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The sailing bible : the complete guide for all sailors from novice to expert
\"Designed to be user-friendly and hands-on, this manual is packed with detailed step-by-step information, lively action photos, explanatory diagrams and helpful advice on getting the most out of your sailing.\"--Page 4 of cover.
Book
The sailing bible : the complete guide for all sailors from novice to expert
\"The Sailing Bible is a comprehensive handbook for all sailors, whatever their experience.\"-- Provided by publisher.
Book
Racial and Ethnic Disparities in Preventive Service Use Among Adults Before and During the COVID-19 Pandemic
Our objective was to assess changes in preventive services use before and during the COVID-19 pandemic. We obtained secondary survey data from the National Health Interview Survey for 2019 and 2021. We examined, six preventive services among all adults. Descriptive and multivariate analyses assessed changes in preventive service use among adults and by race/ethnicity for 2019 and 2021 (drawing from an unweighted sample of 60 843 weighted to be 386.2 million across both years). We used Ordinary least squares estimation to conduct a difference-in-differences analysis that assessed changes in service use for non-white racial/ethnic groups relative to changes for white non-Hispanic adults between 2019 and 2021. We found preventive services use declined overall for each screening service assessed. Asian adults experienced the largest declines relative to white adults for “well visit within the last year” (−7.45 percentage points (pp) relative to white adults), “blood pressure screening within the last year” (−7.85 pp), and “mammograms within the last year” (−12.3 pp). While adults in other racial/ethnic groups did not experience significant declines in preventive services use relative to white adults between 2019 and 2021, pre-existing disparities remained for Hispanic and American Indian/Alaska Native (AIAN) adults compared to white adults. In conclusion, preventive service use declined in the first years of the COVID-19 public health emergency, and existing disparities in access for Hispanic and AIAN adults continued. Future research should investigate barriers Asian adults may face in obtaining access to preventive services after the conclusion of the public health emergency and federal pandemic-related protections.
Journal Article
Ultrasound Mediated Transdermal Insulin Delivery in Pigs Using a Lightweight Transducer
In previous studies, ultrasound mediated transdermal drug delivery has shown a promising potential as a method for noninvasive drug administration. For prospective future human application, this study was designed to determine the feasibility of lightweight cymbal transducer array as a practical device for noninvasive transdermal insulin delivery in large pigs.
Six Yorkshire pigs (100-140 lbs) were divided into two groups. As the control (n = 3), the first group did not receive any ultrasound exposure with the insulin. The second group (n = 3) was treated with ultrasound and insulin at 20 kHz with an I(sptp) = 100 mW/cm(2) at a 20% duty cycle for 60 min. With the pigs in lateral recumbency after anesthesia, the ultrasound transducer with insulin was placed on the axillary area of the pig. At the beginning and every 15 min up to 90 min, the blood glucose level was determined using a glucose monitoring system. To compare the results of individual animals, the change of blood glucose level was normalized to each animal's initial glucose value at the start of the experiment.
Although each animal had a different initial glucose level, the mean and standard error for the six animals was 146 +/- 13 mg/dl. For the control group, the blood glucose level increased to 31 +/- 21 mg/dl compared to the initial baseline over the 90 min experiment. However for the ultrasound with insulin treated group, the glucose level decreased to -72 +/- 5 mg/dl at 60 min (p < 0.05) and continued to decrease to -91 +/- 23 mg/dl in 90 min (p < 0.05).
The results indicate the feasibility of ultrasound mediated transdermal insulin delivery using the cymbal transducer array in animal with a similar size and weight to a human. Based on these result, the cymbal array has potential as a practical ultrasound system for noninvasive transdermal insulin delivery for diabetes management.
Journal Article
Assessing patterns in cancer screening use by race and ethnicity during the coronavirus pandemic using electronic health record data
Background Efforts to prevent the spread of the coronavirus led to dramatic reductions in nonemergency medical care services during the first several months of the COVID‐19 pandemic. Delayed or missed screenings can lead to more advanced stage cancer diagnoses with potentially worse health outcomes and exacerbate preexisting racial and ethnic disparities. The objective of this analysis was to examine how the pandemic affected rates of breast and colorectal cancer screenings by race and ethnicity. Methods We analyzed panels of providers that placed orders in 2019–2020 for mammogram and colonoscopy cancer screenings using electronic health record (EHR) data. We used a difference‐in‐differences design to examine the extent to which changes in provider‐level mammogram and colonoscopy orders declined over the first year of the pandemic and whether these changes differed across race and ethnicity groups. Results We found considerable declines in both types of screenings from March through May 2020, relative to the same months in 2019, for all racial and ethnic groups. Some rebound in screenings occurred in June through December 2020, particularly among White and Black patients; however, use among other groups was still lower than expected. Conclusions This research suggests that many patients experienced missed or delayed screenings during the first few months of the pandemic, which could lead to detrimental health outcomes. Our findings also underscore the importance of having high‐quality data on race and ethnicity to document and understand racial and ethnic disparities in access to care.
Journal Article
Dose comparison of ultrasonic transdermal insulin delivery to subcutaneous insulin injection
Prior studies have demonstrated the effectiveness of noninvasive transdermal insulin delivery using a cymbal transducer array. In this study the physiologic response to ultrasound mediated transdermal insulin delivery is compared to that of subcutaneously administered insulin. Anesthetized rats (350-550 g) were divided into four groups of four animals; one group representing ultrasound mediated insulin delivery and three representing subcutaneously administered insulin (0.15, 0.20, and 0.25 U/kg). The cymbal array was operated for 60 minutes at 20 kHz with 100 mW/cm2 spatial-peak temporal-peak intensity and a 20% duty cycle. The blood glucose level was determined at the beginning of the experiment and, following insulin administration, every 15 minutes for 90 minutes for both the ultrasound and injection groups. The change in blood glucose from baseline was compared between groups. When administered by subcutaneous injection at insulin doses of 0.15 and 0.20 U/kg, there was little change in the blood glucose levels over the 90 minute experiment. Following subcutaneous administration of insulin at a dose of 0.25 U/kg, blood glucose decreased by 190 +/- 96 mg/dl (mean +/- SD) at 90 minutes. The change in blood glucose following ultrasound mediated insulin delivery was -262 +/- 40 mg/dl at 90 minutes. As expected, the magnitude of change in blood glucose between the three injection groups was dependant on the dose of insulin administered. The change in blood glucose in the ultrasound group was greater than that observed in the injection groups suggesting that a higher effective dose of insulin was delivered.
Journal Article
Why so many open windows?
The BMJ is to be congratulated on repeatedly returning to the topic of measures to combat climate change, and encouraging doctors to take an interest in the issues. 1 Preventing unnecessary fuel usage is important not only in combating global warming but it also leads to financial gains.
Journal Article
Provision of evaluation and management visits by nurse practitioners and physician assistants in the USA from 2013 to 2019: cross-sectional time series study
ObjectiveTo examine the proportion of healthcare visits are delivered by nurse practitioners and physician assistants versus physicians and how this has changed over time and by clinical setting, diagnosis, and patient demographics.DesignCross-sectional time series study.SettingNational data from the traditional Medicare insurance program in the USA.ParticipantsOf people using Medicare (ie, those older than 65 years, permanently disabled, and people with end stage renal disease), a 20% random sample was taken.Main outcome measuresThe proportion of physician, nurse practitioner, and physician assistant visits in the outpatient and skilled nursing facility settings delivered by physicians, nurse practitioners, and physician assistants, and how this proportion varies by type of visit and diagnosis.ResultsFrom 1 January 2013 to 31 December 2019, 276 million visits were included in the sample. The proportion of all visits delivered by nurse practitioners and physician assistants in a year increased from 14.0% (95% confidence interval 14.0% to 14.0%) to 25.6% (25.6% to 25.6%). In 2019, the proportion of visits delivered by a nurse practitioner or physician assistant varied across conditions, ranging from 13.2% for eye disorders and 20.4% for hypertension to 36.7% for anxiety disorders and 41.5% for respiratory infections. Among all patients with at least one visit in 2019, 41.9% had one or more nurse practitioner or physician assistant visits. Compared with patients who had no visits from a nurse practitioner or physician assistant, the likelihood of receiving any care was greatest among patients who were lower income (2.9% greater), rural residents (19.7%), and disabled (5.6%).ConclusionThe proportion of visits delivered by nurse practitioners and physician assistants in the USA is increasing rapidly and now accounts for a quarter of all healthcare visits.
Journal Article
Water Heritage and the Importance of Local Knowledge in Climate Action
Thousands of significant archaeological and heritage sites line the coasts of every continent, threatened by loss and damage from rising sea levels and other cascading impacts, such as flooding, landslides, increased salination, erosion, or even the shift from being land-based heritage to being submerged or underwater heritage. There is a need for a sustainable initiative across the national, regional, and local levels to manage this degenerative process. To date, however, measures for mitigating climate change impacts remain insufficient. There is also the need for a further push in thinking about how coastal archaeology and culturally submerged sites may be remembered or, if on the cards, protected. The Coastal and Intertidal Zone Archaeological Network (CITiZAN), a national project working across coastal sites in England, works with communities to support and empower them in identifying and understanding their immediate environment and the relevance of the heritage therein. In this article, the CITiZAN team presents the range of vulnerable coastal heritage found across England, discusses why there is limited capacity or resources to protect these sites, and highlights the communities that have either reactively or proactively responded to changing climate conditions and, in so doing, provide examples of resourcefulness and resilience. The article concludes by highlighting the importance of communities in understanding intertidal-zone and coastal heritage, and the relevance of water heritage to understanding climate change impacts terrestrially.
Journal Article