Large Central Area Research Articles

Geographic Differences in Sex-Specific Chronic Obstructive Pulmonary Disease Mortality Rate Trends Among Adults Aged ≥25 Years - United States, 1999-2019.

Chronic obstructive pulmonary disease (COPD) accounts for the majority of deaths from chronic lower respiratory diseases, the fourth leading cause of death in the United States in 2019.* COPD mortality rates are decreasing overall. Although rates in men remain higher than those in women, declines have occurred among men but not women (1). To examine the geographic variation in sex-specific trends in age-adjusted COPD mortality rates among adults aged ≥25 years, CDC analyzed 1999-2019 death certificate data, by urban-rural status,† U.S. Census Bureau region,§ and state. Among women, no significant change in overall COPD mortality occurred during this period; however, rates increased significantly in small metropolitan (average annual percent change [AAPC]=0.6%), micropolitan (1.2%), and noncore (1.9%) areas and in the Midwest (0.6%). Rates decreased significantly in large central (-0.9%) and fringe metropolitan (-0.4%) areas (and in the Northeast (-0.5%) and West (-1.2%). Among men, rates decreased significantly overall (-1.3%), in all urban-rural areas (range = -1.9% [large central metropolitan] to -0.4% [noncore]) and in all regions (range=-2.0% [West] to -0.9% [Midwest]). Strategies to improve the prevention, treatment, and management of COPD are needed, especially to address geographic differences and improve the trend in women, to reduce COPD deaths.

Magnet mobility myths: exploring geographical mobility amongst people experiencing, or at-risk of, homelessness in Australia

It is often assumed that people experiencing homelessness gravitate to large cities and central city areas because of the concentration of homelessness services — a so-called magnet or honeypot effect. Yet little is actually known about how people experiencing homelessness move across space over time. This article explores this geography by comparing the mobility of those experiencing homelessness, those ‘at-risk’, and those renting privately in Australia, between waves in two Australian panel surveys: Journeys Home and the Household, Income and Labour Dynamics in Australia (HILDA). Results suggest that while people experiencing homelessness are more likely to move than the other two groups, they more similarly short distances and appear more likely to move for reasons such as relationship breakdown, eviction and to escape violence. While some evidence of movement to areas with particular characteristics (sorting) was detected amongst those at-risk and those renting privately, this was not the case for those experiencing homelessness. Results do not support the contention that people experiencing homelessness gravitate to central urban areas well-resourced with homelessness services over time. The findings challenge assumptions about magnet effects and homelessness and have important implications for the provision and delivery of homelessness services in Australia and beyond.

County-level estimates of excess mortality associated with COVID-19 in the United States

The COVID-19 pandemic in the U.S. has been largely monitored using death certificates containing reference to COVID-19. However, prior analyses reveal that a significant percentage of excess deaths associated with the pandemic were not directly assigned to COVID-19. In this study, we estimated a generalized linear model of expected mortality based on historical trends in deaths by county of residence between 2011 and 2019. We used the results of the model to generate estimates of excess mortality and excess deaths not assigned to COVID-19 in 2020 for 1470 county sets in the U.S. representing 3138 counties. Across the country, we estimated that 438,386 excess deaths occurred in 2020, among which 87.5% were assigned to COVID-19. Some regions (Mideast, Great Lakes, New England, and Far West) reported the most excess deaths in large central metros, whereas other regions (Southwest, Southeast, Plains, and Rocky Mountains) reported the highest excess mortality in nonmetro areas. The proportion assigned to COVID-19 was lowest in large central metro areas (79.3%). Regionally, the proportion of excess deaths assigned to COVID-19 was lowest in the Southeast (81.6%), Southwest (82.6%), Far West (83.7%), and Rocky Mountains (86.7%). Across the regions, the number of excess deaths exceeded the number of directly assigned COVID-19 deaths in most counties. The exception to this pattern occurred in New England, which reported more directly assigned COVID-19 deaths than excess deaths in metro and nonmetro areas. Many county sets had substantial numbers of excess deaths that were not accounted for in direct COVID-19 death counts. Estimates of excess mortality at the local level can inform the allocation of resources to areas most impacted by the pandemic and contribute to positive behavior feedback loops, such as increases in mask-wearing and vaccine uptake.

Racial Inequalities in Mortality from Pediatric Asthma in the United States: Clinical and Public Health Challenges

ABSTRACT In the United States (US), morbidity and mortality from pediatric asthma are increasing. We explored racial inequities using the Multiple Causes of Death Files of the US National Center for Health Statistics and the Wide-ranging Online Data for Epidemiologic Research (WONDER) for 1–14-year-olds from 1999 to 2018. We obtained mortality rates, Black:White mortality rate ratios (MRRs) and Annual Percent Change (APC). We tested for significance with 95% confidence intervals and joinpoint regression. Of 2,731 deaths from asthma, Blacks comprised 65.25% and 21.25% of the population. Black:White MRRs were 6.43 for 1–4, 7.54 for 5–9 and 6.88 for 10–14-year-olds of 6.88. The APC decline of −2.56 (p < 0.05) was significant among Whites but not Blacks. MRRs increased significantly from 4.23 in 2000 to16.57 in 2015 and declined to 6.69 in 2018. Among Black boys and girls, mortality rates were highest in Large Central Metropolitan areas. For Whites, rates were similar by urbanization in girls but were highest in Non-core, Non-metropolitan rural areas in boys. These descriptive data demonstrate statistically significant racial inequities in mortality from pediatric asthma in the US. They generate hypotheses, including, but not limited to, those related to under-resourced families and communities as well as economic and social marginalization. These and other plausible hypotheses require direct testing in analytic epidemiologic studies designed a priori to do so. In the meanwhile, efforts are necessary to strengthen community-driven initiatives and focus attention on inequitable systems, hierarchies, social structure and institutional practices. These include multifactorial interventions for individual, environmental and societal risk factors and educational efforts toward health-care providers and their patients about structural racism; these may combat, at least in part, vulnerabilities in US children and youth and improve racial inequities overall and from pediatric asthma.

Characteristics of Regular Pulse Bursts Generated From Lightning Discharges

In this work, we studied the waveforms of all lightning discharges from about 15 min. Eighty-three percent of all lightning discharges contain particular waveforms called regular pulse bursts (RPBs), which have regular microsecond-scale electric or magnetic field pulses. Maximum proportion of RPBs occur in middle or rear of lightning discharges. Prior to or after RPBs, there is always a chaotic pulse period. The analysis indicated that RPBs are caused by a secondary discharge in the fractured old breakdown channel, likeness to dart-stepped leader occuring in negative cloud-to-ground discharge (-CG). Four types of RPBs, namely, category of normal RPBs, category of back RPBs, category of symmetric RPBs, and category of reversal RPBs, were sorted in the light of the evolution of the pulse amplitude, interval between neighboring pulses and pulse polarity. In addition, the difference between normal RPBs and back RPBs was considered to be caused by the distance between neighboring charge pockets and the magnitude of the charge in every charge pocket. The symmetric RPBs were considered to be caused by a discharge channel with a large central charge area. Reversal RPBs were considered to be caused by a bending channel or superposition of two or more RPBs. We located some RPBs in a typical intra-cloud flash (IC) in three-dimensional. The analysis showed that the developing velocity of RPBs ranged from approximately 1.2 × 106 m/s to 3.0 × 106 m/s, which slower less than both of the dart leader or dart-stepped leader process from previous studies. And we found it is several meters to dozens of meters that the lengths range of discharge step which between two adjacent pulses.

Asthma Among Adults and Children by Urban-Rural Classification Scheme, United States, 2016-2018.

Although data on the prevalence of current asthma among adults and children are available at national, regional, and state levels, such data are limited at the substate level (eg, urban-rural classification and county). We examined the prevalence of current asthma in adults and children across 6 levels of urban-rural classification in each state. We estimated current asthma prevalence among adults for urban-rural categories in the 50 states and the District of Columbia and among children for urban-rural categories in 27 states by analyzing 2016-2018 Behavioral Risk Factor Surveillance System survey data. We used the 2013 National Center for Health Statistics 6-level urban-rural classification scheme to define urban-rural status of counties. During 2016-2018, the current asthma prevalence among US adults in medium metropolitan (9.5%), small metropolitan (9.5%), micropolitan (10.0%), and noncore (9.6%) areas was higher than the asthma prevalence in large central metropolitan (8.6%) and large fringe metropolitan (8.7%) areas. Current asthma prevalence in adults differed significantly among the 6 levels of urban-rural categories in 19 states. In addition, the prevalence of current asthma in adults was significantly higher in the Northeast (9.9%) than in the South (8.7%) and the West (8.8%). The current asthma prevalence in children differed significantly by urban-rural categories in 7 of 27 states. For these 7 states, the prevalence of asthma in children was higher in large central metropolitan areas than in micropolitan or noncore areas, except for Oregon, in which the prevalence in the large central metropolitan area was the lowest. Knowledge about county-level current asthma prevalence in adults and children may aid state and local policy makers and public health officers in establishing effective asthma control programs and targeted resource allocation.

Asthma Surveillance - United States, 2006-2018.

ProblemAsthma is a chronic disease of the airways that requires ongoing medical management. Socioeconomic and demographic factors as well as health care use might influence health patterns in urban and rural areas. Persons living in rural areas tend to have less access to health care and health resources and worse health outcomes. Characterizing asthma indicators (i.e., prevalence of current asthma, asthma attacks, emergency department and urgent care center [ED/UCC] visits, and asthma-associated deaths) and determining how asthma exacerbations and health care use vary across the United States by geographic area, including differences between urban and rural areas, and by sociodemographic factors can help identify subpopulations at risk for asthma-related complications.Reporting Period2006–2018.Description of SystemThe National Health Interview Survey (NHIS) is an annual cross-sectional household health survey among the civilian noninstitutionalized population in the United States. NHIS data were used to produce estimates for current asthma and among them, asthma attacks and ED/UCC visits. National Vital Statistics System (NVSS) data were used to estimate asthma deaths. Estimates of current asthma, asthma attacks, ED/UCC visits, and asthma mortality rates are described by demographic characteristics, poverty level (except for deaths), and geographic area for 2016–2018. Trends in asthma indicators by metropolitan statistical area (MSA) category for 2006–2018 were determined. Current asthma and asthma attack prevalence are provided by MSA category and state for 2016–2018. Detailed urban-rural classifications (six levels) were determined by merging 2013 National Center for Health Statistics (NCHS) urban-rural classification data with 2016–2018 NHIS data by county and state variables. All subregional estimates were accessed through the NCHS Research Data Center.ResultsCurrent asthma was higher among boys aged <18 years, women aged ≥18 years, non-Hispanic Black (Black) persons, non-Hispanic multiple-race (multiple-race) persons, and Puerto Rican persons. Asthma attacks were more prevalent among children, females, and multiple-race persons. ED/UCC visits were more prevalent among children, women aged ≥18 years, and all racial and ethnic groups (i.e., Black, non-Hispanic Asian, multiple race, and Hispanic, including Puerto Rican, Mexican, and other Hispanic) except American Indian and Alaska Native persons compared with non-Hispanic White (White) persons. Asthma deaths were higher among adults, females, and Black persons. All pertinent asthma outcomes were also more prevalent among persons with low family incomes. Current asthma prevalence was higher in the Northeast than in the South and the West, particularly in small MSA areas. The prevalence was also higher in small and medium metropolitan areas than in large central metropolitan areas. The prevalence of asthma attacks differed by MSA category in four states. The prevalence of ED/UCC visits was higher in the South than the Northeast and the Midwest and was also higher in large central metropolitan areas than in micropolitan and noncore areas. The asthma mortality rate was highest in non-MSAs, specifically noncore areas. The asthma mortality rate was also higher in the Northeast, Midwest, and West than in the South. Within large MSAs, asthma deaths were higher in the Northeast and Midwest than the South and West.InterpretationDespite some improvements in asthma outcomes over time, the findings from this report indicate that disparities in asthma indicators persist by demographic characteristics, poverty level, and geographic location.Public Health ActionDisparities in asthma outcomes and health care use in rural and urban populations identified from NHIS and NVSS can aid public health programs in directing resources and interventions to improve asthma outcomes. These data also can be used to develop strategic goals and achieve CDC’s Controlling Childhood Asthma and Reducing Emergencies (CCARE) initiative to reduce childhood asthma hospitalizations and ED visits and prevent 500,000 asthma-related hospitalizations and ED visits by 2024.

One new species of Cymbella C.A. Agardh (Bacillariophyta) from high altitude lakes in the Hengduan Mountains of Southwest China

This paper describes a new species of the genus Cymbella C.A. Agardh from an alpine lake in the Hengduan Mountains of southwestern China. A detailed morphological description of the new species, named Cymbella luoyulanae sp. nov., is presented; the description is based on light and scanning electron microscopy. The main features of C. luoyulanae are strongly dorsiventral valves with strongly reverse-lateral raphe branches near the proximal ends, a large central area occupying approximately a half of the width with the valve and slit-like areolae comprising striae that may be unseriate or partially biseriate. The new species has morphological characteristics that resemble those of C. heihainensis Y.Li et Gong, C. modicepunctata Krammer and C. asiatica Metzeltin, Lange-Bertalot et Y.Li, but it differs from these three species in details of size, valve shape, striae density, central area, and number of stigmata.

Racial, Rural, and Regional Disparities in Diabetes-Related Lower-Extremity Amputation Rates, 2009-2017.

To examine the racial/ethnic, rural-urban, and regional variations in the trends of diabetes-related lower-extremity amputations (LEAs) among hospitalized U.S. adults from 2009 to 2017. We used the National Inpatient Sample (NIS) (2009-2017) to identify trends in LEA rates among those primarily hospitalized for diabetes in the U.S. We conducted multivariable logistic regressions to identify individuals at risk for LEA based on race/ethnicity, census region location (North, Midwest, South, and West), and rurality of residence. From 2009 to 2017, the rates of minor LEAs increased across all racial/ethnic, rural/urban, and census region categories. The increase in minor LEAs was driven by Native Americans (annual percent change [APC] 7.1%, P < 0.001) and Asians/Pacific Islanders (APC 7.8%, P < 0.001). Residents of non-core (APC 5.4%, P < 0.001) and large central metropolitan areas (APC 5.5%, P < 0.001) experienced the highest increases over time in minor LEA rates. Among Whites and residents of the Midwest and non-core and small metropolitan areas there was a significant increase in major LEAs. Regression findings showed that Native Americans and Hispanics were more likely to have a minor or major LEA compared with Whites. The odds of a major LEA increased with rurality and was also higher among residents of the South than among those of the Northeast. A steep decline in major-to-minor amputation ratios was observed, especially among Native Americans. Despite increased risk of diabetes-related lower-limb amputations in underserved groups, our findings are promising when the major-to-minor amputation ratio is considered.

Employability Skills and Geographical Location

We study the employability skills expected of accounting graduates in regional metropolitan areas, which may significantly differ from the diverse economies of large central metropolitan areas. We investigate the differences in technical and soft skills demanded by metropolitan areas in the state of Texas. We assess the differences in technical skills versus soft skills for 14 Metropolitan Statistical Areas (MSAs) and 12 Occupational in the State of Texas. We examine the job postings and find that Communication skills are in high demand irrespective of the size of the metropolitan area. Large metro areas have a higher demand for analytical and team/cooperative skills while Medium metro areas and Border cities have a higher demand for organizational, detail oriented/meticulous, and management skills. Although all areas show many similarities in the technical skills they demand, Medium metro areas and Border cities showed a demand for Bilingual skills. We find that the different economic needs should be addressed with a regional perspective.

Geographic Heterogeneity in Influenza and Pneumonia Mortality in Hispanic Americans

(1) Background: Influenza and pneumonia (IP) is a leading cause of death in the US. The hypothesis was tested that the mortality rate differential between Hispanic whites (HW) and non-Hispanic whites (NHW) from IP varied by geographic region in the US. (2) Methods: The CDC database for multiple causes of death between 1999–2018 was used for this study. For ages 25–84, age-adjusted mortality rates per 100,000 (AAMR) for IP were computed by Hispanic ethnicity in whites for 10 Health & Human Services (HHS) regions and for urbanization levels in HHS Region 2. (3) Results: AAMR for IP was 13.76 (13.62–13.9) in HW and 14.91 (14.86–14.95) in NHW (rate ratio 1.08). Among HHS regions, rates were generally lower in HW than in NHW with the major exception of HHS Region 2. The rate there was 21.78 (21.24–22.33) in HW, 36.5% greater (p < 0.05) than that in NHW of 15.71 (15.56–15.86). In large central metro areas of Region 2, the rate was 27.10 (26.36–27.83) in HW compared to 19.78 (19.47–20.09) in NHW. (4) Conclusion: The difference in AAMR from IP between HW and NHW varied by region and urbanization with much higher rates for HW than NHW only in metropolitan areas of New York and New Jersey.

&lt;strong&gt;&lt;em&gt;Cymbella xiaojinensis sp. nov.&lt;/em&gt;, a new cymbelloid diatom species (Bacillariophyceae) from high altitude lakes, China&lt;/strong&gt;

This paper describes a new species of Cymbella from an alpine lake in the Hengduan Mountains, southwestern China. The detailed morphological description of the new species, named Cymbella xiaojinensis sp. nov. is presented, based on light and scanning electron microscopy. The main features of C. xiaojinensis are characterized by strongly dorsiventral, triangular valves with a strongly reverse-lateral raphe system positioned near the proximal ends and an asymmetrical, larger central area, occupying approximately 1/2 of the width with the valve. Most morphological characteristics of the new species are similar to C. shudunensis, C. terrafuegiana, C. pamirensis, and C. gravida, but differ in details of size, valve shape, striae density, central area, and number of stigmata.

Two new marine benthic diatom species of Hippodonta (Bacillariophyceae) from the coast of China: H. nanjiensis sp. nov. and H. qingdaoensis sp. nov.

The diversity and distribution of Hippodonta species on the coast of China are largely unknown due to limited investigations. In this paper, we report the detailed morphology and ultrastructure of two new species: H. nanjiensis sp. nov., collected from intertidal sandy sediments of Nanji Islands, the East China Sea and H. qingdaoensis sp. nov., collected from intertidal sandy sediments of the No. 1 Bathing Beach in Qingdao City, the Yellow Sea. Both species occur mainly in the middle part of the intertidal zone. H. nanjiensis possesses a unique large round central area. H. qingdaoensis differs from congeners in having a unique stria pattern, wherein the areolae in the middle transapical striae are less developed or absent on the primary side of the valve, and two areolae per stria are apparent under light microscopy (LM). This study expands our knowledge of Hippodonta diversity and distribution on the coast of China.

FDG PET/CT and CT Findings of Renal Cell Carcinoma With Sarcomatoid Differentiation.

OBJECTIVE. The purpose of this article is to investigate the value of 18F-FDG PET/CT and enhanced CT in the diagnosis of renal cell carcinoma (RCC) with sarcomatoid differentiation and the differential diagnosis of clear cell renal cell carcinoma (ccRCC). MATERIALS AND METHODS. Among patients with renal tumors confirmed by pathologic examination from September 2010 to August 2019, 29 patients with RCC with sarcomatoid differentiation and 82 patients with ccRCC who underwent FDG PET/CT, renal contrast-enhanced CT examination, or both, before surgery were studied. Features of the two groups on CT and PET/CT were retrospectively reviewed. RESULTS. The tumor size of RCC with sarcomatoid differentiation was larger than that of ccRCC (p = 0.0086). Cystic necrosis, peritumoral neovascularity, and metastasis were more common in RCC with sarcomatoid differentiation (p = 0.0052, p = 0.0008, p < 0.0001, respectively). The ratio of necrotic area to tumor diameter of RCC with sarcomatoid differentiation was statistically significantly larger than that of ccRCC (p = 0.0032). Three cases of RCC with sarcomatoid differentiation showed a large central necrotic area and dense intratu-moral neovascularity in the surrounding parenchyma, defined as the ring-of-fire sign, which was not found in ccRCC. The maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), and peak standardized uptake value (SUVpeak) of RCC with sarcomatoid differentiation were statistically significantly higher than those for ccRCC (all p < 0.0001), and the SUVmax, SUVmean, and SUVpeak cutoff values of 5.4, 4.2, and 5.0, respectively, were helpful for discrimination. CONCLUSION. Imaging features including higher SUVmax, SUVmean, and SUVpeak; a larger ratio of necrotic area to tumor diameter; the presence of peritumoral neovascularity; and metastasis are more commonly associated with RCC with sarcomatoid differentiation than with ccRCC. The ring-of-fire sign and SUVmax, SUVmean, SUVpeak cutoff values of 5.4, 4.2, 5.0, respectively, may be helpful to indicate RCC with sarcomatoid differentiation.

T240. DOES SCHEDULING A POST-DISCHARGE OUTPATIENT MENTAL HEALTH APPOINTMENT INCREASE THE LIKELIHOOD OF SUCCESSFUL TRANSITION FROM HOSPITAL TO COMMUNITY-BASED CARE?

BackgroundScheduling timely appointments for outpatient follow-up care is a discharge planning practice widely accepted as a standard of care for inpatient treatment. Despite these endorsements, however, rates of hospital providers completing these practices vary widely. Timely scheduling of initial outpatient visits following discharge has been associated with improved rates of attending outpatient psychiatric services, although negative findings have also been reported. Nearly all prior studies were single-site case reports that did not use an experimental design and more rigorous research is needed.In this report, we aimed to examine the association between receiving care transition practices and attending outpatient care after controlling for patient, hospital, and system characteristics in a large cohort of inpatient psychiatric admissions in New York State. We hypothesized that patients for whom hospital providers scheduled a mental health outpatient appointment had a higher likelihood of receiving an initial outpatient psychiatric service following discharge after controlling for the aforementioned covariates.MethodsThis is a retrospective cohort study that used 2012–2013 New York State Medicaid claims data for psychiatric inpatients, who were under 65 years, admitted to an inpatient psychiatric unit with a principal diagnosis of a mental disorder and discharged to the community. The outcome variable was defined as attending to outpatient psychiatric services within 7 and 30 days following discharge from an inpatient psychiatric unit. Scheduling a mental health outpatient appointment as a discharge planning was the primary independent variable. To address the wide range of potentially confounding covariates, propensity scores for regression models were estimated based on patient, hospital, and service system factors.ResultsBefore matching by propensity scores, those who had an outpatient mental health appointment scheduled were less likely to be homeless at admission, have a co-occurring substance use diagnosis, and live in large central metro areas, and were more likely to be previously engaged in psychiatric outpatient services. After matching, however, most systematic differences between those who had and those who did not have a mental health outpatient appointment scheduled were substantially diminished (standardized differences of <20%).In the adjusted models including propensity scores, patients who had a mental health outpatient appointment scheduled were more likely to be in treatment in aftercare services compared to patients who did not have an outpatient appointment at both 7 and 30 days following discharge.DiscussionScheduling an outpatient mental health appointment increases aftercare attendance following a psychiatric discharge. This effect was noted across all 5 propensity strata, indicating that discharge planning has a positive impact regardless of the presence of other factors highly predictive of failure to attend aftercare appointments.

SAT-LB42 Bilateral Large Calcified Adrenal Leiomyoma Mimicking Adrenal Malignancy: A Rare Case Report With Literature Review

Background: Adrenal leiomyoma is a very rare benign soft tissue tumor, it is even more unusual if presenting bilaterally; 21 cases have been reported in the literature and only six had bilateral involvement; 5 in the pediatric population and only one in an adult patient. Radiological appearance may frequently be confused with malignancy especially if large, calcified and with central necrosis. We report a rare case of bilateral, large, calcified, non-functioning adrenal leiomyoma in a 20-year-old female, who was suspected for a malignancy preoperatively. Clinical Case: A 20 year-old-female presented with chronic abdominal discomfort, fatigue, and inability to gain weight. On examination, she was normotensive, underweight with BMI of 15.6 kg/m2, and there were no stigmata of Cushing’s syndrome, Addison’s disease or pheochromocytoma. A contrast CT scan of the abdomen revealed the presence of bilateral well-defined suprarenal lesions measuring 8.5 x 8.5 x 7.2 cm and 4.7 x 4.2 x 3.5 cm on the right and left side, respectively. The lesions showed large central areas of necrosis with multiple punctate calcifications and heterogenous peripheral enhancement. The radiological differential diagnosis included adrenal cortical carcinoma, adrenal metastasis, infectious etiology, and bilateral pheochromocytoma. Her hormonal assays showed normal free cortisol and catecholamine metabolites in the urine and normal serum androgens. Thus, the tumors were concluded to be non-functioning. Adrenal insufficiency was ruled out after a short Synacthen test. The patient underwent a successful right adrenalectomy. Resected specimen measured 10 x 9.5 x 7.5 cm. Histology revealed a well-circumscribed and pseudo-encapsulated smooth muscle tumor comprised of bland, spindle-shaped cells. The panel of immunohistochemical stains supported the diagnosis of leiomyoma. Postoperatively, the symptoms improved, she gained 4 kg weight over the following 4 months, and short Synacthen test confirmed an intact adrenal function. To avoid lifelong adrenal insufficiency and after discussion with the patient, we agreed to leave the left adrenal mass and follow it by serial imaging. There was only a minimal increase in the size over the following 4 years (5.5 x 4.5 x 3.8 cm). Conclusion: Adrenal leiomyoma is an extremely rare adrenal tumor and can be confused with adrenal malignancy. Therefore, it should be considered in the differential diagnosis of adrenal incidentalomas. In the case of bilateral etiology, permanent adrenal insufficiency and longterm replacement therapy can be avoided in certain population by removing the larger tumor and continuous follow-up for the other side.

Trends in Endovascular Mechanical Thrombectomy in Treatment of Acute Ischemic Stroke in the United States

Numerous randomized controlled trials have shown that endovascular mechanical thrombectomy (MT) is an effective treatment for large vessel ischemic stroke. This study examines variation in rates of MT across the United States by geographic region and urban-rural areas to identify utilization disparities. Data from the Global Burden of Disease Collaborative Network were used to determine acute ischemic stroke (AIS) incidence by state for 2016. The 2016 National Inpatient Sample was accessed to identify patients who underwent MT and patients who were diagnosed with cerebral infarct due to thrombosis or embolism of anterior circulation arteries representing the AIS population of interest. National Inpatient Sample data were used to create national weighted estimates of the size of subject populations, age at admission, length of stay, and discharge status. In the United States, approximately 13,010 mechanical thrombectomies were performed in 2016, representing 3.1% of the AIS population. Proportions of patients undergoing MT were highest in large central metropolitan areas and lowest in rural settings when compared with the national estimate. East North Central and West South Central regions had significantly lower proportions of patients treated with MT. Discharge destinations, a proxy for clinical outcome, differed significantly by region and urban-rural designation. The number of MTs performed in 2016 increased approximately 1.3 times from 2015. Considering that 10%-17% of patients with AIS may be MT-eligible, current rates of MT are low across all regions, but the most pronounced disparities and poorer clinical outcomes occur in rural areas, particularly in the Northeast/Southwest regions of the Midwest.

Influences of microtidal regime and eutrophication on estuarine zooplankton

This study describes the ecology of mesozooplankton in the shallows of the large central basin area of the Swan-Canning Estuary on the microtidal lower west coast of Australia during the mid-1980s when, as in most other south-western Australian estuaries, it was mesotrophic. As the vast majority of species reproduce within the estuary and there is a lack of a net upstream flow of bottom water during each tidal cycle to facilitate selective tidal transport, the populations of those species are considered autochthonous. Species restricted to the estuary accounted for 63% of the total number of species and 83% of abundance. Contributions by tychoplankton to total number of species (68%) and individuals (59%) exceeded the corresponding values of 18 and 39% for holoplankton and 14 and 2% for meroplankton. Low meroplankton values result from a paucity of benthic macroinvertebrate species with planktotrophic development. Comparisons with data for the shallow basin areas of the nearby highly eutrophic Peel-Harvey Estuary were used to indicate how mesozooplankton in the microtidal estuaries respond to excessive nutrient enrichment. The mean number of species in the Swan-Canning was essentially the same as in the Peel-Harvey, whereas concentrations were only half, reflecting the lower productivity of the former estuary. However, concentrations of the four most abundant species in the Swan-Canning, the amphipod Grandidierella propendatata, the calanoids Gladioferens imparipes and Acartia cf. clausi and a harpacticoid species, exceeded those of these species in the Peel-Harvey by between 1.6 and 11.7 times. Greater concentrations in the Swan-Canning were attributable to this mesotrophic system not undergoing the reduction in oxygen concentrations and/or environmental degradation, to which these species are susceptible. In contrast, concentrations of the amphipods Corophium minor and Tethygenia elanora and large nematodes, which are tolerant of degraded environmental conditions, were greater in the Peel-Harvey. Holoplankton made a far greater contribution in the Swan-Canning than Peel-Harvey, due to substantial numbers of copepods that benefit from good environmental conditions. Mesozooplankton composition in both estuaries underwent cyclical changes during the year due to time-staggered differences in seasonal concentrations of various species. Cyclical changes and variations in composition were more closely related to measured environmental variables in the Swan-Canning than Peel-Harvey estuaries. The concentrations of many species were greater at night than during the day presumably reflecting a nycthemeral response and/or low nocturnal oxygen concentrations at the bottom of the water column.

Congestive heart failure-related hospital deaths across the urban-rural continuum in the United States.

Congestive heart failure (CHF) is a growing public health problem that affects nearly 6.5 million individuals nationwide. Access to quality outpatient care and disease management programs has been shown to improve disease treatment and prognosis. Rural populations face unique challenges in the availability and accessibility of quality cardiovascular care. In 2018, we conducted a pooled cross-sectional analysis of the Nationwide Inpatient Sample (NIS) for 2009–2014 to examine recent trends in CHF-related hospital deaths in the United States, highlighting urban-rural differences within each census region. We performed a multivariable logistic regression analysis to compare the odds of CHF-related hospital death, by levels of rurality and within each census region. Most CHF-related hospital deaths occurred in the South and Midwest census regions and in large central metropolitan areas. Findings from census region stratified models revealed that non-core residents living within the West (OR 1.47, CI 1.26, 1.71), Midwest (OR 1.30, CI 1.17, 1.44), and South (OR = 1.21, 95% C.I. = 1.12–1.32) had a higher relative risk (but not higher absolute numbers) of experiencing death during a CHF-related hospitalization, compared to patients in large central metropolitan areas. Within each census region, there were also differences in odds of a CHF-related hospital death depending on patient sex, comorbidities, insurance type, median annual income, and year. As efforts to reduce rural health disparities in CHF morbidity continue, more work is needed to understand and test interventions to reduce the risk of death from CHF in noncore areas of the West, Midwest, and South.

Racial/Ethnic and Age Group Differences in Opioid and Synthetic Opioid-Involved Overdose Deaths Among Adults Aged ≥18 Years in Metropolitan Areas - United States, 2015-2017.

Among the 47,600 opioid-involved overdose deaths in the United States in 2017, 59.8% (28,466) involved synthetic opioids (1). Since 2013, synthetic opioids, particularly illicitly manufactured fentanyl (IMF), including fentanyl analogs, have been fueling the U.S. overdose epidemic (1,2). Although initially mixed with heroin, IMF is increasingly being found in supplies of cocaine, methamphetamine, and counterfeit prescription pills, which increases the number of populations at risk for an opioid-involved overdose (3,4). With the proliferation of IMF, opioid-involved overdose deaths have increased among minority populations including non-Hispanic blacks (blacks) and Hispanics, groups that have historically had low opioid-involved overdose death rates (5). In addition, metropolitan areas have experienced sharp increases in drug and opioid-involved overdose deaths since 2013 (6,7). This study analyzed changes in overdose death rates involving any opioid and synthetic opioids among persons aged ≥18 years during 2015-2017, by age and race/ethnicity across metropolitan areas. Nearly all racial/ethnic groups and age groups experienced increases in opioid-involved and synthetic opioid-involved overdose death rates, particularly blacks aged 45-54 years (from 19.3 to 41.9 per 100,000) and 55-64 years (from 21.8 to 42.7) in large central metro areas and non-Hispanic whites (whites) aged 25-34 years (from 36.9 to 58.3) in large fringe metro areas. Comprehensive and culturally tailored interventions are needed to address the rise in drug overdose deaths in all populations, including prevention strategies that address the risk factors for substance use across each racial/ethnic group, public health messaging to increase awareness about synthetic opioids in the drug supply, expansion of naloxone distribution for overdose reversal, and increased access to medication-assisted treatment.