Childcare arrangements are key in women's ability to juggle motherhood and working outside the home. As such, the study of the access to childcare and its use is of great policy relevance. We focus ...on a particular kind of informal childcare, the one provided by grandparents. Empirically, assessing the effect of grandparental childcare is not an easy task due to unobserved preferences. In light of the potential outcome framework, we interpret the biases resulting from unobserved preferences as arising from the non-compliance of mothers to the availability of grandparents and from preferences of grandparents for activities other than childcare. Using an Instrumental Variable approach on Italian data, we find that the effect of grandparental childcare on mothers' labour supply is positive, statistically significant and economically relevant. The effect is stronger for lower educated mothers, with young children and living in the North and Centre.
Childcare arrangements are key in women's ability to juggle motherhood and working outside the home. As such, the study of the access to childcare and its use is of great policy relevance. We focus ...on a particular kind of informal childcare, the one provided by grandparents. Empirically, assessing the effect of grandparental childcare is not an easy task due to unobserved preferences. In light of the potential outcome framework, we interpret the biases resulting from unobserved preferences as arising from the non-compliance of mothers to the availability of grandparents and from preferences of grandparents for activities other than childcare. Using an Instrumental Variable approach on Italian data, we find that the effect of grandparental childcare on mothers' labour supply is positive, statistically significant and economically relevant. The effect is stronger for lower educated mothers, with young children and living in the North and Centre.
In the traditional models of female labour supply formal childcare is assumed to be provided by the market. This is not the case in most European countries. In this paper we estimate the causal ...effect of a particular kind of informal care, the one provided by grandparents, on mothers work decisions in Italy. We deal with the endogeneity due to mothers and grandparents unobserved preferences by instrumenting grandparents help. We find that having grandparents helping with childcare increases mothers labour market participation. The effect is particularly strong for lower educated mothers of young children, in North and Centre Italy.
Abstract
Aims
This study assessed the impact of the strain-guided therapeutic approach on cancer therapy-related cardiac dysfunction (CTRCD) and rate of cancer therapy (CT) interruption in breast ...cancer.
Methods and results
We enrolled 116 consecutive female patients with HER2-positive breast cancer undergoing a standard protocol by EC (epirubicine + cyclophosphamide) followed by paclitaxel + trastuzumab (TRZ). Coronary artery, valvular and congenital heart disease, heart failure, primary cardiomyopathies, permanent or persistent atrial fibrillation, and inadequate echo-imaging were exclusion criteria. Patients underwent an echo-Doppler exam with determination of ejection fraction (EF) and global longitudinal strain (GLS) at baseline and every 3 months during CT. All patients developing subclinical (GLS drop >15%) or overt CTRCD (EF reduction <50%) initiated cardiac treatment (ramipril+ carvedilol). In the 99.1% (115/116) of patients successfully completing CT, GLS and EF were significantly reduced and E/e′ ratio increased at therapy completion. Combined subclinical and overt CTRCD was diagnosed in 27 patients (23.3%), 8 at the end of EC and 19 during TRZ courses. Of these, 4 (3.4%) developed subsequent overt CTRCD and interrupted CT. By cardiac treatment, complete EF recovery was observed in two of these patients and partial recovery in one. These patients with EF recovery re-started and successfully completed CT. The remaining patient, not showing EF increase, permanently stopped CT. The other 23 patients with subclinical CTRCD continued and completed CT.
Conclusion
These findings highlight the usefulness of ‘strain oriented’ approach in reducing the rate of overt CTRCD and CT interruption by a timely cardioprotective treatment initiation.
Abstract
Aims
2D echocardiography is limited for identifying chemotherapy-related cardiotoxicity. This study compared standard echo, 2D, and 3D speckle tracking echocardiography (STE) for detection ...of subclinical anthracycline (ANT) cardiotoxicity in breast cancer patients.
Methods and results
One-hundred consecutive breast cancer patients free of cardiac symptoms were treated by multiple protocols including ANT and cyclophosphamide and/or 5-fluorouracil for 3–4 cycles. Both before and after treatment, patients underwent standard echo, 2D STE-derived left ventricular (LV) global longitudinal strain (GLS), 3D volumetric echo and 3D STE with measurements of GLS, global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS). The follow-up period from the beginning of cancer therapy was 129 ± 18 days. All patients completed the chemotherapy cycles, without experiencing symptoms/signs of heart failure. 2D ejection fraction (EF) was not significantly changed after treatment, whereas E/e’ ratio was higher than baseline (from 6.9 ± 2.2 to 7.3 ± 2.1, P = 0.006). 2D GLS was reduced after treatment (from −22.2 ± 2.3% to − 20.1 ± 6.6%, P = 0.004). 3D derived LV end-systolic volume was increased (P < 0.01) and 3D EF (from 62.4 ± 6.5% to 60.3 ± 7.3%, P < 0.01), 3D GLS (P < 0.001) GRS (P < 0.002), GCS, and GAS (both P < 0.0001) were reduced after ANT. Post-ANT 2D GLS was feasible in 90%, 3D EF in 66%, and 3D STE in 60% of patients.
Conclusions
Our study demonstrates potential superiority but also suboptimal feasibility of 3D EF and 3D strain in diagnosing subclinical ANT cardiotoxicity in breast cancer patients. 2D GLS is superior to standard echo and presents a good feasibility. E/e’ ratio also offers advantages in revealing cardiotoxicity.
In luminal-like early breast cancer (BC), the lack of Progesterone Receptor (PR) expression generally correlates with more aggressive behavior but the clinical validity of low PR levels remains a ...debated issue.
The main aim of this retrospective analysis was to assess the survival outcome (Breast cancer specific survival, BCSS) in a cohort of 687 luminal-like HER2 negative early BC patients treated at our Institutions from January 2000 to December 2018, using a sub-classification of tumors in subgroup 1 (PR high/Ki67 low), subgroup 2 (PR high/Ki67 high), subgroup 3 (PR low/Ki67 low), subgroup 4 (PR low/Ki67 high) according to PR and Ki67 values.
At a median follow-up of 7 years, BCSS rates were 96.3%, 89%, 86.8% and 85% in the subgroup 1, 2, 3, 4 respectively. Overall, a statistically significant difference in BCSS rates was observed among the 4 subgroups (p=0.0036). On univariate analysis, post-menopause, older age (≥ 50 years), low PR and high Ki67 expression, poorly differentiated grade and size ≥ 2 cm as well as luminal B-like tumors (subgroups 2, 3, 4) were significantly associated with a worse BCSS. Multivariate analysis identified grade, size and subgroup classification of BC as independent prognostic markers of poorer outcome. In particular, subgroups 4, 3 and 2 displayed a significantly higher risk of BC-related death (HR=4.11; p=0.008; HR=3.43; p=0-007; HR=2.57; p=0.020, respectively) when compared to subgroup 1.
Our results support the usefulness of PR and Ki67 levels as prognostic markers, corroborating their crucial role in the decision-making process of patients with luminal-like HER2 negative early BC. Clinical application of these parameters should be assessed prospectively.
Background: Home Exercise Program is a mainstay of upper limb dysfunction prevention in breast cancer survivors. However, only subjective assessment instruments have been used until now in order to ...prove its effectiveness. In the present observational retrospective study, we assessed, for the first time, the effects of Home Exercise Program on the upper limb function of breast cancer survivors via tridimensional motion analysis. We also aimed to show that good upper extremity performance positively influenced the quality of life of breast cancer survivors. Methods: From the 2016 database of breast cancer survivors who underwent upper limb tridimensional motion analysis 1 and 3 months after modified radical mastectomy, we enrolled 15 patients who spontaneously refused to undergo the post-surgical 14-day Home Exercise Program (group A). In addition, 15 patients who were homogeneous to those of group A, but who agreed to normally undergo Home Exercise Program were selected from the same database, in order to compare upper limb performance (group B). The Constant-Murley, Brief Fatigue Inventory and European Organization for Research and Treatment of Cancer quality of life scores during follow-up were analyzed and compared. Results: Compared to those in group A, on tridimensional motion analysis, patients in group B showed a wider range of motion of the upper limb, with consequently better shoulder and elbow performance, lower incidence of lymphedema, minor fatigue, and better quality of life. Conclusions: We show objectively, by means of tridimensional motion analysis, that Home Exercise Program is an effective tool for preventing upper extremity dysfunction in breast cancer survivors. Hence, it should always be recommended to such patients as it positively influences their quality of life.
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Manufacturing is the bridge between research and patient: without product, there is no clinical outcome. Shortage has a variety of causes, in this paper we analyse only causes related ...to manufacturing technology and we use shortage as a paradigm highliting the relevance of Pharmaceutical Technology. Product and process complexity and capacity issues are the main challenge for the Pharmaceutical Industry Supply chain. Manufacturing Technology should be acknowledged as a R&D step and as a very important matter during University degree in Pharmacy and related disciplines, promoting collaboration between Academia and Industry, measured during HTA step and rewarded in terms of price and reimbursement. The above elements are not yet properly recognised, and manufacturing technology is taken in to consideration only when a shortage is in place. In a previous work, Panzitta et al. proposed to perform a full technology assessment at the Health Technological Assessment stage, evaluating three main technical aspects of a medicine: manufacturing process, physicochemical properties, and formulation characteristics. In this paper, we develop the concept of manufacturing appraisal, providing a technical overview of upcoming challenges, a risk based approach and an economic picture of shortage costs. We develop also an overall quality concept, not limited to GMP factors but broaden to all elements leading to a robust supply and promoting technical innovation.
Background
Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a heavy burden of morbidity and mortality, mainly due to an increased risk of cerebrovascular events ...and cardiac failure. Oral anticoagulant (OAC) treatment prevents stroke and systemic thromboembolism in patients with AF and its use is strongly recommended in guidelines. However, its use in this patient group remains limited. Primary care physicians (PCPs) have an important role to play in this context.
Objective
The primary objective was to estimate prevalence and epidemiological features of AF in the primary care setting, focusing on ischaemic and bleeding risk assessment. A secondary objective was to examine the PCPs’ level of adherence to the guidelines for the prevention of thromboembolic risk in these patients.
Methods
This retrospective, observational study was based on data entered by 128 PCPs into the Health Search (HS) Thales database, identifying patients with a diagnosis of AF at the time of the analysis.
Results
Out of 167,056 patients analysed, 2,173 (1.3 %) were diagnosed with AF, with 86 % at high risk for ischaemic stroke, according to CHA
2
DS
2
-VASc (congestive heart failure, hypertension, age ≥75 years doubled, diabetes, stroke doubled, vascular disease, age 65–74 years, sex category female) stratification. After the diagnosis of AF, 84 % of patients were prescribed OAC treatment. However, at 2 years’ follow-up, only 29.6 % were still being treated with OACs.
Conclusion
The prevalence of AF in this analysis was consistent with previously reported Italian national epidemiological data. Adherence to the European Society of Cardiology AF guidelines by PCPs was low, despite the high levels of stroke risk. At the end of the observation period less than one-third of patients were still on OAC therapy. Awareness of the benefits of OACs in stroke prevention in AF patients needs to be improved.
There is a growing interest in quality improvement collaboratives (QICs), even though less remains known about contextual factors that impact collective and local project implementation. A study was ...undertaken that used the Consolidated Framework for Implementation Research (CFIR) to explore the contextual factors impacting the use of this nationwide QIC in Canada.
A deductive or direct qualitative content analysis using CFIR was employed to explore the contextual factors impacting the implementation of a nationwide QIC and participating organizations. Data were used from document analysis and semi-structured interviews with participants from 30 participating healthcare organizations across Canada.
A variety of contextual factors emerged, which influenced the uptake of the QICs across different settings, including intervention characteristics, outer setting, inner setting, and process factors. This study illustrates how organizations can consider a multi-pronged, theory-driven approach to guide the evaluation of safety and quality improvement efforts.
This study provides insights into contextual factors that impact the implementation of local safety projects involved in a larger QIC, which may serve as a template or blueprint for healthcare leaders in their efforts to guide the co-design, implementation and evaluation of safety and quality improvement efforts.
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