OBJECTIVE Type 2 diabetes is increasingly common and associated with substantial morbidity and mortality. This study examines trends in the patterns and costs of drug treatment of type 2 diabetes ...from 1997 to 2012. RESEARCH DESIGN AND METHODS We conducted descriptive analyses of cross-sectional data using the IMS Health National Disease and Therapeutic Index, a nationally representative audit of ambulatory physician practices in the U.S. We focused on visits for diabetes among patients 35 years of age or older. We used the IMS Health National Prescription Audit of pharmacy dispensing to derive information about drug expenditures. RESULTS Ambulatory diabetes visits increased from 23 million treatment visits in 1997 (95% CI 21-25) to 35 million (32-37) in 2007 and declined to 31 million visits by 2012 (27-31). Between 1997 and 2012 biguanide use increased, from 23% (20-26) to 53% (50-56) of treatment visits. Glitazone use grew from 6% (4-8) in 1997 (41% 39-43 of all visits in 2005), but declined to 16% (14-18) by 2012. Since 2005, dipeptidyl peptidase-4 (DPP-4) inhibitor use increased steadily, representing 21% (18-23) of treatment visits by 2012. Glucagon-like peptide 1 (GLP-1) agonists accounted for 4% of treatment visits in 2012. Visits where two or more drug compounds were used increased nearly 40% from 1997 to 2012. Between 2008 and 2012, drug expenditures increased 61%, driven primarily by use of insulin glargine and DPP-4 inhibitors. CONCLUSIONS Declining sulfonylurea and glitazone use has been offset by increases in DPP-4 inhibitor use and, to a lesser degree, use of GLP-1 agonists. Treatment of diabetes has grown in complexity while older treatments continue to be replaced or supplemented by newer therapies.
OBJECTIVES:Physicians are a key stakeholder in the epidemic of prescription opioid abuse. Therefore, we assessed their knowledge of opioid abuse and diversion, as well as their support for clinical ...and regulatory interventions to reduce opioid-related morbidity and mortality.
MATERIALS AND METHODS:We conducted a nationally representative postal mail survey of 1000 practicing internists, family physicians, and general practitioners in the United States between February and May 2014.
RESULTS:The adjusted response rate was 58%, and all physicians (100%) believed that prescription drug abuse was a problem in their communities. However, only two-thirds (66%) correctly reported that the most common route of abuse was swallowing pills whole, and nearly one-half (46%) erroneously reported that abuse-deterrent formulations were less addictive than their counterparts. In addition, a notable minority of physicians (25%) reported being “not at all” or “only slightly concerned” about the potential for opioid diversion from the licit to the illicit market when this practice is common at all levels of the pharmaceutical supply chain. Most physicians supported clinical and regulatory interventions to reduce prescription opioid abuse, including the use of patient contracts (98%), urine drug testing (90%), requiring prescribers to check a centralized database before prescribing opioids (88%), and instituting greater restrictions on the marketing and promotion of opioids (77% to 82%). Despite this, only one-third of physicians (33%) believed that interventions to reduce prescription opioid abuse had a moderate or large effect on preventing patients’ clinically appropriate access to pain treatment.
DISCUSSION:Although physicians are unaware of some facets of prescription opioid-related morbidity, most support a variety of clinical and regulatory interventions to improve the risk-benefit balance of these therapies.
The assessment of adverse effects of psychiatric medications is important in clinical and research settings because they are often associated with medication discontinuation, symptom exacerbation, ...and reduced quality of life. Currently available assessment tools are either limited with regard to the number and variety of included adverse effects or are not practical for use in most clinical or research settings owing to specialized rater training required and administration length. This report describes a modification of the Monitoring of Side Effects Scale (MOSES), an established adverse effect rating scale, by adding severity anchors to improve its reliability and ease of use. Interrater reliability was good for 7 of the 8 bodily adverse effects assessed, with intraclass correlation coefficients ranging from 0.76 to 0.91 in a sample of patients with severe mental illness. This modified version of the Monitoring of Side Effects Scale holds promise as a useful tool for assessing medication adverse effects in clinical and research settings.
Mesozoic birds display considerable diversity in size, flight adaptations and feather organization
, but exhibit relatively conserved patterns of beak shape and development
. Although Neornithine ...(that is, crown group) birds also exhibit constraint on facial development
, they have comparatively diverse beak morphologies associated with a range of feeding and behavioural ecologies, in contrast to Mesozoic birds. Here we describe a crow-sized stem bird, Falcatakely forsterae gen. et sp. nov., from the Late Cretaceous epoch of Madagascar that possesses a long and deep rostrum, an expression of beak morphology that was previously unknown among Mesozoic birds and is superficially similar to that of a variety of crown-group birds (for example, toucans). The rostrum of Falcatakely is composed of an expansive edentulous maxilla and a small tooth-bearing premaxilla. Morphometric analyses of individual bony elements and three-dimensional rostrum shape reveal the development of a neornithine-like facial anatomy despite the retention of a maxilla-premaxilla organization that is similar to that of nonavialan theropods. The patterning and increased height of the rostrum in Falcatakely reveals a degree of developmental lability and increased morphological disparity that was previously unknown in early branching avialans. Expression of this phenotype (and presumed ecology) in a stem bird underscores that consolidation to the neornithine-like, premaxilla-dominated rostrum was not an evolutionary prerequisite for beak enlargement.
•Quasi-static breaking of a porphyry copper ore with in-situ X-ray µCT imaging.•A new textural analysis method for ore breakage type characterization.•3D mapping of micro-porosity and its effects on ...ore breakage.•Ore texture and breakage characteristics on Cu minerals surface liberation.
As the mining industry continues to seek greater energy efficiency, it needs more effective characterization of ore material as it progresses from mine to mill. The energy cost of ore mineral liberation, for example, is critically dependent on management of rock breakage from blasting to comminution. The study reported here presents a quantitative method for 3D characterization of ore texture and breakage based on X-ray micro-CT and in-situ micromechanical test. A porphyry copper ore is studied from its initial mechanical failure to the onset of fragmentation. This work integrates a quantitative ore textural analysis with 3D mapping of both the dominant minerals and micro-porosity in the ore sample. It enables us to show, as the fractured ore is still under loading, that internal breakage of feldspar grains dominates grain boundary fracturing. We discuss how the microporous regions, mostly found in hydrothermally altered plagioclase, may act as a weakening factor leading to the dominant breakage of plagioclase. We measure quantitatively and discuss how size reduction, ore texture and breakage characteristics control the degree of liberation of Cu minerals. Combining characterisation of ore texture with breakage in 3D could provide much needed insights for achieving more energy-efficient comminution and optimal liberation of critical minerals.
Potassium silicate alteration is a hallmark of the porphyry copper deposits that supply two thirds of the world's annual copper demand. These deposits formed in the cores of calc-alkaline to alkaline ...volcanic systems from the flux of magmatic gas that transported copper and other metals from source to the surface. The giant 3.2 Ma Grasberg CuAu deposit formed within a maar-diatreme complex following a resurgence in magmatism. The defined resources of this deposit occur from a few hundred metres depth to 1.7 km below the paleosurface which, uniquely in this deposit, is partially preserved as a section of maar tuffs.
Potassium silicate alteration has commonly been interpreted as being the result of the addition of potassium to the porphyry copper host rocks via pervasive interaction with a large volume of a potassium-rich brine that is commonly presumed to be of magmatic origin. However, the data reported here show that alteration at the deposit scale is essentially isochemical with respect to the major rock-forming components and that only sulphur and the economic metals (Cu, Mo, Au, etc.) are added by flux of reactive magmatic gas containing SO2 and HCl from source intrusions at depth. Silicate solubilities are very low so that only a minor fraction of the total alkalis in the host rock are extracted by alteration reactions and then discharged at the paleo-surface. Reaction of the magmatic gas phase with plagioclase results in the coupled deposition of anhydrite (CaSO4) and disproportionation of SO2 to release H2S. The in-situ release of H2S immediately scavenges Cu and other chalcophile metals from the continuing magmatic gas flux to form the Cu-, Fe- and other sulphides that, in sufficient concentration, make up the economic reserve available to mining.
The sequestration of Ca into anhydrite, along with deposition of silica into early quartz veins, increases the concentration of the other major components (K2O, Na2O, MgO, etc) in the remaining silicate assemblage within the porous host rock. The result is the development of intermingled potassium-enriched silicate and sulphur-rich (anhydrite-sulphide) sub-assemblages that constitute the mineralised phyllic or potassic alteration zones. These crystallise according to their pressure and depth into alteration assemblages dominated by potassic phyllosilicates, quartz and pyrite in the phyllic alteration zone, and alkali feldspar and phlogopitic-biotite plus minor andalusite and corundum in the central potassic zone. Dissolution and recrystallisation of primary magmatic biotite in the host rock releases K as well as Fe, the latter (along with amphibole and feldspar) providing iron for the formation of chalcopyrite, bornite and pyrite. The in-situ release of H2S through anhydrite formation, immediately scavenges Cu and other chalcophile metals from the continuing magmatic gas flux to form the CuFe sulphides that, in sufficient concentration, make up the economic reserve available to mining. Understanding of the alteration processes during porphyry copper formation also provides insights into gas-solid reactions processes inside active magmatic arc volcanoes but the magnitude of copper mineralisation is dependent on the original metal content of the source of the magmatic gas phase.
•Potassium silicate alteration is commonly assumed to be due to potassium addition•New analytical data from Grasberg show that alteration was quasi-isochemical•Apparent potassium enrichment is due to sequestration of Ca into anhydrite•Anhydrite formation releases H2S from SO2 with co-deposition of sulphides•There is no potassic brine addition during porphyry copper formation
IMPORTANCE: In the United States, Black and Hispanic children have higher rates of asthma and asthma-related morbidity compared with White children and disproportionately reside in communities with ...economic deprivation. OBJECTIVE: To determine the extent to which neighborhood-level socioeconomic indicators explain racial and ethnic disparities in childhood wheezing and asthma. DESIGN, SETTING, AND PARTICIPANTS: The study population comprised children in birth cohorts located throughout the United States that are part of the Children’s Respiratory and Environmental Workgroup consortium. Cox proportional hazard models were used to estimate hazard ratios (HRs) of asthma incidence, and logistic regression was used to estimate odds ratios of early and persistent wheeze prevalence accounting for mother’s education, parental asthma, smoking during pregnancy, child’s race and ethnicity, sex, and region and decade of birth. EXPOSURES: Neighborhood-level socioeconomic indicators defined by US census tracts calculated as z scores for multiple tract-level variables relative to the US average linked to participants’ birth record address and decade of birth. The parent or caregiver reported the child’s race and ethnicity. MAIN OUTCOMES AND MEASURES: Prevalence of early and persistent childhood wheeze and asthma incidence. RESULTS: Of 5809 children, 46% reported wheezing before age 2 years, and 26% reported persistent wheeze through age 11 years. Asthma prevalence by age 11 years varied by cohort, with an overall median prevalence of 25%. Black children (HR, 1.47; 95% CI, 1.26-1.73) and Hispanic children (HR, 1.29; 95% CI, 1.09-1.53) were at significantly increased risk for asthma incidence compared with White children, with onset occurring earlier in childhood. Children born in tracts with a greater proportion of low-income households, population density, and poverty had increased asthma incidence. Results for early and persistent wheeze were similar. In effect modification analysis, census variables did not significantly modify the association between race and ethnicity and risk for asthma incidence; Black and Hispanic children remained at higher risk for asthma compared with White children across census tracts socioeconomic levels. CONCLUSIONS AND RELEVANCE: Adjusting for individual-level characteristics, we observed neighborhood socioeconomic disparities in childhood wheeze and asthma. Black and Hispanic children had more asthma in neighborhoods of all income levels. Neighborhood- and individual-level characteristics and their root causes should be considered as sources of respiratory health inequities.
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