Midwest Region Research Articles

The Impact of Extreme Temperatures on Grain Production in the Huaihe River Basin

The Huaihe River Basin is an important major grain producing area in China, maintaining the stability of grain output is of great significance to food security. However, with global warming, the frequency of extreme temperature events has increased, and the frequent meteorological disasters have brought great challenges to the stable supply of food production. In this paper, the impact of extreme temperature on grain production in the Huaihe River Basin was analyzed by using the daily temperature and agricultural production related data of 28 prefecture-level cities in the Huaihe River Ecological Economic Belt from 2001 to 2020. The following conclusions are drawn: 1) The influence coefficient of extreme high temperature on grain production in the Huaihe River Basin is -0.021, extreme low temperature has no significant impact on food production. 2) The effects of extreme temperature on food production in different regions in the river basin were heterogeneous, but the overall impact was negative. The influence coefficients of extremely high temperature days on the eastern region and Midwest region were -0.035 and -0.052, respectively, while the influence coefficients of extremely low temperature days on the eastern region were -0.413. The results showed that the increase in the number of extremely high temperature days would reduce production in the eastern region andMidwest region of the basin, while the northern region was not significantly affected by extreme heat. The increase in the number of extremely low temperature days will reduce grain production in the eastern region, and the impact on the Midwest region and the northern region will not be significant. Based on the above conclusions, three suggestions are put forward to maintain the safety of food production in the Huaihe River Basin: 1) enhance the ability to detect climate change in the basin; 2) Protect the stability of grain cultivated land in the river basin; 3) Innovative breeding of climate-resilient food crop seeds.

Seropositivity to Cysticercosis in School-Age Children Living in a Low-Income Municipality in the Midwest Region of Brazil.

Human cysticercosis (CC) is a global public health problem, especially in Latin America, including Brazil. We aimed to analyze the seroprevalence of CC among school-age children and adolescents. We analyzed the presence of specific IgG antibodies against Taenia solium metacestodes in 500 serum samples from elementary school children and adolescents in Jataí City, state of Goiás, Brazil. IgG antibodies against the antigenic extract of the parasite were detected and analyzed by ELISA, and specific peptides were identified by confirmatory Western Blotting test. Of the 500 study participants, 205 (41%) were male, and 295 (59%) were female. Participants aged between 4 and 18 years (mean age 8.4 years). The percentage of serum samples reactive by ELISA was 37.2%. These samples were analyzed by Western Blotting, which confirmed that the seropositivity rate was 6.2% (95% CI 2.4-14.7) in 31 samples reactive for CC-specific bands, determined in serum samples from 18 male (5-11 years old) and 13 female (4-12 years old) students. The CC seroprevalence demonstrated in schoolchildren suggests that this parasitosis is endemic in the study area. Further investigations are necessary to clarify the local epidemiology of this parasitosis.

The Impact of COVID-19 on the Financial Performance of Largest Teaching Hospitals.

The COVID-19 pandemic disrupted hospital operations. Anecdotal evidence suggests financial performance likewise suffered, yet little empirical research supports this claim. This study aimed to explore the impact of the pandemic on the financial performance of the most prominent academic hospitals in the United States. Data from the 115 largest major teaching hospitals in the United States were extracted from the American Hospital Directory for three years (2019-2021). We hypothesized that the year and region would moderate the relationship between a hospital's return on assets (financial performance) and specific operational variables. We found evidence through descriptive statistics and multivariate moderated regressions that financial positions rebounded in 2021, mainly through reductions in adjusted full-time employees and liabilities and an increase in non-operating income. Our results also found that the Midwest region significantly outperformed the other three regions, particularly in terms of lower salaries and operational expenses. These findings suggest potential for future initiatives encouraging efficiency and finding alternate sources of income beyond patient income. Hospitals should focus on improving financial reserves, building out non-operational revenue streams, and implementing operational efficiencies to foster better financial resiliency. These suggestions may enable healthcare administrators and facilities to adapt to future pandemics and environmental turbulence.

The birthplace and relative age effects in Brazilian olympic athletes: a cross-national comparison.

Our purpose was to verify the existence of birthplace and relative age effect (RAE), as well as the association between birthplace effect and RAE among Brazilian athletes competing in the Olympic Games. Data included information about Brazilian Summer Olympic athletes from 1920 to 2021. To investigate RAE, athletes' birthdate was distributed into birth quartiles (Q1: Jan-Mar; Q2: Apr-Jun; Q3: Jul-Sep; Q4: Oct-Dec), while birthplace effect was assessed considering the state and the region (Southeast; Northeast; South; North; and Midwest) of birth. The Chi-square test (χ2) was used to verify differences between the birthplace effect and RAE. The sample consisted of 388 Brazilian athletes of both sexes, distributed in 38 sports modalities from 23 Brazilian states (Southeast = 66.5%; South = 14.4%; Northeast = 12.1%; North = 1.5%; Midwest = 5.4%). For both sexes, most of the athletes were from the São Paulo state (37.4%), followed by Rio de Janeiro (18.3%), both from the Southeast region. For birthdate distribution according to birthplace, it was observed that the North region presented the highest frequency of athletes born in Q1 (50%), followed by the Northeast and Southeast regions. No significant differences were found for the birthplace effect (χ2 = 5.69, value of p = 0.128) and RAE between sexes (χ2 = 0.530, value of p = 0.912), nor was shown an association between the birthplace effect and RAE. Most Brazilian Olympic athletes are from the Southeast region, but no RAE was established regarding their birthplace. Results from the present study can guide sports public policies in Brazilian regions, especially in the Midwest, North, and Northeast regions, which are underrepresented in Brazilian high-performance sports.

The availability and type of lesbian, gay, bisexual, transgender, and queer content on sperm, oocyte, and embryo provider websites.

To evaluate and quantify the character and amount of lesbian, gay, bisexual, transgender, and queer (LGBTQ +) content on sperm, oocyte, and embryo provider websites in the USA. Websites with LGBTQ + information were categorized into "minimal," "moderate," and "significant" content. The presence and type (category) of LGBTQ + content were assessed in its relationship to geographic regions, in vitro fertilization (IVF) cycles/year, and website types. Interobserver reliability was assessed for the categorization system created. Out of 373 unique websites, 191 (51.2%) had LGBTQ + content of any kind. Regarding the amount of content, websites were categorized as "none" (48.8%), "minimal" (8.0%), "moderate" (28.4%), and "significant" (14.8%). "Private fertility clinic" websites were more likely to have LGBTQ + content and a significantly increased amount of content compared to other website types ("academic hospital" and "sole sperm, oocyte, and embryo provider" websites) (p < 0.0001). Fertility clinics with more IVF cycles/year were more likely to have increased amount of LGBTQ + content compared to those with fewer IVF cycles/year (OR = 4.280; 95% CI, 1.952-9.388). Northeast, West, South, and Midwest regions showed no statistically significant difference in presence and type of content (p = 0.06 and p = 0.13, respectively). Approximately half of websites had LGBTQ + content. Private fertility clinics and fertility clinics with increased IVF cycles/year show a positive relationship to the presence and type of LGBTQ + content, while LGBTQ + website content was similar across four geographic regions.

Virucidal antiviral activity of Maytenus quadrangulata extract against Mayaro virus: Evidence for the presence of catechins.

Mayaro virus (MAYV) is an arbovirus endemic to the Amazon region, which comprises the states of the North and Midwest region of Brazil and encompasses the largest tropical forest in the world, the Amazon Forest. The confirmation of its potential transmission by Aedes aegypti and recent cases in Brazil, mainly in large centers in the northern region, led to the classification of Mayaro fever as an emerging disease. Traditional medicine is commonly used to treat various diseases, mainly by local riverside populations. Some species of the genus Maytenus, which have similar morphologies, are popularly used to treat infections and inflammations. In this context, our research group has studied and confirmed the antiviral activity of several plant-derived compounds. However, several species of this same genus have not been studied and therefore deserve attention. This study aimed to demonstrate the effects of ethyl acetate extracts of leaves (LAE) and branches (TAE) of Maytenus quadrangulata against MAYV. Mammalian cells (Vero cells) were used to evaluate the cytotoxicity of the extracts. After cell infection by MAYV and the treatment with the extracts, we evaluated the selectivity index (SI), the virucidal effect, viral adsorption and internalization, and the effect on viral gene expression. The antiviral action was confirmed by quantifying the viral genome using RT-qPCR and by analyzing the effect on virus yield in infected cells. The treatment was performed based on the effective concentration protective for 50% of the infected cells (EC50). The leaves (LAE; EC50 12.0μg/mL) and branches (TAE; EC50 101.0μg/mL) extracts showed significative selectivity against the virus, with SI values of 79.21 and 9.91, respectively, which were considered safe. Phytochemical analysis revealed that the antiviral action was associated with the presence of catechins, mainly in LAE. This extract was chosen for the subsequent studies since it reduced the viral cytopathic effect and virus production, even at high viral loads [MOI (multiplicity of infection) 1 and 5]. The effects of LAE resulted in a marked reduction in viral gene expression. The viral title was drastically reduced when LAE was added to the virus before infection or during replication stages, reducing virus production up to 5-log units compared to infected and untreated cells. Through kinetic replication, MAYV was not detected in Vero cells treated with LAE throughout the viral cycle. The virucidal effect of LAE inactivates the viral particle and can intercept the virus at the end of the cycle when it gains the extracellular environment. Therefore, LAE is a promising source of antiviral agents.

La Crosse Virus Circulation in Virginia, Assessed via Serosurveillance in Wildlife Species.

Mosquito-borne La Crosse virus (LACV; family: Peribunyaviridae) is the leading cause of pediatric arboviral encephalitis in the United States, with clinical cases generally centered in the Midwest and Appalachian regions. Incidence of LACV cases in Appalachian states has increased, such that the region currently represents the majority of reported LACV cases in the USA. The amount of reported LACV cases from Virginia, however, is minimal compared to neighboring states such as North Carolina, West Virginia, and Tennessee, and non-Appalachian regions of Virginia are understudied. Here we examine the hypothesis that LACV is circulating widely in Virginia, despite a low clinical case report rate, and that the virus is circulating in areas not associated with LACV disease. In this study, we screened local mammalian wildlife in northwestern counties of Virginia using passive surveillance via patients submitted to wildlife rehabilitation centers. Blood sera (527 samples; 9 species, 8 genera) collected between October 2019 and December 2022 were screened for neutralizing antibodies against LACV, indicating prior exposure to the virus. We found an overall LACV seroprevalence of 1.90% among all wild mammals examined and reveal evidence of LACV exposure in several wild species not generally associated with LACV, including eastern cottontails and red foxes, along with established reservoirs, eastern gray squirrels, although there was no serological evidence in chipmunks. These data indicate the circulation of LACV in Virginia outside of Appalachian counties, however, at a lower rate than reported for endemic areas within the state and in other states.

Characterizing Opioid Use Disorder Encounters in the Midwest Region, USA.

The opioid epidemic has taken its toll on the Midwest, a census region of the USA. The Midwest includes two census divisions: East North Central and West North Central. This study aimed (1) to characterize patient encounters of opioid use disorder (OUD) in the Midwest using the Health Facts® database; and (2) to compare selected patient and facility characteristics between the two census divisions. This study was a sub-analysis of a retrospective analysis of the Health Facts® database. For the first objective, the unit of analysis was a patient encounter. Selected patient characteristics were age, gender, marital status, race, length of stay, and patient type. Selected facility characteristics were census division and urban versus rural areas. Descriptive statistics were conducted, and population-based rates of OUD were calculated for categorical variables. For the second objective, t tests were performed for age and length of stay, and chi-square tests for categorical variables. A total of 13,129 (23.7%) encounters were in East North Central, and 42,271 (76.3%) in West North Central. Patient characteristics that were associated with the highest frequency of encounters were Caucasian, male, single, and other patient types. In addition, rural areas had a higher number of encounters than urban areas. Compared with East North Central, West North Central had a greater average age and a longer average length of stay (p<0.001). West North Central had a significantly higher proportion of patient encounters associated with patients being male, African American, single, and facilities being in rural areas (p<0.001). Compared to East North Central, patient encounters of OUD were more frequent and the average length of stay was longer than in West North Central. A significantly higher proportion of patient encounters in West North Central were associated with patients being male, African American, and single, and facilities being in rural areas.

Prevalence of Enterovirus in Water Consumed in Rural Areas in a State in the Midwest Region of Brazil

Individuals in rural communities often obtain water from surface and groundwater sources, where the microbial quality is often unknown. Enteric viruses are among the main pathogenic microorganisms responsible for waterborne disease outbreaks. Thus, the objective of this work was to search for enterovirus in water samples from 25 rural communities. For this, 160 water samples were collected. Detection and quantification of the enterovirus (EV) were performed through molecular tests using the two main amplification reagents for qPCR. The prevalence of EV was identified in 4.4% (7/160) of the samples when Sybr Green® was used, all in groundwater sources. Additionally, EV was found in 9.7% of shallow tubular wells, 3.8% of deep tubular wells, 4.3% of shallow dug wells and 5.9% of spring water. When using TaqMan®, there was no amplification of the EV cDNA. Conclusions: Sybr Green®, being a more accessible reagent, has a greater predilection for molecular tests, but the study showed that Taqman® could suffer less interference from environmental samples, resulting in more reliable values of viral quantification. In this context, the detection of EV in groundwater can help in monitoring the virus in this source, in addition to helping managers of these communities in decision making.

Acute exacerbation of chronic obstructive pulmonary disease in United States emergency departments, 2010–2018

ObjectivesLittle is known about the recent status of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the U.S. emergency department (ED). This study aimed to describe the disease burden (visit and hospitalization rate) of AECOPD in the ED and to investigate factors associated with the disease burden of AECOPD.MethodsData were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010–2018. Adult ED visits (aged 40 years or above) with AECOPD were identified using International Classification of Diseases codes. Analysis used descriptive statistics and multivariable logistic regression accounting for NHAMCS’s complex survey design.ResultsThere were 1,366 adult AECOPD ED visits in the unweighted sample. Over the 9-year study period, there were an estimated 7,508,000 ED visits for AECOPD, and the proportion of AECOPD visits in the entire ED population remained stable at approximately 14 per 1,000 visits. The mean age of these AECOPD visits was 66 years, and 42% were men. Medicare or Medicaid insurance, presentation in non-summer seasons, the Midwest and South regions (vs. Northeast), and arrival by ambulance were independently associated with a higher visit rate of AECOPD, whereas non-Hispanic black or Hispanic race/ethnicity (vs. non-Hispanic white) was associated with a lower visit rate of AECOPD. The proportion of AECOPD visits that were hospitalized decreased from 51% to 2010 to 31% in 2018 (p = 0.002). Arrival by ambulance was independently associated with a higher hospitalization rate, whereas the South and West regions (vs. Northeast) were independently associated with a lower hospitalization rate. The use of antibiotics appeared to be stable over time, but the use of systemic corticosteroids appeared to increase with near statistical significance (p = 0.07).ConclusionsThe number of ED visits for AECOPD remained high; however, hospitalizations for AECOPD appeared to decrease over time. Some patients were disproportionately affected by AECOPD, and certain patient and ED factors were associated with hospitalizations. The reasons for decreased ED admissions for AECOPD deserve further investigation.

A novel spatio-temporal clustering algorithm with applications on COVID-19 data from the United States

A new clustering algorithm for spatio-temporal data is developed. The proposed method leverages a weighted combination of a spatial haversine distance matrix and a spectral-density based temporal distance matrix between the locations. Concepts of partition around medoids algorithm and the gap statistic are utilized to develop the algorithm and to determine the optimal number of clusters. Such a non-parametric algorithm is novel as it incorporates both spatial and temporal distances of the units and it can work for time-series of possibly different lengths. Theoretical guarantee of consistency of the proposed method is provided. An elaborate simulation study is also given to demonstrate the efficacy of the algorithm. As an interesting real life application, the proposed algorithm is implemented to analyze the spatio-temporal dynamics of the time series of coronavirus (COVID-19) incidence rates observed at county-level in the United States of America. The results are demonstrated on datasets of different sizes: the entire country, the Midwest region and the state of California. Special emphasis is given on the last two cases to display how the clustering results offer interesting insights into the epidemic progression in these areas. Particularly, it sheds light on whether state-mandated restrictions impacted the entire state similarly or if there are interesting local behaviors in terms of the COVID-19 spread.

Epidemiology, Trends, Utilization Disparities, and Outcomes of Catheter Ablation and Its Association With Coronary Vasospasm Amongst Patients With Non-valvular Atrial Fibrillation: A Nationwide Burden of Last Decade.

Catheter ablation (CA) is an important curative treatment for non-valvular atrial fibrillation (NVAF), however, nationwide data on its utilization and disparities is limited. Coronary vasospasm is arare, life-threatening, peri-operativecomplication of CA with limited literature in Caucasians. We performed a retrospective study on adult hospitalizations in the USA from 2007 to 2017 by obtaining the data from National Inpatient Sample.The primary endpoints of our study were to identify the utilization rate of CA, disparities in utilization, and study the outcomes associated with CA. The secondary endpoints of the study were to identify the incidence of coronary vasospasm amongst patientswho underwent CA, evaluate their association, and identify the predictors of coronary vasospasm. From 35,906,946 patients with NVAF, 343641 (0.96%) underwent CA. Its utilization decreased from 1% in 2007 to 0.71% in 2017. Patients who underwent CA, compared to those without CA, fared better in terms of hospital length of stay, mortality rate, disability rate, and discharge to the non-home facility. Patients in the 50-75 years age group, Native Americans, those with private insurance, and median household income of 76-100th percentile were associated with higher odds of CA utilization. Urban teaching hospitals and large-bedded hospitals performed more ablations, while the Mid-West region fared lower than the South, the West, and the Northeast. The prevalence of coronary vasospasm was higher amongst CA in comparison without CA, however, in regression analysis, no significant association was demonstrated between CA and coronary vasospasm. CA is an important treatment modality that is associated with improved clinical outcomes. Identification of factors associated with lower utilization of CA and its disparities will help to mitigate the burden associated with NVAF.

Ecological zoning of Euschistus heros in Brazil based on the net reproductive rate at different temperatures and relative-humidity levels.

The Neotropical brown stink bug, Euschistus heros (Fabricius, 1798) (Hemiptera: Pentatomidae), is one of the major insect pests in soybean crops, causing severe damage; however, some aspects of its biology that are essential for management remain unknown. To aid in the management of E. heros, the present study investigated the fertility life table of this species at 7 temperatures (18, 20, 22, 25, 28, 30, and 32 ± 1 °C) and 4 relative-humidity levels (30, 50, 70, and 90 ± 10%). Based on the net reproductive rate, R0, we developed an ecological zoning for this pest in Brazil, to identify climatically favorable areas for population growth. Our results indicated that the most favorable range is between 25 and 28 °C and above 70% RH. The ecological zoning indicated that farmers should be more concerned in the northern and Midwest regions, which include the state of Mato Grosso, the largest soybean and corn producer in Brazil. These results provide valuable information, indicating the hotspots most likely to be attacked by the Neotropical brown stink bug.

Effect of Mineral and Organic Nitrogen Sources on Vegetative Development, Nutrition, and Yield of Sugarcane

Although sugarcane yield is directly influenced by the availability of nitrogen (N), the efficiency of mineral N (MN) fertilization is considered to be low due to nitrate leaching and ammonia volatilization. Thus, the search for alternative sources of N that are cheaper and more consistent with sustainable farming practices has been stimulated. As chicken litter is an organic waste with the potential to supply N to major crops, we tested the hypothesis that the use of this litter as a source of organic N (ON) is as efficient as the application of MN (ammonium nitrate) in promoting the growth, nutrition, and yield of sugarcane plants grown during both plant cane and ratoon cane seasons. Experiments were conducted in a 5 × 5 × 2 subdivided plot scheme in the growing area of the Denusa Mill, Destilaria Nova União S/A, located in the midwest region of Brazil, with treatments consisting of five doses each of MN (0, 40, 80, 120, and 160 kg ha−1) and ON (0, 2, 4, 6, and 8 T ha−1), evaluated in two crop seasons (plant cane-2019/2020 and ratoon cane-2020/2021). The application of different doses of MN or ON influenced the height and number of tillers of sugar cane plants, and the application of ON, supplied by chicken litter, to this crop was as efficient as that of MN in promoting plant growth. MN and ON also increased the leaf content of N, P, and K; moreover, the absence of one source of nitrogen was compensated by the other. ON application (up to 4.8 T ha−1) also increased sugarcane yield in addition to promoting growth. Furthermore, this study highlighted the superior quality of the regrowth observed in the IACSP95-5094 cultivar, which manifested in increased tillering and stem diameter, resulting in consistently higher yields in the ratoon crop.

The implementation of value-based frameworks, clinical care pathways, and alternative payment models for cancer care in the United States.

BACKGROUND: Cancer treatment is a significant driver of rising health care costs in the United States, where the annual cost of cancer care is estimated to reach $246 billion in 2030. As a result, cancer centers are considering moving away from fee-for-service models and transitioning to value-based care models, including value-based frameworks (VBFs), clinical care pathways (CCPs), and alternative payment models (APMs). OBJECTIVE: To assess the barriers and motivations for using value-based care models from the perspectives of physicians and quality officers (QOs) at US cancer centers. METHODS: Sites were recruited from cancer centers in the Midwest, Northeast, South, and West regions in a 15/15/20/10 relative distribution. Cancer centers were identified based on prior research relationships and known participation in the Oncology Care Model or other APMs. Based on a literature search, multiple choice and open-ended questions were developed for the survey. A link to the survey was emailed to hematologists/oncologists and QOs at academic and community cancer centers from August to November 2020. Results were summarized using descriptive statistics. RESULTS: A total of 136 sites were contacted; 28 (21%) centers returned completed surveys, which were included in the final analysis. 45 surveys (23 from community centers, 22 from academic centers) were completed: 59% (26/44), 76% (34/45), and 67% (30/45) of physicians/QOs respondents had used or implemented a VBF, CCP, and APM, respectively. The top motivator for VBF use was "producing real-world data for providers, payers, and patients" (50% [13/26]). Among those not using CCPs, the most common barrier was a "lack of consensus on pathway choices" (64% [7/11]). For APMs, the most common difficulty was that "innovations in health care services and therapies must be adopted at the site's own financial risk" (27% [8/30]). CONCLUSIONS: The ability to measure improvements in cancer health outcomes was a large motivator for implementing value-based models. However, heterogeneity in practice size, limited resources, and potential increase in costs were possible barriers to implementation. Payers need to be willing to negotiate with cancer centers and providers to implement the payment model that will most benefit patients. The future integration of VBFs, CCPs, and APMs will depend on reducing the complexity and burden of implementation. DISCLOSURES :Dr Panchal was affiliated with the University of Utah at the time this study was conducted and discloses current employment with ZS. Dr McBride discloses employment with Bristol Myers Squibb. Dr Huggar and Dr Copher report employment, stock, and other ownership interests in Bristol Myers Squibb. The other authors have no competing interests to disclose. This study was funded by an unrestricted research grant from Bristol Myers Squibb to the University of Utah.

Comparison of the performance of estimated precipitation data via remote sensing in the Midwest Region of Brazil

Comparison of the performance of estimated precipitation data via remote sensing in the Midwest Region of Brazil

A Decade of Decision Making: Prosecutorial Decision Making in Sexual Assault Cases

In the United States, it is estimated that fewer than 30% of sexual assaults are reported to law enforcement, less than 5% will result in an arrest, and approximately 3% will result in a felony conviction. The present study examines a census of sexual assault reports from 2012 to 2020 in a large police department in the Midwest region of the United States, considering only those cases presented to the district attorney’s office for consideration (n = 700). Victim characteristics, suspect characteristics, and incident characteristics were examined as relating to a prosecutor accepting a case for charges. Further, a series of “ideal victim” characteristics were identified and used to create an additive scale based on prior research. The most significant predictors of prosecutor acceptance in the full sample were a lack of “date rape” drugs, continued cooperation from the victim, the suspect having a prior arrest for sexual assault, and the assault being reported within 24 h of occurring. A separate model was conducted for only those cases with continued cooperation from the victim. The researchers discuss the implications of these significant factors and suggest training to change false perceptions of victims among criminal justice officials and to increase victim reporting/cooperation in cases of sexual assault.

Mortality by road transport injury in Brazilian municipalities between 2000 and 2018

ObjectivesThis study aimed to investigate patterns of mortality by road transport injury (RTI) in Brazilian municipalities, focused on deaths of motorcyclists, between 2000 and 2018, and their relation with population size and economic status. Study designThis was an ecological epidemiological study with a descriptive and analytical nature. MethodsThe age-standardized RTI mortality rates were calculated for the Brazilian municipalities, referring to the 3-year periods of 2000/2002 (T1), 2009/2011 (T2), and 2016/2018 (T3). The rates were stratified according to macroregion and population size and were compared in terms of percentage variation from one 3-year period to another. The Moran Global and Local indices were used in the spatial point-pattern analysis of the rates. To verify the association with the gross domestic product (GDP) per capita, the Spearman correlation coefficient was applied. ResultsA decline in RTI mortality rates was found between 2000 and 2018, with the most significant declines observed in municipalities from the South and Southeast regions of Brazil. However, increases were observed among motorcyclists. Clusters of municipalities were detected, which presented high mortality rates among the motorcyclists in the Northeast region and in some states of the North and Midwest regions. The mortality rates showed a negative correlation with the GDP per capita of the Brazilian municipalities. ConclusionsAlthough there were decreases in RTI mortality rates between 1990 and 2018, there was a significant increase in deaths among motorcyclists, especially in the Northeast, North, and Midwest regions of the country. Such differences can be explained by unequal growth in the size of the motorcycle fleet in those regions, by less law enforcement capability, and by the implementation of educational actions.

Pediatric Melanoma: Geographic Trends in Incidence, Stage, and Mortality in the United States

IntroductionPediatric melanoma is the most commonly diagnosed skin cancer in children, with the annual incidence recently increasing by an average of 2% each year. Ultraviolet (UV) radiation from excessive sun exposure is an important carcinogenic risk factor, with penetration varying greatly throughout the country. Consequently, an individual's geographic location may play a role in how much exposure to high UV index rays they receive throughout their lifetime. The objective of this study was to use the surveillance, epidemiology, and end results SEER database to study geographic trends in incidence, staging, and mortality of pediatric melanoma between 2009 and 2019 and determine their relation to UV index in the United States. Materials and methodsA retrospective analysis of pediatric patients from 0 to 19 years in the surveillance, epidemiology, and end results 22 registries incidence database (17 states) and 17 registries incidence-based mortality database (12 states) was conducted from 2009 to 2019 based on a diagnosis of melanoma of the skin using the International Classification of Childhood Cancer codes for malignant melanoma. Data regarding patient demographics and incidence, staging, and mortality per state were extracted. Incidence data were geographically mapped and mean UV index distribution from www.epa.gov was superimposed. ResultsIncidence of pediatric melanoma was stratified regionally, with a total of 1665 new cases from 2009 to 2019. The Northeast had 393 new cases, with 244 (62.1%) localized cases, 55 (14.0%) lymph node-invasive and metastatic (advanced) cases, and 6/146 (4.1%) cases of mortality. The Midwest had 209 new cases, with 123 (58.9%) localized cases, 29 (13.9%) advanced cases, and 1/57 (1.8%) case of mortality. The South had 487 new cases, with 224 (46.0%) localized cases, 104 (21.4%) advanced cases, and 8/232 (3.4%) cases of mortality. The West had 576 new cases, with 364 (63.2%) localized cases, 82 (14.2%) advanced cases, and 23/551 (4.2%) cases of mortality. Mean UV index was 4.4 in the Northeast, 4.8 in the Midwest, 7.3 in the South, and 5.5 in the West from 2006 to 2020. The regional difference in incidence was not statistically significant. There was a statistically significant increased number of advanced cases in the South as compared to the Northeast (P = 0.005), West (P = 0.002), and Midwest (P = 0.02), with a significant correlation coefficient of 0.7204 between advanced cases and mean UV index in the South. ConclusionsThere is a statistically significant increased incidence of lymph node-invasive and metastatic pediatric melanoma cases in the South as compared to the West, Northeast, and Midwest regions of the United States. There is also a significant correlation between the incidence of lymph node-invasive and metastatic pediatric melanoma cases and UV index. In the pediatric population, there is no statistically significant association between total incidence and mortality of melanoma and geographic region. There is an increased prevalence of pediatric melanoma seen in White and female patients. This suggests that an individual's geographic location in the United States during childhood may play a role in their likelihood of malignant melanoma development, advanced-stage melanoma development, and mortality.

Pulmonary embolism in United States emergency departments, 2010–2018

Little is known about pulmonary embolism (PE) in the United States emergency department (ED). This study aimed to describe the disease burden (visit rate and hospitalization) of PE in the ED and to investigate factors associated with its burden. Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2010 to 2018. Adult ED visits with PE were identified using the International Classification of Diseases codes. Analyses used descriptive statistics and multivariable logistic regression accounting for the NHAMCS’s complex survey design. Over the 9-year study period, there were an estimated 1,500,000 ED visits for PE, and the proportion of PE visits in the entire ED population increased from 0.1% in 2010–2012 to 0.2% in 2017–2018 (P for trend = 0.002). The mean age was 57 years, and 40% were men. Older age, obesity, history of cancer, and history of venous thromboembolism were independently associated with a higher proportion of PE, whereas the Midwest region was associated with a lower proportion of PE. The utilization of chest computed tomography (CT) scan appeared stable, which was performed in approximately 43% of the visits. About 66% of PE visits were hospitalized, and the trend remained stable. Male sex, arrival during the morning shift, and higher triage levels were independently associated with a higher hospitalization rate, whereas the fall and winter months were independently associated with a lower hospitalization rate. Approximately 8.8% of PE patients were discharged with direct-acting oral anticoagulants. The ED visits for PE continued to increase despite the stable trend in CT use, suggesting a combination of prevalent and incident PE cases in the ED. Hospitalization for PE remains common practice. Some patients are disproportionately affected by PE, and certain patient and hospital factors are associated with hospitalization decisions.