Leap DayNew iconOld iconDescriptionA jumping game with a brand new level every day.InformationDeveloperNitromeRelease dateApp Store and Google Play: May 11th, 2016Current versionApple App Store: 1.119.6Google Play: 1.119.5Latest releaseApp Store: May 22nd, 2022Google Play: March 22nd, 2022LevelsInfinitePlatformsApp Store, Google Play storeDownload itApp Store, Google PlayGenre(s)PlatformerCreditsSee Credits sectionMusicMenu :Leap_day_titleandmenu.oggGame :Leap_day_main_1.ogg :Leap_day_main_2.ogg :Leap_day_main_3.ogg :Leap_Day_Totem_theme.ogg :Leap_Day_City_theme.ogg :Leap_Day_Beach_theme.ogg :Leap_Day_Winter_theme.ogg :Leap_Day_Casino_theme.ogg :Leap_Day_Sewer_theme.ogg :Leap_Day_Mud_theme.oggOtherSpecialLevels are created via an algorithm
This update was released on June 14th, 2016, and is labelled Version 1.3.1. This update makes small adjustment to the sharing function and changes the pop-up that reminds the user to download the latest update so that it does not appear when the user has no internet access.
By May 27th, 2016, Leap Day had received one million downloads across both the Apple App Store and Google Play. For its first and second weeks, it brought in the most revenue out of all of Nitrome's mobile games over the same timeframe.
Welcome to the much anticipated world download for my Minecraft medieval village and castle. This world is still a work in progress but has grown loads over the course of the last 6 months. We now have a fully furnished castle with dungeon and a large village and farming town. I still have many plans for this world but you can download it now and take a look for yourself.
Respondents who experienced the following criteria associated with major depressive episode (MDE) were classified as being affected by lifetime depression: 1) a period of two weeks or more with depressed mood or loss of interest or pleasure and at least five additional symptoms from the following nine: depressed mood, diminished interest in hobbies or activities, significant weight loss/gain or change in appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness, diminished ability to think or concentrate, and recurrent thoughts of death, 2) clinically significant distress or social or occupational impairment; and, 3) the symptoms are not better accounted for by bereavement.
Also, respondents who experienced the following criteria associated with MDE were classified as having 12-month depression, 1) meet the criteria for lifetime diagnosis of MDE, 2) report a 12-month episode, and 3) report marked impairment in occupational or social functioning. These definitions are consistent with the classifications of major depression found in the DSM-IV . The standard algorithm for establishing the existence of depression on the CIDI was used and no further restrictions were used except for those indicated above. The additional requirement of meeting clinical significance was not noted in the CCHS 1.2, which has been suggested to minimize any potential over-reporting of mental disorders using the CIDI [33, 35].
Acute otitis media (AOM) is characterized by middle ear effusion, inflammation of the tympanic membrane, and the rapid onset of signs and symptoms of an acute infection [1, 2]. Approximately 23% of children in the United States (USA) experience an AOM episode before the age of one and about 60% of children experience an AOM episode before the age of three . AOM is a leading cause of physician office visits and antibiotic prescriptions in children and is associated with medical expenditures of about $4 billion annually in the USA .
AOM-related complications such as tympanic membrane perforation, otorrhea, and acute mastoiditis were identified using ICD-9/ICD-10-CM diagnosis codes observed within 21 days of the index date of each AOM episode . AOM-related surgical procedures such as myringotomy and ventilation tube insertion occurring any time during the calendar year were identified using ICD-9/10-CM procedure codes and Current Procedure Terminology (CPT) codes  (the full list of diagnosis and procedure codes used in the study is shown in Additional file 1: Table A1. Procedures with the same code occurring on the same day were only counted once.
Crude annual incidence rates (IRs) for AOM episodes were calculated by dividing the total number of AOM episodes by the total number of PY of health plan enrollment for all children in the corresponding calendar year and were expressed as episodes per 1000 PY. As the exact date of birth was not available, age was imputed assuming July 1 as the birthdate in each study year. IRs were calculated separately for simple and recurrent AOM episodes. IRs for AOM-related complications and AOM-related surgical procedures were similarly calculated.
Interrupted time series (ITS) analyses were conducted to assess changes in the temporal trends of IRs before and after the introduction of PCV7 and PCV13. The ITS analyses were performed using generalized linear models (GLMs) with a negative binomial distribution and log link. Specifically, the AOM episode counts in each month were modeled in a segmented regression framework, with the number of enrolled children in each month included as an offset term. For the commercially insured population model, monthly AOM IRs in the early PCV7, late PCV7, early PCV13, and late PCV13 periods were each compared with those in the previous period. For each period, adjusted incidence rate ratios (IRRs) and 95% confidence intervals (95% CIs) were estimated for changes in level (i.e., an immediate change in IRs compared to the previous period) and changes in trend (i.e., a gradual change in IRs over time compared to the trends in the previous period). Models adjusted for seasonal fluctuations in IRs by using monthly indicators.
Two sensitivity analyses were conducted with alternative definitions of disease episodes. In the first sensitivity analysis, to explore the sensitivity of results to the gap definition, a gap of at least 28 days with no AOM-related diagnoses was used to define the start of a new episode (see Additional file 1: Appendix) .
In the second sensitivity analysis, a broader definition of OM was used, which included both AOM and OME. OME was defined by the presence of diagnosis codes for nonsuppurative OM and Eustachian tube disorder (ICD-9-CM: 381.x ICD-10-CM: H65.xx, H68.xx, H69.xx), or acute myringitis without mention of OM (ICD-9-CM: 384.0x; ICD-10-CM: H73.0x). This analysis was conducted to reflect revised diagnostic criteria issued by the American Academy of Pediatrics in 2013 to better discriminate between AOM and OME and reduce unnecessary antibiotic prescriptions . This definition is consistent with some previously published studies, which typically analyzed AOM and OME together as OM . In this sensitivity analysis, OM episodes were defined using a gap of at least 28 days between consecutive claims with relevant diagnosis codes (see Additional file 1: Appendix).
IRs of risk factors for pneumococcal disease in the 6 months prior to AOM episodes are shown in Additional file 1: Table A6. The most common risk factor was chronic lung disease including asthma, present on average across the study periods in 1.9% to 2.7% of commercially insured children with AOM. The second most common risk factor was cancer and iatrogenic immunosuppression, including radiotherapy, present in 0.9% to 1.5% of children.
Extrapolating results based on nationally available data, AOM IRs decreased from 268 episodes per 1000 PY in 2001 to 208 episodes per 1000 PY in 2018 (Fig. 2). Given these IRs and the overall pediatric population estimates in the US, there were approximately 3.80 million fewer AOM episodes projected in 2018 compared to 2001 among USA children (i.e. 19.47 million vs. 15.27 million episodes), a decrease of 21.6%.
The results of the sensitivity analyses are consistent with the main analysis. First, AOM IRs using a 28-day gap between consecutive claims to define disease episodes show similar trends over time, although the rates were lower overall (Additional file 1: Figs. A12, A13). Similarly, IRs of OM episodes show similar levels and trends over time, suggesting the results are robust to alternative outcome definitions (Additional file 1: Figs. A14, A15).
The results of the current analyses suggest that the majority of AOM episodes are simple AOM episodes; however, younger children are more likely to experience recurrent events than older children. This is consistent with a 2018 study by Kaur et al., which found that younger age was a strong predisposing characteristic for recurrent AOM episodes . In the current study simple and recurrent AOM IRs have decreased in all age groups over time following the introduction of PCV7 and PCV13.
This study comprehensively investigated AOM IRs before and after the introduction of PCV7 and PCV13 from 1998 to 2018. However, the study has several limitations. First, as with most observational studies using claims databases, miscoding of diagnoses or procedures may occur, potentially leading to misclassification and measurement error. While it is possible for some of the sources of miscoding to remain relatively constant over time, other secular changes in clinical practice patterns or classification may also bias the results from the time-trends analyses. For example, changes from ICD-9-CM to ICD-10-CM diagnosis coding systems in 2015 may have affected the classification of diseases over time, potentially affecting the comparison of periods before vs. periods after this transition. Moreover, the current study examined AOM episodes due to all pathogens and all serotypes, being unable to identify the proportion of S. pneumoniae, and specific disease-causing serotypes from the claims database. Changes in clinical practice guidelines, parental behaviors, or prevalence of risk factors for AOM such as daycare attendance, breastfeeding, passive smoking, and influenza vaccination over time were not included in the study and may have also impacted trend comparisons. Moreover, an increase in enrollment for consumer-directed and high deductible health plans is evident over the timeframe of the study, from 0.0% in the pre-PCV7 period to 20.5% in the late PCV13 period; these plans incentivize less intensive care-seeking behavior, particularly for outpatient visits, which could have also contributed to declining trends in AOM episodes. 2b1af7f3a8