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Rationale: Known as the "Black-White mental health paradox," Black Americans typically report better mental health than White Americans, despite chronic exposure to the psychologically harmful effects of racism and discrimination. Yet, researchers rarely examine how mental health is experienced across racial groups in economically distressed rural regions where all residents have disproportionately less access to mental healthcare resources., Objective: The purpose of this study was to explore how the racialized social system potentially contributes to the mental health beliefs and attitudes of racially majoritized and minoritized rural residents., Methods: We conducted a secondary analysis of 29 health-focused oral history interviews from Black American (n = 16) and White American (n = 13) adults in rural North Carolina. Through critical discourse analysis, we found nuanced discourses linked to three mental-health-related topics: mental illness, stressors, and coping., Results: White rural residents' condemning discourses illustrated how their beliefs about mental illnesses were rooted in meritocratic notions of individual choice and personal responsibility. Conversely, Black rural residents offered compassionate discourses toward those who experience mental illness, and they described how macro-level mechanisms can affect individual well-being. Stressors also differed along racial lines, such that White residents were primarily concerned about perceived social changes, and Black residents referenced experiences of interpersonal and structural racism. Related to coping, Black and White rural residents characterized the mental health benefits of social support from involvement in their respective religious organizations. Only Black residents signified that a personal relationship with a higher power was an essential positive coping mechanism., Conclusions: Our findings suggest that belief (or disbelief) in meritocratic ideology and specific religious components could be important factors to probe with Black-White patterning in mental health outcomes. This research also suggests that sociocultural factors can disparately contribute to mental health beliefs and attitudes among diverse rural populations., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

This study analyzed the impact of urban-soil pedogenesis on soil lead (Pb) contamination from paint and gasoline in the historic core of Durham, North Carolina. Total soil Pb in 1000 samples from streetsides, residential properties, and residual upland and floodplains ranged from 6 to 8825 mg/kg (mean = 211 mg/kg), with 50% of samples between 50 and 200 mg/kg soil Pb. The highest Pb concentrations were within 1 m of pre-1978 residential foundations, with concentrations inversely correlated with house age. Streetside soil Pb concentrations were elevated over the geologic background of <30 mg/kg and correlated with traffic flow. Streetside soil Pb concentrations were lower than Durham streetside soils collected in the 1970s, which was attributed to urban pedogenesis, the complex of natural and human processes that change soils over time. Accelerated erosion redistributes legacy Pb and floodplain sampling indicates sedimentation rates of up to 4 mm/year. Mixing and burial of soil with elevated Pb are also lowering soil Pb concentrations over time. These mechanisms are likely of greater significance on streetsides than near foundation soils. The development of an urban-pedogenesis framework can help guide public health approaches to Pb exposure by incorporating pedogenic processes that reduce and dissipate soil Pb contamination.

Background: While programmed cell death protein 1 (PD-1) and programmed death-ligand 1 (PD-L1) antagonists have improved the prognosis for many patients with melanoma, around 60% fail therapy. PVSRIPO is a non-neurovirulent rhinovirus:poliovirus chimera that facilitates an antitumor immune response following cell entry via the poliovirus receptor CD155, which is expressed on tumor and antigen-presenting cells. Preclinical studies show that oncolytic virus plus anti-PD-1 therapy leads to a greater antitumor response than either agent alone, warranting clinical investigation., Methods: An open-label phase I trial of intratumoral PVSRIPO in patients with unresectable melanoma (American Joint Committee on Cancer V.7 stage IIIB, IIIC, or IV) was performed. Eligible patients had disease progression on anti-PD-1 and V-raf murine sarcoma viral oncogene homolog B (BRAF)/mitogen activated protein kinase kinase (MEK) inhibitors (if BRAF mutant). The primary objective was to characterize the safety and tolerability of PVSRIPO. Twelve patients in four cohorts received a total of 1, 2 or 3 injections of PVSRIPO monotherapy, with 21 days between injections., Results: PVSRIPO injections were well tolerated with no serious adverse events (SAEs) or dose-limiting toxicities (DLTs) reported. All adverse events (AEs) were grade (G) 1 or G2 (G1 pruritus most common at 58%); all but two PVSRIPO-treatment related AEs were localized to the injected or adjacent lesions (n=1 G1 hot flash, n=1 G1 fatigue). Four out of 12 patients (33%) achieved an objective response per immune-related response criteria (two observations, 4 weeks apart), including 4/6 (67%) who received three injections. In the four patients with in-transit disease, a pathological complete response (pCR) was observed in two (50%) patients. Following study completion, 11/12 patients (92%) reinitiated immune checkpoint inhibitor-based therapy, and 6/12 patients (50%) remained without progression at a median follow-up time of 18 months., Conclusion: Intratumoral PVSRIPO was well tolerated. Despite the limited number of PVSRIPO treatments relative to the overall lesion burden (67% patients>5 lesions), intratumoral PVSRIPO showed promising antitumor activity, with pCR in injected as well as non-injected lesions in select patients., Trial Registration Number: NCT03712358., Competing Interests: Competing interests: SKN owns intellectual property related to this research, which has been licensed to Istari Oncology, Inc. DDB and MG have financial interest in Istari Oncology, Inc. Duke University (Licensor of PVSRIPO) has a financial interest in Istari Oncology, Inc., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Scientists from multiple basic disciplines and an international group of physician-scientists from the field of obstetrics and gynecology presented recent studies and discussed new and evolving theories of uterine fibroid etiology, growth and development at The Basic Science of the Uterine Fibroids meeting, sponsored by the Campion Fund and the National Institute of Environmental Health Sciences. The purpose was to share up-to date knowledge and to stimulate new concepts regarding the basic molecular biology and pathophysiology of uterine fibroids, and to promote future collaborations. The meeting was held at the National Institute of Environmental Health Sciences in North Carolina on February 28, 2020. Speakers reviewed recent advances in cellular and molecular processes that contribute to fibroid growth and new opportunities for treatment. At the conclusion of the conference, attendees identified important new directions for future research.

Genetic architecture and phenotypic plasticity are important considerations when studying trait variation within and among populations. Since environmental change can induce shifts in the genetic architecture and plasticity of traits, it is important to consider both genetic and environmental sources of phenotypic variation. While there is overwhelming evidence for environmental effects on phenotype, the underlying mechanisms are less clear. Variation in DNA methylation is a potential mechanism mediating environmental effects on phenotype due to its sensitivity to environmental stimuli, transgenerational inheritance, and influences on transcription. To characterize the effect of environment on methylation, we created two 6 × 6 (North Carolina II) Chinook salmon breeding crosses and reared the offspring in two environments: uniform hatchery tanks and seminatural stream channels. We sampled the fish twice during development, at the alevin (larval) and fry (juvenile) stages. We measured DNA methylation at 13 genes using a PCR-based bisulfite sequencing protocol. The genetic architecture of DNA methylation differed between rearing environments, with greater additive and nonadditive genetic variance in hatchery fish and greater maternal effects in seminatural channel fish, though gene-specific variation was evident. We observed plasticity in methylation across all assayed genes, as well as gene-specific effects at two genes in alevin and six genes in fry, indicating developmental stage-specific effects of rearing environment on methylation. Characterizing genetic and environmental influences on methylation is critical for future studies on DNA methylation as a potential mechanism for acclimation and adaptation.

Background: Economically damaging infestations of the tarnished plant bug, Lygus lineolaris (Palisot de Beauvois), have become more frequent in Virginia and North Carolina cotton since 2013 and 2010, respectively. Foliar insecticide use has increased dramatically in response. Efficacy data (LC 50 ) are needed to evaluate L. lineolaris susceptibility and resistance levels (RR 50 ) to commonly used and recommended insecticides for managing this pest in the southeastern USA., Results: Elevated resistance levels to acephate and bifenthrin were measured in L. lineolaris populations collected from wild and cultivated hosts in Virginia, North Carolina and northern Alabama when compared to a susceptible laboratory population. High levels of bifenthrin resistance were observed in 2018 and 2019. Mixed-function oxidase and esterase (EST) inhibitors, piperonyl butoxide and S,S,S-Tributyl phosphotrithioate, respectively, had a synergistic effect on bifenthrin with resistant populations of L. lineolaris. Bifenthrin-resistant L. lineolaris populations expressed elevated levels of cytochrome P450 (CYP 450 ) monooxygenase and general EST activity. Results suggest that insecticide resistance is present in some locations and that CYP 450 and EST activity in L. lineolaris contribute to pyrethroid resistance in the southeastern USA., Conclusions: Results can serve as a baseline for continued monitoring of L. lineolaris insecticide resistance and inform insecticide resistance management strategies that help southeastern USA cotton producers to minimize inputs and slow resistance development. © 2020 Society of Chemical Industry., (© 2020 Society of Chemical Industry.)

Economically damaging infestations of Lygus lineolaris (Palisot de Beauvois), tarnished plant bug, were sporadic in Virginia and North Carolina cotton before 2010. Given the sudden rise of L. lineolaris as an economic pest in these states, regionally specific management practices (i.e., chemical and cultural control) are needed to help producers protect yield potential while minimizing input costs. Field experiments were conducted in Virginia and North Carolina in 2018 and 2019 to 1) determine the effects of various management practices on L. lineolaris density, plant injury (i.e., square retention, internal boll injury), and lint yield, 2) calculate the economic trade-offs between integrated pest management (IPM) systems approach and current management practices for L. lineolaris in these states, and 3) evaluate economic benefits associated with various sampling thresholds. Lygus lineolaris populations peaked mid-season (i.e., August) during cotton flowering in both states. Weekly scouting and applying foliar insecticides when the current University Extension recommended economic threshold was reached was the most critical management treatment in maximizing economic returns. Additional costs among various IPM practices did not translate into significant yield protection and economic gains. Moreover, there were additional economic benefits associated with protecting glabrous and longer maturing varieties in Virginia. Lygus lineolaris density varied significantly between states; therefore, management recommendations should be modified based on the growing region. Results from this study will be used to create an IPM strategy to help cotton producers effectively manage this insect pest in the Southeast., (© The Author(s) 2020. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

As part of an ongoing longitudinal study in North and South Carolina, this study reports the recovery of Helicoverpa zea (Boddie) pupae in field trials with genetically engineered corn, Zea mays L., hybrids that produce insecticidal toxins from Bacillus thuringiensis (Bt) in 2017-2019. In total, 10,400 corn ears were collected, which led to 3,927 H. zea pupae (2,215 in South Carolina and 1,712 in North Carolina). Late-planted corn led to a 3.39-fold increase in recovery of pupae compared to early-planted corn. Bt corn expressing Cry1F + Cry1Ab and Cry1A.105 + Cry2Ab2 had 1.67-fold and 2.51-fold fewer pupae than non-Bt near-isolines, respectively. Only six pupae were recovered from the hybrid expressing Cry1F + Cry1Ab + Vip3Aa20. Averaged across trials, Bt corn expressing either Cry1A.105 + Cry2Ab2 or Cry1F + Cry1Ab significantly reduced pupal weight compared to non-Bt near-isolines in North and South Carolina. Combining our data with a previous study at the same locations (Bilbo et al. 2018), reduction in pupal weight between Bt and non-Bt near-isolines significantly declined from 2014 to 2019 for Cry1Ab + Cry1F in North and South Carolina. This decline in levels of a sublethal effect of Bt corn expressing Cry1Ab + Cry1F on H. zea at both locations is likely correlated with resistance development., (© The Author(s) 2020. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Economic yield loss and reduction in grain quality from brown stink bug, Euschistus servus (Say), feeding injury in early and late stages of maize, Zea mays (Poales: Poaceae, Linnaeus), development was assessed in Virginia and North Carolina in 2018 and 2019. Varying levels of stink bug infestations were introduced to seedling maize (V2-early stage), and a range of late-stages of maize, including 1) the last stage of vegetative development (V12/V14), 2) prior to tasseling, 3) at tasseling (VT), and 4) across all tested late growth stages. Euschistus servus infestation levels included 33, 67, and 100% of maize seedlings, and 25, 50, 100, and 200% of plants during later stages. Infestations were maintained on seedling maize for 7 d, and 8 or 16 d in reproductive stages. Infestation level in seedling maize had an impact on grain yield. Infestation level and growth stage both had an impact on grain yield in reproductive maize. The percentage of discolored kernels was also affected by infestation level, but not growth stage. Regression analysis between grain yield and infestation level indicated that the average economic injury level is 7% in seedling maize (7 bugs/100 plants) and 12% (12 bugs/100 plants) from the last vegetative stages (V12/V14) through pollination (VT). The economic injury level in the late vegetative stages is only applicable when infestations are present for an extended period of time (16 d), emphasizing the need for continued scouting of maize throughout the season to make informed management decisions., (© The Author(s) 2020. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Megacopta cribraria (F.) (Hemiptera: Plataspidae) is an invasive pest of soybean that has spread across the southeastern United States since its initial discovery in 2009 in Georgia. Previous studies in the southeastern states have documented both the population dynamics of this pest and host plant resistance (HPR) among soybean varieties, although the specific mechanisms of HPR remain unknown. The objectives of this study were, therefore, to 1) quantify field resistance to M. cribraria in multiple soybean varieties in two states previously affected by severe M. cribraria infestations, North Carolina (NC) and South Carolina (SC); and 2) study the role of soybean trichome density in imparting resistance against M. cribraria. Soybean variety 'Camp' was least attractive to M. cribraria, through time and locations, suggesting consistent resistance. Other varieties showed variable performance among the locations and sampling dates. A significant difference in trichome density was evident. However, there was no correlation between trichome density and M. cribraria infestation. Compared to a previously published study in the same location, when M. cribraria adults emerging from overwintering dispersed into soybeans, in our study only first-generation adults dispersed into soybeans. Considering the current trend of significantly lower M. cribraria infestation rates in North and South Carolina, this pest may be finally succumbing to indigenous natural enemies and should be managed by incorporating integrated pest management tactics, such as HPR, that help conserve natural enemy populations., (© The Author(s) 2020. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Economically damaging infestations of Lygus lineolaris (Palisot de Beauvois) (Hemiptera: Miridae), the tarnished plant bug, have been increasing in North Carolina and Virginia cotton since 2009. We conducted experiments to compare prophylactically timed sprays based on cotton phenology and current action thresholds based on sweep net and drop cloth sampling. In the second year of the study, we included planting date as a factor, with early and late-planted cotton. We found L. lineolaris nymph densities were reduced by at least 60% in North Carolina and 74% in Virginia in threshold plots when compared with the untreated control. Protecting the crop from first square through the fourth week of bloom afforded at least 30% control across planting dates in Virginia and at least 40% control in North Carolina. Economic returns were two to three times greater in early-planted cotton than in late-planted cotton. Treating cotton at action threshold or using prophylactic sprays from first square until the sixth week of bloom in early-planted cotton yielded over $500/ha in net returns in both North Carolina and Virginia. This study supports previous research that shows controlling L. lineolaris infestations during squaring and early weeks of flowering is critical for maximizing yield potential. Our findings also suggest that prebloom and bloom thresholds based on adult and nymphal density devised in the Mid-South may need revision in North Carolina and Virginia., (© The Author(s) 2019. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Endocrine active compounds (EACs) are pollutants that have been recognized as an emerging and widespread threat to aquatic ecosystems globally. Intersex, the presence of female germ cells within a predominantly male gonad, is considered a biomarker of endocrine disruption caused by EACs. We measured a suite of EACs and assessed their associated impacts on fish intersex occurrence and severity in a large, regulated river system in North Carolina and South Carolina, USA. Our specific objective was to determine the relationship of contaminants in water, sediment, and fish tissue with the occurrence and severity of the intersex condition in wild, adult black bass (Micropterus), sunfish (Lepomis), and catfish (Ictaluridae) species at 11 sites located on the Yadkin-Pee Dee River. Polycyclic aromatic hydrocarbons (PAHs), ethinylestradiol (EE2), and heavy metals were the most prevalent contaminants that exceeded effect levels for the protection of aquatic organisms. Fish intersex condition was most frequently observed and most severe in black basses and was less frequently detected and less severe in sunfishes and catfishes. The occurrence of the intersex condition in fish showed site-related effects, rather than increasing longitudinal trends from upstream to downstream. Mean black bass and catfish tissue contaminant concentrations were higher than that of sunfish, likely because of the latter's lower trophic position in the food web. Principal component analysis identified waterborne PAHs as the most correlated environmental contaminant with intersex occurrence and severity in black bass and sunfish. As indicated by the intersex condition, EACs have adverse but often variable effects on the health of wild sport fishes in this river, likely due to fluctuations in EAC inputs and the dynamic nature of the riverine system. These findings enhance the understanding of the relationship between contaminants and fish health and provide information to guide ecologically comprehensive conservation and management decisions., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Brown stink bug, Euschistus servus (Say), is a damaging pest of corn, Zea mays (L.), in the southeastern United States. Developing a reliable and practical sampling plan for population monitoring of this pest is essential for implementing integrated pest management measures. E. servus was sampled from commercial corn fields (n = 14) in North Carolina in 2016 and 2017. Both the adults and nymphs had a predominantly aggregated spatial distribution, estimated using the variance to mean ratio and Taylor's power law constant (b). Using the Taylor's power law constants, the optimum sample size required to estimate population density with a given level of reliability was calculated. For early vegetative stage corn (V4-V6), using whole plant visual sampling and an economic threshold density of 2 adult stink bugs per 20 plants, 27 sample units were required to estimate population density within 30% of the mean. At the same growth stage, using partial plant sampling and an economic threshold density of 1.73 adult stink bugs per 20 plants, 28 sample units were required to estimate population density with the same level of reliability. Reproductive stage corn (R1-R4) required eight sample units for whole plant sampling and nine sample units for partial plant sampling (Dx = 0.3). For E. servus adults, the partial plant sampling method was equally or more cost-reliable than the whole-plant sampling method for pest management in all corn growth stages tested., (© The Author(s) 2018. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Evidence of practical resistance of Helicoverpa zea (Boddie) (Lepidoptera: Noctuidae) to Bt cotton in the United States is debatable, supported with occasional reports of boll damage in the field. Our objective was to provide both empirical and long-term observational evidence of practical resistance by linking both in-season and end-of-season measurements of H. zea damage to pyramided Bt cotton bolls and to provide Cry1Ac diet-based bioassay data in support of these damage estimates. In-season boll damage from H. zea was highly correlated to end-of-season damaged bolls. Across North Carolina, Bt cotton fields with end-of-season bolls damaged by H. zea increased during 2016 compared to previous years. Elevated damage was coupled with an increase in field sprays targeting H. zea during 2016, but not related to an increase in H. zea abundance. Bioassay data indicated that there was a range of Cry1Ac susceptibility across the southeastern United States. Given the range of susceptibility to Cry1Ac across the southeastern United States, it is probable that resistant populations are common. Since H. zea is resistant to cotton expressing pyramided Cry toxins, the adoption of new cotton varieties expressing Vip3Aa will be rapid. Efforts should be made to delay resistance of H. zea to the Vip3Aa toxin to avoid foliar insecticide use., (© The Author(s) 2018. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Transgenic corn, Zea mays L., hybrids expressing insecticidal proteins from Bacillus thuringiensis (Bt) and non-Bt near isolines were sampled for injury from Helicoverpa zea (Boddie) in North and South Carolina from 2012 to 2017. A total of 7,260 ears were sampled, with an average kernel injury from H. zea feeding of 1.22 ± 0.02 (SEM) cm2. The χ2 statistics for observed and Poisson predicted distributions of the area of kernel injury indicated nonrandom distributions for all hybrids (P < 0.0001), which were confirmed by all variance to mean ratios (ID) being significantly greater than one. Slopes b of Taylor's power law and β of Iwao's patchiness regressions for the area of kernel injury were all either not significantly (P > 0.05) different from a value of one or significantly (P < 0.05) less than a value of one. Within each family of hybrids, relationships between proportions of ear samples with injury and area of kernel injury were similar among Bt and non-Bt hybrids. For the same level of injury, to reach a population estimate within 10% of the mean (Dx = 0.1), the number of sample units required was large (>100), particularly at low levels of injury. Sample sizes for estimates within 30% of the mean (Dx = 0.3) were considerable smaller. Sample size for Bt hybrids relative to non-Bt hybrids varied with the levels of injury and with family. Our study has provided the first sampling recommendations for population estimates of H. zea injury to corn ears.

We sought to determine the relationship of fibroids to pregnancy loss in a prospective cohort in which fibroid status was uniformly documented in early pregnancy. Participants had an intake interview, transvaginal ultrasonography, computer-assisted telephone interview, and follow-up assessment of outcomes. We recruited diverse participants for the Right From the Start study from 8 metropolitan areas in 3 states in the United States during 2000-2012. Participants were at least 18 years of age, trying to become pregnant or at less than 12 weeks' gestation, not using fertility treatments, fluent in English or Spanish, and available for telephone interviews. Miscarriage was defined as loss before 20 weeks' gestation. Fibroid presence, number, type, and volume were assessed using standardized ultrasonography methods. We used proportional hazards models to estimate associations. Among 5,512 participants, 10.4% had at least 1 fibroid, and 10.8% experienced a miscarriage. Twenty-three percent had experienced a prior miscarriage and 52% prior births. Presence of fibroids was associated with miscarriage in models without adjustments. Adjusting for key confounders indicated no increase in risk (adjusted hazard ratio = 0.83, 95% confidence interval: 0.63, 1.08). No characteristic of fibroids was associated with risk. Prior evidence attributing miscarriage to fibroids is potentially biased. These findings imply that surgical removal of fibroids to reduce risk of miscarriage deserves careful scrutiny., (© The Author(s) 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The Hessian fly, Mayetiola destructor (Say) (Diptera: Cecidomyiidae), is the most important insect pest of wheat (Triticum aestivum L. subsp. aestivum) in the southeastern United States, and the deployment of genetically resistant wheat is the most effective control. However, the use of resistant wheat results in the selection of pest genotypes that can overcome formerly resistant wheat. We have evaluated the effectiveness of 16 resistance genes for protection of wheat from Hessian fly infestation in the southeastern United States. Results documented that while 10 of the genes evaluated could provide protection of wheat, the most highly effective genes were H12, H18, H24, H25, H26, and H33. However, H12 and H18 have been reported to be only partially effective in field evaluations, and H24, H25, and H26 may be associated with undesirable effects on agronomic traits when introgressed into elite wheat lines. Thus, the most promising new gene for Hessian fly resistance appears to be H33. These results indicate that identified highly effective resistance in wheat to the Hessian fly is a limited resource and emphasize the need to identify novel sources of resistance. Also, we recommend that the deployment of resistance in gene pyramids and the development of novel strategies for engineered resistance be considered., (Published by Oxford University Press on behalf of Entomological Society of America 2015. This work is written by US Government employees and is in the public domain in the US.)

Background: With initiation of transcatheter aortic valve replacement (TAVR) programs, centers may see changes in surgical aortic valve replacement (SAVR) populations and related outcomes because of more high-risk patients undergoing TAVR rather than SAVR. Little data exist on the potential changes in the risk profiles and outcomes of SAVR patients from the pre- to post-TAVR eras. As such, this study sought to evaluate changes in the SAVR population at a tertiary referral center after TAVR program initiation., Methods: Using a single-center valve surgical database, annual volume, patient characteristics, operative details, and predicted and observed mortality for patients undergoing isolated SAVR or SAVR + coronary artery bypass grafting (CABG) from 2006 to 2013 were evaluated. Patients were divided into 3 eras: (1) pre-TAVR (January 2006-June 2009), (2) transition (July 2009-March 2011), and (3) TAVR (April 2011-June 2013). The primary analysis compared predicted and observed mortality in pre-TAVR and TAVR eras., Results: From 2006 to 2013, 1,380 SAVR patients were identified, with 505 (36.6%), 330 (23.9%), and 545 (39.5%) patients from the pre-TAVR, transition, and TAVR eras, respectively. SAVR case volume increased from 131 to 256 cases per year (95.4% increase) from the pre-TAVR to the post-TAVR eras. Predicted risk of mortality (PROM) for SAVR patients from the pre-TAVR to TAVR eras by The Society of Thoracic Surgeons (STS)-PROM was stable near 3.8% (p = 0.82). Crude 30-day SAVR mortality trended down from 2.8% in the pre-TAVR era to 1.5% in the post-TAVR era (p = 0.23)., Conclusions: Consistent with previous studies, initiation of a TAVR program was associated with increased SAVR volume. Risk profiles for SAVR patients in the TAVR era remained similar by the STS-PROM, indicating generally stable risk among surgical patients after launching a TAVR program. These data suggest that significant changes in the risk profiles of SAVR patients should not be expected with the initiation of a TAVR program. Further research will need to reevaluate these changes once TAVR becomes more widely available., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Sampling of herbivorous stink bugs in southeastern U.S. cotton remains problematic. Remote sensing was explored to improve sampling of these pests and associated boll injury. Two adjacent 14.5-ha cotton fields were grid sampled in 2011 and 2012 by collecting stink bug adults and bolls every week during the third, fourth, and fifth weeks of bloom. Satellite remote sensing data were collected during the third week of bloom during both years, and normalized difference vegetation index (NDVI) values were calculated. Stink bugs were spatially aggregated on the third week of bloom in 2011. Boll injury from stink bugs was spatially aggregated during the fourth week of bloom in 2012. The NDVI values were aggregated during both years. There was a positive association and correlation between stink bug numbers and NDVI values, as well as injured bolls and NDVI values, during the third week of bloom in 2011. During the third week of bloom in 2012, NDVI values were negatively correlated with stink bug numbers. During the fourth week of bloom in 2011, stink bug numbers and boll injury were both positively associated and correlated with NDVI values. During the fourth week of bloom in 2012, stink bugs were negatively correlated with NDVI values, and boll injury was negatively associated and correlated with NDVI values. This study suggests the potential of remote sensing as a tool to assist with sampling stink bugs in cotton, although more research is needed using NDVI and other plant measurements to predict stink bug injury., (© The Author 2015. Published by Oxford University Press on behalf of the Entomological Society of America.)

Background: Little is known about the barriers faced by families of children with birth defects in obtaining healthcare. We examined reported perceived barriers to care and satisfaction with care among mothers of children with orofacial clefts., Methods: In 2006, a validated barriers to care mail/phone survey was administered in North Carolina to all resident mothers of children with orofacial clefts born between 2001 and 2004. Potential participants were identified using the North Carolina Birth Defects Monitoring Program, an active, state-wide, population-based birth defects registry. Five barriers to care subscales were examined: pragmatics, skills, marginalization, expectations, and knowledge/beliefs. Descriptive and bivariate analyses were conducted using chi-square and Fisher's exact tests. Results were stratified by cleft type and presence of other birth defects., Results: Of 475 eligible participants, 51.6% (n = 245) responded. The six most commonly reported perceived barriers to care were all part of the pragmatics subscale: having to take time off work (45.3%); long waits in the waiting rooms (37.6%); taking care of household responsibilities (29.7%); meeting other family members' needs (29.5%); waiting too many days for appointments (27.0%); and cost (25.0%). Most respondents (72.3%, 175/242) felt "very satisfied" with their child's cleft care., Conclusion: Although most participants reported being satisfied with their child's care, many perceived barriers to care were identified. Due to the limited understanding and paucity of research on barriers to care for children with birth defects, including orofacial clefts, additional research on barriers to care and factors associated with them are needed., (© 2014 Wiley Periodicals, Inc.)

Providing breast milk is challenging for non-nursing mothers of premature infants. Early breast milk expression results in successful and longer lactation in mothers of very low birth weight (VLBW) infants. This quality improvement initiative sought to increase the rate of early milk expression in mothers of VLBW infants and increase the proportion of infants receiving maternal breast milk (MBM) at 28 days of age and at discharge. Phase 1 (n = 45) occurred between April 1, 2012, and August 31, 2012. Phase 2 (n = 58) occurred between September 1, 2012, and February 28, 2013. Pre-phase 2 actions included increased lactation consultant workforce, early lactation consultation, tracking of MBM supply, and physician education. Inborn infants < 1500 grams were eligible. Primary outcomes were the time of first maternal milk expression (TFME) and infant feeding type at 28 days of age and at discharge. The median TFME decreased from 9 (25th, 75th percentile; 6, 16) hours to 6 (5, 11) hours after implementation (P = .06). The proportion of infants receiving exclusive MBM at 28 days and at discharge was 64% and 74%, respectively (P = .40), and the proportion of infants receiving exclusive MBM at discharge increased from 37% to 59% (P = .046). In conclusion, a multidisciplinary initiative aimed at improving the rate of early milk expression was associated with more VLBW infants receiving exclusive MBM at discharge., (© The Author(s) 2014.)

Spatial distribution of boll injury caused by stink bugs to developing cotton (Gossypium hirsutum L.) bolls was studied in five commercial fields (≍22 ha each) in 2011 and 2012 to understand variability in boll injury dynamics within fields. Cotton bolls and stink bugs were sampled weekly from a georeferenced grid of sampling points (one sample per 0.40 ha) in each field, but no samples were taken within 30 m of field edges. The inverse distance weighted interpolation, variogram analysis, and Moran's I were used to describe spatial variability of boll damage within the fields. Boll injury was found to be spatially associated at distances ranging from ≍75 to 275 m with an average distance ≍150 m. An exponential variogram model was selected as the best fitting model to describe the spatial association in four of the five fields. Moran's I indicated that spatial association was significant in three of the five fields. The spread of boll injury from stink bugs was gradual in most fields and always exceeded the treatment threshold during the fourth or fifth week of bloom. Capture of stink bugs using a sweep net was inefficient, strongly suggesting that quantifying boll injury is a better sampling method and predictor of stink bug activity when sampling all but the edges of the field. These data suggest that scouts need to sample boll injury from sample locations separated by at least 150 m to assure independence in the central part of large fields. Second, future researchers who plan to use parametric statistical methods could use a 150-m grid, as opposed to a denser grid that would require greater time and effort.

Objectives: We investigated the health profile of lesbian, gay, and bisexual (LGB) adults in North Carolina, the first state in the South to include a measure of sexual orientation identity in a probability-based statewide health survey., Methods: Using data from 9876 respondents in the 2011 North Carolina Behavioral Risk Factor Surveillance Survey, we compared sexual minorities to heterosexuals on a variety of health indicators., Results: LGB respondents were younger and more likely to be reached by cell phone. Many examined indicators were not different by sexual orientation. Significant results, however, were consistent with findings from state population surveys in other regions of the country, including disparities in mental health and, among women, smoking., Conclusions: Reporting LGB identity in North Carolina is associated with poorer health. The concentration of anti-LGB policies in the South warrants ongoing monitoring of LGB health disparities in North Carolina and in other Southeastern states for potential effects on the health and well-being of LGB populations.

Euschistus servus (Say) can develop a generation on wheat, Triticum aestivum L., before moving to corn, Zea mays L., where it can be a pest. Because effective management methods are unknown, this study sought to describe the spatial distribution and dispersal of E. servus in the wheat and corn interface. In addition, Oebalus pugnax (F.) densities were documented in both crops. Wheat fields adjacent to the corn were sampled before harvest and stink bugs were marked using a product containing egg whites. Dispersal into the adjacent corn was measured using grid sampling, and dispersion was measured over time using an immunoassay targeting egg albumin on E. servus collected in corn. Dispersion was measured using Anselin Local Moran's I for unmarked stink bugs only. O. pugnax was prominent in wheat but was rarely recovered from corn. In contrast, E. servus was common in wheat during both years and dispersed into the adjacent corn. E. servus nymph and adult densities increased quadratically over time in corn in 2011. In contrast, E. servus nymph densities decreased over time in corn in 2012, while adult densities remained static. Most aggregations of E. servus nymphs and adults were located on the edge of the corn, directly adjacent to the harvested wheat. This is likely the first study to directly document the movement of E. servus nymphs to the adjacent crop. Movement from wheat to corn was not consistent between the years and may have been influenced by factors such as variations in weather, timing of wheat harvest, or other available alternative hosts.

Background: Information on travel distance and time to care for children with birth defects is lacking. We examined factors associated with travel distance and time to cleft care among children with orofacial clefts., Methods: In 2006, a mail/phone survey was administered in English and Spanish to all resident mothers of children with orofacial clefts born 2001 to 2004 and identified by the North Carolina birth defects registry. We analyzed one-way travel distance and time and the extent to which taking a child to care was a problem. We used multivariable logistic regression to examine the association between selected sociodemographic factors and travel distance (≤60 miles and >60 miles) and time (≤60 min and >60 min) to cleft care., Results: Of 475 eligible participants, 51.6% (n = 245) responded. Of the respondents, 97.1% (n = 238) were the child's biological mother. Approximately 83% (n = 204) of respondents were non-Hispanic White; 33.3% (n = 81) were college educated; and 50.0% (n = 115) had private health insurance. One-way mean and median travel distances were 80 and 50 miles, respectively (range, 0-1058 miles). One-way mean and median travel times were 92 and 60 min, respectively (range, 5 min to 8 hr). After adjusting for selected sociodemographics, travel distance varied significantly by maternal education, child's age, and cleft type. Travel time varied significantly by child's age. Approximately 67% (n = 162) reported taking their child to receive care was not a problem., Conclusion: Approximately 48% of respondents traveled > 1 hr to receive cleft care. Increasing access to care may be important for improving health outcomes among this population., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: Timeliness of care may contribute to racial disparities in breast cancer mortality. African American women experience greater treatment delay than White women in most, but not all studies. Understanding these disparities is challenging as many studies lack patient-reported data and use administrative data sources that collect limited types of information. We used interview and medical record data from the Carolina Breast Cancer Study (CBCS) to identify determinants of delay and assess whether disparities exist between White and African American women (n = 601)., Methods: The CBCS is a population-based study of North Carolina women. We investigated the association of demographic and socioeconomic characteristics, healthcare access, clinical factors, and measures of emotional and functional well-being with treatment delay. The association of race and selected characteristics with delays of more than 30 days was assessed using logistic regression., Results: Household size, losing a job due to one's diagnosis, and immediate reconstruction were associated with delay in the overall population and among White women. Immediate reconstruction and treatment type were associated with delay among African American women. Racial disparities in treatment delay were not evident in the overall population. In the adjusted models, African American women experienced greater delay than White women for younger age groups: OR, 3.34; 95% confidence interval (CI), 1.07-10.38 for ages 20 to 39 years, and OR, 3.40; 95% CI, 1.76-6.54 for ages 40 to 49 years., Conclusions: Determinants of treatment delay vary by race. Racial disparities in treatment delay exist among women younger than 50 years., Impact: Specific populations need to be targeted when identifying and addressing determinants of treatment delay.

Purpose: To examine the importance of self-reported family history of uterine leiomyoma (fibroids) as a marker of risk., Methods: Women, aged 35 to 49, were randomly selected from the membership of a large, urban health plan. Participants completed a self-administered questionnaire about family history of fibroids. Ultrasound screening for fibroids followed, regardless of whether participants had been previously diagnosed (660 black, 412 white). Data for each ethnic group were analyzed separately using Poisson regression., Results: In both ethnic groups, women who reported a family history of fibroids had an elevated risk of fibroids compared with those without family history. However, no elevated risk was apparent for cases who did not know they had fibroids when they reported the family history information., Conclusions: Many women may first learn about their family history of fibroids when discussing their own clinical diagnosis with family members. Such bias would invalidate self-reported family history as a predictor of fibroid risk. As new pharmacologic treatments for fibroids are developed, women at high risk of fibroids would benefit from early screening and pharmacologic treatment to delay development of large fibroids and reduce the need for invasive treatments. Self-reported family history is not useful for identifying high-risk women., (Published by Elsevier Inc.)

Background: Proper positioning of the left ventricular (LV) lead improves clinical outcomes and survival in patients receiving cardiac resynchronization therapy (CRT). Techniques of LV lead insertion using contrast injection and a telescoping system of delivery catheters to support advancement of the lead into the target branch may allow more efficient, targeted lead placement. We sought to evaluate the impact of an LV lead implant approach using telescoping-support catheters (group TS) on success rate, lead location, and procedural time compared to standard over-the-wire implant techniques (group OTW)., Methods: Four hundred thirty-seven consecutive patients undergoing CRT implantation were divided into group TS (n = 105) or group OTW (n = 332) based upon a review of the operative technique used for LV lead implantation. The primary outcome was success of LV lead implantation at the index procedure. Secondary endpoints included optimal positioning of the LV lead and reduction in procedural fluoroscopy time., Results: Failed LV lead placement was lower (1.9% vs 8.1%, P = 0.02) and optimal lead positioning was achieved more often for group TS than group OTW (87% vs 75%, P = 0.01). In addition, there were significantly shorter fluoroscopy times for group TS versus group OTW (29.6 minutes vs 41.9 minutes, P < 0.01)., Conclusion: A CRT-implant approach using contrast injection and a telescoping-support catheter system results in fewer failed LV lead implants, improved LV lead location, and shorter procedure times., (©2013, The Authors. Journal compilation ©2013 Wiley Periodicals, Inc.)

High serum follicle-stimulating hormone (FSH) levels have been associated with diminished ovarian reserve; however, the association between high urinary FSH and reduced natural fertility has yet to be established. We sought to characterize the relationship between a single or multiple measurements of early follicular phase urinary FSH and fertility. Women (n = 209), 30 to 44 years old with no history of infertility, who had been trying to conceive for less than 3 months, provided early follicular phase urine. Participants subsequently kept a diary to record bleeding and intercourse and conducted standardized pregnancy testing for up to 6 months. A subset of women (N = 95) collected urine on cycle day 3 for up to 6 cycles. Urine was analyzed for FSH and creatinine (cr) corrected. Proportional hazard models were used to calculate fecundability ratios (FRs). Urinary FSH levels across cycles from the same woman were highly correlated (adjusted intraclass correlation = .77); within-woman variance was 3-fold lower than variance among women. Women with an initial urinary FSH level <7 mIU/mg cr exhibited a nonsignificant reduction in the probability of pregnancy (adjusted FR 0.71, 95% confidence interval [CI]: 0.45-1.13), as did women with elevated urinary FSH (≥12 mIU/mg cr; adjusted FR 0.78, 95% CI: 0.46-1.32). Using the most recent or maximum urinary FSH value did not strengthen the association. In the general population, urinary FSH levels appear to be nonlinearly associated with fertility; however, broad CIs indicate a lack of statistical significance. Repetitive testing appears to be of little benefit.

Megacopta cribraria (F.) (Hemiptera: Plataspidae) was first reported in 2009 near Atlanta, GA. The insect undergoes two generations per year. The first-generation is reported mainly in kudzu during May and June, with the second establishing on both kudzu and soybean during July and August. A greenhouse study was conducted to determine the suitability of two legumes as hosts for first generation M. cribraria. First generation M. cribraria successfully developed on caged potted soybean plants. Conversely, snap beans were not a suitable host under the conditions of this study. A range of 45-50 d was needed to transition from the egg to adult on soybean plants. Although this study was limited to the greenhouse, kudzu may not be an obligate host for the development of first-generation M. cribraria. An important implication of this finding is the establishment for this pest on spring-planted soybean and for the possible expanded geographic range for this pest beyond that of kudzu.

Consumption of fish has well-known human health benefits, though some fish may contain elevated levels of mercury (Hg) that are especially harmful to developing children. Fish length is most often the basis for establishing fishery harvest regulations that determine which fish will ultimately be consumed by humans. It is, therefore, essential to quantify the relationship between fish length and Hg accumulation in regard to harvest regulations for effective fishery and public health policy. We examined this relationship for three sportfish from six lakes across North Carolina, USA. Bluegill (Lepomis macrochirus) had the lowest Hg levels and only the very largest fish in the most contaminated site exceeded the US Environmental Protection Agency (USEPA) Hg screening level. Black crappie (Pomoxis nigromaculatus) had an intermediate level of Hg and larger individuals exceeded the USEPA screening level; however, they tended not to exceed this level before reaching the harvest length limit. Largemouth bass (Micropterus salmoides) exceeded the USEPA screening level at sizes below the fishery length limit in two lakes, leaving only higher risk fish for anglers to harvest and consume. Removing the effects of fish age and trophic position, we found strong positive correlations between Hg and fish length for largemouth bass and black crappie. We suggest public health officials and wildlife managers collaborate to structure fishery regulations and length-based fish consumption advisories that protect consumers from Hg exposure and communicate the relative risk of fish consumption.

Objective: We studied patients' experiences with oncology providers regarding communication about sexual issues during and after treatment for cancer., Methods: During development of the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) Sexual Function measure, we collected focus group and survey data on communication with oncology professionals about sexual problems. We conducted 16 focus groups with patients and survivors (n = 109) and analyzed the discussions for major themes, including experiences discussing sex during oncology visits. During testing of the PROMIS Sexual Function measure, we assessed experiences discussing sexual problems with oncology professionals (n = 819) and measured bivariate associations between asking for information from clinicians and sexual function and satisfaction with sex life., Results: Most patients and survivors (74%) thought that discussions with oncology professionals about sexual problems were important, but whether they had ever received information about sexual function from a provider varied by cancer type (23% lung, 29% breast, 39% colorectal, and 79% prostate). Those who had asked an oncology professional about sexual problems had significantly greater interest in sexual activity as well as more sexual dysfunction., Conclusions: Sexual problems are a widespread concern among patients and survivors, but there is much variation in experiences of communication about sexual issues, and many patients do not receive the information they need from their oncology providers. There are large differences in sexual function between patients who do and do not ask providers about sexual problems. Sexual health has yet to be fully integrated into oncology care, even for cancers involving sex organs., (Copyright © 2011 John Wiley & Sons, Ltd.)

Objective: To examine maternal perceptions of barriers to care of children with orofacial clefts (OFC) in a population-based survey that solicited open-ended qualitative responses., Design and Setting: In 2006, a combination mail/phone survey was sent to all mothers of children with OFC. The questionnaire included 76 items. A final open-ended question was included for additional information about cleft-related care. The analysis included responses to the open-ended question and sociodemographic characteristics of the respondents. Qualitative responses were transcribed and entered into a qualitative software package for analysis, and common themes were elucidated., Participants/patients: The North Carolina Birth Defects Monitoring Program was used to identify all resident infants born with OFC from 2001 to 2004. Of 478 eligible mothers, 52.9% (n  =  248) responded to the survey, and 39.5% (n  =  98) responded to the final open-ended question., Main Outcome Measures: Percentage reporting problems accessing care, frequency of positive and negative comments, and indicators of financial, personal, and structural barriers to care., Results: Of the 98 respondents, the majority (n  =  95, 96.99%) were the biological mother. Almost 40% of mothers indicated that accessing primary craniofacial care was a problem. Of those citing perceived barriers to care, the major issues cited were financial, structural, and personal barriers., Conclusions: Collaborative efforts between craniofacial centers and teams, health care systems, and birth defects registries are warranted to reduce perceived barriers to care among families of children with OFC. Further exploration of the themes and factors associated with barriers to care and services is needed.

Consumption of marine fish provides both benefits (lean protein, omega-3 fatty acids and essential nutrients) and risks (main source of mercury (Hg) exposure for humans). Mercury is a potent neurotoxin and the source of more fish advisories nationwide than any other toxicant. Despite the widespread nature of Hg, it is unknown whether local Hg contamination reflects national and regional levels often used as bases to inform consumers of potential fish consumption risk. Thus, the objectives of our study were to examine Hg levels of six commonly consumed marine species harvested locally off the North Carolina coast and to compare our results to published regional (Monterey Bay Aquarium's Seafood Watch List) and national (Environmental Protection Agency, EPA, and Food and Drug Administration, FDA) Hg averages, action levels, and guidelines. We found significant differences in Hg concentrations among collected species, and we identified correlations between Hg concentration and fish length and trophic levels. Collected mahi mahi and triggerfish were below the EPA fish tissue action level (0.3ppm). Wahoo and grouper exceeded the EPA action level but were below the FDA action level (1.0ppm). King mackerel had the highest Hg concentration among targeted species, exceeding both EPA and FDA action levels. Further, our local results were not always consistent with calculated averages from EPA and FDA databases for the same species, and although many of our findings were consistent with Monterey Bay Aquarium's Seafood Watch List (southeast region), recommendations based on Hg levels would conflict with recommendations they provide based on sustainability. We find regional and national averages are not always reflective of local Hg contamination and suggest local data may be needed to accurately assess consumer risk.

Background: Much of the epidemiologic research on risk factors for fibroids, the leading indication for hysterectomy, relies on self-reported outcome. Self-report is subject to misclassification because many women with fibroids are undiagnosed. The purpose of this analysis was to quantify the extent of misclassification and identify associated factors., Methods: Self-reported fibroid status was compared to ultrasound screening from 2046 women in Right From The Start (RFTS) and 869 women in the Uterine Fibroid Study (UFS). Log-binomial regression was used to estimate sensitivity (Se) and specificity (Sp) and examine differences by ethnicity, age, education, body mass index, parity, and miscarriage history., Results: Overall sensitivity was ≤0.50. Sensitivity was higher in blacks than whites (RFTS: 0.34 vs. 0.23; UFS: 0.58 vs. 0.32) and increased with age. Parous women had higher sensitivity than nulliparae, especially in RFTS whites (Se ratio=2.90; 95% confidence interval [CI]: 1.51, 5.60). Specificity was 0.98 in RFTS and 0.86 in UFS. Modest ethnic differences were seen in UFS (Sp ratio, black vs. white=0.90; 95% CI: 0.81, 0.99). Parity was inversely associated with specificity, especially among UFS black women (Sp ratio=0.84; 95% CI: 0.73, 0.97). Among women who reported a previous diagnosis, a shorter time interval between diagnosis and ultrasound was associated with increased agreement between the two measures., Conclusions: Misclassification of fibroid status can differ by factors of etiologic interest. These findings are useful for assessing (and correcting) bias in studies using self-reported clinical diagnosis as the outcome measure.

Mercury in fish tissue is a major human health concern. Consumption of mercury-contaminated fish poses risks to the general population, including potentially serious developmental defects and neurological damage in young children. Therefore, it is important to accurately identify areas that have the potential for high levels of bioaccumulated mercury. However, due to time and resource constraints, it is difficult to adequately assess fish tissue mercury on a basin wide scale. We hypothesized that, given the nature of fish movement along streams, an analytical approach that takes into account distance traveled along these streams would improve the estimation accuracy for fish tissue mercury in unsampled streams. Therefore, we used a river-based Bayesian Maximum Entropy framework (river-BME) for modern space/time geostatistics to estimate fish tissue mercury at unsampled locations in the Cape Fear and Lumber Basins in eastern North Carolina. We also compared the space/time geostatistical estimation using river-BME to the more traditional Euclidean-based BME approach, with and without the inclusion of a secondary variable. Results showed that this river-based approach reduced the estimation error of fish tissue mercury by more than 13% and that the median estimate of fish tissue mercury exceeded the EPA action level of 0.3 ppm in more than 90% of river miles for the study domain.

BACKGROUND Late implantation and the pattern of early rise in hCG have been associated with early pregnancy loss. We explored factors that might be predictive of these markers of poor embryonic health in spontaneously conceived pregnancies. METHODS Participants in the North Carolina Early Pregnancy Study collected daily first-morning urine specimens while attempting to conceive. Samples were assayed for estrogen and progesterone metabolites (to identify day of ovulation) and hCG (to detect conception). Data were available for 190 pregnancies, 48 of which ended in early loss (within 6 weeks of the last menstrual period). We used logistic regression to identify characteristics associated with late implantation (≥10 days post-ovulation). For pregnancies surviving at least 6 weeks (n= 142), we used linear mixed models to identify factors associated with variations in hCG rise in the first 7 days from detection. RESULTS Later implantation was associated with current maternal smoking [odds ratio (OR): 5.7; 95% confidence interval (CI): 1.1-30] and with oocytes that were likely to have been fertilized late in their post-ovulatory lifespan (OR: 5.1; CI: 1.9-16). Older women had a faster rise in hCG (P= 0.01), as did women who had relatively late menarche (P for trend = 0.02). Women exposed in utero to diethylstilbestrol showed an unusual pattern of slow initial hCG rise followed by a fast increase, a pattern significantly different from that of unexposed women (P= 0.002). CONCLUSIONS Although limited by small numbers and infrequent exposures, our analyses suggest that a woman's exposures both early in life and at the time of pregnancy may influence early development of the conceptus.

This article is a case study of a patient cared for in the hours before her death. After the patient's death, we learned the patient died of a black widow spider bite. This article sheds light on the potential seriousness of this venom and allows for more rapid detection and treatment of those who are unfortunate enough to be bitten. The authors have documented the sequence of events for the patient, outlined the care the patient received, examined the pathophysiology of the body to a spider bite, and then made a passionate appeal for other nurses who work in critical care to do the same with patients in similar situations.

Background: Optimal timing of surgery in degenerative mitral regurgitation (MR) remains a controversial topic. The impact of current ACC/AHA guideline recommendations about optimal timing of surgery on outcomes is untested and contemporary data are lacking., Objective: To assess the association between the timing of surgery and long-term survival in patients with severe MR., Methods: A cohort of 481 patients with severe, degenerative mitral regurgitation (1995-2007) from the Duke Cardiovascular Disease Databank who fulfilled at least one ACC/AHA guideline indication for surgery was identified. Exclusion criteria were rheumatic disease, congenital mitral valve (MV) disease, hypertrophic cardiomyopathy, coronary disease in more than one vessel, endocarditis, other severe valve disease, h/o valve repair/replacement. Patients were grouped into early surgery (in ≤ 2 months of presenting with surgical indications) and late surgery (>2 months) groups. An adjusted Cox regression model was constructed for time to death after 2 months with a time-dependent covariate term for late surgery., Results: 168 patients had early surgery (median time to surgery 0.42 months) with 153 followed up after 2 months, 94 had late surgery (median time to surgery 8.75 months) and 219 medically managed. 127/168 in the early surgery group and 84/94 in the late surgery group received MV repair (p=0.02). Over 5.6 years' (median) follow-up there were 35 deaths (21%) in the early surgery group, with two occurring before 2 months and 20 (21%) in the late group. In the multivariable model, those undergoing early surgery had a lower hazard for death than those who underwent late surgery (HR=0.54 (95% CI 0.30 to 0.97), p=0.039). MV repair was independently associated with survival (HR=0.45 (95% CI 0.25 to 0.83), p=0.01)., Conclusions: In patients with severe MR who presented with guideline indications for surgery, those selected for earlier surgery had improved survival. These data support the current guidelines for early referral to surgery in patients with severe MR for enlarged left ventricular dimensions, reduced ejection fraction and symptoms rather than delaying surgery. Larger randomised trials are needed to definitively answer the question of optimal timing of surgery in patients with severe degenerative MR.

Background: Necrotizing enterocolitis (NEC) and periventricular hemorrhagic infarction (PVHI) are complications of prematurity associated with poor neurodevelopmental outcomes., Objectives: We characterized temporal and causal associations between NEC and type of PVHI as well as associations with outcomes., Methods: This was a multicenter retrospective study of infants with birth weight <1,500 g and diagnosis of PVHI by a pediatric radiologist at 3 neonatal intensive care units in North Carolina, USA, between January 1998 and December 2004. NEC was confirmed using radiological and surgical pathology findings. Infants were assessed by 3 years using the Bayley Scales of Infant Development, second edition., Results: 35 of 112 (31%) of study patients developed NEC. NEC was diagnosed subsequent to PVHI by a median of 16.6 days (95% CI [9.5, 24.9], p < 0.0001). Indomethacin use and the presence of bilateral PVHI were associated with an increased risk of subsequent NEC (OR 2.8, 95% CI [1.1, 7.2] and OR 2.4, 95% CI [1.1, 5.7], respectively). Having bilateral versus unilateral PVHI was associated with a 2.34-fold increased risk of death (95% CI [1.27, 4.33], p = 0.007). NEC was not associated with worse motor outcomes in this population. Overall, the probability of a mental development index >70 was greatest for infants with unilateral PVHI versus bilateral PVHI, although the presence of NEC was associated with worse cognitive outcomes in both groups., Conclusions: Premature infants with PVHI often subsequently develop NEC, especially if they have bilateral PVHI and are exposed to indomethacin. While NEC results in worse neurodevelopmental outcomes, PVHI severity appears more important to the outcome of these infants., (Copyright © 2010 S. Karger AG, Basel.)

Context: In 2008, the Centers for Medicare & Medicaid Services (CMS) required U.S. hospices to implement comprehensive quality improvement programs. CMS contracted with the Quality Improvement Organization in North and South Carolina to develop quality measures and instruments to assess hospice and palliative care quality., Objectives: To develop a set of quality measures, with complete specifications, and data collection tools for use by hospice and palliative care providers in quality improvement., Methods: Quality measures were identified from: published literature, the National Quality Forum, CMS measures, the National Quality Measures Clearinghouse, and measures submitted by two national hospice organizations. Available data on the quality measures were gathered and pilot data were collected for measures with no available data. A Technical Expert Panel (TEP) rated quality measures on: importance, scientific soundness, feasibility and usability, using numeric scores for each dimension. Scores for quality measures were averaged across dimensions and across TEP members to identify measures for further development., Results: Of 174 measures identified, 88 were determined appropriate to the setting and were reviewed and rated by the TEP. Measures with overall scores ≥75th percentile (n = 23), measures with high importance scores (n = 7), measures for under-represented domains (n = 2), and process measures antecedent to TEP identified measures (n = 2), and were selected., Conclusions: Specifications and data collection tools are available for 34 PEACE quality measures that were highly rated by experts in hospice and palliative care. Future research should assess the scientific soundness and responsiveness of these measures to quality improvement.

Background: Studies from the 1990s suggested sex with older partners was associated with HIV infection. We evaluated the hypothesized association between primary HIV infection (PHI) and having older sexual partners among men who have sex with men (MSM)., Methods: MSM with PHI and HIV-uninfected MSM completed audio computer-assisted self-interviews exploring behaviors involving their 3 most recent sexual partners before enrollment (if uninfected) or diagnosis (if PHI)., Results: Of 74 men reporting any lifetime sex with men, 20 had PHI (27%). Demographics (including age) were similar between groups; 39% were non-white and 74% identified as gay. The mean age of sex partners differed significantly: men with PHI had partners on average 6 years older than themselves, whereas uninfected men's partners were 4 months their junior (P < 0.001). After adjusting for race, sex while intoxicated, and having a serodiscordant/serostatus unknown partner, a participant had twice the odds of PHI if his sex partner was 5 years his senior (odds ratio 2.0, 95% confidence interval: 1.2 to 3.3)., Conclusions: Among a sample of young MSM, the odds of HIV infection increased significantly as the age of sexual partners increased. These findings can inform behavioral interventions in communities of at-risk MSM and secondary prevention efforts among those already living with HIV.

Objective: Periventricular hemorrhagic infarction (PVHI) is a major contributing factor to poor neurodevelopmental outcomes in preterm infants. We hypothesized that surviving infants with unilateral PVHI would have more favorable outcomes than those with bilateral PVHI., Methods: This was a multicenter, retrospective study of infants who were admitted to 3 NICUs in North Carolina from 1998 to 2004. The clinical course and late neuroimaging studies and neurodevelopmental outcomes of 69 infants who weighed <1500 g and had confirmed PVHI on early cranial ultrasonography were reviewed. A predictive model for Bayley Scales of Infant Development, Second Edition, Mental Developmental Index (MDI) <70 was constructed by using radiologic and clinical variables., Results: Infants with unilateral PVHI had higher median MDI (82 vs 49) and Psychomotor Developmental Index (53 vs 49) than infants with bilateral PVHI. Infants with unilateral PVHI were less likely to have severe cerebral palsy (adjusted odds ratio: 0.15 [95% confidence interval (CI): 0.05-0.45]) than infants with bilateral PVHI. Infants who had unilateral PVHI and developed periventricular leukomalacia and retinopathy of prematurity that required surgery had an increased probability of having MDI <70 compared with those without these complications (probability of MDI <70: 89% [95% CI: 0.64-1.00] vs 11% [95% CI: 0.01-0.28])., Conclusions: Infants with unilateral PVHI had better motor and cognitive outcomes than infants with bilateral PVHI. By combining laterality of PVHI, periventricular leukomalacia, and retinopathy of prematurity it is possible to estimate the probability of having an MDI <70, which will assist clinicians when counseling families.

Stroke and cardiovascular disease are major health problems for African Americans. This article describes challenges, strategies employed, and successes in implementing a combination "faith-based" and "faith-placed" health promotion program called the BLESS Project in a small rural church in North Carolina. The project was implemented by a congregational nurse who teaches nursing at a nearby HBCU and students with a grant from a local agency and partnerships with local health-care agencies. Despite numerous challenges in implementing the project, it was successful in increasing awareness of stroke and heart disease and the need for improving diet and increasing physical activity. Research is needed to test the efficacy of combining faith-based and faith-placed activities in preventing cardiovascular disease in African Americans.

Asymmetry of the arytenoid complex is considered when evaluating a patient for a voice disorder. This study sought to determine if there were differences in arytenoid adduction asymmetry in persons with and without voice disorders. Three aspects of arytenoid adduction asymmetry were judged from still frames of the arytenoids in the adducted position from stroboscopy recordings of 52 vocally normal speakers and 54 persons with voice disorders. Asymmetry of the arytenoids was prevalent in both normophonic and dysphonic speakers. The lack of strong differences in the prevalence of arytenoid asymmetries in the adducted position between normophonic and dysphonic speakers suggests that caution should be taken when using these asymmetries as indicator of or related to a voice disorder.

Purpose: Reaction time is an important indicator of neuromuscular status in older adults. A simple, portable, and inexpensive method of measuring reaction time is needed for use in geriatric clinical settings. The purpose of this study was to examine the reliability and validity of the response speed subtest of the Bruininks-Oseretsky Test of Motor Proficiency (BOT) as an indicator of reaction time in older adults., Methods: A volunteer sample of 30 community-dwelling men and women over the age of 65 years performed the response speed subtest of the BOT and an electronic reaction time test during a single test session. Statistical analyses included calculation of the intraclass correlation coefficient (ICC) for reliability testing and the Pearson product-moment correlation coefficient (r) for validity testing., Results: Intertester reliability for the BOT response speed subtest using either mean or median scores for 7 test trials for each subject was ICC[2,1] = 0.99. Test-retest reliability for the BOT was ICC [2,1] = 0.53 using mean scores and ICC[2,1] = 0.65 using median scores. Mean scores from both the first and second administrations of the BOT subtest were correlated with electronic reaction time test scores (r = -0.41 and r = -0.45, respectively; P < .05). Scores improved significantly from the first to the second test administration., Conclusions: Although intertester reliability was excellent, test-retest reliability for the BOT response speed subtest was not in an acceptable range for this sample of community-dwelling older adults. Further study of optimal methods of administration is needed to develop this measure for use in screening and examination of older adults.

Background: Success with preoperative weight loss (PWL) is often mandated by the bariatric team to assess patient compliance and has been suggested to correlate with improved postoperative weight loss outcomes., Methods: We performed a retrospective analysis of 1629 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass at Duke University Medical Center. Patients with a preoperative weight gain (PWG) or loss of > or =10 lb were compared. Patients with <12 months of follow-up were excluded., Results: We found no difference between the 2 groups (PWG, n = 115, PWL, n = 88) with regard to age, gender, race, preoperative body mass index, presence of co-morbidities, or interval between the initial program-entry weight and surgery (149 versus 141 d). No difference was found in the percentage of excess weight loss (EWL) at 12 months, when calculated using the patient's immediate preoperative weight (PWG group, 63.5% EWL versus PWL group, 63.9% EWL, P = NS). If the %EWL was calculated using the initial program-entry weight, the PWL did confer a transient postoperative weight loss advantage; however, this did not persist past 24 months postoperatively. At both 12 and 24 months, the resolution rates of diabetes (82% versus 83% at 2 yr; P = NS), hypertension (48% versus 42% at 2 yr, P = NS), and continuous positive airway pressure discontinuation (87% versus 87% at 1 yr, P = NS) were equivalent. No differences in perioperative complications or conversion rates were detected. The operative time was slightly longer for the PWG group (119.7 versus 104.9 min, P = .02)., Conclusion: The results of our study have shown that weight loss before laparoscopic Roux-en-Y gastric bypass is not mandatory and might deter patients from considering weight loss surgery. Laparoscopic Roux-en-Y gastric bypass can be performed safely with equivalent co-morbidity resolution and %EWL regardless of PWG or PWL.

Henneguya gurlei was isolated from Ameiurus nebulosus captured in North Carolina and redescribed using critical morphological features and 18S small-subunit ribosomal RNA (SSU rDNA) gene sequence. Plasmodia are white, spherical, or subspherical, occur in clusters, measure up to 1.8 mm in length, and are located on the dorsal, pectoral, and anal fins. Histologically, plasmodia are located in the dermis and subdermally, and the larger cysts disrupt the melanocyte pigment layer. The spore body is lanceolate, 18.2 +/- 0.3 microm (range 15.7-20.3) in length, and 5.4 +/- 0.1 microm (range 3.8-6.1) in width in valvular view. The caudal appendages are 41.1 +/- 1.1 microm (range 34.0-49.7) in length. Polar capsules are pyriform and of unequal size. The longer polar capsule measures 6.2 +/- 0.1 microm (range 5.48-7.06), while the shorter is 5.7 +/- 0.1 microm (range 4.8-6.4) in length. Polar capsule width is 1.2 +/- 0.03 microm (range 1.0-1.54). The total length of the spore is 60.9 +/- 1.2 microm (range 48.7-68.5). Morphologically, this species is similar to other species of Henneguya that are known to infect ictalurids. Based on SSU rDNA sequences, this species is most closely related to H. exilis and H. ictaluri, which infect Ictalurus punctatus.