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The author reflects on his letter regarding boycotting the Soviet Union in relation to the arrest of Yuri Orlov. His letter were particularly sent to all physicists of the United States National Academy of Sciences. Through his letter, he suggested that the American scientists demand admission of their representatives to the trial of Yuri Orlov. He further suggested that the scientists boycott cooperation with the Soviet Union if they refuse their requests.

This article describes and analyses a database on the dynamics of sociopolitical instability in the United States between 1780 and 2010. The database was constructed by digitizing data collected by previous researchers, supplemented by systematic searches of electronic media archives. It includes 1,590 political violence events such as riots, lynchings, and terrorism. Incidence of political violence fluctuated dramatically over the 230 years covered by the database, following a complex dynamical pattern. Spectral analysis detected two main oscillatory modes. The first is a very long-term – secular – cycle, taking the form of an instability wave during the second half of the 19th century, bracketed by two peaceful periods (the first quarter of the 19th century and the middle decades of the 20th century, respectively). The second is a 50-year oscillation superimposed on the secular cycle, with peaks around 1870, 1920, and 1970. The pattern of two periodicities superimposed on each other is characteristic of the dynamics of political instability in many historical societies, such as ancient Rome and medieval and early-modern England, France, and Russia. A possible explanation of this pattern, discussed in the article, is offered by the structural-demographic theory, which postulates that labor oversupply leads to falling living standards and elite overproduction, and those, in turn, cause a wave of prolonged and intense sociopolitical instability. [ABSTRACT FROM PUBLISHER]

Examines the role of the availability of food in population dynamics of arvicoline rodents. Tritrophic model that includes vegetation, rodents and their specialist predators; Application of the theory to one specific system, the brown lemmings at Point Barrow, Alaska; Oscillations providing support to the food hypothesis.

BACKGROUND As hypertension increases the risk of vascular complications in patients with type 2 diabetes mellitus, the American Diabetes Association has recommended a blood pressure goal of <130/80 mmHg for affected individuals. OBJECTIVE To assess clinical decision making in the primary-care setting when patients with type 2 diabetes mellitus present with hypertension at routine evaluation. DESIGN AND INTERVENTION This observational study enrolled adult patients with type 2 diabetes mellitus, who attended one of 26 primary-care practices in Colorado, USA, between June 2003 and May 2004. The health-care provider completed a questionnaire after each routine visit, which provided information on demographics, insurance status (as a measure of income), blood pressure measurements, whether any action was taken, the type of action taken (lifestyle modification or medication), and if no action was taken the reason for inaction. OUTCOME MEASURE Blood pressure was the main outcome measure. High blood pressure was diagnosed when the systolic measurement was ≥130 mmHg and/or the diastolic measurement was ≥80mmHg. Patients were subclassified in three groups: at goal (systolic <130mmHg and diastolic <80 mmHg), above previous goal (systolic ≥140 mmHg or diastolic ≥90 mmHg), or near goal (systolic <140 mmHg and diastolic <90mmHg). RESULTS Of the 26 primary-care practices that participated in the study, 22 were family medicine practices, 4 were general internal medicine practices, and 14 were in rural locations. Questionnaires were available for 778 patient visits. Patients were predominantly women (62.7%) and Hispanic (47.9%), and the mean age was 58.1 years. Overall, 45.6% of patients were classified as low income. The mean blood pressure was 130/74 mmHg. The systolic and diastolic goals were achieved by 48% and 60% of patients, respectively; however, only 38% of the patients achieved both goals. A total of 203 patients (26%) were classified as near goal. For patients with high blood pressure, action was taken in 34.9% of cases. Although patients classified as above previous goal received intervention in 50.9% of cases, action was taken in only 13.3% of patients classified as near goal. Patients with high blood pressure were given medication more often than lifestyle modification. Action was also more likely when patients were already receiving six or less prescription medications or a single blood pressure medication. When no action was taken, the reasons for inaction included blood pressure at or near goal (53.7%), new or transient increase in blood pressure (17.4%), competing demands (17.0%), and unfamiliarity with the patient (9.3%). CONCLUSION Although action was more common in patients with elevated blood pressure than in those near goal, the overall rate of action by primary-care providers was low (34.9%), which suggests that clinical inertia might be a barrier to patient care in type 2 diabetes mellitus. [ABSTRACT FROM AUTHOR]

Aims: To investigate real-world treatment adherence and persistence in people with type 2 diabetes newly initiating oral semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1 RA), or a dipeptidyl peptidase-4 inhibitor (DPP-4i)., Methods: This retrospective cohort study used the Merative™ MarketScan® Commercial and Medicare databases. Index date was the first fill for the cohort medication. Adherence was defined as proportion of days covered (PDC) over the 12-month post-index period ('adherent' = ≥0.8). Persistence was number of days until discontinuation, based on a 45-day gap. Results were compared between cohorts using inverse probability treatment weighting., Results: Oral semaglutide (n=5485) and DPP-4i (n=4980) cohorts had similar percentages of people who were adherent (PDC ≥0.8; 41.6 % vs. 42.9 %; P = 0.182) and persistent for ≥9 months (45.0 % vs. 46.3 %; P = 0.185). The DPP-4i cohort used significantly more anti-diabetic medication (ADM) classes over the post-index period (mean±SD: 2.6±1.0 vs. 2.9±1.1, P < 0.001), with 23.2 % filling a GLP-1 RA in the post-period., Conclusions: Adherence and persistence were similar between cohorts. However, there are potential benefits to prescribing oral semaglutide over DPP-4is, including reduced need for additional ADM., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Statin associated side effects (SASE) are a leading cause of statin discontinuation., Objective: We evaluated patient, provider, and facility characteristics associated with SASEs and whether these characteristics impact statin utilization., Methods: Patients with atherosclerotic cardiovascular disease (ASCVD) receiving care across the Veterans Affairs healthcare system from October 1, 2014 to September 30, 2015 were included. Multivariable logistic regression analyses were performed to determine (a) factors associated with SASE and (b) factors associated with statin use in those with SASE., Results: Our cohort included 1,225,576 patients with ASCVD. Of these, 171,189 (13.7%) had at least 1 reported SASE since year 2000. The most significant odds for SASEs were observed with female sex (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.36, 1.45), White race (OR 1.43, 95% CI 1.41, 1.45), hypertension (OR 1.37, 95% CI 1.33, 1.41) and ischemic heart disease (IHD: OR 1.45, 95% CI 1.43, 1.47). Lower odds were noted with care at a teaching facility (OR 0.89, 95% CI 0.88, 0.90). Factors most associated with being on a statin among patients with SASE included having diabetes (OR 1.18, 95% CI 1.15, 1.20), IHD (OR 1.39, 95% CI 1.35, 1.43) and a higher number of cardiology visits (OR 1.08, 95% CI 1.07, 1.09), while female sex was associated with lower odds (OR 0.65, 95% CI 0.61, 0.69)., Conclusion: There are significant disparities in statin use by sex, ASCVD type, and comorbidities among secondary prevention patients with SASE, which represent areas for improvement in optimizing statin utilization., (Copyright © 2021. Published by Elsevier Inc.)

Background: Medicare patients with coronary artery disease (CAD) have been a significant focus of value-based payment programs for outpatient practices. Physicians and policymakers, however, have voiced concern that value-based payment programs may penalize practices that serve vulnerable populations. This study evaluated whether outpatient practices that serve socioeconomically disadvantaged populations have worse CAD outcomes, and if this reflects the delivery of lower-quality care or rather, patient and community factors beyond the care provided by physician practices., Methods and Results: Retrospective cohort study of Medicare fee-for-service patients ≥65 years with CAD at outpatient practices participating in the the Practice Innovation and Clinical Excellence registry from January 1, 2010 to January 1, 2015. Outpatient practices were stratified into quintiles by the proportion of most disadvantaged patients-defined by an area deprivation score in the highest 20% nationally-served at each practice site. Prescription of guideline recommended therapies for CAD as well as clinical outcomes (emergency department presentation for chest pain, hospital admission for unstable angina or acute myocardial infarction [AMI], 30-day readmission after AMI, and 30-day mortality after AMI) were evaluated by practice-level socioeconomic disadvantage with hierarchical logistic regression models, using practices serving the fewest socioeconomically disadvantaged patients as a reference. The study included 453 783 Medicare fee-for-service patients ≥65 years of age with CAD (mean [SD] age, 75.3 [7.7] years; 39.7% female) cared for at 271 outpatient practices. At practices serving the highest proportion of socioeconomically disadvantaged patients (group 5), compared with practices serving the lowest proportion (group 1), there was no significant difference in the likelihood of prescription of antiplatelet therapy (odds ratio [OR], 0.94 [95% CI, 0.69-1.27]), β-blocker therapy if prior myocardial infarction or left ventricular ejection fraction <40% (OR, 0.97 [95% CI, 0.69-1.35]), ACE (angiotensin-converting enzyme) inhibitor or angiotensin receptor blocker if left ventricular ejection fraction <40% and/or diabetes mellitus (OR, 0.93 [95% CI, 0.74-1.19]), statin therapy (OR, 0.88 [95% CI, 0.68-1.14]), or cardiac rehabilitation (OR, 0.45 [95% CI, 0.20-1.00]). Patients cared for at the most disadvantaged-serving practices (group 5) were more likely to be admitted for unstable angina (adjusted OR, 1.46 [95% CI, 1.04-2.05]). There was no significant difference in the likelihood of emergency department presentation for chest pain or hospital admission for AMI between practices. Thirty day mortality rates after AMI were higher among patients at the most disadvantaged-serving practices (aOR, 1.31 [95% CI, 1.02-1.68]), but 30-day readmission rates did not differ. All associations were attenuated after additional adjustment for patient-level area deprivation index., Conclusions: Physician outpatient practices that serve the most socioeconomically disadvantaged patients with CAD perform worse on some clinical outcomes, despite providing similar guideline-recommended care as other practices, and consequently could fare poorly under value-based payment programs. Social factors beyond care provided by outpatient practices may partly explain worse outcomes. Policymakers should consider accounting for socioeconomic disadvantage in value-based payment programs initiatives that target outpatient practices.

Introduction: Primary care provider encounters are associated with health and well-being; however, limited evidence guides optimal primary care provider rate of visit, referred to as encounter cadence. This study measures associations between primary care provider encounter cadence and diabetes outcomes among individuals newly diagnosed with type 2 diabetes mellitus., Methods: In this retrospective cohort study, 7,106 people enrolled in Medicare Advantage and newly diagnosed with type 2 diabetes mellitus between July 1, 2012 and June 30, 2013 were identified and followed for 36 months. Two methods measured primary care provider encounter cadence: total primary care provider encounters (frequency) and quarters with primary care provider encounter (regularity). Logistic regression measured relationships between primary care provider encounter cadence and non-insulin diabetes medication adherence, HbA1c control, emergency department visits, and inpatient admissions. Non-insulin diabetes medication adherence was defined according to the National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set specifications and measured using healthcare claims data. Post-hoc models examined adherence and diabetes control among those nonadherent (n=5,212) and with noncontrolled HbA1c (n=326) during the encounter/cadence period. Data were extracted and analyzed in 2017., Results: Adjusted models indicated that both frequency (AOR=1.08, 95% CI=1.06, 1.10) and regularity (AOR=1.18, 95% CI=1.13, 1.22) of primary care provider encounters were associated with increased odds of adherence. Post-hoc analyses indicated that more frequent (AOR=1.12, 95% CI=1.10, 1.15) and regular (AOR=1.27, 95% CI=1.22, 1.33) primary care provider encounters were associated significantly with adherence and were associated directionally with HbA1c control., Conclusions: More frequent and regular primary care provider encounters are associated with an increased likelihood of non-insulin diabetes medication adherence. These findings contribute to data needed to establish evidence-based guidelines for primary care provider encounter cadence for those newly diagnosed with type 2 diabetes mellitus., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: One-third of Medicare beneficiaries are enrolled in Medicare Advantage (MA), Medicare's private plan option. Medicare Advantage incentivizes performance on evidence-based care, but limited information exists using reliable clinical data to determine whether this translates into better quality for patients with coronary artery disease (CAD) enrolled in MA compared with those enrolled in traditional fee-for-service (FFS) Medicare., Objective: To determine differences in evidence-based secondary prevention treatments and intermediate outcomes among patients with CAD enrolled in MA vs FFS Medicare., Design, Setting, and Participants: In this observational, retrospective, cohort study, deidentified data from patients 18 years or older diagnosed as having CAD between January 1, 2013, and May 1, 2014, at cardiology practices participating in the Practice Innovation and Clinical Excellence (PINNACLE) registry were studied, including 35 563 patients enrolled in MA and 172 732 enrolled in FFS Medicare. Data were analyzed from March to July 2018., Exposures: Medicare Advantage enrollment., Main Outcomes and Measures: Medication prescription patterns among eligible patients and intermediate outcomes, including blood pressure and low-density lipoprotein cholesterol., Results: Of the 35 563 patients with CAD enrolled in MA, 20 193 (56.8%) were male, and the mean (SD) age was 76.7 (7.6) years; of the 172 732 patients with CAD enrolled in FFS Medicare, 100 025 (57.9%) were male, and the mean (SD) age was 77.5 (8.0) years. Patients enrolled in MA were younger, less likely to be white, and more likely to be female and to have heart failure, diabetes, and chronic kidney disease compared with those enrolled in FFS Medicare. Compared with FFS Medicare beneficiaries, MA beneficiaries were more likely to receive secondary prevention treatments, including β-blockers (80.6% vs 78.8%; P < .001), angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (70.7% vs 65.1%; P < .001), and statins (68.4% vs 64.5%; P < .001). Patients enrolled in MA were also more likely to receive all 3 medications when eligible (48.9% vs 40.4%; P < .001). After adjustment, MA beneficiaries had higher odds of receiving guideline-recommended therapy compared with FFS Medicare beneficiaries for β-blockers (odds ratio, 1.10; 95% CI, 1.04-1.17; P = .002), angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (odds ratio, 1.13; 95% CI, 1.08-1.19; P < .001), and all 3 medications (odds ratio, 1.23; 95% CI, 1.001-1.50; P = .047). There were no significant differences in intermediate outcomes between those enrolled in MA and FFS Medicare, including systolic and diastolic blood pressure and low-density lipoprotein cholesterol levels., Conclusions and Relevance: Among patients with CAD in the PINNACLE registry, MA beneficiaries had more comorbidities than FFS Medicare beneficiaries and were more likely to receive secondary prevention treatments. However, this did not translate into differences in intermediate outcomes. These findings suggest that MA plans may drive improvements in process-based quality measures for Medicare beneficiaries, although this may have a limited effect on improving patient outcomes over FFS Medicare.

Background: Calciphylaxis, a rare disease seen in chronic dialysis patients, is associated with significant morbidity and mortality. As is the case with other rare diseases, the precise epidemiology of calciphylaxis remains unknown. Absence of a unique International Classification of Diseases (ICD) code impedes its identification in large administrative databases such as the United States Renal Data System (USRDS) and hinders patient-oriented research. This study was designed to develop an algorithm to accurately identify cases of calciphylaxis and to examine its incidence and mortality., Design, Participants, and Main Measures: Along with many other diagnoses, calciphylaxis is included in ICD-9 code 275.49, Other Disorders of Calcium Metabolism. Since calciphylaxis is the only disorder listed under this code that requires a skin biopsy for diagnosis, we theorized that simultaneous application of code 275.49 and skin biopsy procedure codes would accurately identify calciphylaxis cases. This novel algorithm was developed using the Partners Research Patient Data Registry (RPDR) (n = 11,451 chronic hemodialysis patients over study period January 2002 to December 2011) using natural language processing and review of medical and pathology records (the gold-standard strategy). We then applied this algorithm to the USRDS to investigate calciphylaxis incidence and mortality., Key Results: Comparison of our novel research strategy against the gold standard yielded: sensitivity 89.2%, specificity 99.9%, positive likelihood ratio 3,382.3, negative likelihood ratio 0.11, and area under the curve 0.96. Application of the algorithm to the USRDS identified 649 incident calciphylaxis cases over the study period. Although calciphylaxis is rare, its incidence has been increasing, with a major inflection point during 2006-2007, which corresponded with specific addition of calciphylaxis under code 275.49 in October 2006. Calciphylaxis incidence continued to rise even after limiting the study period to 2007 onwards (from 3.7 to 5.7 per 10,000 chronic hemodialysis patients; r = 0.91, p = 0.02). Mortality rates among calciphylaxis patients were noted to be 2.5-3 times higher than average mortality rates for chronic hemodialysis patients., Conclusions: By developing and successfully applying a novel algorithm, we observed a significant increase in calciphylaxis incidence. Because calciphylaxis is associated with extremely high mortality, our study provides valuable information for future patient-oriented calciphylaxis research, and also serves as a template for investigating other rare diseases.

Background: Many patients with high blood pressure (BP) do not have antihypertensive medications appropriately intensified at clinician visits. We investigated whether an online spaced-education (SE) game among primary care clinicians can decrease time to BP target among their hypertensive patients., Methods and Results: A 2-arm randomized trial was conducted over 52 weeks among primary care clinicians at 8 hospitals. Educational content consisted of 32 validated multiple-choice questions with explanations on hypertension management. Providers were randomized into 2 groups: SE clinicians were enrolled in the game, whereas control clinicians received identical educational content in an online posting. SE game clinicians were e-mailed 1 question every 3 days. Adaptive game mechanics resent questions in 12 or 24 days if answered incorrectly or correctly, respectively. Clinicians retired questions by answering each correctly twice consecutively. Posting of relative performance among peers fostered competition. Primary outcome measure was time to BP target (<140/90 mm Hg). One hundred eleven clinicians enrolled. The SE game was completed by 87% of clinicians (48/55), whereas 84% of control clinicians (47/56) read the online posting. In multivariable analysis of 17 866 hypertensive periods among 14 336 patients, the hazard ratio for time to BP target in the SE game cohort was 1.043 (95% confidence interval, 1.007-1.081; P=0.018). The number of hypertensive episodes needed to treat to normalize one additional patient's BP was 67.8. The number of clinicians needed to teach to achieve this was 0.43., Conclusions: An online SE game among clinicians generated a modest but significant reduction in the time to BP target among their hypertensive patients., Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT00904007., (© 2014 American Heart Association, Inc.)

Serious medication errors occur commonly in the period after hospital discharge. Medication reconciliation in the postdischarge ambulatory setting may be one way to reduce the frequency of these errors. The authors describe the design and implementation of a novel tool built into an ambulatory electronic medical record (EMR) to facilitate postdischarge medication reconciliation. The tool compares the preadmission medication list within the ambulatory EMR to the hospital discharge medication list, highlights all changes, and allows the EMR medication list to be easily updated. As might be expected for a novel tool intended for use in a minority of visits, use of the tool was low at first: 20% of applicable patient visits within 30&emsp14;days of discharge. Clinician outreach, education, and a pop-up reminder succeeded in increasing use to 41% of applicable visits. Review of feedback identified several usability issues that will inform subsequent versions of the tool and provide generalizable lessons for how best to design medication reconciliation tools for this setting.

Objective: The Centers for Disease Control (CDC) recommends pneumococcal vaccination for immunocompromised patients. Data suggest that rates of vaccination in this population are not optimal. To support continuous quality improvement efforts, we electronically measured vaccination status among rheumatology outpatients over time., Methods: Using data from administrative (billing) and electronic health record sources, we identified rheumatology clinic patients seen between 1 February 2008 and 31 January 2010 and prescribed an immunosuppressive medication. CDC recommendations for pneumococcal vaccination were applied. We calculated the proportion of eligible patients who were up-to-date with pneumococcal vaccination: (i) while on an immunosuppressive medication and (ii) before newly starting an immunosuppressive medication in the last 12 months., Results: We identified 2763 rheumatology clinic patients on immunosuppressive medications, with 568 initiated in the last 12 months. The mean age was 57 years, 75% were female and 77% were Caucasian. The most frequent disease was RA (50%) and the most common immunosuppressive medication was MTX (59%). Of patients on immunosuppressive medications, 1491/2763 (54%) were up to date with pneumococcal vaccination. Among new initiators of immunosuppressive medications, 258/568 (45%) were vaccinated before starting the immunosuppressive medication. Patients treated by rheumatologists in practice for ≤10 years were more likely to be up to date with pneumococcal vaccination (72%) than those with providers in practice >10 years (52%, P < 0.001)., Conclusion: The proportion of patients who are up to date with documented pneumococcal vaccination was suboptimal in our rheumatology practice. The ability to continuously repeat electronic measurement permits us to initiate continuous quality improvement efforts.

Many e-prescribing systems allow for both structured and free-text fields in prescriptions, making possible internal discrepancies. This study reviewed 2914 electronic prescriptions that contained free-text fields. Internal discrepancies were found in 16.1% of the prescriptions. Most (83.8%) of the discrepancies could potentially lead to adverse events and many (16.8%) to severe adverse events, involving a hospital admission or death. Discrepancies in doses, routes or complex regimens were most likely to have a potential for a severe event (p=0.0001). Discrepancies between structured and free-text fields in electronic prescriptions are common and can cause patient harm. Improvements in electronic medical record design are necessary to minimize the risk of discrepancies and resulting adverse events.

Errors in clinical research databases are common but relatively little is known about their characteristics and optimal detection and prevention strategies. We have analyzed data from several clinical research databases at a single academic medical center to assess frequency, distribution and features of data entry errors. Error rates detected by the double-entry method ranged from 2.3 to 26.9%. Errors were due to both mistakes in data entry and to misinterpretation of the information in the original documents. Error detection based on data constraint failure significantly underestimated total error rates and constraint-based alarms integrated into the database appear to prevent only a small fraction of errors. Many errors were non-random, organized in special and cognitive clusters, and some could potentially affect the interpretation of the study results. Further investigation is needed into the methods for detection and prevention of data errors in research.

Background: Regular recertification is mandatory to maintain board certification status in all specialties. However, the evidence that physicians' performance decreases with time since initial certification is limited. We therefore carried out a study to determine whether the frequency of antihypertensive treatment intensification for diabetic patients changes with time since their physicians' last board certification., Methods and Results: In this retrospective cohort study, we analyzed treatment of 8127 hypertensive patients with diabetes mellitus treated by 301 internists at primary care practices affiliated with 2 large academic hospitals. Patient visits with documented blood pressure > or = 130/85 mm Hg between January 1, 2000, and August 31, 2005, were studied. The association between the number of years since the physician's last board certification and the probability of pharmacological antihypertensive treatment intensification at a given visit was analyzed. Frequency of treatment intensification decreased from 26.7% for physicians who were board certified the previous year to 6.9% for physicians who were board certified 31 years before the visit. Treatment intensification rate was 22.5% for physicians certified < or = 10 years ago versus 16.9% for physicians last certified > 10 years ago (P<0.0001). Multivariable analysis adjusted for patient and visit characteristics and physician age showed that for every decade since the physician's last board certification, the probability of treatment intensification decreased by 21.3% (P=0.0097)., Conclusions: Physician intensification of pharmacological therapy for blood pressure levels above the recommended treatment goals decreases with time since the last board certification. This finding supports the current policy of mandatory recertification.

Objective: A new medium--World Wide Web (WWW)--has grown rapidly over the last few years. It provides opportunities for development of new educational tools and facilitates learning through interactivity, self-paced study and easy access. The aim of this project was to devise all educational WWW site (Active Learning Centre) that would take advantage of the capabilities of the new medium and assess its utilization by users., Methods: Active Learning Centre provides customizable computer-generated feedback tests, searchable databases (currently Microbiology, Pharmacology, Vaccines, and Spanish-language Cardiovascular Medications), remote WWW-based database authoring, and multilingual support. Its modular architecture allows easy expansion into new areas of knowledge. To evaluate the Active Learning Centre we conducted a study evaluating utilization of the site and user feedback., Results: The site is being used by thousands of patrons from around the world, the majority of whom are health professionals/health profession students from English-speaking countries. Customizable interactive tests are the most popular feature of the site. Most users give the site high ratings and would like it to expand further., Conclusion: The paradigm of combining interactive feedback tests with searchable % reference databases has been successful. Further expansion of the site to incorporate other areas of knowledge is planned.