The economic crisis and community development finance: an industry assessment

For thirty years, the community development finance industry—banks, credit unions, loan funds, community development corporations, venture funds, microfinance institutions—has quietly provided responsible, well-designed and well priced credit to lower-income people and communities. These entities have provided this credit with the support of the federal government, through the Community Development Financial Institutions Fund, the Low Income Housing and New Markets Tax Credits, the Small Business Association, the U.S. Department of Agriculture, and various housing and facilities development programs. The industry has also been supported in its efforts by mainstream institutions such as banks and insurance companies, most frequently motivated by the Community Reinvestment Act (CRA) or by concern that CRA-like obligations would be imposed. Philanthropic foundations and supporters and state and local governments have also played their parts. The result: a community development finance industry that has survived and even prospered during recessions and political downdrafts. But the field, and the communities, businesses, and individuals it serves, are hurting now, and fearing bigger hurt. This paper examines this situation and focuses attention on what needs to be done.

Effects of the components of positive airway pressure on work of breathing during bronchospasm

INTRODUCTION: Partial assist ventilation reduces work of breathing in patients with bronchospasm; however, it is not clear which components of the ventilatory cycle contribute to this process. Theoretically, expiratory positive airway pressure (EPAP), by reducing expiratory breaking, may be as important as inspiratory positive airway pressure (IPAP) in reducing work of breathing during acute bronchospasm. METHOD: We compared the effects of 10 cmH(2)O of IPAP, EPAP, and continuous positive airwaypressure (CPAP) on inspiratory work of breathing and end-expiratory lung volume (EELV) in a canine model of methacholine-induced bronchospasm. RESULTS: Methacholine infusion increased airway resistance and work of breathing. During bronchospasm IPAP and CPAP reduced work of breathing primarily through reductions in transdiaphragmatic pressure per tidal volume (from 69.4 ± 10.8 cmH(2)O/l to 45.6 ± 5.9 cmH(2)O/l and to 36.9 ± 4.6 cmH(2)O/l, respectively; P < 0.05) and in diaphragmatic pressure–time product (from 306 ± 31 to 268 ± 25 and to 224 ± 23, respectively; P < 0.05). Pleural pressure indices of work of breathing were not reduced by IPAP and CPAP. EPAP significantly increased all pleural and transdiaphragmatic work of breathing indices. CPAP and EPAP similarly increased EELV above control by 93 ± 16 ml and 69 ± 12 ml, respectively. The increase in EELV by IPAP of 48 ± 8 ml (P < 0.01) was significantly less than that by CPAP and EPAP. CONCLUSION: The reduction in work of breathing during bronchospasm is primarily induced by the IPAP component, and that for the same reduction in work of breathing by CPAP, EELV increases more

Association of aspirin use with mortality risk among older adult participants in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

Importance: Aspirin use has been associated with reduced risk of cancer mortality, particularly of the colorectum. However, aspirin efficacy may be influenced by biological characteristics, such as obesity and age. With the increasing prevalence of obesity and conflicting data regarding the effect of aspirin in older adults, understanding the potential association of aspirin use with cancer mortality according to body mass index (BMI) and age is imperative. Objectives: To investigate the association of aspirin use with risk of all-cause, any cancer, gastrointestinal (GI) cancer, and colorectal cancer (CRC) mortality among older adults and to perform an exploratory analysis of the association of aspirin use with mortality stratified by BMI. Design, Setting, Participants: This cohort study evaluated aspirin use among participants aged 65 years and older in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial at baseline (November 8, 1993, to July 2, 2001) and follow-up (2006-2008). Analysis began in late 2018 and was completed in September 2019. Main Outcomes and Measures: All-cause, any cancer, GI cancer, or CRC mortality. Multivariable hazard ratios (HRs) and 95% CIs were calculated using time-varying Cox proportional hazards regression modeling, adjusting for additional factors. Results: A total of 146 152 individuals (mean [SD] age at baseline, 66.3 [2.4] years; 74 742 [51.1%] women; 129 446 [88.6%] non-Hispanic white) were included in analysis. The median (interquartile range) follow-up time was 12.5 (8.7-16.4) years, encompassing 1 822 164 person-years. Compared with no use, aspirin use 1 to 3 times per month was associated with reduced risk of all-cause mortality (HR, 0.84; 95% CI, 0.80-0.88; P \u3c .001) and cancer mortality (HR, 0.87; 95% CI, 0.81-0.94; P \u3c .001). Aspirin use 3 or more times per week was associated with decreased risk of mortality of all causes (HR, 0.81; 95% CI, 0.80-0.83; P \u3c .001), any cancer (HR, 0.85; 95% CI, 0.81-0.88; P \u3c .001), GI cancer (HR, 0.75; 95% CI, 0.66-0.84; P \u3c .001), and CRC (HR, 0.71; 95% CI, 0.61-0.84; P \u3c .001). When stratified by BMI (calculated as weight in kilograms divided by height in meters squared), aspirin use 3 or more times per week among individuals with BMI 20 to 24.9 was associated with reduced risk of all-cause mortality (HR, 0.82; 95% CI, 0.78-0.85; P \u3c .001) and any cancer mortality (HR, 0.86; 95% CI, 0.79-0.82; P \u3c .001). Among individuals with BMI 25 to 29.9, aspirin use 3 or more times per week was associated with reduced risk of all-cause mortality (HR, 0.82; 95% CI, 0.79-0.85; P \u3c .001), any cancer mortality (HR, 0.86; 95% CI, 0.81-0.91; P \u3c .001), GI cancer mortality (HR, 0.72; 95% CI, 0.60-0.86; P \u3c .001), and CRC mortality (HR, 0.66; 95% CI, 0.51-0.85; P = .001). Conclusions and Relevance: In this cohort study, aspirin use 3 or more times per week was associated with a reduction in all-cause, cancer, GI cancer and CRC mortality in older adults

Local Compression in Automated Breast Ultrasound in the Mammographic Geometry

Background, Motivation and Objective: Automated ultrasound scanning (AUS) of the breast has developed more slowly than anticipated. The main limitation, beyond achieving adequate acoustic coupling to the breast, has been excessive shadow artifacts, as reflecting structures at acute angles to the ultrasound beam are not flattened by the transducer as well as in manual scanning. We believe that imaging of the breast in near mammographic compression provides much of the needed flattening. The question under initial study in this effort is, whether in breast AUS under very light mammographic compression, local compression by the transducer might flatten the acutely oriented structures further and reduce the acoustic path length to key structures in the breast. We suspect these improvements will be possible without distorting the breast so dramatically that the lesion registration advantages of scanning the breast in the same system as mammography or digital breast tomosynthesis (DBT) are not realized. Preliminary tests are reported here, as well as design of a system for a more refined human study. Statement of Contribution/Methods: Initial imaging tests were performed in our combined AUS/DBT system. A fiber mesh, loosened slightly in its frame, replaced the standard plastic mammography compression paddle. The transducer, in contact with the mesh and the breast, was translated by motors. The compression force of the linear array transducer on its vertical was manually controlled. Breast phantoms and the breasts of three women were scanned with usual compression by the mesh paddle and then with less global, but added local, compression. Results: Examples of flattened structures were observed more brightly in the locally compressed breasts, and acoustic paths longer than 35 mm were reduced, by _10 mm. In many areas image penetration was 3 cm greater. In one case, image volumes w/wo local compression were spatially aligned by nonlinear image registration software. - - Discussion and Conclusions: Visual indicators of image features expected to provide improved ultrasonic imaging were observed with local compression and lateral movement of tissues appeared acceptable. These results motivated design and construction of an apparatus to make local compression practical and safe. It utilizes joystick control of the vertical compression force during scanning, realized by pneumatic actuators attached to the transducer. The air pressure applied to these actuators is also applied to actuators in the joystick for force feedback to the operator. Two miniature vibrators attached to the joystick provide vibrotactile feedback of the reaction torques computed from the measurements of 6 force sensors on the transducer holder. The fail-safe system design insures no pneumatic compression force application to the breast in case of power loss or emergency shutdown.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/87269/4/Saitou50.pd

Patterns of finasteride and dutasteride use in the prostate, lung, colorectal and ovarian (PLCO) cancer screening trial cohort: effects of socio-demographic factors and a black box warning

Background: Five-alpha reductase inhibitors (5-ARIs), specifically finasteride and dutasteride, have been shown to significantly reduce prostate cancer incidence. However, these agents were also associated with a significant increase in the detection of high-grade prostate cancer leading to an FDA black box warning in 2011. Little is known about the effect of this warning on the subsequent use of these 5-ARIs. The purpose of this analysis was to assess use patterns of finasteride and dutasteride before and after the black box warning. Methods: This cohort study evaluated men enrolled in the Prostate, Lung, Colorectal and Ovarian (PLCO) screening trial who had ≥12 months of Medicare Part D coverage from 2008 to 2015, and had not been diagnosed with prostate cancer through 2007. Socio-demographic factors and benign prostatic hyperplasia (BPH) status were ascertained from follow-up questionnaires, while medication use was ascertained from linkage to Medicare Part D claims data. Results: Of 14,833 eligible men, 88.7% identified as non-Hispanic white, 1.7% as African-American, 5.2% as Asian/Pacific Islander and 1.7% as Hispanic. The median age was 72 years; 41.8% reported a BPH diagnosis. Only 13.6% and 4% of the population took finasteride or dutasteride, respectively, at any time from 2008 to 2015. During this period, finasteride use significantly increased from 3.6% to 9.7% and was highest among men with BPH; dutasteride use remained low and decreased from 2.8% to 1.9%. Conclusions: Finasteride use significantly increased after the FDA’s 2011 black box warning, while dutasteride use remained low and steady throughout the study period

Faculty Roundtable Discussion

SELECTING INITIAL REGIMENS MR. FROST (MODERATOR): I want to ask Dr. Saag, the question that I think is probably one of the most frequently asked. What do you start treatment with? Suppose a new patient, with no retroviral history, comes to you with a CD4 count between 400 and 500 and a viral load of 10,000 to 15,000 copies. DR. SAAG: There is more to consider in initial therapies than just retroviral load and CD4 count. It is also about who are they as a person, how motivated are they, and are they ready to start therapy? DR. SAAG: Alright. Then in talking to you, I would find out whether you want to be hyperaggressive or whether you want to be more conservative in treatment approach

Question and Answer Session

PROPHYLAXIS OF OPPORTUNISTIC INFECTIONS QUESTION: In your clinic do you stop prophylaxis for PCP when patients go up above a CD4 count of 200? DR. CURRIER: Not routinely. I enroll the patients in the ongoing study, if they are interested. Sometimes patients stop prophylaxis on their own and do not tell me that they have decided to discontinue it. But I have not been routinely recommending discontinuation without more data. MR. FROST (MODERATOR): What about mycobacterium avium complex (MAC)? DR. CURRIER: It is [stopped]. But I do not go around discontinuing it as a matter of routine

Genomic stability through time despite decades of exploitation in cod on both sides of the Atlantic

The mode and extent of rapid evolution and genomic change in response to human harvesting are key conservation issues. Although experiments and models have shown a high potential for both genetic and phenotypic change in response to fishing, empirical examples of genetic responses in wild populations are rare. Here, we compare whole-genome sequence data of Atlantic cod (Gadus morhua) that were collected before (early 20th century) and after (early 21st century) periods of intensive exploitation and rapid decline in the age of maturation from two geographically distinct populations in Newfoundland, Canada, and the northeast Arctic, Norway. Our temporal, genome-wide analyses of 346,290 loci show no substantial loss of genetic diversity and high effective population sizes. Moreover, we do not find distinct signals of strong selective sweeps anywhere in the genome, although we cannot rule out the possibility of highly polygenic evolution. Our observations suggest that phenotypic change in these populations is not constrained by irreversible loss of genomic variation and thus imply that former traits could be reestablished with demographic recovery.publishedVersio

Breast Mass Characterization Using 3‐Dimensional Automated Ultrasound as an Adjunct to Digital Breast Tomosynthesis

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135628/1/jum201332193.pd

Comparing Benefits from Many Possible Computed Tomography Lung Cancer Screening Programs: Extrapolating from the National Lung Screening Trial Using Comparative Modeling

Background: The National Lung Screening Trial (NLST) demonstrated that in current and former smokers aged 55 to 74 years, with at least 30 pack-years of cigarette smoking history and who had quit smoking no more than 15 years ago, 3 annual computed tomography (CT) screens reduced lung cancer-specific mortality by 20% relative to 3 annual chest X-ray screens. We compared the benefits achievable with 576 lung cancer screening programs that varied CT screen number and frequency, ages of screening, and eligibility based on smoking. Methods and Findings: We used five independent microsimulation models with lung cancer natural history parameters previously calibrated to the NLST to simulate life histories of the US cohort born in 1950 under all 576 programs. ‘Efficient’ (within model) programs prevented the greatest number of lung cancer deaths, compared to no screening, for a given number of CT screens. Among 120 ‘consensus efficient’ (identified as efficient across models) programs, the average starting age was 55 years, the stopping age was 80 or 85 years, the average minimum pack-years was 27, and the maximum years since quitting was 20. Among consensus efficient programs, 11% to 40% of the cohort was screened, and 153 to 846 lung cancer deaths were averted per 100,000 people. In all models, annual screening based on age and smoking eligibility in NLST was not efficient; continuing screening to age 80 or 85 years was more efficient. Conclusions: Consensus results from five models identified a set of efficient screening programs that include annual CT lung cancer screening using criteria like NLST eligibility but extended to older ages. Guidelines for screening should also consider harms of screening and individual patient characteristics