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Background: Over the past 2 decades, guidelines for digoxin use have changed significantly. However, little is known about the national-level trends of digoxin use, hospitalizations for toxicity, and subsequent outcomes over this time period.Methods: To describe digoxin prescription trends, we conducted a population-level, cohort study using data from IQVIA, Inc.'s National Prescription Audit (2007-2014) for patients aged ≥65 years. Further, in a national cohort of Medicare fee-for-service beneficiaries aged ≥65 years in the United States, we assessed temporal trends of hospitalizations associated with digoxin toxicity and the outcomes of these hospitalizations between 1999 and 2013.Results: From 2007 through 2014, the number of digoxin prescriptions dispensed decreased by 46.4%; from 8,099,856 to 4,343,735. From 1999 through 2013, the rate of hospitalizations with a principal or secondary diagnosis of digoxin toxicity decreased from 15 to 2 per 100,000 person-years among Medicare fee-for-service beneficiaries. In-hospital and 30-day mortality rates associated with hospitalization for digoxin toxicity decreased significantly among Medicare fee-for-service beneficiaries; from 6.0% (95% confidence interval [CI], 5.2-6.8) to 3.7% (95% CI, 2.2-5.7) and from 14.0% (95% CI, 13.0-15.2) to 10.1% (95% CI, 7.6-13.0), respectively. Rates of 30-day readmission for digoxin toxicity decreased from 23.5% (95% CI, 22.1-24.9) in 1999 to 21.7% (95% CI, 18.0-25.4) in 2013 (P < .05).Conclusion: While digoxin prescriptions have decreased, it is still widely prescribed. However, the rate of hospitalizations for digoxin toxicity and adverse outcomes associated with these hospitalizations have decreased. These findings reflect the changing clinical practice of digoxin use, aligned with the changes in clinical guidelines. [ABSTRACT FROM AUTHOR]

Core Ideas: Furrow diking increases soybean irrigation water use efficiency.Furrow diking should be a Mid‐Southern USA BMP.Furrow diking reduces Mississippi River Valley Alluvial Aquifer overdrafts. Best management practices (BMP) to improve irrigation efficiency and rainfall capture are needed in the Mid‐Southern USA to ease overdrafts from the Mississippi River Valley Alluvial Aquifer (MRVAA). One potential BMP is furrow diking (FD), wherein tillage is used to create small basins within the furrow to capture water from rainfall and irrigation. The objective of this research was to quantify the effect of FD on soybean grain yield, IWUE, and economic analysis under both irrigated and rainfed environments. Two studies were conducted to evaluate FD in irrigated and rainfed systems. Treatments included FD and non‐diked (control) in a randomized complete block design with six replications. Furrow diking had no impact on soybean grain yield in either irrigated or rainfed environments (P > 0.05). Similar yields were maintained in the FD system when 25% less water was applied, increasing the irrigation water use efficiency by 28% (P < 0.0001). No effect of FD was observed on total revenue or net returns above FD costs (P > 0.05). These data indicate FD is a possible BMP for increasing irrigation efficiency and decreasing aquifer withdrawals in Mid‐Southern USA soybean production. [ABSTRACT FROM AUTHOR]

Critical limb ischemia (CLI) is the most advanced form of peripheral artery disease. It is associated with significant morbidity and mortality and high management costs. It carries a high risk of amputation and local infection. Moreover, cardiovascular complications remain a major concern. Although it is a well-known entity and new technological and therapeutic advances have been made, this condition remains poorly addressed, with significantly heterogeneous management, especially in nonexperienced centers. This review, from a third-level dedicated inpatient and outpatient cardioangiology structure, aims to provide an updated summary on the topic of CLI of its complexity, encompassing epidemiological, social, economical and, in particular, diagnostic/imaging issues, together with potential therapeutic strategies (medical, endovascular, and surgical), including the evaluation of cardiovascular risk factors, the diagnosis, and treatment together with prognostic stratification. [ABSTRACT FROM AUTHOR]

We evaluated whether community-level home health agencies and nursing home performance is associated with community-level hospital 30-day all-cause risk-standardized readmission rates for Medicare patients using data from the Centers for Medicare & Medicaid Services from 2010 to 2012. Our final sample included 2,855 communities that covered 4,140 hospitals with 6,751,713 patients, 13,060 nursing homes with 1,250,648 residents, and 7,613 home health agencies providing services to 35,660 zip codes. Based on a mixed-effect model, we found that increasing nursing home performance by 1 star for all of its four measures and home health performance by 10 points for all of its six measures is associated with decreases of 0.25% point (95% confidence interval [CI], 0.17-0.34) and 0.60% point (95% CI, 0.33-0.83), respectively, in community-level risk-standardized readmission rates. [ABSTRACT FROM AUTHOR]

Throughout the Cold War, Italy was one of the most steadfast NATO allies in hosting American nuclear weapons on its territory. Such a policy could easily be construed as an example of almost automatic confidence in the US nuclear umbrella, yet only on the surface did extended deterrence appease Italian anxieties about the uncertainties of the American nuclear guarantee. The Italian rationale for accepting a large array of US nuclear weapons did as a matter of fact involve a complex mix of reasons, ranging from trying to ensure that the Italian government would be consulted in the event of a major crisis, to willingness to enhance the country’s profile inside any Western multilateral fora. The paper will investigate this policy by looking at how the Italian government behaved at the height of the NATO nuclear sharing debate, between 1957 and 1962, arguably one of the historical moments in the Cold War when the concept of extended deterrence was most intensely discussed. Drawing up on hitherto classified archival sources as well as on some less-known public ones, the paper will show how Italian diplomats, military leaders and policymakers understood the dangers and political implications of US nuclear policies. It will, hopefully, demonstrate that Italy’s persistent search for a multilateral solution to the nuclearisation of NATO strategy shows that Italy never saw extended deterrence as a solution per se, but only as a temporary means to an end. [ABSTRACT FROM PUBLISHER]

The new nuclear history can make a critical contribution by forcing us to reconsider or reframe the theoretical premises of the concepts we apply to our understanding of the present – and with which we try to navigate the future. It bears on fundamental questions, such as: How should the US manage its alliances? Should it establish a multilateral nuclear policy dialogue in Asia? In what depth should it discuss issues of doctrine and targeting with its Asian allies? What capabilities might reassure European allies in light of current Russian revisionism? Could nuclear war be limited and controlled in an East Asian maritime arena? Do nuclear weapons strengthen an alliance, or do they introduce a divisive bone of contention? Is extended nuclear deterrence (END) stabilizing or is it on the contrary pushing the allies to ask for more? What is the relationship between nuclear and conventional forces in END credibility? How do nuclear alliances contribute to international security and international order? The lessons and insights from these papers, which look at five historical cases of US extended deterrence during the Cold War, should help us think about crucial current issues, and be of use both to historians who want to have a better understanding of the Cold War past and to policymakers who are currently grappling with these issues. [ABSTRACT FROM PUBLISHER]

Importance: Little contemporary information is available about comparative performance between Veterans Affairs (VA) and non-VA hospitals, particularly related to mortality and readmission rates, 2 important outcomes of care.Objective: To assess and compare mortality and readmission rates among men in VA and non-VA hospitals.Design, Setting, and Participants: Cross-sectional analysis involving male Medicare fee-for-service beneficiaries aged 65 years or older hospitalized between 2010 and 2013 in VA and non-VA acute care hospitals for acute myocardial infarction (AMI), heart failure (HF), or pneumonia using the Medicare Standard Analytic Files and Enrollment Database together with VA administrative claims data. To avoid confounding geographic effects with health care system effects, we studied VA and non-VA hospitals within the same metropolitan statistical area (MSA).Exposures: Hospitalization in a VA or non-VA hospital in MSAs that contained at least 1 VA and non-VA hospital.Main Outcomes and Measures: For each condition, 30-day risk-standardized mortality rates and risk-standardized readmission rates for VA and non-VA hospitals. Mean aggregated within-MSA differences in mortality and readmission rates were also assessed.Results: We studied 104 VA and 1513 non-VA hospitals, with each condition-outcome analysis cohort for VA and non-VA hospitals containing at least 7900 patients (men; ≥65 years), in 92 MSAs. Mortality rates were lower in VA hospitals than non-VA hospitals for AMI (13.5% vs 13.7%, P = .02; -0.2 percentage-point difference) and HF (11.4% vs 11.9%, P = .008; -0.5 percentage-point difference), but higher for pneumonia (12.6% vs 12.2%, P = .045; 0.4 percentage-point difference). In contrast, readmission rates were higher in VA hospitals for all 3 conditions (AMI, 17.8% vs 17.2%, 0.6 percentage-point difference; HF, 24.7% vs 23.5%, 1.2 percentage-point difference; pneumonia, 19.4% vs 18.7%, 0.7 percentage-point difference, all P < .001). In within-MSA comparisons, VA hospitals had lower mortality rates for AMI (percentage-point difference, -0.22; 95% CI, -0.40 to -0.04) and HF (-0.63; 95% CI, -0.95 to -0.31), and mortality rates for pneumonia were not significantly different (-0.03; 95% CI, -0.46 to 0.40); however, VA hospitals had higher readmission rates for AMI (0.62; 95% CI, 0.48 to 0.75), HF (0.97; 95% CI, 0.59 to 1.34), or pneumonia (0.66; 95% CI, 0.41 to 0.91).Conclusions and Relevance: Among older men with AMI, HF, or pneumonia, hospitalization at VA hospitals, compared with hospitalization at non-VA hospitals, was associated with lower 30-day risk-standardized all-cause mortality rates for AMI and HF, and higher 30-day risk-standardized all-cause readmission rates for all 3 conditions, both nationally and within similar geographic areas, although absolute differences between these outcomes at VA and non-VA hospitals were small. [ABSTRACT FROM AUTHOR]

Background: Successful diabetes disease management involves routine medical care with individualized patient goals, self-management education and on-going support to reduce complications. Without interventions that facilitate patient scheduling, improve attendance to provider appointments and provide patient information to provider and care team, preventive services cannot begin. This review examines interventions based upon three focus areas: 1) scheduling the patient with their provider; 2) getting the patient to their appointment, and; 3) having patient information integral to their diabetes care available to the provider. This study identifies interventions that improve appointment management and preparation as well as patient clinical and behavioral outcomes. Methods: A systematic review of the literature was performed using MEDLINE, CINAHL and the Cochrane library. Only articles in English and peer-reviewed articles were chosen. A total of 77 articles were identified that matched the three focus areas of the literature review: 1) on the schedule, 2) to the visit, and 3) patient information. These focus areas were utilized to analyze the literature to determine intervention trends and identify those with improved diabetes clinical and behavioral outcomes. Results: The articles included in this review were published between 1987 and 2013, with 46 of them published after 2006. Forty-two studies considered only Type 2 diabetes, 4 studies considered only Type 1 diabetes, 15 studies considered both Type 1 and Type 2 diabetes, and 16 studies did notmention the diabetes type. Thirty-five of the 77 studies in the review were randomized controlled studies. Interventions that facilitated scheduling patients involved phone reminders, letter reminders, scheduling when necessary while monitoring patients, and open access scheduling. Interventions used to improve attendance were letter reminders, phone reminders, short message service (SMS) reminders, and financial incentives. Interventions that enabled routine exchange of patient information included web-based programs, phone calls, SMS, mail reminders, decision support systems linked to evidence-based treatment guidelines, registries integrated with electronic medical records, and patient health records. Conclusions: The literature review showed that simple phone and letter reminders for scheduling or prompting of the date and time of an appointment to more complex web-based multidisciplinary programs with patient self-management can have a positive impact on clinical and behavioral outcomes for diabetes patients. Multifaceted interventions aimed at appointment management and preparation during various phases of the medical outpatient care process improves diabetes disease management. [ABSTRACT FROM AUTHOR]

IMPORTANCE In a period of dynamic change in health care technology, delivery, and behaviors, tracking trends in health and health care can provide a perspective on what is being achieved. OBJECTIVE To comprehensively describe national trends in mortality, hospitalizations, and expenditures in the Medicare fee-for-service population between 1999 and 2013. DESIGN, SETTING, AND PARTICIPANTS Serial cross-sectional analysis of Medicare beneficiaries aged 65 years or older between 1999 and 2013 using Medicare denominator and inpatient files. MAIN OUTCOMES AND MEASURES For all Medicare beneficiaries, trends in all-cause mortality; for fee-for-service beneficiaries, trends in all-cause hospitalization and hospitalization-associated outcomes and expenditures. Geographic variation, stratified by key demographic groups, and changes in the intensity of care for fee-for-service beneficiaries in the last 1, 3, and 6 months of life were also assessed. RESULTS The sample consisted of 68 374 904 unique Medicare beneficiaries (fee-for-service and Medicare Advantage). All-cause mortality for all Medicare beneficiaries declined from 5.30% in 1999 to 4.45% in 2013 (difference, 0.85 percentage points; 95% CI, 0.83-0.87). Among fee-for-service beneficiaries (n = 60 056 069), the total number of hospitalizations per 100 000 person-years decreased from 35 274 to 26 930 (difference, 8344; 95% CI, 8315-8374). Mean inflation-adjusted inpatient expenditures per Medicare fee-for-service beneficiary declined from $3290 to $2801 (difference, $489; 95% CI, $487-$490). Among fee-for-service beneficiaries in the last 6 months of life, the number of hospitalizations decreased from 131.1 to 102.9 per 100 deaths (difference, 28.2; 95% CI, 27.9-28.4). The percentage of beneficiaries with 1 or more hospitalizations decreased from 70.5 to 56.8 per 100 deaths (difference, 13.7; 95% CI, 13.5-13.8), while the inflation-adjusted inpatient expenditure per death increased from $15 312 in 1999 to $17 423 in 2009 and then decreased to $13 388 in 2013. Findings were consistent across geographic and demographic groups. CONCLUSIONS AND RELEVANCE Among Medicare fee-for-service beneficiaries aged 65 years or older, all-cause mortality rates, hospitalization rates, and expenditures per beneficiary decreased from 1999 to 2013. In the last 6 months of life, total hospitalizations and inpatient expenditures decreased in recent years. [ABSTRACT FROM AUTHOR]

This Viewpoint discusses how family, friends, social media, the larger public, and others can influence an individual's health care decisions, including COVID-19 vaccination, and offers ways in which to build confidence in vaccination among groups that may be skeptical of getting the vaccine. [ABSTRACT FROM AUTHOR]

The article describes the performance of the U.S. financial secondaries market during the 2008-09 financial crisis that led to its near-collapse in 2009. The market recovered quickly and showed no discernable lag, relative to that of the U.S. stock markets. It identifies the widening valuation gap as key metric of market illiquidity and analyzes the market behavior during the crisis through behavioral and accounting-based explanations. The article concludes that the resiliency of the secondaries market was proven during the crisis.

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The article argues that at the beginning of the 1960s Western Europe, and Germany in particular, retained a crucial role in American global strategy, and that keeping the Atlantic alliance solid and cohesive remained a key goal of the new Kennedy administration that took office in January 1961. Europe at this time was still the main arena of the cold war. Yet this constant objective of American cold war strategy had to be balanced against other realities of the new phase of the global confrontation, such as the emergence of the 'third world' and the new threat represented by Soviet Intercontinental Ballistic Missiles (ICBMs). In this process of readjustment there began a gradual, but significant, downsizing of the relative weight of Europe in American grand strategy. [ABSTRACT FROM AUTHOR]

Abstract: Crop production in the Southeastern U.S. can be limited by water; thus, supplemental irrigation is needed to sustain profitable crop production. Increased water capture would efficiently improve water use and reduce supplemental irrigation amounts/costs, thus improving producer''s profit margin. We quantified infiltration (INF), runoff (R), and sediment (E) losses from furrow diked (+DT) and non-furrow diked (−DT) tilled conventional (CT) and strip tillage (ST) systems. In 2008, a field study (Tifton loamy sand, Typic Kandiudult) was established with DT, ST, and CT systems. In 2009, a field study (Faceville loamy sand, Typic Kandiudult) was established with DT and ST systems. Treatments (6) included: CT−DT, CT+DT, ST1 (1-year old)−DT, ST1 +DT, ST10 (10-year old)−DT, and ST10 +DT. Simulated rainfall (50mmh−1 for 1h) was applied to each 2-m×3-m plots (n =3). Runoff and E were measured from each 6-m2 plot. ST1 +DT plots had 80–88% less R than ST1 −DT plots. Any disturbance associated with DT in ST1 systems did not negatively impact E values. For both soils, CT−DT plots represented the worst-case scenario in terms of measured R and E; ST+DT plots represented the best-case scenario. Trends for R, E, and estimated plant available water (PAW) values decreased in order of CT−DT, CT+DT, ST1 −DT, ST1 +DT, ST10 −DT, and ST10 +DT treatments. From a hydrology standpoint, ST1 −DT plots behaved more similarly to CT plots than to other ST plots; from a sediment standpoint, ST1 −DT plots behaved more similarly to other ST plots than to CT plots. DT had no effect on ST10 plots. CT−DT and ST10 +DT plots resulted in 5.9 (worst-case) and 8.1 (best-case) days of water for crop use, a difference of 2.2 days of water for crop use or 37%. Compared to the CT−DT treatment, an agricultural field managed to CT+DT, ST1 −DT, ST1 +DT, ST10 −DT, and ST10 +DT would save a producer farming the CT−DT field $5.30, $9.42, $13.55, $14.14, and $14.14ha−1, respectively, to pump the amount of water lost to R and not saved as INF back onto the field. The most water/cost savings occurred for CT and ST1 plots as a result of DT. Savings for CT+DT, ST1 −DT, and ST1 +DT treatments represent 27%, 47%, and 68% of the cost of DT ($20ha−1) and 37%, 67%, and 96% of the savings a producer would have if managing the field to ST for 10 years without DT (ST10 −DT) in a single 50-mm rainfall event. For row-crop producers in the Southeastern U.S. with runoff producing rainfall events during the crop growing season, DT is a management practice that is cost-effective from a natural resource and financial standpoint for those producers that continue to use CT systems and especially those that have recently adopted ST systems into their farming operations. [Copyright &y& Elsevier]

A reply is presented to a response to the authors' article "Association of Admission to Veterans Affairs Hospitals vs non-Veterans Affairs Hospitals With Mortality and Readmission Rates Among Older Men Hospitalized With Acute Myocardial Infarction, Heart Failure, or Pneumonia."

Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation. [ABSTRACT FROM AUTHOR]

The American Medical Society for Sports Medicine (AMSSM) convened a writing group to address the current evidence and knowledge gaps regarding preparticipation evaluation of athletes during the SARS-CoV2 pandemic. The writing group held a series of meetings beginning in April 2020. The task force reviewed the available literature and used an iterative process and expert consensus to finalize this guidance statement that is intended to provide clinicians with a clinical framework to return athletes of all levels to training and competition during the pandemic. The statement is not intended to address treatment, infection control principles, or public health issues related to SARS-CoV2. The AMSSM task force acknowledges the clinical uncertainty, evolving public health objectives, and the limited data currently available to create this guidance statement. [ABSTRACT FROM AUTHOR]

This AMSSM position statement update is directed toward health care providers of patients involved in sport and exercise. There have been significant advances in clinical and scientific research in the understanding of blood-borne pathogens (BBPs), and this update incorporates these advancements. This document is intended as a general guide to clinical practice based on the current state of evidence, while acknowledging the need for modification as new knowledge becomes available. Confirmed transmission of BBPs during sport is exceedingly rare. There are no well-documented reports of HIV, hepatitis C virus, or hepatitis D virus transmission during sport. There is also no evidence for universal testing for BBPs as a specific requirement for participation in sports. Competitive athletes and nonathletes should follow appropriate general public health agency recommendations for screening for BBPs, considering their individual risk factors and exposures. Standard (universal) precautions must be followed by those providing care to athletes. Exercise and athletic participation can help promote a healthy lifestyle for persons living with BBPs. Those with acute symptomatic BBP infection should limit exercise intensity based on their current health status. Education is the key tool for preventing BBP transmission. Research gaps include evaluation of the prevalence of BBP infections in competitive athletes, the effects of long-term, intense training on infected athletes, and the effects of BBP treatment therapies on performance. [ABSTRACT FROM AUTHOR]

Abstract: In the Southeastern Coastal Plain (USA) farmers with access to irrigation commonly water in herbicides following their preemergence application to improve efficacy of the herbicide. This practice increases near surface soil water content and may promote increased runoff during subsequent storm events. The objective of our study was to determine differences in P and N runoff from conventional tillage (CT) and no tillage (NT) systems when herbicides were watered into loamy sand Ultisols fertilized with broiler litter. Simulated rain with variable intensity was applied for 70min with runoff samples collected every 5min and analyzed for total P and N, PO4 3−, NH4 + and NO3 −. Results indicated the no-tillage treatment lost significantly more PO4 3− and NH4 + than the conventional tillage treatment. However, total P and N and NO3 − runoff losses were significantly less in the no-tillage treatment. The proportion of total P and N leached through NT residues was 5.6% and 22% of the P and N applied as broiler litter, and the proportion of total P and N in runoff was 0.8% and 1.2% of the P and N applied in broiler litter. Overall 3.4 times more N and 2.7 more P were lost in runoff from the CT treatments than for the NT treatments. Reduced tillage was found to reduce N and P losses when combined with watering-in of surface applied broiler litter. [Copyright &y& Elsevier]