Donna J. Petersen

Assuring Public Health Professionals Are Prepared for the Future: The UAB Public Health Integrated Core Curriculum

In response to calls to improve public health education and our own desire to provide a more relevant educational experience to our Master of Public Health students, the University of Alabama at Birmingham (UAB) School of Public Health designed, developed, and instituted a fully integrated public health core curriculum in the fall of 2001. This curriculum combines content from discipline-specific courses in biostatistics, environmental health, epidemiology, health administration, and the social and behavioral sciences, and delivers it in a 15 credit hour, team-taught course designed in modules covering such topics as tobacco, infectious diseases, and emergency preparedness. Weekly skills-building sessions increase student competence in data analysis and interpretation, communication, ethical decision-making, community-based interventions, and policy and program planning. Evaluations affirm that the integrated core is functioning as intended: as a means to provide critical content in the core disciplines in their applied context. As public health education continues to be debated, the UAB public health integrated core curriculum can serve as one model for providing quality instruction that is highly relevant to professional practice.

Maternal and Child Health Graduate and Continuing Education Needs: A National Assessment

Objectives: The purpose of this report is to describe the methodology and results of a recent national assessment of long-term graduate and short-term continuing education needs of public health and health care professionals who serve or are administratively responsible for the U.S. maternal and child health population and also to offer recommendations for future training initiatives. Methods: The target of this needs assessment was all directors of state MCH, CSHCN and Medicaid agencies, as well as a 20% random sample of local public health departments. A 7-page needs assessment form was used to assess the importance of and need for supporting graduate and continuing education training in specific skill and content areas. The needs assessment also addressed barriers to pursuing graduate and continuing education. Respondents (n = 274) were asked to indicate the capacity of their agency for providing continuing education as well as their preferred modalities for training. Results: Regardless of agency type, i.e., state MCH, CSHCN, Medicaid or local health department, having employees with a graduate education in MCH was perceived to be of benefit by more than 70% of the respondents. Leadership, systems development, management, administration, analytic, policy and advocacy skills, as well as genetics, dentistry, nutrition and nursing, were all identified as critical unmet needs areas for professionals with graduate training. Education costs, loss of income, and time constraints were the identified barriers to graduate education. More than 90% of respondents from each agency viewed continuing education as a benefit for their staff, although the respondents indicated that their agencies have limited capacity to either provide such training or to assess their staffs need for continuing education. Program managers and staff were perceived in greatest need of continuing education and core public health skills, leadership, and administration were among the most frequently listed topics to receive continuing education training support dollars. Time away from work, lack of staff to cover functions, and cost were the top barriers to receiving continuing education. While attending on-site, in-state, small conferences was the continuing education modality of first preference, there was also considerable interest expressed in web-based training. Conclusions: Six recommendations were developed on the basis of the findings and address the following areas: the ongoing need for continued support of both graduate and continuing education efforts; the development of a national MCH training policy analysis center; the incorporation of routine assessments of training needs by states as part of their annual needs assessments; the promotion of alternative modalities for training, i.e., web-based; and, the sponsorship of academic/practice partnerships for cross-training.

The recommended critical component elements of an undergraduate major in public health.

Public Health Reports / September–October 2013 / Volume 128 11. Riegelman RK. Undergraduate public health education: past, present, and future. Am J Prev Med 2008;35:258-63. 12. Gebbie K, Merrill J, Hwang I, Gebbie EN, Gupta M. The public health workforce in the year 2000. J Public Health Manag Pract 2003;9:79-86. 13. Rosenstock L, Silver GB, Helsing K, Evashwick C, Katz R, Klag M, et al. Confronting the public health workforce crisis: ASPH statement on the public health workforce. Public Health Rep 2008;123:395-8. 14. Eyler J, Giles DE Jr. Where’s the learning in service-learning? San Francisco: Jossey-Bass; 1999. 15. Barry WA, Doherty RJ. Contemplatives in action: the Jesuit way. Mahwah (NJ): Paulist Press; 2002. 16. Association of Schools of Public Health, Association of American Colleges and Universities, Association for Prevention Teaching and Research, Centers for Disease Control and Prevention (US). Undergraduate public health learning outcomes model. Washington: ASPH; 2011. 17. Fleming ML, Parker E, Gould T, Service M. Educating the public health workforce: issues and challenges. Aust N Z Health Policy 2009;6:8.

A comparison of gestational age reporting methods based on physician estimate and date of last normal menses from fetal death reports.

Utilizing 10,587 cases from the 1980 National Center for Health Statistics Fetal Death Statistics File, we examined the comparability of two methods of determining the gestational age of a fetal death, the calculated interval from date of last normal menses (DLNM) and the physicians estimate. The physician estimated gestational age distribution exhibits even number digit preference and a distinct clustering at the 40-week value. The DLNM distribution appears more smoothly distributed but with a more pronounced post-term tail. An exact agreement between the two methods is observed in only 27.9 per cent of the cases. A 1.7 week mean difference between the methods indicates a systematic underestimation by physician reported gestational age when compared to that calculated from the DLNM, potentially biasing gestational age distributions when the physician estimate is substituted for cases with a missing DLNM. Over 8 per cent of cases 20+ weeks by DLNM are estimated as less than 20 weeks by the physician. This underestimation has important implications for the completeness of reporting of fetal deaths on vital records and the comparability of fetal death rates. Further, it may limit investigations of the completeness of reporting of less than 500 gram live births.

On Academics Developing an Educated Citizenry: The Undergraduate Public Health Learning Outcomes Project:

In its seminal 1988 report, “The Future of Public Health,” the Institute of Medicine (IOM) called public health “what we do as a society collectively to assure the conditions in which people can be healthy.”1 Public health interventions may occur in myriad institutions, through a variety of direct and indirect mechanisms in communities across the country. Yet, despite the many proven benefits of health approaches based on prevention and the well-being of populations, public health does not enjoy popular support and is poorly understood by most Americans.2 The dominance of medical solutions to health challenges, even in the face of overwhelming evidence regarding the effectiveness of community-based preventive approaches, is illustrative of this broad lack of understanding. In 2003, the IOM suggested that the nation’s health would benefit from a greater understanding of the profession’s potential. To promote this enhanced awareness among the public, the IOM report called for every undergraduate to have access to education in public health.3 This call for broader public health education led to the formation of the Educated Citizen and Public Health initiative led by the Association for Prevention Teaching and Research, the Council of Colleges of Arts and Sciences, the Association of Schools and Programs of Public Health (ASPPH), and the Association of American Colleges and Universities (AAC&U). The initiative intended to respond to growing demand in the field and bring leadership to the suddenly explosive growth of courses and programs. The initiative further intended to introduce undergraduate study of integrative public health to all institutions of higher education and to take an interdisciplinary and inter-professional approach to collaboration.4 In recognition of the growth in undergraduate public health programs at colleges and universities, many without schools or programs of public health, ASPPH determined that it should actively engage in defining the learning outcomes and design of undergraduate public health programs. Many questions immediately surfaced: Should the traditional liberal arts be the recommended framework? Should programs prepare associate and baccalaureate graduates to enter the workforce? Should curricula include an internship or apprenticeship? Should programs focus on lifelong learning? How would an undergraduate public health degree articulate to existing master’s degrees in public health? And what faculty development opportunities would be needed to support the integration of public health theory and content into other areas of inquiry in an undergraduate setting? In September 2009, ASPPH convened an Undergraduate Task Force to consider these issues and to develop a strategy for integrating public health knowledge and principles in undergraduate education.

The national board of public health examiners : Credentialing public health graduates

The National Board of Public Health Examiners (NBPHE, the Board) is the result of many years of intense discussion about the importance of credentialing within the public health community. The Board is scheduled to begin credentialing graduates of programs and schools of public health accredited by the Council on Education for Public Health (CEPH) in 2008. Among the many activities currently underway to improve public health practice, the Board views credentialing as one pathway to heighten recognition of public health professionals and increase the overall effectiveness of public health practice. The process underway includes developing, preparing, administering, and evaluating a voluntary certification examination that tests whether graduates of CEPH-accredited schools and programs have mastered the core knowledge and skills relevant to contemporary public health practice. This credentialing initiative is occurring at a time of heightened interest in public health education, and an anticipated rapid turnover in the public health workforce. It is fully anticipated that active discussion about the credentialing process will continue as the Board considers the many aspects of this professional transition. The Board wishes to encourage these discussions and welcomes input on any aspects relating to implementation of the credentialing process.

Assessing the Extent of Medical Home Coverage Among Medicaid-Enrolled Children

Objectives: In light of the transition of the Alabama Medicaid program to a primary care case management model, we assessed the level to which children had access to a medical home before and after implementation of that model. Given the growing emphasis within the MCH community on assuring children medical homes, we explored whether Medicaid claims data could be used to assess medical home coverage. Methods: We operationally defined “medical home” as use of a single primary care physician combined with receipt of at least one well child visit from that physician during the year. Using Alabama Medicaid claims data we assessed whether childrens receipt of health care services met this defintion, the extent to which Medicaid-enrolled children had primary care providers and received well child visits, and changes in the source of well child visits before and after implementation of a primary care case management model in 26 of Alabamas 67 counties. Results: In general, Medicaid-enrolled children in Alabama did not meet our definition of medical home either before or after implementation of a primary care case management model. Only 11.8% of children saw a single provider and had a well child visit from that provider during the baseline year. A majority of children (49.9%) however had both a primary care provider and received a well child visit. Sixteen percent of children saw a primary care physician but received no identifiable well visit, while 11% had well child care but did not see a primary care physician. Of particular concern, 23% neither saw a primary care physician nor had a well child visit during the baseline year. These figures changed only slightly in the 26 counties examined before and after implementation of the primary care case management model. Conclusions: State Maternal and Child Health programs are required to report as a performance measure “the percent of children with special health care needs in the state who have a medical/health home” as part of their Block Grant application. Using Medicaid data, this simple measurement strategy can provide an indication of the extent to which at least one population of children receive care through a medical home.

Variations in the reporting of gestational age at induced termination of pregnancy.

Utilizing the 1980 Induced Abortion File maintained by the National Center for Health Statistics, we compared gestational age from date of last normal menses and the physician-based estimate of gestational age. An average .51 week difference between the two methods was observed. Beyond seven weeks gestation, the date of last normal menses value was underestimated by the physician-based estimate with a markedly greater divergence after 20 weeks. A relatively greater underestimation of the date of last normal menses interval by the physician estimate was apparent for Whites after 13 weeks. The data of last normal menses value for non-state residents was overestimated across the entire range of the date of last normal menses gestational age distribution until 21 weeks.

The US Cancer Moonshot initiative

Correspondence avoid surgery in rapidly progressive or chemo-insensitive disease. 4 Genotyping of pancreatic tumours via fine needle aspiration could influence the clinical management of pancreatic cancer. Fine-needle aspiration sequencing was used to identify subgroups of patients with specific actionable mutations related to resectable or locally advanced tumours. 5 In patients with radiologically resectable or borderline resectable tumours, preoperative fine-needle aspiration sequencing could distinguish between patients with a genetic pattern associated with micrometastatic tumours, who should undergo neoadjuvant therapy, and those with a truly localised disease that would be amenable to a surgery-first strategy. Michele Reni has served as a consultant for or on the advisory boards of Celgene, Boehringer-Ingelheim, Lilly, Genentech, Baxalta, Novocure, Astra-Zeneca, Pfizer, and Merck-Serono, and has received honoraria from Celgene. Massimo Falconi has received honoraria from Celgene, Ipsen and Novartis. The other authors declare no competing interests. *Stefano Crippa, Michele Reni, Gianpaolo Balzano, Claudio Doglioni, Massimo Falconi crippa1.stefano@hsr.it Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy (SC, GB, MF); Medical Oncology Department, IRCCS San Raffaele Hospital , Milan, Italy (MR); Department of Pathology, IRCCS San Raffaele Hospital , Milan, Italy (CD); Clinical and Translational Research Program on Pancreatic Cancer, IRCCS San Raffaele Hospital, Milan, Italy (SC, MR, GB, CD, MF) e178 Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24 Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefit of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103: 179–91. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer 2011; Sohal DP, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst 2014; 106: dju011 Valero V, Saunders TJ, He J, et al. Reliable detection of somatic mutations in fine needle aspirates of pancreatic cancer with next-generation sequencing: implications for surgical management. Ann Surg 2016; Author’s reply Stefano Crippa and colleagues, in responding to our manuscript, 1 agree that increasing the radicality of surgery for pancreatic ductal adenocarcinoma, including synchronous vein resection, is suspect. Indeed, a recent meta-analysis 2 indicates that synchronous vein resection, as reported, increases mortality and decreases survival. Crippa and colleagues put forward two interesting ideas that warrant further discussion. The first is that the surgery-first approach for pancreatic ductal adenocarcinoma might ultimately be retired, given that pancreatic ductal adenocarcinoma is usually systemic at presentation, local treatments have little effect, and neoadjuvant therapy has possible benefits. For now, the absence of high-level evidence for neoadjuvant therapy leaves largely theoretical benefits; namely that neoadjuvant therapy will reveal the biology (ie, those patients that can progress on neoadjuvant therapy will avoid futile surgery), or alter the biology (ie, those patients that are downstaged will become resectable). The preliminary results of the ALLIANCE trial 3 damages the lustre of these purported benefits with no improvement in the number of resections (10 [50%] of 20 patients who completed all preoperative therapy), and no rescue of aggressive tumour biology. This leads to the second idea, in which Crippa and colleagues suggest a biological (rather than radiological) basis for selecting patients for neoadjuvant therapy with a view to reduce the number of synchronous vein resections. Endoscopic ultrasonography- guided genotyping is a possible way to select subgroups of patients with heterogenous pancreatic ductal adenocarcinoma 4 who will benefit from neoadjuvant therapy. In support of this method, Hruban and colleagues 5 suggested that an intact SMAD4/DPC4 gene might be used to select surgery because there is lesser risk of distant metastases for this genotype. 6 In the future, we hope to more accurately select a subgroup of patients in whom a surgery-first approach, and even synchronous vein resection, is justified, but it is much more likely that precision neoadjuvant therapy will ultimately result in less radical surgery and the introduction of non-surgical techniques to support the response to neoadjuvant therapy. We declare no competing interests. Savio G Barreto, *John A Windsor j.windsor@auckland.ac.nz Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India (SGB); Hepatobiliary Pancreatic and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand (JAW) Barreto S, Windsor J. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24. Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; Varadhachary G, Fleming J, Crane C, et al. Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma. Proc Am Soc Clin Oncol 2015; 33 (suppl 3): abstr 362. Killock D. Pancreatic cancer: a problem quartered—new subtypes, new solutions? Nat Rev Clin Oncol 2016; 13: 201. Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009; The US Cancer Moonshot initiative We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to www.thelancet.com/oncology Vol 17 May 2016

Acknowledgment of Reviewers 2012

Matti Aapro* Neil K. Aaronson* Inmaculada Aban Camille N. Abboud James L. Abbruzzese Eddie K. Abdalla Samah G. Abdel Baki Omar Abdel-Wahab* Kaleab Z. Abebe* Gregory A. Abel* Ghassan K. Abou-Alfa* Jame Abraham Donald I. Abrams Judith Abrams* Thomas A. Abrams* Jeremy S. Abramson Lauren E. Abrey Peter Abt Denise Adams M. Jacob Adams Val R. Adams Lucile Adams-Campbell Peter C. Adamson* Clement A. Adebamowo David J. Adelstein Douglas Adkins Adam C. Adler Anjali S. Advani* Ranjana Advani* Shoaib Afzal Walter Ageno Ninna Aggerholm-Pedersen Mark Agulnik Roger P. A’Hern* Tim A. Ahles* Sangeeta Ahluwalia Nita Ahuja* Joseph Aisner Jaffer A. Ajani* Hideyuki Akaza Tatsuo Akechi William Alago Steven R. Alberts Peter C. Albertsen Kenneth D. Aldape H. Richard Alexander* Sarah Alexander Catherine M. Alfano Shabbir M.H. Alibhai* Ash A. Alizadeh Carmen J. Allegra* Aaron Allen Steven L. Allen Kimberly Allison D. Craig Allred William Allum Todd A. Alonzo Waddah B. Al-Refaie Nasser K. Altorki Ronald D. Alvarez Edwin P. Alyea Laurence Amar Robert J. Amato Peter F. Ambros* Christine B. Ambrosone Eitan Amir* Roland A. Ammann Judy Amorosa John Anastasi Sonia Ancoli-Israel Paolo Anderlini Carey K. Anders* Kenneth G. Andersen Benjamin O. Anderson Christopher B. Anderson Garnet Anderson Harald Anderson* James R. Anderson* Karen O. Anderson* Kenneth C. Anderson Larry D. Anderson Jr Steven M. Anderson William F. Anderson* Richard Andrassy Fabrice Andre Adin-Cristian Andrei* Gerald L. Andriole* Leslie A. Andritsos Michael A. Andrykowski* Stephen M. Ansell* David A. Anthoney Joseph Antin Emmanuel S. Antonarakis Katsuyuki Aozasa Richard Aplenc* Frederick R. Appelbaum Jane F. Apperley* Robert J. Arceci* Pedram Argani Peter A. Argenta Andreas A. Argyriou Maurizio Arico Tannaz Armaghany* Saro Armenian Jane M. Armer* James O. Armitage* Andrew J. Armstrong Floyd D. Armstrong Gregory T. Armstrong* Carola Arndt* Volker Arndt* Andrew M. Arnold Dirk Arnold* Robert Arnold Neeraj K. Arora Carlos L. Arteaga* Andrew S. Artz Patrick Arveux* Sylvia L. Asa Takamaru Ashikaga* Kimlin Ashing-Giwa Bernard Asselain Barbara Asselin Michael B. Atkins Chloe E. Atreya* Eyal C. Attar David A. August Nancy E. Avis* Norbert Avril David Azria Thomas Bachelot Anthony L. Back Hoda Badr Joachim M. Baehring Maria R. Baer Rochelle Bagatell Howard H. Bailey Justin N. Baker K. Scott Baker Sharyn D. Baker Marie Bakitas* Tracy A. Balboni* Charles M. Balch* Lodovico Balducci* Frank M. Balis David Ball Mark Ball Rachel Ballard-Barbash Karen K. Ballen Karla V. Ballman* Hanna Bandos Mousumi Banerjee Udai Banerji* Ying Bao Claudia R. Baquet Vickie E. Baracos* JOURNAL OF CLINICAL ONCOLOGY ACKNOWLEDGMENT OF REVIEWERS VOLUME 31 NUMBER 12 APRIL 2