Time Series Cross-sectional Study Research Articles

Changes in Purchases for Intensive Care Medicines During the COVID-19 Pandemic: A Global Time Series Study

BackgroundDrug supply disruptions have increased during the COVID-19 pandemic, especially for medicines used in the ICU. Despite reported shortages in wealthy countries, global analyses of ICU drug purchasing during COVID-19 are limited.Research QuestionHas COVID-19 impacted global drug purchases of first-, second-, and third-choice agents used in intensive care?Study Design and MethodsWe conducted a cross-sectional time series study in a global pharmacy sales dataset comprising approximately 60% of the world’s population. We analyzed pandemic-related changes in units purchased per 1,000 population for 69 ICU agents. Interventional autoregressive integrated moving average models tested for significant changes when the pandemic was declared (March 2020) and during its first stage from April through August 2020, globally and by development status.ResultsRelative to 2019, ICU drug purchases increased by 23.6% (95% CI, 7.9%-37.9%) in March 2020 (P < .001) and then decreased by 10.3% (95% CI, –16.9% to –3.5%) from April through August (P = .006). Purchases for second-choice medicines changed the most, especially in developing countries (eg, 29.3% increase in March 2020). Despite similar relative changes (P = .88), absolute purchasing rates in developing nations remained low. The observed decrease from April through August 2020 was significant only in developed countries (–13.1%; 95% CI, –17.4% to –4.4%; P < .001). Country-level variation seemed unrelated to expected demand and health care infrastructure.InterpretationPurchases for intensive care medicines increased globally in the month of the COVID-19 pandemic declaration, but before peak infection rates. These changes were most pronounced for second-choice agents, suggesting that inexpensive, generic medicines may be purchased more easily in anticipation of pandemic-related ICU surges. Nevertheless, disparities in access persisted. Trends seemed unrelated to expected demand, and decreased purchasing from April through August 2020 may suggest overbuying. National and international policies are needed to ensure equitable drug purchasing during future pandemics.

Impact of changes in opioid funding and clinical policies on rapid tapering of opioids in Ontario, Canada.

Reports have emerged of abrupt tapering among recipients of long-term prescription opioids to conform new prescribing guidelines. We conducted a population-based, repeated cross-sectional time-series study among very high-dose (≥200 MME) opioid recipients in Ontario, Canada, to examine changes in the monthly prevalence of rapid tapering from 2014 to 2018, defined as recipients experiencing either a ≥50% reduction in daily doses or abrupt discontinuation sustained for 30 days. Interventional autoregressive integrated moving average models were used to test for significant changes following key guidelines and drug policies and programs. A sensitivity analysis examined rapid tapering sustained for 90 days. The monthly prevalence of rapid tapering events was stable from January 2014 to September 2016 (average monthly prevalence: 1.4%) but increased from 1.4% in October 2016 to 1.8% in April 2017 (P = 0.001), coincident with Ontario's Fentanyl Patch-for-Patch Return Program implementation. Transient spikes in the prevalence of rapid tapering also occurred 2 months after Ontario's delisting of publicly funded high-strength opioids and the release of updated Canadian Opioid Prescribing Guideline for Chronic Pain, reaching 2.3% in March 2017 and July 2017, respectively. However, this prevalence decreased to 1.2% in December 2018 (P < 0.0001). Although the prevalence of abrupt opioid discontinuation was lower, similar trends were observed. Our sensitivity analysis examining long-lasting rapid tapering found similar trends but lower prevalence, with no changes in complete discontinuation. These temporary increases in rapid tapering events highlight the need for improved communication and evidence-based resources for prescribers to minimize negative consequences of evolving policies and guidelines.

Association of Wildfire Air Pollution and Health Care Use for Atopic Dermatitis and Itch

Air pollution is a worldwide public health issue that has been exacerbated by recent wildfires, but the relationship between wildfire-associated air pollution and inflammatory skin diseases is unknown. To assess the associations between wildfire-associated air pollution and clinic visits for atopic dermatitis (AD) or itch and prescribed medications for AD management. This cross-sectional time-series study assessed the associations of air pollution resulting from the California Camp Fire in November 2018 and 8049 dermatology clinic visits (4147 patients) at an academic tertiary care hospital system in San Francisco, 175 miles from the wildfire source. Participants included pediatric and adult patients with AD or itch from before, during, and after the time of the fire (October 2018 through February 2019), compared with those with visits in the same time frame of 2015 and 2016, when no large wildfires were near San Francisco. Data analysis was conducted from November 1, 2019, to May 30, 2020. Wildfire-associated air pollution was characterized using 3 metrics: fire status, concentration of particulate matter less than 2.5 μm in diameter (PM2.5), and satellite-based smoke plume density scores. Weekly clinic visit counts for AD or itch were the primary outcomes. Secondary outcomes were weekly numbers of topical and systemic medications prescribed for AD in adults. Visits corresponding to a total of 4147 patients (mean [SD] age, 44.6 [21.1] years; 2322 [56%] female) were analyzed. The rates of visits for AD during the Camp Fire for pediatric patients were 1.49 (95% CI, 1.07-2.07) and for adult patients were 1.15 (95% CI, 1.02-1.30) times the rate for nonfire weeks at lag 0, adjusted for temperature, relative humidity, patient age, and total patient volume at the clinics for pediatric patients. The adjusted rate ratios for itch clinic visits during the wildfire weeks were 1.82 (95% CI, 1.20-2.78) for the pediatric patients and 1.29 (95% CI, 0.96-1.75) for adult patients. A 10-μg/m3 increase in weekly mean PM2.5 concentration was associated with a 7.7% (95% CI, 1.9%-13.7%) increase in weekly pediatric itch clinic visits. The adjusted rate ratio for prescribed systemic medications in adults during the Camp Fire at lag 0 was 1.45 (95% CI, 1.03-2.05). This cross-sectional study found that short-term exposure to air pollution due to the wildfire was associated with increased health care use for patients with AD and itch. These results may provide a better understanding of the association between poor air quality and skin health and guide health care professionals' counseling of patients with skin disease and public health practice.

Trends in social inequalities in breastfeeding and infant formulas in Latin American countries between the 1990 and 2010 decades.

To analyse trends of social inequality in breastfeeding and infant formula (IF) use in Latin America between 1990 and 2010 decades. Time-series cross-sectional study with data from Demographic and Health Surveys. We described the prevalence of exclusive breastfeeding (EBF), breastfeeding between 6 and 12 months (BF6-12) and IF for infants under 6 months (IF < 6) and between 6 and 12 months (IF6-12). Social inequalities were assessed using the slope index of inequality (SII) and concentration index (CIX). Trends in the prevalence of breastfeeding, IF and index of social inequality were analysed by a linear regression model with weighted least squares variance. Bolivia, Colombia, Dominican Republic, Guatemala, Haiti and Peru. 51·358 alive infants younger than 12 months. Five countries showed an increasing trend for EBF and BF6-12, four increased for IF < 6 and six for IF6-12. Simultaneous decrease in IF < 6 (Colombia: -0·3/year; Haiti: -0·02/year) and increase in EBF (Colombia: +2·0/year; Haiti: +1·9/year) were observed only in two countries. EBF prevalence was high in the lowest income quintiles in five countries, and IF prevalence was high in the highest income quintiles in all countries and over the decades. For BF6-12, a decrease in inequality (prevalence increased in the highest quintile) was observed in Guatemala (SII1995 = -0·42; SII2015 = -0·28) and the Dominican Republic (SII1996 = -0·54; SII2013 = -0·26). Guatemala was the only country showing a decrease in inequality for BF (SII = -0·005; CIX = -0·0035) and an increase for IF (SII = 0·022; CIX = 0·01). The inequality in BF and IF remained over time. However, inequality in IF < 6 has decreased because low-income infants have increased use and high-income infants have decreased.

Seasonal variation of diarrheal diseases and drinking water quality in resettlement colony in Delhi, India: A community-based cross-sectional study.

Seasonal variation plays an important role in the occurrence of diarrheal diseases and distinct seasonal occurrence of diarrheal diseases, with bacterial diarrhea occurring more during the warm seasons and viral diarrhea occurring during the drier cool months, has been observed due to seasonal variation. Time-series cross-sectional study was conducted from January to December 2018 among 553 under-five children to assess seasonal variation of diarrheal diseases and its association with the drinking water quality in a resettlement colony of Delhi. The prevalence of diarrhea was 40.7% and was highest during the rainy season (67.6%). Majority of the water samples were found to be unsatisfactory for human consumption during the rainy and summer seasons. Significant and moderate relationship was found between the seasonal variation and occurrence of diarrhea (r = 0.728, P < 0.05) and most probable number count (r = 0.50, P < 0.05), respectively. Understanding the environmental factors that influences the occurrence of diarrheal diseases is warranted.

Distribution of indicators for chronic non-communicable diseases in adult women beneficiaries and non-beneficiaries of the Bolsa Família Program - Vigitel 2016-2019.

To compare the prevalence of and trend in risk and protective factors for chronic non-communicable diseases (NCDs) among women beneficiaries and non-beneficiaries of Bolsa Família from 2016 to 2019. This is a cross-sectional time-series study. We estimated the prevalence and prevalence ratios, both crude and adjusted for age and schooling, of NCD indicators with their respective confidence intervals, using the Poisson regression model. A time-trend analysis was also performed employing a simple linear regression model, regarding the indicators as the outcome variable and the year of the survey as the explanatory variable. Women beneficiaries were more exposed to risk factors for NCDs compared to non-beneficiaries. Prevalence ratios adjusted for smokers were 1.15 (1.07 - 1.24), for overweight were 1.08 (1.03 - 1.14), and for obesity were 1.09 (1.04 - 1.14), while the recommended fruit and vegetable consumption was 0.93 (0.87 - 0.99); they also showed lower practice of leisure-time physical activities (0.88; 0.82 - 0.93), spent more time watching TV (1.08; 1.02 - 1.13), had worse self-rated health status (1.12; 1.04 - 1.21), and lower rates of mammography (0.80; 0.71 - 0.90) and pap smear (0.93; 0.88 - 0.98). Among the beneficiaries, the trend analysis showed an increased prevalence of overweight, from 55.9 to 62.6%, and screen time except for TV, from 13.5 to 27.8%. NCD risk factors were higher among women beneficiaries of Bolsa Família, indicating the importance of maintaining affirmative policies for this vulnerable population.

Severe Acute Respiratory Syndrome Coronavirus 2 Testing in Children in a Large Regional US Health System During the Coronavirus Disease 2019 Pandemic.

The objective was to evaluate patterns of pediatric coronavirus disease 2019 testing in a large health system throughout the pandemic, before and after school reopening. This was a cross-sectional time-series study of clinical virology results from children tested for severe acute respiratory syndrome coronavirus 2 in Southern Connecticut and areas of New York and Rhode Island. Data collected include demographics, hospital admission, changes in percent positive tests over time, detection intervals in persistently positive children and cycle threshold values. The setting was the Yale New Haven Health System has 6 hospitals at 4 Connecticut locations, 1 hospital in Rhode Island and ambulatory locations in Connecticut, Rhode Island and New York. Participants included twenty-three-thousand one-hundred thirty-seven children ≤ 18 years of age, tested for coronavirus disease 2019 at an ambulatory testing site, the emergency department or on an inpatient unit within the Yale New Haven Health System. Among all tests, 3.2% were positive. Older children consistently made up the larger portion of positive pediatric cases, regardless of community prevalence. Increased pediatric cases later in the pandemic when prevalence in adults was relatively low correlates with a higher number of tests performed in children and not with an increased positivity rate. No significant changes in trends of positivity were detected after the reopening of schools. Symptomatic and asymptomatic children had similar cycle threshold values regardless of age, and a subset of children demonstrated persistent viral detection, some for as long as 6 weeks. An increase in pediatric cases documented in the late summer was predominately due to increased access to testing for children. The percent positivity in children did not change in the first 3 weeks after school opened. A subset of children has detectable severe acute respiratory syndrome coronavirus 2 RNA in the upper respiratory tract for weeks after the initial infection.

Dentists' Adoption of Silver Diamine Fluoride among 1- to 5-Year-Old Children in North Carolina.

A natural experiment was conducted to observe the adoption of silver diamine fluoride (SDF) by Medicaid-enrolled dentists in North Carolina (NC). The purpose of this study was to describe the sociocontextual and community health characteristics where dentists adopted SDF, determine the association between SDF use and general anesthesia (GA) use, and examine the changes in GA utilization following implementing SDF reimbursement. NC Medicaid initiated SDF reimbursement in 2016 for children ages 1 to 5 y. This cross-sectional time series study used aggregate NC Medicaid claims, including geographic data, from 2014 to 2018. All dentists who provided GA and/or SDF to children ages 1 to 5 y were included. County health ranking data described social and community health indicators. Descriptive statistics, spatial data techniques, and multivariable methods were used. From 2016 to 2018, the number of dentists using SDF increased from 35 to 258, or 637%, whereas the number of dentists using GA increased from 179 to 211, or 17%. SDF utilization spread outward from areas of good social and health indicators to areas of poorer indicators. SDF utilization increased from 0.35 to 0.65 per 1,000 children, whereas GA utilization decreased from 2.57 to 2.47 per 1,000 children. GA utilization was positively associated with SDF utilization and poorer county health ranking but did not change before and after SDF implementation. Early adopters of SDF in NC practiced in areas with positive social and community health indicators. Over time, SDF was adopted in resource-poor communities. It remains too early to determine the public health impacts of SDF treatment on GA utilization. Policy makers and clinicians can use the results of this study to develop geographically targeted interventions that could lead to clinically and cost-effective public health programs.

Effects of particulate air pollution on tuberculosis development in seven major cities of Korea from 2010 to 2016: methodological considerations involving long-term exposure and time lag.

OBJECTIVESEpidemiological evidence of associations between ambient particulate matter (PM) and tuberculosis (TB) risk is accumulating. Two previous studies in Korea found associations between air pollution—especially sulfur dioxide (SO2)—and TB. In this study, we conducted an annual time-series cross-sectional study to assess the effect of PM with an aerodynamic diameter less than 10 μm (PM10) on TB risk in seven major cities of Korea from 2010 to 2016, taking into account time lag and long-term cumulative exposure.METHODSAge-standardized TB notification rates were derived using the Korea National TB Surveillance System. Annual average PM10 concentrations were obtained from annual Korean air quality reports. We applied a generalized linear mixed model with unconstrained distributed lags of exposure to PM10. We adjusted for potential confounders such as age, health behaviors, and area-level characteristics.RESULTSBoth average annual PM10 concentrations and age-standardized TB notification rates decreased over time. The association between cumulative exposure to PM10 and TB incidence became stronger as a longer exposure duration was considered. An increase of one standard deviation (5.63 μg/m3) in PM10 exposure for six years was associated with a 1.20 (95% confidence interval, 1.17 to 1.22) times higher TB notification rate. The marginal association of exposure duration with the TB notification rate was highest at four and five years prior to TB notification. This association remained consistent even after adjusting it for exposure to SO2.CONCLUSIONSThe findings of this study suggest that cumulative exposure to PM10 may affect TB risk, with a potential lag effect.

Assessing the impact of an opioid prescribing guideline for dentists in Ontario, Canada

BackgroundThe Royal College of Dental Surgeons of Ontario introduced a new dental opioid prescribing guideline in November 2015. The authors examined whether introduction of this guideline was associated with changes in opioid prescribing patterns. MethodsThe authors conducted a population-based, cross-sectional time series study of Ontarians who received opioids prescribed by dentists from July 1, 2012 through September 30, 2017. They examined the impact of the guideline on dental prescribing patterns by calculating the monthly rate of opioid dispensing from dentists per 100,000 population, as well as the population exposure to opioids expressed as milligram morphine equivalents per 100 population. ResultsOntario dentists issued 1,571,897 opioid prescriptions to 1,157,102 patients over the study period. The guideline was not associated with a change in opioid dispensing rates, but it was associated with a significant reduction in the volume of opioids dispensed (28.1% reduction, from 22.1 to 15.9 milligram morphine equivalents per 100 population from October 2015 through September 2017; P = .01). ConclusionsIntroduction of the prescribing guideline was associated with no change in the rate of opioid prescribing by dentists, but it was associated with a roughly 25% reduction in the volume of opioids prescribed. Practical ImplicationsIntroduction of the new opioid prescribing guideline for Ontario dentists was associated with a reduction in the overall volume of opioids dispensed.

Incidence of Newly Diagnosed Tuberculosis among Healthcare Workers in a Teaching Hospital, Thailand.

Background:Data on the incidence of new onset tuberculosis (TB) infection among healthcare workers (HCWs) in Thailand was scarce and not current.Objectives:To determine the incidence of TB, as well as the impact of TB on HCWs in a teaching hospital in Bangkok, Thailand.Methods:A time series cross-sectional study was conducted at Ramathibodi Hospital, Bangkok, Thailand. It was a teaching hospital with 9,562 employees. Medical records of personnel with TB infection between October 1st, 2010 and September 30th, 2015 were reviewed to determine the newly diagnosed TB infection. The personnel who were treated in fiscal year 2015 were interviewed about work-related issues, health status and the impact of TB.Findings:In five years, 109 personnel were diagnosed with new onset TB disease. The infection rates were 2.04, 1.97, 2.85, 2.53, and 1.35 per 1,000 persons in 2011, 2012, 2013, 2014, and 2015, respectively. The most prevalent type of TB infection was pulmonary TB. The infection rate in males was higher than in females. Pharmacists had the highest proportion of infected personnel. The second highest rate of infection was in support staff related to patient care. Twenty personnel were interviewed. Most of them worked in patient care units with central-type air-conditioning system without negative-pressure rooms for TB patients. Contracting TB had an impact on productivity at work, health (physically, mentally and socially) and incomes.Conclusions:Ramathibodi HCWs had higher rate of TB infection than the general Thai population, but the incidence was noted to be decreasing from 2013 to 2015. HCWs suffered from the impact of TB on their lives in multiple ways. Due to the adverse impact of TB on the health and welfare of its employees, hospital administration should apply effective preventive measures and develop a compensation system for HCWs infected with TB.

Internal migration and public opinion about the European Union: a time series cross-sectional study

Abstract Although the European Union (EU) allows citizens from member countries to migrate freely within its confines to facilitate integration, it may be alienating public support for Europe. This article investigates this by extending group threat theory to explain how internal migration is related to public opinion about the EU using annual Eurobarometer data from 1998 to 2014 across 15 Western European countries. Employing a pooled time cross-sectional design, I find that the presence of EU citizens from Central and Eastern European member states is positively related to public beliefs that EU membership is not beneficial for their country. The results also show that this relationship is even stronger during an economic downturn. There is weak evidence that it may be related to distrust in European institutions as well. These findings shed light on why public support for the EU can erode over time and how it responds to contextual changes in Europe’s internal migration patterns. The study concludes by discussing how group threat theory is relevant for understanding public opinion about the EU.

Financial and other frauds in the United States: a panel analysis approach

PurposeThe purpose of this paper is to report on the findings and implications associated with the millions of financial and other fraud complaints that are reported to the Federal Trade Commission and published in the Consumer Sentinel Network Data Book each year since 2002. Based on the three dimensions, namely, the number of complaints, growth rates and geographic locations of those crimes, this study found similar as well as unique trends that are new and are critical for addressing the rise of cybercrimes in the USA. The trends and patterns identified may also have implications for addressing cybercrimes in other parts of the world.Design/methodology/approachThis research is a cross-sectional time-series study that covers frauds and cybercrimes in the USA from 2002 to 2015. The observed cases included the number of total complaints, complaints categories and payment amount or loss incurred both at the national and state levels. First, aggregate fraud totals, categories, payments and payment methods were analyzed and ranked. Second, state data for fraud categories, payments and filing rate per capita were organized into panel data for analysis, comparison and ranking. This cross-sectional and longitudinal approach of the different dimensions of financial and other frauds generate new rankings and more robust results.FindingsThe key findings are related to the long-term occurrences and trends of financial and online frauds in the USA. While some general trends are consistent with prior studies, the cross-sectional and longitudinal panel analysis produced some unique results. States that reported the most complaints do not necessarily rank high when examined with their growth per capital or their rates of growth. Their rankings could change dramatically due to other factors. In addition, eight of the top ten crime categories are the same both at the national and state levels, indicating that law enforcement could target the same crime categories.Originality/valueThe panel data analysis is new (first attempt at using this technique on the data set) and robust because it allows cross-sectional and longitudinally analysis of the various financial and online fraud crimes, in aggregate and by state, for a more comprehensive and comparative examination of the fraud behavioral trends. This research can be viewed as an improvement over earlier studies because the panel analysis identifies what fraud trends, scam types and payment amount exist on the national and state levels. The rate of fraud growth in the respective states provides a better understanding about future development of this problem.

Health Expenditure and All-Cause Mortality in the 'Galaxy' of Italian Regional Healthcare Systems: A 15-Year Panel Data Analysis.

The sustainability of healthcare systems is a topic of major interest. During periods of economic instability, policy makers typically reallocate resources and execute linear cuts in different areas of public spending, including healthcare. The aim of this paper was to examine whether and how per capita public healthcare expenditure (PHE) in the Italian regions was related to the all-cause mortality rate (MR) between 1999 and 2013 and to determine which expenditure item most affected mortality in the short and very short term. We conducted a pooled cross-sectional time series study. Secondary data were extracted from 'Health for All', a database released periodically by the Italian National Institute of Statistics. PHE is subdivided into directly provided services (DPS), pharmaceutical care, general practitioner care, specialist medical care, privately delivered hospital care, other privately delivered medical services, and psychiatric support and rehabilitation. We used a fixed-effects regression to assess the effects of PHE items on the MR after controlling for a number of socioeconomic and supply variables. Higher spending on DPS was associated with a lower MR. Other expenditure variables were not significantly associated with the MR. The results highlight the importance of medical services and goods provided directly by public services (i.e. hospital-based general and specialized wards and offices, emergency departments, etc.). DPS represents the driving force of the system and should be considered a determinant of the health of the Italian population. Our results suggest that the context and financing methods of a healthcare system should be carefully analysed before linear cuts are made or resources are reallocated.

Investigation of the Association Between Alcohol Outlet Density and Alcohol-Related Hospital Admission Rates in England: Study Protocol.

BackgroundAvailability of alcohol is a major policy issue for governments, and one of the availability factors is the density of alcohol outlets within geographic areas.ObjectiveThe aim of this study is to investigate the association between alcohol outlet density and hospital admissions for alcohol-related conditions in a national (English) small area level ecological study.MethodsThis project will employ ecological correlation and cross-sectional time series study designs to examine spatial and temporal relationships between alcohol outlet density and hospital admissions. Census units to be used in the analysis will include all Lower and Middle Super-Output Areas (LSOAs and MSOAs) in England (53 million total population; 32,482 LSOAs and 6781 MSOAs). LSOAs (approximately 1500 people per LSOA) will support investigation at a fine spatial resolution. Spatio-temporal associations will be investigated using MSOAs (approximately 7500 people per MSOA). The project will use comprehensive coverage data on alcohol outlets in England (from 2003, 2007, 2010, and 2013) from a commercial source, which has estimated that the database includes 98% of all alcohol outlets in England. Alcohol outlets may be classified into two broad groups: on-trade outlets, comprising outlets from which alcohol can be purchased and consumed on the premises (eg, pubs); and off-trade outlets, in which alcohol can be purchased but not consumed on the premises (eg, off-licenses). In the 2010 dataset, there are 132,989 on-trade and 51,975 off-trade outlets. The longitudinal data series will allow us to examine associations between changes in outlet density and changes in hospital admission rates. The project will use anonymized data on alcohol-related hospital admissions in England from 2003 to 2013 and investigate associations with acute (eg, admissions for injuries) and chronic (eg, admissions for alcoholic liver disease) harms. The investigation will include the examination of conditions that are wholly and partially attributable to alcohol, using internationally standardized alcohol-attributable fractions.ResultsThe project is currently in progress. Results are expected in 2017.ConclusionsThe results of this study will provide a national evidence base to inform policy decisions regarding the licensing of alcohol sales outlets.

Radiological features of healing in newborn clavicular fractures

Given the frequency of abusive fractures among infants, and the lack of research and or evidence for the phases of fracture healing seen in this age group, this study aims to describe a timetable of radiological features of fracture healing among infants in the first months of life. We completed a retrospective cross-sectional time-series study of birth-related clavicle fractures from 2006-2013. A total of 108 digital images were available for review from 61 infants. The presence or absence of four features of healing including periosteal reaction, callus formation, bridging callus and remodelling were scored by three radiologists. The level of agreement between the radiologists was good to high (0.60-0.90). Features of healing were first seen at 7days (periosteal reaction), 11days (callus), 20days (bridging) and 35days (remodelling), respectively. The peak periods that each feature was present are as follows: periosteal reaction 11-42 days, callus 12-61 days, bridging 22-63 days and remodelling 49-59 days. Birth-associated clavicle fractures in infants follow a logical progression of healing changes. Understanding the expected progression and timing of fracture healing may be helpful as it pertains to the timing of injury in cases of abuse in infants. • Large study describing the time frames of fracture healing in young infants. • Features of fracture healing develop in a logical progression. • Evidence provided for determining fractures are consistent with a proposed time frame. • It is of critical importance to have sound evidence for the dating of fractures.

Social anxiety in medical students: A five-year follow-up

Introduction Social anxiety is known to interfere with academic attainment. Its negative effects may be more pronounced in medical students, since symptoms may prevent acquisition of necessary skills for appropriate medical examination or procedures. Objectives Medical education in Turkey lasts six years. Clinical internship (6th year) is qualitatively different from other years, since the student assumes the responsibilities similar to those of resident physicians. The transformation involved in this process may have an effect on the social anxiety levels of students. Aims Our aim was to examine how medical education effects social anxiety level, focusing on the change from start to graduation. Methods This was a pooled, time series cross-sectional study. Independent samples of students from same group were assessed for demographic information and social anxiety at three time points: at the first year of medical school ( n =152), at the beginning of 6th year of medical school ( n =153), and at the end of the 6th year ( n =130). Results Social anxiety levels declined from Time 1 (Liebowitz Social Anxiety Scale [LSAS]=44.3) to Time 2 (LSAS=30.6), and was stable after that (LSAS at Time 3=30.7). Social anxiety was predicted by having another phobia at Time 1; and by psychiatric history in family at Times 2 and 3. Conclusions Our study shows that medical education probably has a positive effect on social anxiety, but this effect does not continue into the last year, i.e. internship. This is unexpected, because internship requires the acquisition of new social and professional skills. Findings will be discussed in the light of relevant literature.

Provision of Preventive Dental Services in Children Enrolled in Medicaid by Nondental Providers.

Aims of this study are to determine (1) the association of oral health services (OHS) provided by nontraditional providers with the percentage of Medicaid children 0 to 5 years of age who receive ≥1 preventive services from all provider types in the United States; and (2) characteristics of state Medicaid policies associated with provision of OHS. We conducted a time-series cross-sectional study of preventive services provided by nontraditional (OHS) and dental (PDS) providers for Medicaid-enrolled children from birth to 5 years of age in all states during 2010 to 2013 (204 observations). We applied panel data multiple regression analysis techniques to exploit year and state variation in aggregate data available in Centers for Medicare and Medicaid Services reports (form CMS-416). Total preventive dental services (TPDS =OHS + PDS) was predicted by months since state enactment of a policy to reimburse medical providers for OHS. The 44 states with a policy reported 4.3% of children per state per year with any OHS. For all states, an average of 30.1% received PDS and 34.5% TPDS. The delivery of OHS was associated with a small increase in percentage with TPDS. One year of Medicaid OHS availability was associated with an increase of 1.5% in the percentage of children with TPDS per state per year. Implementation of policies by Medicaid programs to support integration of OHS into primary care is associated with increases in overallTPDS use, but efforts are needed to improve implementation in practice to achieve national impact on access.

Plasma 25-hydroxycholecalciferol before and after supplementation in paediatric oncology patients from Scotland: a time-series cross-sectional study

Plasma 25-hydroxycholecalciferol before and after supplementation in paediatric oncology patients from Scotland: a time-series cross-sectional study

Associations between the prevalence of Mollicutes and Mycoplasma bovis and health and performance in stocker calves

A longitudinal cross-sectional time-series study was carried out to determine the prevalence of nasal mycoplasma carriage, serostatus and seroconversion, and to evaluate the associations between these parameters and health and...