Relative Percentage Change Research Articles

Synoptic approach to evaluate the effect of temperature on pediatric respiratory disease-related hospitalization in Seoul, Korea

BackgroundThe spatial synoptic classification (SSC) scheme is a daily weather-type classification scheme that is widely used in climatological and epidemiological investigations. We investigated the modification effect of temperature on respiratory disease-related hospital admissions (RAs) in children based on the SSC type. MethodsData on RAs among children aged ≤19 years were collected from the National Inpatient Sample (NIS) database between 2011 and 2015 in Seoul, Korea. In this time-series study, we used Poisson generalized linear models allowing for over-dispersion, with stratification by season and each of the seven distinctive SSC types (Dry moderate [DM], Dry polar [DP], Dry tropical [DT], Moist moderate [MM], Moist polar [MP], Moist tropical [MT], and Transition [T]). We investigated the modification effects of temperature by SSC type through seasonal stratification, adjusting for other meteorological conditions, air pollution, and time trends, and considered the delayed effect for up to four consecutive days. We reported the relative risk percentage change with 95% confidence intervals (CIs) of RAs for every 1 °C increase in ambient temperature, by season and SSC type. ResultsOf the 8346 RAs overall investigated between 2011 and 2015, there were 5271 [63.2%] RAs in children aged 0–4 years. Overall, on majority of the days, the SSC types were DM (665 days [36.4%]), and DP (371 days [20.3%]). With regard to seasons, the different SSC types were distributed as follows: spring, DM (193 days [42.0%]); summer, MT (193 days [42.0%]); fall, DM (241 days [53.0%]); and winter, DP (228 days [50.6%]). A stronger association between RAs and temperature was observed overall (1.28% [95% CI; 0.04%, 2.53%]), and in spring (2.10% [0.62%, 3.60%]). According to SSC type, increased associations between RAs and temperature were detected with DM (2.20% [0.47%, 3.97%]) condition during spring and DT (2.41% [0.22%, 4.64%]) during fall. In addition, on re-categorizing the SSC types from a temperature or humidity standpoint, a modified association was observed especially in children aged ≤4 years and 5–9 years during spring. ConclusionsUsing temperature variability to distinguish seasonal characteristics, we found that the relationship between temperature and RAs in children varied by SSC type. Application of the SSC scheme as an integrative approach may assist in gaining an understanding of seasonal characteristics and health effects due to temperature change.

Intravoxel incoherent motion (IVIM) for response assessment in patients with osteosarcoma undergoing neoadjuvant chemotherapy

PurposeTo explore the role of quantitative Intravoxel incoherent motion (IVIM) parameters and their histogram analysis in characterizing changes in Osteosarcoma receiving neoadjuvant chemotherapy (NACT) and evaluating therapeutic response. MethodsForty patients (N = 40; Male:Female = 30:10; Age = 17.7 ± 5.9years; Metastatic:localized = 17:23) with histologically confirmed Osteosarcoma treated with 3-cycles of NACT were analyzed prospectively. All patients underwent Diffusion weighted imaging (DWI) with 11 b-values (0–800 s/mm2) using 1.5 T MRI scanner at pre-treatment (t0), after 1-cycle (t1) and after 3-cycles (t2) of NACT. Non-invasive response evaluation of NACT was performed using RECIST1.1 criteria. Apparent-diffusion-coefficient (ADC) and IVIM parameters – Diffusion-coefficient (D), Perfusion-coefficient (D*) & Perfusion-fraction (f) and their relative percentage changes from time-point t0–t1 (Δ2) and t0–t2 (Δ2) were evaluated and histogram analysis was performed at three time-points and compared with respect to RECIST1.1 scores. ResultsUsing RECIST1.1 criteria, 11 (27.5%), 21 (52.5%) and 8 (20%) patients were in Partial-responder (PR), Stable-disease (SD) and Progressive-disease (PD) groups respectively. Pre-NACT (t0), average ADC, D,D*&f in tumor volume were 1.36 ± 0.33 × 10−3 mm2/s, 1.3 ± 0.3 × 10−3 mm2/s, 28.44 ± 10.34 × 10−3 mm2/s & 13.95 ± 2.83% respectively. Using ANOVA test, during NACT (t1, t2), D*-variance (p = 0.038, 0.003) and f-skewness (p = 0.03, 0.03) and at t2, D*-entropy (p = 0.001) and f-entropy (p = 0.002) and their Δ2 changes (p = 0.001, 0.003) were statistically significant among response groups. At t1, D*-variance and f-skewness jointly showed AUC = 0.77 & 0.74 in classifying PR (Sensitivity = 73%; Specificity = 70%) and SD (Sensitivity = 74; Specificity = 75%) groups respectively in patient cohort. Δ1 & Δ2 changes of D*-mean, D*-variance, D*-entropy and f-entropy correlated well (0.5-0.6) with tumor-diameter and tumor-volume changes. ConclusionsQuantitative IVIM parameters, especially D* &f and their histogram analysis were informative and can be used as noninvasive surrogate markers for early response assessment during the course of NACT in Osteosarcoma.

Norursodeoxycholic acid versus placebo in the treatment of non-alcoholic fatty liver disease: a double-blind, randomised, placebo-controlled, phase 2 dose-finding trial

Norursodeoxycholic acid is an orally administered side chain-shortened homologue of ursodeoxycholic acid that undergoes hepatic enrichment with hepatoprotective, anti-inflammatory, and antifibrotic activity. We assessed the efficacy of two doses of norursodeoxycholic acid versus placebo for the treatment of non-alcoholic fatty liver disease. We did a multicentre, double-blind, placebo-controlled, randomised, phase 2 dose-finding clinical trial in tertiary referral hospitals and medical centres in Austria (n=6) and Germany (n=23) for patients with non-alcoholic fatty liver disease with or without diabetes. Patients with a clinical diagnosis of non-alcoholic fatty liver disease and serum alanine aminotransferase (ALT) concentrations of more than 0·8 times the upper limit of normal were randomly assigned (1:1:1) using a computer-generated central randomisation. Patients were randomly assigned to receive either norursodeoxycholic acid capsules at 500 mg per day or 1500 mg per day, or placebo, for 12 weeks with a subsequent 4-week follow-up period. All individuals involved in the trial were masked to treatment allocation. The primary efficacy endpoint was the mean relative percentage change in ALT concentrations between baseline and end of treatment assessed in the intention-to-treat population. This trial is registered with EudraCT, number 2013-004605-38. Between March 30, 2015, and Sept 20, 2016, of 198 individuals included in the analysis, 67 patients were randomly assigned to receive 500 mg norursodeoxycholic acid, 67 to 1500 mg norursodeoxycholic acid, and 64 to placebo. A dose-dependent reduction in serum ALT between baseline and end of treatment was observed with norursodeoxycholic acid versus placebo, with a significant effect in the 1500 mg group (mean change -27·8%, 95% repeated CI -34·7 to -14·4; p<0·0001). Serious adverse events (n=6) and treatment-emergent adverse events (n=314) were reported in a similar proportion of patients across groups. 112 treatment-emergent adverse events occurred in the 1500 mg group, 99 in the 500 mg group, and 103 in the placebo group. The most frequent adverse events were headache, gastrointestinal disorders, and infections (eg, diarrhoea, abdominal pain, or nasopharyngitis). Norursodeoxycholic acid at 1500 mg resulted in a significant reduction of serum ALT within 12 weeks of treatment when compared with placebo. Norursodeoxycholic acid was safe and well tolerated encouraging further studies. Dr Falk Pharma GmbH.

Impact of nasopharyngeal irradiation and gadolinium administration on changes in T1 signal intensity of the dentate nucleus in nasopharyngeal malignancy patients without intracranial abnormalities.

Irradiation has been found to increase T1 signal intensity (SI) of the dentate nucleus (DN) by accelerating the gadolinium deposition in patients after multiple gadolinium-based contrast agent (GBCA) administrations. Several reports have focused on this phenomenon in patients with brain tumors; however, data in patients receiving irradiation with no intracranial abnormalities (NIAs) are lacking. To explore how nasopharyngeal irradiation affected SI changes on unenhanced T1 -weighted imaging (T1 WI) in the DN in nasopharyngeal malignancy (NPM) patients who presented with NIAs and who had multiple injection doses (IDs) of linear GBCAs. Single-center, retrospective, case-control study. In all, 132 subjects: 66 NPM patients, 66 matched controls. 1.5T and 3T/T1 WI, T2 WI, and fluid-attenuated inversion recovery (FLAIR). Radiation doses (RDs) were calculated by a radiotherapy technician. SIs were measured by a radiologist. The DN-to-cerebellar white matter (CWM) SI ratios and their relative percentage change (Rchange ) were compared. Shapiro-Wilk test, paired t-test, independent t-test, Mann-Whitney U-test, Pearson and Spearman correlation. DN/CWM b ratios or R change from the NPM group were significantly higher than those from the control group (P < 0.001). No significant difference of DN/CWM a ratios was found between the two groups (P > 0.05). Positive correlations between R change , DN/CWM b ratio, and the number of IDs were found in both the NPM and control groups (P < 0.01). The overall changes of DN/CWM b ratio or R change between NPM and control groups were higher for the higher-IDs subgroup (≥10) than for the lower-IDs subgroup (<10). Nasopharyngeal irradiation appeared to increase SI in T1 WI in NPM patients with NIAs and repeated GBCA administrations relative to control patients who also underwent GBCA administrations, especially when IDs ≥10. However, no significant association between R change and RDs to the DNs was found. 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:250-259.

The PRINTO evidence-based proposal for glucocorticoids tapering/discontinuation in new onset juvenile dermatomyositis patients

BackgroundPrednisone (PDN) in juvenile dermatomyositis (JDM), alone or in association with other immunosuppressive drugs, namely methotrexate (MTX) and cyclosporine (CSA), represents the first-line treatment option for new onset JDM patients. No clear evidence based guidelines are actually available to standardize the tapering and discontinuation of glucocorticoids (GC) in JDM. Aim of our study was to provide an evidence-based proposal for GC tapering/discontinuation in new onset juvenile dermatomyositis (JDM), and to identify predictors of clinical remission and GC discontinuation.MethodsNew onset JDM children were randomized to receive either PDN alone or in combination with methotrexate (MTX) or cyclosporine (CSA). In order to derive steroid tapering indications, PRINTO/ACR/EULAR JDM core set measures (CSM) and their median absolute and relative percent changes over time were compared in 3 groups. Group 1 included those in clinical remission who discontinued PDN, with no major therapeutic changes (MTC) (reference group) and was compared with those who did not achieve clinical remission, without or with MTC (Group 2 and 3, respectively). A logistic regression model identified predictors of clinical remission with PDN discontinuation.ResultsBased on the median change in the CSM of 30/139 children in Group 1, after 3 pulses of methyl-prednisolone, GC could be tapered from 2 to 1 mg/kg/day in the first two months from onset if any of the CSM decreased by 50–94%, and from 1 to 0.2 mg/kg/day in the following 4 months if any CSM further decreased by 8–68%, followed by discontinuation in the ensuing 18 months. The achievement of PRINTO JDM 50–70-90 response after 2 months of treatment (ORs range 4.5–6.9), an age at onset > 9 years (OR 4.6) and the combination therapy PDN + MTX (OR 3.6) increase the probability of achieving clinical remission (p < 0.05).ConclusionsThis is the first evidence-based proposal for glucocorticoid tapering/discontinuation based on the change in JDM CSM of disease activity.Trial registrationTrial full title: Five-Year Single-Blind, Phase III Effectiveness Randomized Actively Controlled Clinical Trial in New Onset Juvenile Dermatomyositis: Prednisone versus Prednisone plus Cyclosporine A versus Prednisone plus Methotrexate. EUDRACT registration number: 2005–003956-37. Clinical Trial.gov is NCT00323960. Registered on 17 August 2005.

Targeting B-cell malignancies: Impact of an educational curriculum on BTK inhibitors.

10531 Background: We sought to determine if a curriculum of online continuing medical education (CME) activities could improve hematologists/oncologists (hem/onc) knowledge and competence related to clinical decision making in the use of BTKi in patients with B-cell lymphomas. Methods: An expert panel identified knowledge/competence gaps related to the use of Bruton's tyrosine kinase inhibitors (BTKi) in B-cell lymphomas. A clinical practice assessment (CPA) survey was launched May 2018 to further assess baseline educational needs. Based on the needs identified, 7 activities were posted online between May-Dec 2018. Multiple-choice questions were asked before and after participation in each activity and were grouped into learning topics. Mean knowledge/competence was calculated for the CPA and across all 7 activities. The impact of education was examined using a pre/post design. Statistical significance was assessed using a chi-square statistic ( P &lt; .05 level). Results: For all topics except foundational/differentiating BTKi, the audiences participating in the baseline CPA and the other 7 activities, were similar or lower at pre-test, suggesting that learning needs continued until our education addressed them. All changes from pre-to-post-test were significant ( P &lt; .001). The largest relative percent change from pre- to post-test was seen with knowledge of resistance mechanisms for BTKi as well as knowledge/competence managing AE of BTKi. Post-test there was a high level of knowledge about the selectivity seen with 2nd generation BTKi. Conclusions: This analysis shows that online CME, utilizing many different formats (video, text, panel discussions) can significantly improve the knowledge and competence of hem/oncs in multiple areas surrounding the use of BTKi for the treatment of B-cell lymphomas. Results also suggest the following areas warrant further education: awareness of clinical trial safety and efficacy data for BTKi and mechanisms for resistance to BTKi. [Table: see text]

Association of Stratification by Dual Enrollment Status With Financial Penalties in the Hospital Readmissions Reduction Program

ImportanceBeginning in fiscal year 2019, Medicare’s Hospital Readmissions Reduction Program (HRRP) stratifies hospitals into 5 peer groups based on the proportion of each hospital’s patient population that is dually enrolled in Medicare and Medicaid. The effect of this policy change is largely unknown.ObjectiveTo identify hospital and state characteristics associated with changes in HRRP-related performance and penalties after stratification.Design, Setting, and ParticipantsA cross-sectional analysis was performed of all 3049 hospitals participating in the HRRP in fiscal years 2018 and 2019, using publicly available data on hospital penalties, merged with information on hospital characteristics and state Medicaid eligibility cutoffs.ExposuresThe HRRP, under the 2018 traditional method and the 2019 stratification method.Main Outcomes and MeasuresPerformance on readmissions, as measured by the excess readmissions ratio, and penalties under the HRRP both in relative percentage change and in absolute dollars.ResultsThe study sample included 3049 hospitals. The mean proportion of dually enrolled beneficiaries ranged from 9.5% in the lowest quintile to 44.7% in the highest quintile. At the hospital level, changes in penalties ranged from an increase of $225 000 to a decrease of more than $436 000 after stratification. In total, hospitals in the lowest quintile of dual enrollment saw an increase of $12 330 157 in penalties, while those in the highest quintile of dual enrollment saw a decrease of $22 445 644. Teaching hospitals (odds ratio [OR], 2.13; 95% CI, 1.76-2.57; P < .001) and large hospitals (OR, 1.51; 95% CI, 1.22-1.86; P < .001) had higher odds of receiving a reduced penalty. Not-for-profit hospitals (OR, 0.64; 95% CI, 0.52-0.80; P < .001) were less likely to have a penalty reduction than for-profit hospitals, and hospitals in the Midwest (OR, 0.44; 95% CI, 0.34-0.57; P < .001) and South (OR, 0.42; 95% CI, 0.30-0.57; P < .001) were less likely to do so than hospitals in the Northeast. Hospitals with patients from the most disadvantaged neighborhoods (OR, 2.62; 95% CI, 2.03-3.38; P < .001) and those with the highest proportion of beneficiaries with disabilities (OR, 3.12; 95% CI, 2.50-3.90; P < .001) were markedly more likely to see a reduction in penalties, as were hospitals in states with the highest Medicaid eligibility cutoffs (OR, 1.79; 95% CI, 1.50-2.14; P < .001).Conclusions and RelevanceStratification of the hospitals under the HRRP was associated with a significant shift in penalties for excess readmissions. Policymakers should monitor the association of this change with readmission rates as well as hospital financial performance as the policy is fully implemented.

Incidence of V˙O2max Responders to Personalized versus Standardized Exercise Prescription.

Despite knowledge of cardiorespiratory fitness (CRF) training responders and nonresponders, it is not well understood how the exercise intensity prescription affects the incidence of response. The purpose of this study was to determine CRF training responsiveness based on cohort-specific technical error after 12 wk of standardized or individually prescribed exercise and the use of a verification protocol to confirm maximal oxygen uptake (V˙O2max). Sedentary adult participants (9 men, 30 women; 48.2 ± 12.2 yr) completed exercise training on 3 d·wk for 12 wk, with exercise intensity prescribed based on standardized methods using heart rate reserve or an individualized approach using ventilatory thresholds. A verification protocol was used at baseline and 12 wk to confirm the identification of a true V˙O2max and subsequent relative percent changes to quantify CRF training responsiveness. A cohort-specific technical error (4.7%) was used as a threshold to identify incidence of response. Relative V˙O2max significantly increased (P < 0.05) from 24.3 ± 4.6 to 26.0 ± 4.2 and 29.2 ± 7.5 to 32.8 ± 8.6 mL·kg·min for the standardized and individualized groups, respectively. Absolute V˙O2max significantly increased (P < 0.05) from 2.0 ± 0.6 to 2.2 ± 0.6 and 2.4 ± 0.8 to 2.6 ± 0.9 L·min for the standardized and individualized groups, respectively. A significant difference in responsiveness was found between the individualized and standardized groups with 100% and 60% of participants categorized as responders, respectively. A threshold model for exercise intensity prescription had a greater effect on the incidence of CRF training response compared with a standardized approach using heart rate reserve. The use of thresholds for intensity markers accounts for individual metabolic characteristics and should be considered as a viable and practical method to prescribe exercise intensity.

Sex differences in stroke metrics among Southeast Asian countries: Results from the Global Burden of Disease Study 2015.

Sex differences in cardiovascular diseases generally disadvantage women, particularly within developing regions. This study aims to examine sex-related differences in stroke metrics across Southeast Asia in 2015. Furthermore, relative changes between sexes are compared from 1990 to 2015. Data were sourced from the Global Burden of Disease Study. Incidence and mortality from ischemic and hemorrhagic strokes were explored with the following statistics derived: (1) women-to-men incidence/mortality ratio and (2) relative percentage change in rate. Women had lower incidence and mortality from stroke compared to men. Notable findings include higher ischemic stroke incidence for women at 30-34 years in high-income countries (women-to-men ratio: 1.3, 95% CI: 0.1, 16.2 in Brunei and 1.3, 95% CI: 0.5, 3.2 in Singapore) and the largest difference between sexes for ischemic stroke mortality in Vietnam and Myanmar across most ages. Within the last 25 years, greater reductions for ischemic stroke metrics were observed among women compared to men. Nevertheless, women below 40 years in some countries showed an increase in ischemic stroke incidence between 0.5% and 11.4%, whereas in men, a decline from -4.2% to -44.2%. Indonesia reported the largest difference between sexes for ischemic stroke mortality; a reduction for women whereas an increase in men. For hemorrhagic stroke, findings were similar: higher incidence among young women in high-income countries and greater reductions for stroke metrics in women than men over the last 25 years. Distinct sex-specific differences observed across Southeast Asia should be accounted in future stroke preventive guidelines.

Continuation of Gender Disparities in Pay Among Academic Emergency Medicine Physicians.

The objective was to identify the effects of gender and other predictors of change in the salary of academic emergency physicians over a four sequential time period of survey administration, across a sample of physicians within different emergency departments (EDs) and within states representing the four main geographical regions of the United States. This was a successive cross-sectional observational study of EDs in the United States using an annual salary survey distributed to all Association of Academic Chairs in Emergency Medicine (AACEM) and Academy of Administrators in Academic Emergency Medicine (AAAEM) members in 2013, 2015, 2016, and 2017 with a sample size of 7,102 respondents over all time periods. The primary variable of interest was the adjusted base salary, calculated to be the full-time effort of the physician without any enhancements (e.g., without stipend, release time, extra hours). Institutional predictive variables included U.S. region that ED was in and if the site was an academic or community academic hybrid ("community") ED. Individual level variables included gender, academic rank, years at academic rank, years at rank within the ED, and primary duty (clinical or other). A series of Wilcoxon tests were conducted to determine if the unadjusted difference in salaries by gender for each year of the survey were significantly different. The effects of relative change in adjusted base salary over time were assessed using a mixed-effects regression model, with institutional- and individual-level predictors included in the model. Data were provided by 81 departments across the four geographic regions of the United States (Northeast, South, West, and Midwest). Most of the survey respondents across the four time periods of administration were male (65%) and reported primary clinical appointments at an academic ED (94%). Overall salaries increased across the four time points of the data with an overall relative 10.8% (95% confidence interval [CI]= 9.6%-12%) change in median salary between 2013 and 2017; the relative percentage change for female respondents was 10.6% (95% CI= 9.4%-11.85%) and 11.1% (95% CI= 10.2%-12%) for males. Within survey years, not adjusting for academic rank, the median salary increase for males was higher ($226,746 in 2013 to $252,000 in 2017) than females ($217,000 in 2013 to $240,000 in 2017), with significance at all four time points (Z=6.33, p<0.001), with a median average salary gap of $12,000 in 2017. In the predictive model that adjusted for covariates, gender significantly predicted median adjusted salary, with males earning significantly more than females (F(1)=22.5, p<0.001). Despite previously published data showing an inappropriate gender salary gap in emergency medicine, this gap has remained essentially unchanged over the past 4 years.

Abstract WP212: Trends in Acute Ischemic Stroke Hospitalizations by Age Groups, Length of Stay, Mortality and Hospital Costs in the United States From 2000-2014

Background and Purpose: Acute Ischemic Stroke (AIS) is a significant cause of long term disability. The primary objective of our study was to analyze the trends in AIS hospitalizations by age groups, Length of Stay (LOS), Mortality and hospital costs in the United States over a 15-year period from the years 2000 to 2014. Methods: Nationwide inpatient sample (NIS) database was used to identify AIS admissions in all patients from 2000 to 2014 using ICD-9-CM codes 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, and 436 as the principal discharge diagnosis. NIS is the largest all-payer inpatient care database in the United States, containing data on more than 7 million hospital stays. It has a large sample size which is ideal for developing national and regional estimates. Results: A total of 554,226,249 discharges with a diagnosis of AIS were analyzed from 2000 to 2014 from the NIS database. Hospitalization rates for AIS increased significantly from years 2000 to 2014 for ages 18-44 (relative percentage change (RPC): +33.75%) and ages 45-64(RPC: +41.21%). Hospitalization rates for AIS have significantly decreased in the age group 65-84 (RPC: -16.69%). In-hospital mortality decreased from 6.97% in 2000 to 4.4% in 2014. Mean LOS has decreased from 6.19 days to 4.2 days during the same period. Mean hospital costs have gone up from $6,975 to $12,322. Conclusion: Overall in-hospital mortality and LOS associated with AIS has decreased over the years. AIS US hospitalizations have significantly increased in the age groups from 18-64 while there was a significant decrease in the rate of hospitalizations in the age groups 65-84. Further research needs to be done to identify the risk factors contributing to a substantial rise in AIS hospitalizations in young to middle age adults.

Variability of Future Rainfall over the Mono River Basin of West-Africa

This study assessed the rainfall trends and changes over Mono river basin under the highest greenhouse gas emission scenario RCP8.5. Simulations of eight regional climate models (RCMs) provided by Africa-CORDEX program were considered. To analyze the performance of a set of regional climate models, the MBE (mean bias error), the RMSE (root mean square error), the volume bias (VB), correlation coefficient (R2) and the t-Test statistics were calculated. The precipitation concentration index (PCI), Mann-Kendall trend test, Theil-Sen’s slope estimator (β), and relative percentage change methods were also adopted for data analysis. Changes from the baseline period 1981-2010 were computed for far future (2061-2090 and 2071-2100). As results, the analysis herein highlighted the multi-models’ mean ability to simulate the Mono river basin rainfall adequately. Two distinct patterns emerged from the calculated PCI indicating that stations in southern basin will have moderate, irregular, and strongly irregular rainfall concentrations, whereas stations in northern basin will have irregular and strongly irregular rainfall concentrations. Significant declining in the rainfall was detected in most stations for the future period. The evolution of the monthly average rainfall amounts will be broadly characterized by a decrease and increase between 32.4 and 12% with late rainy seasons. It is understood that future changes in rainfall distribution and trends will affect the availability of water for crops, which should affect the productivity of rain fed agriculture.

National Burden of Heart Failure Events in the United States, 2006 to 2014.

Heart failure (HF)-a serious and costly condition-is increasingly prevalent. We estimated the US burden including emergency department (ED) visits, inpatient hospitalizations and associated costs, and mortality. We analyzed 2006 to 2014 data from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample, the Healthcare Cost and Utilization Project National (nationwide) Inpatient Sample, and the National Vital Statistics System. International Classification of Disease codes identified HF and comorbidities. Burden was estimated separately for ED visits, hospitalizations, and mortality. In addition, criteria were applied to identify total unique acute events. Rates of primary HF (primary diagnosis or underlying cause of death) and comorbid HF (comorbid diagnosis or contributing cause of death) were calculated, age standardized to the 2010 US population. In 2014, there were an estimated 1 068 412 ED visits, 978 135 hospitalizations, and 83 705 deaths with primary HF. There were 4 071 546 ED visits, 3 370 856 hospitalizations, and 230 963 deaths with comorbid HF. Between 2006 and 2014, the total unique acute event rate for primary HF declined from 536 to 449 per 100 000 (relative percent change of -16%; P for trend, <0.001) but increased for comorbid HF from 1467 to 1689 per 100 000 (relative percentage change, 15%; P for trend, <0.001). HF-related mortality decreased significantly from 2006 to 2009 but did not change meaningfully after 2009. For hospitalizations with primary HF, the estimated mean cost was $11 552 in 2014, totaling an estimated $11 billion. Given substantial healthcare and mortality burden of HF, rising healthcare costs, and the aging US population, continued improvements in HF prevention, management, and surveillance are important.

Analysis of Rainfall Distribution, Temporal Trends, and Rates of Change in the Savannah Zones of Nigeria

ABSTRACT The impact of climate change is often demonstrated by rainfall and its attributes. Consequently, this study analyzes rainfall concentration, temporal trends, and rates of change in the savannah zones of Nigeria. Rainfall data were acquired from the archives of the Environmental Management Programme, Federal University of Technology, Minna, for 13 synoptic stations at annual, seasonal, and monthly time scales for the 1970–2016 period. The precipitation concentration index (PCI), Mann–Kendall trend test, Theil–Sen’s slope estimator (β), and relative percentage change methods were adopted for data analysis. The findings reveal that PCI calculated on an annual scale falls into three categories 11–15, 16–20, and PCI > 20. Two distinct patterns emerged from the calculated PCI indicating that stations in the Guinea savannah zone (Bida, Yola, Minna, Jos, Bauchi, and Kaduna) have moderate, irregular, and strongly irregular rainfall concentrations, whereas stations in the Sudano-Sahelian savannah zone (Kano, Gusau, Maiduguri, Yelwa, Nguru, Sokoto, and Katsina) have irregular and strongly irregular rainfall concentrations. The Mann–Kendall analysis of the PCI values reveals that 8 of the 13 stations (62%) experienced downward trends. This implies that rainfall is sliding toward a moderate to uniform distribution. The trends, and consequently the variability in the annual and seasonal rainfall, reveal that, with the exception of Yola and Jos stations, where the trends were downward, the overall rainfall was increasing significantly in some areas and insignificantly in others. The magnitude of the significant upward trends in the annual rainfall was found to be 3.59 mm yr−1 at Yelwa station, 9.84 mm yr−1 at Bauchi station, 17.13 mm yr−1 at Kano station, 3.98 mm yr−1 at Sokoto station, and 3.11 mm yr−1 at Katsina station. It is understood that the changes in rainfall distribution and trends have positive effects on water availability for crops, and this should facilitate enhanced productivity in rain-fed farming.

Trends in attention-deficit hyperactivity disorder medication use: a retrospective observational study using population-based databases

The use of medications to treat attention deficit hyperactivity disorder (ADHD) has increased, but the prevalence of ADHD medication use across different world regions is not known. Our objective was to determine regional and national prevalences of ADHD medication use in children and adults, with a specific focus on time trends in ADHD medication prevalence. We did a retrospective, observational study using population-based databases from 13 countries and one Special Administrative Region (SAR): four in Asia and Australia, two in North America, five in northern Europe, and three in western Europe. We used a common protocol approach to define study populations and parameters similarly across countries and the SAR. Study populations consisted of all individuals aged 3 years or older between Jan 1, 2001, and Dec 31, 2015 (dependent on data availability). We estimated annual prevalence of ADHD medication use with 95% CI during the study period, by country and region and stratified by age and sex. We reported annual absolute and relative percentage changes to describe time trends. 154·5 million individuals were included in the study. ADHD medication use prevalence in 2010 (in children aged 3-18 years) varied between 0·27% and 6·69% in the countries and SAR assessed (0·95% in Asia and Australia, 4·48% in North America, 1·95% in northern Europe, and 0·70% in western Europe). The prevalence of ADHD medication use among children increased over time in all countries and regions, and the absolute increase per year ranged from 0·02% to 0·26%. Among adults aged 19 years or older, the prevalence of any ADHD medication use in 2010 varied between 0·003% and 1·48% (0·05% in Asia and Australia, 1·42% in North America, 0·47% in northern Europe, and 0·03% in western Europe). The absolute increase in ADHD medication use prevalence per year ranged from 0·0006% to 0·12%. Methylphenidate was the most commonly used ADHD medication in most countries. Using a common protocol and data from 13 countries and one SAR, these results show increases over time but large variations in ADHD medication use in multiple regions. The recommendations of evidence-based guidelines need to be followed consistently in clinical practice. Further research is warranted to describe the safety and effectiveness of ADHD medication in the short and long term, and to inform evidence-based guidelines, particularly in adults. None.

P176] Evaluating automatic contour propagation for estimating tumour shrinkage in small-cell lung cancer patients treated with chemo-radiotherapy

Purpose The clinical relevance of tumour shrinkage during thoracic radiotherapy remains unknown with studies showing conflicting results whether shrinkage predicts outcome. Previous work has relied on manual contouring on cone beam CT (CBCT). To enable large scale analysis, automated methods for contour propagation and quantification of tumour shrinkage are essential. Methods 20 small-cell lung cancer patients treated with concurrent chemo-radiotherapy were selected. All patients had a planning CT and, in total, 81 weekly CBCT scans were available. An experienced lung cancer radiation oncologist manually contoured the GTV on all scans. Additionally, the GTV contour of the planning CT was automatically propagated across the CBCTs, using ADMIRE (Research v1.13, Elekta AB, Stockholm, Sweden). To investigate the accuracy of the automated contour propagation, a comparison against the manual contours was performed using median distance to agreement (mDTA). To quantify tumour shrinkage, volumes were calculated for propagated and manual contours. Differences in volumes were assessed using a Bland–Altman plot. Finally, using the day one CBCT as reference volume, the relative percentage change was calculated at each time-point and fitted using linear regression. The slopes for manual versus propagated contours were compared. Results ADMIRE successfully propagated GTV contours all CBCTs. Concordance between the manual and propagated contours showed an unsigned mDTA of 3 mm across all CBCT. Results were worse for GTV contours overlapping with the mediastinum. The Bland–Altman analysis for absolute differences in volume at each time-point resulted a mean of −1.6 cm3. Relative differences provided a mean of −4.8%, with manual contours showing smaller volumes. Finally, manual contours estimated a consistently faster rate of tumour shrinkage (0.018 cm3/day) than automatically propagated contours (0.014 cm3/day). A linear fit between the manual and propagated gradients per patient found a slope of 0.68 (1 for perfect agreement). Conclusions The results show that automatic contour propagation performance is acceptable for use in wider research studies. There are differences between the manual and propagated contours, with the clinician estimated a larger rate of tumour shrinkage, which is suggestive of an observer bias. We will now apply this technique to investigate tumour shrinkage and outcome in the CONVERT trial patients.

Improving Appropriate Basal Insulin Use in Clinical Practice—Impact of Physician Education on T2D Clinical Management

Although insulin is among the most effective antihyperglycemic agents, initiation is often delayed. We studied whether online continuing medical education (CME) could improve the clinical performance and confidence of primary care physicians (PCPs) and endocrinologists (endos) regarding use of basal insulin. The CME activity consisted of an online, 30-minute, video-based roundtable panel discussion. Educational effects were assessed using 3 case-based and 1 self-efficacy repeated pair pre-/post-assessment questions and McNemar’s chi-squared test. The activity launched online August 16, 2016, and data were collected through December 20, 2016. Overall improvements were seen for PCPs (n = 197; P &amp;lt;.001) and endos (n = 27; P =0.014). Relative percent changes from pre- to post-assessment were between 15% and 126% for PCPs and -4% to 40% for endos. While only 7% of PCPs and 19% of endos answered all 4 questions correctly on the pre-assessment, 28% of PCPs and 41% of endos answered all correctly on the post-assessment. The greatest improvements were seen in dosing strategies for preventing hypoglycemia (44% improvement in PCP, P &amp;lt;.001, and 18% in endos, P = 0.025), individualizing therapy in a patient with high glucose variation (23% improvement in PCP, P &amp;lt;.001, and 7% in endos, P = 0.4), and insulin initiation (8% improvement in PCP, P = 0.039, and 22% in endos, P = 0.058). PCPs reported a confidence level of 2.86 on the pre-assessment and 3.45 on the post -assessment, for a total confidence shift of 20.6%. Endos reported a confidence level of 4.04 on the pre-assessment and 4.44 on the post -assessment for a confidence shift of 10.1%. This study demonstrates the success of an online, roundtable activity in improving performance of PCPs and endos regarding use of newer basal insulins. Studies have shown that case questions are an effective way to measure clinical performance in practice; therefore this activity is expected to translate into improved T2D management in clinical care. Disclosure A. Larkin: None. M. LaCouture: None. A. Le: None.

Acupuncture for hip osteoarthritis.

Hip osteoarthritis (OA) is a major cause of pain and functional limitation. Few hip OA treatments have been evaluated for safety and effectiveness. Acupuncture is a traditional Chinese medical therapy which aims to treat disease by inserting very thin needles at specific points on the body. To assess the benefits and harms of acupuncture in patients with hip OA. We searched Cochrane CENTRAL, MEDLINE, and Embase all through March 2018. We included randomized controlled trials (RCTs) that compared acupuncture with sham acupuncture, another active treatment, or no specific treatment; and RCTs that evaluated acupuncture as an addition to another treatment. Major outcomes were pain and function at the short term (i.e. < 3 months after randomization) and adverse events. We used standard methodological procedures expected by Cochrane. Six RCTs with 413 participants were included. Four RCTs included only people with OA of the hip, and two included a mix of people with OA of the hip and knee. All RCTs included primarily older participants, with a mean age range from 61 to 67 years, and a mean duration of hip OA pain from two to eight years. Approximately two-thirds of participants were women. Two RCTs compared acupuncture versus sham acupuncture; the other four RCTs were not blinded. All results were evaluated at short term (i.e. four to nine weeks after randomization).In the two RCTs that compared acupuncture to sham acupuncture, the sham acupuncture control interventions were judged believable, but each sham acupuncture intervention was also judged to have a risk of weak acupuncture-specific effects, due to placement of non-penetrating needles at the correct acupuncture points in one RCT, and the use of penetrating needles not inserted at the correct points in the other RCT. For these two sham-controlled RCTs, the risk of bias was low for all outcomes.The combined analysis of two sham-controlled RCTs gave moderate quality evidence of little or no effect in reduction in pain for acupuncture relative to sham acupuncture. Due to the small sample sizes in the studies, the confidence interval includes both the possibility of moderate benefit and the possibility of no effect of acupuncture (120 participants; Standardized Mean Difference (SMD) -0.13, (95% Confidence Interval (CI) -0.49 to 0.22); 2.1 points greater improvement with acupuncture compared to sham acupuncture on 100 point scale (i.e., absolute percent change -2.1% (95% CI -7.9% to 3.6%)); relative percent change -4.1% (95% CI -15.6% to 7.0%)). Estimates of effect were similar for function (120 participants; SMD -0.15, (95% CI -0.51 to 0.21)). No pooled estimate, representative of the two sham-controlled RCTs, could be calculated or reported for the quality of life outcome.The four other RCTs were unblinded comparative effectiveness RCTs, which compared (additional) acupuncture to four different active control treatments.There was low quality evidence that addition of acupuncture to the routine primary care that RCT participants were receiving from their physicians was associated with statistically significant and clinically relevant benefits, compared to the routine primary physician care alone, in pain (1 RCT; 137 participants; mean percent difference -22.9% (95% CI -29.2% to -16.6%); relative percent difference -46.5% (95% CI -59.3% to -33.7%)) and function (mean percent difference -19.0% (95% CI -24.41 to -13.59); relative percent difference -38.6% (95% CI -49.6% to -27.6%)). There was no statistically significant difference for mental quality of life and acupuncture showed a small, significant benefit for physical quality of life.The effects of acupuncture compared with either advice plus exercise or NSAIDs are uncertain.We are also uncertain whether acupuncture plus patient education improves pain, function, and quality of life, when compared to patient education alone.In general, the overall quality of the evidence for the four comparative effectiveness RCTs was low to very low, mainly due to the potential for biased reporting of patient-assessed outcomes due to lack of blinding and sparse data.Information on safety was reported in four RCTs. Two RCTs reported minor side effects of acupuncture, which were primarily minor bruising, bleeding, or pain at needle insertion sites. Four RCTs reported on adverse events, and none reported any serious adverse events attributed to acupuncture. Acupuncture probably has little or no effect in reducing pain or improving function relative to sham acupuncture in people with hip osteoarthritis. Due to the small sample size in the studies, the confidence intervals include both the possibility of moderate benefits and the possibility of no effect of acupuncture. One unblinded trial found that acupuncture as an addition to routine primary physician care was associated with benefits on pain and function. However, these reported benefits are likely due at least partially to RCT participants' greater expectations of benefit from acupuncture. Possible side effects associated with acupuncture treatment were minor.

Platelet-rich plasma on female androgenetic alopecia: Tested on 10 patients.

Recently, platelet-rich plasma (PRP) injection has been proposed as a potential adjuvant therapy to treat androgenetic alopecia. Investigate the efficacy, tolerability, and clinical improvement of PRP for the treatment of female AGA. A total of 10 female patients affected by AGA and not responding to treatment with minoxidil and/or oral antiandrogens were enrolled. The clinical improvement was evaluated by pull test, global photographs, and Trichoscan at weeks 9, 12, and 24, and hair measurements were performed at baseline and 12 and 24weeks after the first session. After 24weeks, the median relative percentage change (%RC) for all the parameters of hair density was mostly positive. After 12weeks, the medium hair diameter in frontal area showed a significant increase (%RD=12.5, with P-value<.05), and after 24weeks (%RD=14.6, P-value<.05), the vellus relative change instead showed a decrease, especially in the front and the central area, while for the vertex, the decrease was mainly visible at the end (-6.6%). No adverse events were reported. Platelet-rich plasma injections have a positive therapeutic effect on hair density and hair diameter improvement.

The Impact of Aerobic Exercise Training on Autonomic Function in Adolescent Sport‐Related Concussion

IntroductionImpairments in autonomic function such as increased heart rate (HR) and reduced heart rate variability (HRV), have been observed in patients diagnosed with concussion. This may be indicative of cardiovascular and autonomic uncoupling. Aerobic exercise can help improve cardiac autonomic balance, and increase HRV. Accordingly, controlled aerobic exercise may help restore autonomic balance in adolescents diagnosed with a concussion.ObjectiveTo test the hypothesis that aerobic exercise rehabilitation can help restore autonomic functioning in adolescents diagnosed with a concussion.MethodsParticipants with a confirmed concussion diagnosis were recruited for this study. Participants were randomly allocated into one of two conditions, 1) Exercise (n=7, 14.2±1.7 years, 22.8±5.2 BMI) and; 2) Usual care (n=8, 14.6±1.6 years, 23.4±6.3 BMI). At baseline testing, each participant completed a five‐minute resting supine trial to record measures of the HRV signal. Following, participants performed a 10‐minute exertion test on a treadmill to symptom exacerbation, similar to previous work. The exercise group completed three additional days of monitored aerobic exercise at 80% HR of their symptom exacerbation. All exercise training was completed on a cycle ergometer within one‐week of baseline. The usual care group did not perform any exercise for one‐week. Follow‐up testing occurred one‐week post baseline. Main outcome measures for supine HRV were, root mean square of successive NN interval differences (RMSSD), standard deviation of successive NN interval differences (SDNN), total power, high frequency power, and low frequency power. HRV measures are reported as mean±standard deviation. The relative percent change between baseline and follow‐up were calculated for each outcome measure, and an independent samples t‐test was used to measure differences between conditions.ResultsCompared to study entry baseline levels, there was a significant main effect for exercise group RMSSD increased from baseline (44±21 ms) to follow‐up (50±22 ms) (p &lt; 0.05, d = 1.3). However, RMSSD decreased for the usual care group from baseline (87±34 ms) to follow‐up (70±39). Similarly, was a statistically significant difference in SDNN scores (p &lt; 0.05, d = 1.2) between conditions. SDNN increased in the exercise group from baseline (52.4±20.0 ms) to follow‐up (58.2±16.6 ms), and decreased in the usual care condition from baseline (80.5±22.3 ms) to follow‐up (67±24.7 ms) (p &lt; 0.05, d = 1.2). There were no statistically significant differences for any frequency domain measures.ConclusionOur findings suggest monitored aerobic exercise training at 80% HR of symptom exacerbation may help restore autonomic imbalances associated with concussion injury in adolescents.Support or Funding InformationChildren's Health Research InstituteThis abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.