP17 ratios were significantly associated with an increased chance of achieving a pCR, and the latter two associations were confirmed in the validation cohort. No other immunohistochemical or histopathological markers were associated with pCR. CONCLUSIONS: This retrospective study of two community-based NAC-treated HER2-positive breast cancer patient cohorts identified high mean HER2 copy numbers as a strong predictor for pCR. Further studies on larger cohorts are required to determine a precise cut-point for this predictive marker.

Association of the COVID-19 Pandemic With Women, Infants, and Children (WIC) Receipt Among Pregnant Individuals: United States, 2016-2022.

Objectives. To evaluate the effect of COVID-19 on Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) receipt among pregnant individuals overall and by race/ethnicity. Methods. We measured changes in WIC receipt among Medicaid-covered births (n = 10 484 697) from the US National Center for Health Statistics Natality Files (2016-2022). Our interrupted time series logistic model included a continuous monthly variable, a binary post-COVID variable, and a continuous slope shift variable. We additionally fit separate models for each race/ethnicity relative to White individuals, using interaction terms between the time series variables and race/ethnicity. Results. We found decreases in WIC receipt (adjusted odds ratio [AOR] = 0.899; P < .001) from before COVID (66.6%) to after COVID (57.9%). There were larger post-COVID decreases for American Indian/Alaska Native (AOR = 0.850; P < .001), Native Hawaiian/Other Pacific Islander (AOR = 0.877; P = .003), Black (AOR = 0.974; P < .001), and Hispanic (AOR = 0.972, P < .001) individuals relative to White individuals. Conclusions. The greater reductions in WIC receipt among minoritized individuals highlights a pathway through which the pandemic may have widened gaps in already disparate maternal and infant health. Public Health Implications. Continued efforts to increase WIC utilization are needed overall and among minoritized populations. (Am J Public Health. 2023;113(S3):S240-S247. https://doi.org/10.2105/AJPH.2023.307525).

The Shared Ethical Responsibility of Medically and Non-medically Qualified Experts in Human Drug Development Teams.

The complexity of developing and applying increasingly sophisticated new medicinal products has led to the participation of many non-medically qualified scientists in multi-disciplinary non-clinical and clinical drug development teams world-wide. In this introductory paper to the "IFAPP International Ethics Framework for Pharmaceutical Physicians and Medicines Development Scientists" it is argued that all members of such multidisciplinary teams must share the scientific and ethical responsibilities since they all influence directly or indirectly both the outcome of the various phases of the medicines development projects and the safety of the research subjects involved. The participating medical practitioner retains the overriding responsibility and the final decision to stop a trial if the well-being of the research subjects is seriously endangered. All the team members should follow the main ethical principles governing human research, the respect for autonomy, justice, beneficence and non-maleficence. Nevertheless, the weighing of these principles might be different under various conditions according to the specialty of the members.

Fostering Competence in Medicines Development: The IFAPP Perspective.

IFAPP (International Federation of Associations of Pharmaceutical Physicians and Pharmaceutical Medicine) is a nonprofit organization with the mission to promote Pharmaceutical Medicine & Medicines Development (PM&MD) by enhancing the competencies and maintaining high research ethical standards of Pharmaceutical Physicians and other professionals involved in medicines development worldwide, leading to the availability and appropriate use of medicines for the benefit of patients and society. About 30 national professional associations related to PM&MD, involving 7000 professionals, are affiliated to IFAPP. Medicines development has traditionally been a challenging enterprise, with high risk, high investment, and potentially high returns in the lengthy and complex process of identifying a new chemical entity as a candidate for development and possibly succeeding in bringing it as a pharmaceutical product to the market. However, the emergence of genomics, translational research, biomarkers, and precision medicine pose challenges going forward involving allocation of resources, price, market access, and cost-effectiveness as opposed to the traditional concepts of "efficacy" and "safety." Education and Continuing Professional Development (CPD) are a major focus of IFAPP. The International Conference on Pharmaceutical Medicine (ICPM) is the largest event for our organization; ICPM is held every 2 or 3 years and is aimed to provide the state of the art in key areas for our discipline and profession. The paper is a reflection on the role of competency-based education and training for Pharmaceutical Physicians and medicines development scientists, as was discussed during the recent ICPM 2016 held in Sao Paulo, Brazil on April 18-19, with the support of the Brazilian Association of Pharmaceutical Medicine, and gathered around 200 representatives from the pharmaceutical, clinical research and regulatory arenas from all over the world,.

Cost-effectiveness of prucalopride in the treatment of chronic constipation in the Netherlands.

OBJECTIVE: To assess the cost-effectiveness of prucalopride vs. continued laxative treatment for chronic constipation in patients in the Netherlands in whom laxatives have failed to provide adequate relief. METHODS: A Markov model was developed to estimate the cost-effectiveness of prucalopride in patients with chronic constipation receiving standard laxative treatment from the perspective of Dutch payers in 2011. Data sources included published prucalopride clinical trials, published Dutch price/tariff lists, and national population statistics. The model simulated the clinical and economic outcomes associated with prucalopride vs. standard treatment and had a cycle length of 1 month and a follow-up time of 1 year. Response to treatment was defined as the proportion of patients who achieved "normal bowel function". One-way and probabilistic sensitivity analyses were conducted to test the robustness of the base case. RESULTS: In the base case analysis, the cost of prucalopride relative to continued laxative treatment was € 9015 per quality-adjusted life-year (QALY). Extensive sensitivity analyses and scenario analyses confirmed that the base case cost-effectiveness estimate was robust. One-way sensitivity analyses showed that the model was most sensitive in response to prucalopride; incremental cost-effectiveness ratios ranged from € 6475 to 15,380 per QALY. Probabilistic sensitivity analyses indicated that there is a greater than 80% probability that prucalopride would be cost-effective compared with continued standard treatment, assuming a willingness-to-pay threshold of € 20,000 per QALY from a Dutch societal perspective. A scenario analysis was performed for women only, which resulted in a cost-effectiveness ratio of € 7773 per QALY. CONCLUSION: Prucalopride was cost-effective in a Dutch patient population, as well as in a women-only subgroup, who had chronic constipation and who obtained inadequate relief from laxatives.

Education and training for medicines development, regulation, and clinical research in emerging countries.

The aim of this satellite workshop held at the 17th World Congress of Basic and Clinical Pharmacology (WCP2014) was to discuss the needs, optimal methods and practical approaches for extending education and teaching of medicines development, regulation, and clinical research to Low and Middle Income Countries (LMICs). It was generally agreed that, for efficiently treating the rapidly growing number of patients suffering from non-communicable diseases, modern drug therapy has to become available more widely and with a shorter time lag in these countries. To achieve this goal many additional experts working in medicines development, regulation, and clinical research have to be trained in parallel. The competence-oriented educational programs designed within the framework of the European Innovative Medicine Initiative-PharmaTrain (IMI-PhT) project were developed with the purpose to cover these interconnected fields. In addition, the programs can be easily adapted to the various local needs, primarily due to their modular architecture and well defined learning outcomes. Furthermore, the program is accompanied by stringent quality assurance standards which are essential for providing internationally accepted certificates. Effective cooperation between international and local experts and organizations, the involvement of the industry, health care centers and governments is essential for successful education. The initiative should also support the development of professional networks able to manage complex health care strategies. In addition it should help establish cooperation between neighboring countries for jointly managing clinical trials, as well as complex regulatory and ethical issues.

Assessing the impact of dietary habits on health-related quality of life requires contextual measurement tools.

The increase of non-communicable diseases at all ages has fostered the general concern for sustaining population health worldwide. Unhealthy lifestyles and dietary habits impacting physical and psycho-social health are well known risk factors for developing life threatening diseases. Identifying the determinants of quality of life is an important task from a Public Health perspective. Consumer-Reported Outcome measures of health-related quality of life (HRQoL) are becoming increasingly necessary and relevant in the field of nutrition. However, quality of life questionnaires are seldom used in the nutrition field. We conducted a scientific literature search to find out the questionnaires used to determine the association between dietary habits and quality of life. A total of 13 studies were eligible for inclusion. Across these studies the short form-36, a generic (non-disease specific) HRQoL measurement instrument was the most widely used. However, generic measures may have limited content validity in the context of dietary habits interventions. We recommend additional contextual diet-specific HRQoL measures are also needed for evaluating the impact of diet habits on daily life functioning and well-being.

Psychometric properties of PedsQL generic core scales for children with functional constipation in the Netherlands.

OBJECTIVES: The aim of the study was to evaluate the psychometric properties of the Dutch translation of the Pediatric Quality of Life Inventory version 4.0 Generic Core Scales (PedsQL) in children with functional constipation (FC). METHODS: The PedsQL was completed by children with FC ages 5 to 18 years and by the parents of children ages 2 to 18 years. To assess construct validity, all of the parents and children completed the PedsQL Gastrointestinal Symptoms Module (GI module) and children ages 8 to 18 years completed the defecation disorder list. Item response distributions, internal consistency reliability, patient-parent agreement, and discriminating ability were evaluated. RESULTS: Overall, 269 children were enrolled. The PedsQL showed minimal missing responses (self-report: 5.3% with >50% missing, parent report: 2.6% with >50% missing) and achieved satisfactory internal consistency for the total (self-report: α = 0.86, parent report: α = 0.88), physical health (self-report: α = 0.75, parent report α = 0.83), and psychosocial health (self-report: α = 0.80; parent report: α = 0.85) scores. Internal consistency was less convincing for those ages 5 to 7 years (α = 0.53-0.77) than for older individuals. Self-reported health-related quality of life was lower than parent reported, with the exception of children ages 5 to 7 years. Interrater reliability intraclass correlations were 0.52 to 0.61 for the overall population. Correlations among the PedsQL, GI module, and defecation disorder list were consistent with a priori hypotheses and generally supported construct validity. The PedsQL distinguished between a previously published healthy reference sample and children with FC, and between those with mild and severe symptoms (P < 0.05). CONCLUSIONS: The self-reported and proxy reported PedsQL demonstrated satisfactory measurement properties in Dutch children with FC ages 8 to 18 years. Further research is needed to establish internal consistency and validity in those ages 5 to 7 years.

Corrigendum: Core competencies for pharmaceutical physicians and drug development scientists.

[This corrects the article on p. 105 in vol. 4, PMID: 23986704.].

Core competencies for pharmaceutical physicians and drug development scientists.

Professional groups, such as IFAPP (International Federation of Pharmaceutical Physicians and Pharmaceutical Medicine), are expected to produce the defined core competencies to orient the discipline and the academic programs for the development of future competent professionals and to advance the profession. On the other hand, PharmaTrain, an Innovative Medicines Initiative project, has become the largest public-private partnership in biomedicine in the European Continent and aims to provide postgraduate courses that are designed to meet the needs of professionals working in medicines development. A working group was formed within IFAPP including representatives from PharmaTrain, academic institutions and national member associations, with special interest and experience on Quality Improvement through education. The objectives were: to define a set of core competencies for pharmaceutical physicians and drug development scientists, to be summarized in a Statement of Competence and to benchmark and align these identified core competencies with the Learning Outcomes (LO) of the PharmaTrain Base Course. The objectives were successfully achieved. Seven domains and 60 core competencies were identified and aligned accordingly. The effective implementation of training programs using the competencies or the PharmaTrain LO anywhere in the world may transform the drug development process to an efficient and integrated process for better and safer medicines. The PharmaTrain Base Course might provide the cognitive framework to achieve the desired Statement of Competence for Pharmaceutical Physicians and Drug Development Scientists worldwide.

Health economics and nutrition: a review of published evidence.

The relationship between nutrition and health-economic outcomes is important at both the individual and the societal level. While personal nutritional choices affect an individual's health condition, thus influencing productivity and economic contribution to society, nutrition interventions carried out by the state also have the potential to affect economic output in significant ways. This review summarizes studies of nutrition interventions in which health-related economic implications of the intervention have been addressed. Results of the search strategy have been categorized into three areas: economic studies of micronutrient deficiencies and malnutrition; economic studies of dietary improvements; and economic studies of functional foods. The findings show that a significant number of studies have calculated the health-economic impacts of nutrition interventions, but approaches and methodologies are sometimes ad hoc in nature and vary widely in quality. Development of an encompassing economic framework to evaluate costs and benefits from such interventions is a potentially fruitful area for future research.

European initiative towards quality standards in education and training for discovery, development and use of medicines.

This position paper recommends a set of standards for quality assessment of continuing professional development (CPD) for medicines research and development (R&D). We have developed these standards to help us achieve the education and training goals of the Innovative Medicines Initiative (IMI; www.imi.europa.eu/), which is developing courses to address the skills gaps in European medicines R&D. The IMI shared standard for course quality will enable professionals in medicines R&D to create a personalized portfolio of education and training that best suits their needs. Individuals already working in the pharmaceutical industry will be able to select modules for study on an as-needs basis, which may be combined to gain a qualification that is recognized throughout Europe. By seeking input from the medicines R&D community, especially professional bodies involved in the career development of biomedical scientists, we hope to initiate the creation of a mutually recognized framework for lifelong learning in medicines R&D. The shared standards call for defined and transparent admission criteria, a predefined set of teaching objectives leading to defined learning outcomes, assessment of the students' achievement, a system for collecting, assessing and addressing feedback, and provision of appropriate and updated reference material. This framework will make it easier for professionals to develop the skills required by industry, and easier for employers to recognize professionals with appropriate skills. It will obviate some of the need for retraining personnel who have already developed appropriate skills in a different setting, thereby saving the industry additional effort. Fulfilment of quality standards by course providers will be made transparent within the IMI's catalogue of courses, on-course (www.on-course.eu), which will be made publicly available during 2012.

Economic evaluation of OROS hydromorphone for chronic pain: a Pan-European perspective.

OBJECTIVES: OROS hydromorphone (osmotic extended-release oral delivery system [OROS] hydromorphone) is a long-acting opioid analgesic, which is approved in Europe for the management of severe pain. The authors aimed to estimate the economic value of this product relative to other widely used oral opioids, including sustained-release morphine, extended-release (ER) oxycodone, and twice-daily (bid) hydromorphone. DESIGN: An adaptable, decision-analytic cost-utility model was developed. Separate versions of the model were developed for five European countries: Germany, Denmark, Slovakia, Portugal, and Italy. RESULTS: OROS hydromorphone represents a cost-effective alternative to other strong oral opioids in the treatment of both nonmalignant and malignant pain in all five countries. In the treatment of chronic severe nonmalignant pain, OROS hydromorphone was dominant (ie, lower cost and incremental quality-adjusted life years gains) when compared with ER oxycodone in Denmark and bid hydromorphone in Germany. Likewise, OROS hydromorphone was dominant in the treatment of chronic severe malignant pain when compared with ER oxycodone in both Germany and Denmark and when compared with bid hydromorphone in all markets where hydromorphone was marketed. CONCLUSIONS: This model demonstrates the cost effectiveness of OROS hydromorphone relative to other strong oral opioids in the treatment of chronic severe malignant and nonmalignant pain.

Cost-utility analysis: current methodological issues and future perspectives.

The use of cost-effectiveness as final criterion in the reimbursement process for listing of new pharmaceuticals can be questioned from a scientific and policy point of view. There is a lack of consensus on main methodological issues and consequently we may question the appropriateness of the use of cost-effectiveness data in health care decision-making. Another concern is the appropriateness of the selection and use of an incremental cost-effectiveness threshold (Cost/QALY). In this review, we focus mainly on only some key methodological concerns relating to discounting, the utility concept, cost assessment, and modeling methodologies. Finally we will consider the relevance of some other important decision criteria, like social values and equity.

The cost utility of autologous chondrocytes implantation using ChondroCelect® in symptomatic knee cartilage lesions in Belgium.

BACKGROUND: Knee cartilage lesions increase the risk of developing osteoarthritis (OA), and may eventually result in a total knee replacement (TKR). There is currently no consensus on the optimal treatment of cartilage lesions. ChondroCelect® (CC) is a cell-based therapy approved for use in autologous chondrocytes implantation (ACI) to treat symptomatic cartilage defects of the femoral condyle. Its capacity to safely restore good-quality cartilage was demonstrated in a randomized controlled trial (RCT) versus the surgical procedure microfracture (MFX). OBJECTIVE: This study investigated the cost utility of CC used in ACI compared with MFX to treat symptomatic knee cartilage lesions in Belgium. METHODS: A decision tree model comparing CC with MFX over a 40-year horizon was developed in TreeAge Pro™. The key timepoints of the model were (i) clinical assessment 5 years after initial intervention (success or no success, with or without re-operation); (ii) development of OA at 15 years (yes/no); (iii) need for TKR at 20 years (yes/no); and (iv) need for prosthesis revision at 35 years (yes/no). Clinical data provided by the RCT of CC versus MFX were the clinical success (response) rate based on the Knee injury and Osteoarthritis Outcome Score (KOOS) at 36 months (82.9% vs 62.0%; p = 0.048) and the proportion of good structural repair/presence of hyaline cartilage based on International Cartilage Repair Society (ICRS II) visual item at 12 months (44.9% vs 23.2%; p = 0.023). Utility scores by surgery outcome were derived from the SF-36 questionnaire responses collected in the RCT. Conservative assumptions related to the incidences of OA, TKR and prosthesis revision relied on a literature search. A patient chart review (n = 82) provided follow-up costs by surgery outcome. National tariffs were applied to direct medical resources used (healthcare payer perspective, year 2008 costs). Annual discounting was applied to costs (3%) and effects (1.5%) as recommended by the Belgian pharmacoeconomic guidelines. RESULTS: The incremental cost per QALY gained for CC compared with MFX was €16,229, with a difference in costs of €20,802 and 1.282 QALYs gained. Sensitivity analyses indicated that the key model drivers were the proportion of patients with hyaline cartilage and the correlation between hyaline cartilage formation and later avoidance of OA. Probabilistic sensitivity analyses showed robustness of the results, with 80% of the simulations below the usual UK National Institute for Health and Clinical Excellence (NICE) threshold of €22,000 per QALY. CONCLUSIONS: Assuming a good correlation between high-quality cartilage repair and avoidance of OA at a later stage, the benefits of the cell therapy CC over MFX in terms of QALYs gained and OA-related costs avoided appear real. Further research is required to explore long-term effects of cartilage repair and reduce uncertainty on quality of life of patients with OA before and after joint replacement.