Largest Relative Increase Research Articles

Colorectal cancer incidence among Hispanics and non-Hispanic Whites in the United States.

Colorectal cancer (CRC) incidence has declined over the past two decades; however, these declines have not occurred equally in all populations. To better understand the impact of CRC among Hispanics, we examined incidence trends by age and Hispanic ethnicity. Using data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results Program, we estimated CRC incidence rates during the period 2001-2014, and across all 50 U.S. states. We estimated incidence rates in younger (age < 50years) and older (age ≥ 50years) adults by anatomic subsite and stage at diagnosis, separately for non-Hispanic Whites and Hispanic Whites. CRC incidence rates declined among older (age ≥ 50years) Whites and Hispanics, but Whites experienced a greater decline (31% vs. 27% relative decline among Hispanics). In contrast to older adults, there were continued increases in CRC incidence from 2001 to 2014 among younger (age 20-49years) adults. The largest relative increases in incidence occurred in Hispanics aged 20-29years (90% vs. 50% relative increase among Whites). Opposing incidence trends in younger versus older Hispanics may reflect generational differences in CRC risk by birth cohort, as well as environmental exposures and lifestyle-related risk factors associated with immigration and acculturation.

Trends in Dental Implant Use in the U.S., 1999–2016, and Projections to 2026

Dental implants have become an increasingly popular treatment choice for replacing missing teeth. Yet, little is known about the prevalence and sociodemographic distribution of dental implant use in the United States. To address this knowledge gap, we analyzed data from 7 National Health and Nutrition Examination Surveys from 1999 to 2016. We estimated dental implant prevalence among adults missing any teeth for each survey period overall as stratified by sociodemographic characteristics. We calculated absolute and relative differences from 1999–2000 to 2015–2016 and fit logistic regression models to estimate changes over time. We also used multivariable logistic regression to estimate independent associations of sociodemographic covariates with the presence of any implant. We projected the proportion of patients treated with dental implants into the year 2026 under varying assumptions of how the temporal trend would continue. There has been a large increase in the prevalence of dental implants, from 0.7% in 1999 to 2000 to 5.7% in 2015 to 2016. The largest absolute increase in prevalence (12.9%) was among individuals 65 to 74 y old, whereas the largest relative increase was ~1,000% among those 55 to 64 y old. There was an average covariate-adjusted increase in dental implant prevalence of 14% per year (95% CI, 11% to 18%). Having private insurance (vs. none or public insurance) or more than a high school education (vs. high school or less) was each associated with a 2-fold increase in prevalence, with an almost 13-fold (95% CI, 8 to21) increase for older adults. Dental implant prevalence projected to 2026 ranged from 5.7% in the most conservative scenario to 23% in the least. This study demonstrates that dental implant prevalence among US adults with missing teeth has substantially increased since 1999. Yet access overall is still very low, and prevalence was consistently higher among more advantaged groups.

Cardiovascular disease in diabetes type 2: current concepts

Type 2 diabetes is a major and accelerating public health challenge. Between 1980 and 2014, a period of just 35 years, the number of adults with diabetes globally is estimated to have increased from 108 to 422 million, due not only to sharply rising obesity rates, but also to increasing population size, longer life expectancy, and rising prevalence of diabetes worldwide. Overall, worldwide age-standardized adult diabetes prevalence doubled from 4.3% to 9.0% in men and from 5.0% to 7.9% in women. The largest increases in diabetes type 2 have been demonstrated in low- and middle-income countries, whilst rises in high-income countries have been less marked, or even flat. Diabetes type 2 rates in low- and middle-income countries now in many instances surpass those in high-income countries, in response to changes in lifestyle. One factor of particular concern are the large relative increases in type 2 diabetes amongst young individuals observed in many countries, their higher overall risk factor burden, long exposure to hyperglycaemia and greater risk of complications over the life course. Type 2 diabetes is increasingly found to be a heterogeneous condition, where risk of cardiovascular disease that traditionally has been estimated at 2-4 times that of the nondiabetic population varies substantially with diabetes phenotype and accordingly diabetes does not confer the same increase in relative or absolute risk in all people. New research shows that excess risk varies substantially with type of outcome, age, glycaemic control, the presence of renal complications and other factors. Heart failure, previously less recognized that other cardiovascular conditions, is increasingly coming into focus, because of strong links with poor glycaemic control and obesity. The knowledge about risk of cardiovascular disease in diabetes is almost entirely derived from high-income countries, whereas there is comparatively very little data from low- and middle income countries, where the majority of persons with type 2 diabetes live, and where management in many cases is far from optimal. The reductions in cardiovascular disease incidence and mortality now observed in high-income countries are encouraging, because this reinforces the fact that improvement is possible and that a near-normal, or even normal life-expectancy can be achieved in subtypes of type 2 diabetes.

Adverse Health Effects of Abuse-Deterrent Opioids: Evidence From the Reformulation of Oxycontin

The US is currently in the midst of the worst drug overdose epidemic in its history, with nearly 64,000 drug overdose deaths in 2016. In response, pharmaceutical companies have begun introducing abuse-deterrent painkillers, pills with properties that make the drug more difficult to misuse. The first such painkiller, a reformulated version of OxyContin, was released in 2010. Previous research has found no net effect on opioid mortality, with users substituting away from OxyContin toward heroin. This paper explores health effects of the reformulation beyond mortality. Exploiting variation across states in OxyContin misuse prior to the reformulation, I find large relative increases in the spread of hepatitis B and C in states most likely to be affected by the reformulation. In aggregate, the estimates suggest that absent the reformulation we would have observed between 66-75% fewer cases of hepatitis C and 46-60% fewer cases of hepatitis B. I document further evidence that points to the likely cause of these effects: the reformulation led individuals to substitute from OxyContin to heroin, which is substantially more likely to be injected, increasing exposure to blood-borne diseases.

Rising Trends of Prescription Opioid Sales in Contemporary Brazil, 2009-2015.

To present and discuss recent patterns of prescription opioid sales throughout Brazil. We graphed linear trends of opioid prescriptions sold from registered pharmacies across Brazil from 2009 to 2015. We then calculated the change in rate of prescriptions sold per 1000 persons in 2015 compared with 2009. Opioid sales increased across Brazil from 1 601 043 prescriptions in 2009 to 9 045 945 prescriptions in 2015, corresponding to a 465% increase in 6 years. The largest absolute increase was for codeine products (rate ratio (RR) = 5.30; 95% confidence interval [CI] = 5.29, 5.31), accounting for more than 98% of prescriptions in both years. Oxycodone had the largest relative increase (RR = 11.39; 95% CI = 11.19, 11.59), and fentanyl products had the smallest absolute and relative increase (RR = 2.91; 95% CI = 2.78, 3.03). Given rapid increases in opioid sales across Brazil, it is critical to introduce effective prescribing and monitoring methods that allow patients to access necessary medications without escalating risk of opioid misuse and related consequences. Careful surveillance of supply and subsequent outcomes are needed to prevent the development of another devastating opioid epidemic in the Americas.

A multidisciplinary team-oriented intervention to increase guideline recommended care for high-risk prostate cancer: A stepped-wedge cluster randomised implementation trial

BackgroundThis study assessed whether a theoretically conceptualised tailored intervention centred on multidisciplinary teams (MDTs) increased clinician referral behaviours in line with clinical practice guideline recommendations.MethodsNine hospital Sites in New South Wales (NSW), Australia with a urological MDT and involvement in a state-wide urological clinical network participated in this pragmatic stepped wedge, cluster randomised implementation trial. Intervention strategies included flagging of high-risk patients by pathologists, clinical leadership, education, and audit and feedback of individuals’ and study Sites’ practices. The primary outcome was the proportion of patients referred to radiation oncology within 4 months after prostatectomy. Secondary outcomes were proportion of patients discussed at a MDT meeting within 4 months after surgery; proportion of patients who consulted a radiation oncologist within 6 months; and the proportion who commenced radiotherapy within 6 months. Urologists’ attitudes towards adjuvant radiotherapy were surveyed pre- and post-intervention. A process evaluation measured intervention fidelity, response to intervention components and contextual factors that impacted on implementation and sustainability.ResultsRecords for 1071 high-risk post-RP patients operated on by 37 urologists were reviewed: 505 control-phase; and 407 intervention-phase. The proportion of patients discussed at a MDT meeting increased from 17% in the control-phase to 59% in the intervention-phase (adjusted RR = 4.32; 95% CI [2.40 to 7.75]; p < 0·001). After adjustment, there was no significant difference in referral to radiation oncology (intervention 32% vs control 30%; adjusted RR = 1.06; 95% CI [0.74 to 1.51]; p = 0.879). Sites with the largest relative increases in the percentage of patients discussed also tended to have greater increases in referral (p = 0·001). In the intervention phase, urologists failed to provide referrals to more than half of patients whom the MDT had recommended for referral (78 of 140; 56%).ConclusionsThe intervention resulted in significantly more patients being discussed by a MDT. However, the recommendations from MDTs were not uniformly recorded or followed. Although practice varied markedly between MDTs, the intervention did not result in a significant overall change in referral rates, probably reflecting a lack of change in urologists’ attitudes. Our results suggest that interventions focused on structures and processes that enable health system-level change, rather than those focused on individual-level change, are likely to have the greatest effect.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910). Registered 6 December 2011.

An analysis of the global pharmacy workforce capacity trends from 2006 to 2012

BackgroundHuman resources for health are at a critical low. The World Health Organization estimates that the current shortage of health workers, including pharmacists, is in excess of 7.2 million worldwide and that, by 2035, the shortage will reach 12.9 million. Pharmacists, in particular, are lacking in the workforce in many countries. The International Pharmaceutical Federation (FIP) and academic partners have conducted periodic global pharmacy workforce surveys in 2006, 2009 and 2012 which have monitored and reported on the status of the pharmacy workforce at the country and territory levels. This current analysis is a synthesis of workforce capacity data from these date points to provide an overview of the global trends and changes to pharmacy workforce capacity over this time period.MethodsThe methodology proceeded with accessing workforce capacity data collated in 2006, 2009 and 2012 held on file at the FIP Collaborating Centre. This data had previously been validated and made available to WHO Human Resources for Health. The data focused (due to limitations from 2006 databank) on pharmacist workforce capacity. Countries and territories were identified that had data available across at least two of the three time points (2006, 2009 and 2012). Missing time-point data for some countries (data gaps) were subject, where possible, to literature and online data searching to capture possible missing data. Country-level capacity data were plotted against time to identify trends coupled with comparative analysis of the trends.ResultsThe countries and territories identified as having valid data for each of the time points 2006, 2009 and 2012 were present in all WHO regions, with Europe having the most countries with data available and South East Asia the fewest.All WHO regions have experienced an increase in the density of pharmacists (measured as number of pharmacists per 10 000 population) over the period 2006–2012. However, some countries show a reduction in the density of pharmacists. African countries show large relative increases in acceleration of capacity building but remain significantly behind in terms of absolute capacity per capita. South East Asian and Middle Eastern countries also show large proportional changes in pharmacist workforce.ConclusionThe global trend is an increase in workforce across all nations and regions, and this is a move in the right direction towards improved access to, and availability of, pharmaceutical expertise. However, there is still much to be done, with some regions and low-income countries still displaying a disproportionately low number of pharmacists on small overall capacity for delivering pharmacy services.

A bump in the high road

Aviation Clear-air turbulence (CAT), which is invisible to the naked eye and undetectable by sensors onboard aircraft, can cause discomfort or injuries to passengers and often forces planes to alter their flight paths to avoid it. Storer et al. use a global climate model to project how climate warming is expected to influence CAT. They find large relative increases in CAT, particularly in the midlatitudes, with some regions experiencing several times more turbulence during the period from 2050 to 2080 than now. Within that interval, severe CAT becomes as common as moderate CAT has been historically, and the strongest turbulence increases the most. Geophys. Res. Lett. 10.1002/2017GL074618 (2017).

Global Response of Clear‐Air Turbulence to Climate Change

AbstractClear‐air turbulence (CAT) is one of the largest causes of weather‐related aviation incidents. Here we use climate model simulations to study the impact that climate change could have on global CAT by the period 2050–2080. We extend previous work by analyzing eight geographic regions, two flight levels, five turbulence strength categories, and four seasons. We find large relative increases in CAT, especially in the midlatitudes in both hemispheres, with some regions experiencing several hundred per cent more turbulence. The busiest international airspace experiences the largest increases, with the volume of severe CAT approximately doubling over North America, the North Pacific, and Europe. Over the North Atlantic, severe CAT in future becomes as common as moderate CAT historically. These results highlight the increasing need to improve operational CAT forecasts and to use them effectively in flight planning, to limit discomfort and injuries among passengers and crew.

Broad Trends in Radiation Utilization From 1973 to 2012 Among Elderly Patients Aged 85 and Older: An Analysis of the Surveillance, Epidemiology, and End Results Database

Though the prevalence of elderly patients diagnosed with cancer is increasing with improving life expectancy, use of tumor-directed therapy in the oldest individuals remains controversial. The goal of our study was to analyze historical trends in radiation therapy (RT) for patients 85 years and older to determine how RT utilization has changed over time and how this may inform current and future use in this age group. The National Cancer Institute’s Surveillance, Epidemiology, and End Results database (SEER-18) was interrogated for patients ≥85 years of age who received RT for either local, regional, or metastatic disease. Patients were categorized by primary disease site and decade when they received treatment. Primary site included head and neck, colorectal, breast, gynecologic, prostate, lung, central nervous system (CNS), non-prostate genitourinary (GU), or other gastrointestinal (GI) cancers. Univariate analysis was used to compared characteristics of this cohort to those younger than 85. Multivariate logistic regression was done to identify factors independently associated with receiving radiation based on disease extent. A total of 1,915,296 adults (≥18 years old) were identified who received radiation therapy between 1973 and 2012. The median age was 63 and 51,759 (2.7%) were ≥85 years old. The percentage of patients receiving radiation who were ≥85 increased from 1.9% in the 1970s to 2.7% in the 2000s and 3.4% in 2011/2012. The relative percentage of ≥85 year olds receiving RT was 2.5% for locoregional disease and 3.2% for metastatic disease, with a percentage change from the 1970s to 2011/12 of +0.9% and +2.3%, respectively. By disease site, the median change in relative percentage of ≥85 year old patients receiving RT by decade over time was +1.6%. Only prostate cancer experienced a relative decline in RT usage (-0.3%). The largest relative increase in utilization between the 1970s and 2011/12 was seen in lung (+4.5%) and non-prostate GU cancers (+10.5%). Univariate analysis showed a significant difference between patients <85 and ≥85 who received RT with regard to gender, race, marital status, disease extent, and primary site (p <0.001). On multivariate analysis, age ≥85 was not independently associated with receiving radiation for distant disease (OR 1.01, 95% CI: 0.98 to 1.04, p=0.40). Patients ≥85 years old constitute an increasing percentage of patients receiving RT, particularly in recent years. Disease extent does not appear to impact relative utilization, however RT use in particular disease sites including lung and non-prostate GU demonstrated a considerable relative increase in this population. Based on these findings, further exploration of RT in the elderly can be targeted to these subpopulations.

Differential effect of Platelet Endothelial Cell Adhesion Molecule-1 (PECAM-1) on leukocyte infiltration during contact hypersensitivity responses.

Background2′–4′ Dinitrofluorobenzene (DNFB) induced contact hypersensitivity is an established model of contact sensitivity and leukocyte migration. Platelet Endothelial Cell Adhesion Molecule-1 (PECAM-1) deficient mice were used to examine the role of PECAM-1 in the migration capacity of several different leukocyte populations after primary and secondary application.Resultsγδ T lymphocytes, granulocytes, and Natural Killer cells were most affected by PECAM-1 deficiency at the primary site of application. γδ T lymphocytes, granulocytes, DX5+ Natural Killer cells, and, interestingly, effector CD4+ T lymphocytes were most affected by the loss of PECAM-1 at the secondary site of application.ConclusionsPECAM-1 is used by many leukocyte populations for migration, but there are clearly differential effects on the usage by each subset. Further, the overall kinetics of each population varied between primary and secondary application, with large relative increases in γδ T lymphocytes during the secondary response.

Circulating Mitochondrial (mt) DNA Fragments as Precursors of Inflammation in Early Stages of Atherogenesis

Atherosclerosis and its vascular complications are the leading cause of morbidity and mortality among Western populations. It is widely accepted that inflammation plays a major role in all stages of atherogenesis, including its initial phases. However, the mechanisms of initiation of inflammatory response predisposing to the development of atherosclerosis are not well understood. Mitochondrial dysfunction underlies many key processes in the development of atherosclerosis, including generation of reactive oxygen species, apoptosis, and inflammation. There is growing evidence that oxidative mtDNA damage can directly promote atherosclerosis. The mechanism linking mitochondrial damage to atherogenesis remains unclear, but may include initiation of inflammation by circulating mtDNA fragments known as DAMPs (Damage Associated Molecular Patterns). Previously, we have demonstrated that mice deficient in DNA repair glycosylase Ogg1 and fed a high fat diet developed larger fatty streaks in the aortic valve as a sign of early atherogenesis that was correlated with higher mtDNA oxidative damage in cardiac tissue and elevated content of plasma mtDNA fragments in comparison to wild type animals. In the present study we tested the hypothesis that development of atherosclerosis in animal model is associated with increased abundance of circulating pro‐inflammatory mtDNA fragments. ApoE‐null and wild type mice of increasing age were analyzed for atherosclerotic burden within the aortic valve and for abundance of mtDNA fragments in plasma. ApoE‐null mice develop atherosclerotic plaque in the aortic valve either spontaneously with age or after feeding a high fat diet. Early lesions were detected in ApoE‐null mice by 3 months of age whereas in 5‐month old animals they became prominent. Atherosclerotic burden reached 30% of valve area in 10‐month old animals and remained at that level in 12‐month old mice. Wild type animals did not develop lesions within the aortic valve at any age. The abundance of circulating mtDNA fragments was higher in ApoE‐null mice in all age groups when compared to wild type animals. Importantly, the largest relative increase in mtDNA fragments (5 to 6.5 fold vs. age‐matched controls) was observed in ApoE‐null mice at 3 and 5 months. These results indicate that circulating mtDNA fragments could be precursors of inflammation development in early stages of atherogenesis and suggest that efficient maintenance of mtDNA integrity could be an important target for atheroprotection.Support or Funding InformationNIH R01 HL113614

Partially Reduced Graphene Oxide Modified Tetrahedral Amorphous Carbon Thin-Film Electrodes as a Platform for Nanomolar Detection of Dopamine

In this study we present for the first time tetrahedral amorphous carbon (ta-C)—a partially reduced graphene oxide (PRGO) hybrid electrode nanomaterial platform for electrochemical sensing of dopamine (DA). Graphene oxide was synthesized with the modified Hummer’s method. Before modification of ta-C by drop casting, partial reduction of the GO was carried out to improve electrochemical properties and adhesion to the ta-C thin film. A facile nitric acid treatment that slightly reoxidized the surface and modified the surface chemistry was subsequently performed to further improve the electrochemical properties of the electrodes. The largest relative increase was seen in carboxyl groups. The HNO3 treatment increased the sensitivity toward DA and AA and resulted in a cathodic shift in the oxidation of AA. The fabricated hybrid electrodes were characterized with scanning electron microscopy (SEM), Raman spectroscopy, Fourier transform infrared spectroscopy (FT-IR), X-ray photoelectron spectroscopy (XPS), X-ray...

Effect of hammer mass on upper extremity joint moments

This study used an OpenSim inverse-dynamics musculoskeletal model scaled to subject-specific anthropometrics to calculate three-dimensional intersegmental moments at the shoulder, elbow and wrist while 10 subjects used 1 and 2 lb hammers to drive nails. Motion data were collected via an optoelectronic system and the interaction of the hammer with nails was recorded with a force plate. The larger hammer caused substantial increases (50–150%) in moments, although increases differed by joint, anatomical component, and significance of the effect. Moment increases were greater in cocking and strike/follow-through phases as opposed to swinging and may indicate greater potential for injury. Compared to shoulder, absolute increases in peak moments were smaller for elbow and wrist, but there was a trend toward larger relative increases for distal joints. Shoulder rotation, elbow varus-valgus and pronation-supination, and wrist radial-ulnar deviation and rotation demonstrated large relative moment increases. Trial and phase durations were greater for the larger hammer. Changes in moments and timing indicate greater loads on musculoskeletal tissues for an extended period with the larger hammer. Additionally, greater variability in timing with the larger hammer, particularly for cocking phase, suggests differences in control of the motion. Increased relative moments for distal joints may be particularly important for understanding disorders of the elbow and wrist associated with hammer use.

Trends and racial and ethnic disparities in the prevalence of pregestational type 1 and type 2 diabetes in Northern California: 1996–2014

Despite concern for adverse perinatal outcomes in women with diabetes mellitus before pregnancy, recent data on the prevalence of pregestational type 1 and type 2 diabetes mellitus in the United States are lacking. The purpose of this study was to estimate changes in the prevalence of overall pregestational diabetes mellitus (all types) and pregestational type 1 and type 2 diabetes mellitus and to estimate whether changes varied by race-ethnicity from 1996-2014. We conducted a cohort study among 655,428 pregnancies at a Northern California integrated health delivery system from 1996-2014. Logistic regression analyses provided estimates of prevalence and trends. The age-adjusted prevalence (per 100 deliveries) of overall pregestational diabetes mellitus increased from 1996-1999 to 2012-2014 (from 0.58 [95% confidence interval, 0.54-0.63] to 1.06 [95% confidence interval, 1.00-1.12]; Ptrend <.0001). Significant increases occurred in all racial-ethnic groups; the largest relative increase was among Hispanic women (121.8% [95% confidence interval, 84.4-166.7]); the smallest relative increase was among non-Hispanic white women (49.6% [95% confidence interval, 27.5-75.4]). The age-adjusted prevalence of pregestational type 1 and type 2 diabetes mellitus increased from 0.14 (95% confidence interval, 0.12-0.16) to 0.23 (95% confidence interval, 0.21-0.27; Ptrend <.0001) and from 0.42 (95% confidence interval, 0.38-0.46) to 0.78 (95% confidence interval, 0.73-0.83; Ptrend <.0001), respectively. The greatest relative increase in the prevalence of type 1 diabetes mellitus was in non-Hispanic white women (118.4% [95% confidence interval, 70.0-180.5]), who had the lowest increases in the prevalence of type 2 diabetes mellitus (13.6% [95% confidence interval, -8.0 to 40.1]). The greatest relative increase in the prevalence of type 2 diabetes mellitus was in Hispanic women (125.2% [95% confidence interval, 84.8-174.4]), followed by African American women (102.0% [95% confidence interval, 38.3-194.3]) and Asian women (93.3% [95% confidence interval, 48.9-150.9]). The prevalence of overall pregestational diabetes mellitus and pregestational type 1 and type 2 diabetes mellitus increased from 1996-1999 to 2012-2014 and racial-ethnic disparities were observed, possibly because of differing prevalence of maternal obesity. Targeted prevention efforts, preconception care, and disease management strategies are needed to reduce the burden of diabetes mellitus and its sequelae.

Impacts of biofuel-based land-use change on water quality and sustainability in a Kansas watershed

The growth in ethanol production in the United States has sparked interest in potential land-use change and the associated environmental impacts that may occur in order to accommodate the increasing demand for grain feedstocks. In this study water quality and sustainability indicators are used to evaluate the impacts of land-use change to increase corn and grain sorghum acreage for biofuel production in the Perry Lake watershed in northeast Kansas. Water quality indicators include sediment loads per converted land acreage and the relative increase of total nitrogen, total phosphorus and sediment loads compared to the baseline conditions. Sustainability indicators include land-use, water use, and nutrient use efficiencies. Hay, Conservation Reserve Program (CRP), and winter wheat were selected as targeted land-uses for conversion to biofuel feedstocks. The Soil and Water Assessment Tool (SWAT) was used to evaluate 6 different scenarios, each at 10 land-use change increments, for a total of 60 simulations. Results demonstrate that increased corn production generates significantly greater sediment loads than increased grain sorghum production and larger relative increases in nutrient loads. Expansion of corn or grain sorghum cropland by replacing hay or CRP land-uses resulted in the highest sediment loads and relative increases in nutrient loads. Expansion of corn or grain sorghum by replacing winter wheat cropland produced the lowest relative changes in nutrient and sediment loads and therefore may be a more sustainable land-use change. Corn had a higher yield potential per km2 compared to grain sorghum, resulting in better land, nutrient and water use efficiencies.

A Comparison of Oral Anticoagulant Use for Atrial Fibrillation in the Pre- and Post-DOAC Eras.

Direct oral anticoagulants (DOACs) have seen rapid uptake for the prevention of stroke associated with non-valvular atrial fibrillation (NVAF). It is unclear whether use of DOACs represents direct therapeutic substitution over warfarin or if this coincides with an increase in overall treatment rates. This study sought to describe the difference in oral anticoagulant (OAC) use in the pre-DOAC and post-DOAC eras. Incident cases of NVAF were identified from the Truven Marketscan database during the years 2005-2009 ('pre-DOAC') and 2013 ('post-DOAC'). Demographic and clinical characteristics were compared for the overall cohorts and among those who did and did not receive OAC in both time periods. OAC treatment was observed by stroke (CHA2DS2-VASc) and bleed risk (HAS-BLED) scores. Logistic regression was used to compare the individual characteristics associated with OAC use between the study periods. During the pre- and post-DOAC eras, 105,610 and 11,992 NVAF patients were identified. OAC treatment increased from 42.2 to 54.0% (absolute change 11.8%, relative change 28.0%) from the pre- to post-DOAC periods without meaningful differences between the populations. Larger relative increases in OAC treatment were observed for those at high risk of stroke (33.9% increase) and for those with moderate (30.4% increase) to high risk (28.6% increase) of bleed. Other than time period of diagnosis, no patient characteristics differed between those treated with OACs in the pre and post periods. There has been an overall increase in OAC use in the NVAF population, attributable to both favorable randomized trial results and aggressive marketing of DOACs in the USA.

Implementation of a Mini-CEX Requirement Across All Third-Year Clerkships

ABSTRACTProblem: Direct observation of medical students performing clinical tasks, such as eliciting a patient history or examining a patient, and the provision of feedback, are foundational to student improvement but have been reported to occur infrequently. The mini clinical evaluation exercise (mini-CEX) is a tool that can facilitate direct observation and feedback. This study assessed the impact of a mini-CEX requirement across all 3rd-year clerkships on student report of direct observation by faculty and objectively measured clinical skills. Intervention: A mini-CEX requirement across all 3rd-year clerkships was implemented in the 2012–2013 academic year. The impact of the mini-CEX requirement on student report of direct observation was assessed by end-of-clerkship surveys and Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) items on direct observation. The impact on students' clinical skills was assessed by a summative Objective Structured Clinical Examination (OSCE). Pre/post comparisons were assessed with chi-square and Fisher's exact tests. Context: A mini-CEX requirement had been in place for the internal medicine clerkship, and student reports of direct observation were historically higher for the internal medicine clerkship than for other clerkships. Faculty, residents, and students at each of the clinical sites across all 6 clerkships were oriented to the use of the mini-CEX; the feasibility of its use during usual patient interaction settings and the importance of direct observation and feedback for student improvement were emphasized during these sessions. Outcome: Adherence to the mini-CEX requirement was high: 92% of required forms were completed, and 78% of completed forms indicated that specific feedback was given. The proportion of students reporting direct observation of physical examination significantly increased in all clerkships, with the largest relative increase occurring in surgery (from 49% to 87%), χ2(1, N = 225) = 37.70, p < .0001. Significant increases were seen in faculty observation of history taking in pediatrics, surgery, and psychiatry. Direct observation rates also increased on the AAMC GQ items for history taking and physical exam for all clerkships. Failures on the summative OSCE decreased from 12% preintervention to 2% postintervention (p = .0046). Lessons Learned: Institution of a mini-CEX requirement was feasible across all 3rd-year clerkships and was associated with a significant increase in student report of direct observation by faculty and a decrease in summative OSCE failure rates.

Microcredit and adjustment to environmental shock: Evidence from the Great Famine in Ireland

The Great Famine of Ireland from 1845 to 51 ranks as one of the most lethal of all time, claiming approximately one eighth of the country's population. Utilizing Famine Relief Commission reports to develop a micro-level dataset of blight severity, I find that in the short run, districts more severely infected by blight experienced larger population declines and accumulations of buffer livestock by small- to medium-sized farms. In the medium and long runs, however, worse affected districts experienced greater substitutions toward other tillage crops and grazing livestock, particularly by small- to medium-sized farms. Using annual reports of the Irish Loan Funds, I further find that access to microfinance credit was an important factor in non-demographic adjustment to blight. Worse affected districts with at least one microfinance fund during the famine experienced substantially smaller relative population declines and larger relative increases in buffer livestock during and immediately after the famine, and greater relative medium- and long-run substitutions toward other crops and grazing livestock, than worse affected districts without a fund.

Differences in the Biometry of the Levator Hiatus at Rest, During Contraction, and During Valsalva Maneuver Between Women with and Without Provoked Vestibulodynia Assessed by Transperineal Ultrasound Imaging

Pelvic floor muscle (PFM) involvement is suspected in the pathophysiology of provoked vestibulodynia (PVD); however, the underlying mechanisms are unclear. PFM morphology can be inferred from the biometry of the levator hiatus determined through dynamic ultrasound imaging. The aim of this study was to determine the nature of PFM involvement in women with PVD via an evaluation of the biometry of the levator hiatus at rest, upon maximal voluntary contraction (MVC) of the PFMs, and upon maximal Valsalva maneuver (MVM). Thirty-eight women with PVD and 39 asymptomatic controls were imaged using 3D transperineal ultrasound. Levator hiatal dimensions (area; left-right [LR] and anteroposterior [AP] diameters) were measured at rest, on MVC, and on MVM. Differences in hiatal dimensions and in relative changes in dimensions from rest to MVC and from rest to MVM were compared between groups using separate 1-way analyses of variance for each measure and task. Analysis of covariance models were used to investigate the impact of levator hiatal dimensions at rest on the relative changes in the levator hiatal dimensions during MVC and MVM. Levator hiatal area, LR, and AP diameters, at rest, on MVC, and on MVM were the main outcome measures. Relative changes in hiatal dimensions were assessed as the percent change in hiatal area, LR diameter, and AP diameter. In comparison with controls, women with PVD had smaller hiatal areas at rest, on MVC, and on MVM, concurrent with smaller LR diameters on MVM. Women with PVD had a significantly smaller change in hiatal area on MVM than controls, but no differences were evident on MVC. In both groups, smaller levator hiatal dimensions at rest were associated with smaller relative decreases in dimensions on MVC and larger relative increases in dimensions on MVM. In comparison to controls, women with PVD appear to have narrower levator hiatus' and less capacity to distend their hiatus on Valsalva. The state of the PFMs at rest appears to significantly influence biometric changes in the PFMs during contraction and Valsalva.