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Research with American preschool children has shown that in some core domains - such as naive biological reasoning - young children's explanations can sensitively reveal their understanding, at times more sensitively than do their predictions and judgments. However, little is known about children's explanatory reasoning in cultural contexts outside the U.S. The present study examined Chinese preschool children's (N = 26) explanations for contamination and illness, as well as comparing their performance on parallel explanations and prediction tasks. In addition, their explanations and prediction were directly compared to those from American children (N = 36) who responded to parallel and strictly comparable items. Chinese children provided both biological contamination and culturally-specific explanations that referred to unseen mechanisms and processes. Moreover, their explanations were as accurate as their predictions and compared favorably to performance by American children, providing evidence for sophisticated explanatory reasoning among Chinese children as well as cultural similarities and differences in early biological reasoning. [ABSTRACT FROM AUTHOR]

Aims: To examine the relationship between alcohol outlet density and violent crime controlling for neighbourhood sociostructural characteristics and the effects of spatially autocorrelated error Design: The sample for this ecologic study comprised 188 census tracts from the City of Austin, Texas and 263 tracts from the City of San Antonio, Texas. Data pertaining to neighbourhood social structure, alcohol density and violent crime were collected from archival sources, and analysed using bivariate, multivariate and geospatial analyses. Results: Using ordinary least squares analysis, the neighbourhood sociostructural covariates explained close to 59% of the variability in violent crime rates in Austin and close to 39% in San Antonio. Adding alcohol outlet density in the target and adjacent census tracts improved the explanatory power of both models. Alcohol outlet density in the target census tract remained a significant predictor of violent crime rates in both cities when the effects of autocorrelated error were controlled for. In Austin, the effects of alcohol outlet density in the adjacent census tracts also remained significant. The final model explains 71% of the variance in violent crime in Austin and 56% in San Antonio. Conclusions: The findings show a clear association between alcohol outlet density and violence, and suggest that the issues of alcohol availability and access are fundamental to the prevention of alcohol-related problems within communities. [ABSTRACT FROM AUTHOR]

Presents an accelerated method to calculate the quasi-periodic state of switched networks. Way in which stitching may be performed; Details of the study.

Objective: This study aimed to investigate the association between antimony (Sb) exposure and glycated hemoglobin (HbA1c) levels in adolescents., Methods: A cross-sectional study of 751 adolescents aged 12-19 years was conducted via the National Health and Nutrition Examination Survey (NHANES, 2013-2016). Survey-weighted linear regression and restricted cubic spline (RCS) analyses were applied to evaluate the relationship of urinary Sb exposure with HbA1c., Results: A significant relationship was observed between urinary Sb concentrations and HbA1c levels (percent change: 0.93; 95% CI: 0.42, 1.45) after full adjustment. After converting urinary Sb levels to a categorical variable by tertiles (T1-T3), the highest quantile was associated with a significant increase in HbA1c (percent change: 1.45; 95% CI: 0.38, 2.53) compared to T1. The RCS models showed a monotonically increasing relationship of urinary Sb with HbA1c. Subgroup analyses revealed a sex-specific relationship between urinary Sb exposure and HbA1c with a significant positive association in males and a non-significant positive association in females. Sensitivity analyses further confirmed the relationship between urinary Sb and HbA1c, even after excluding participants who were overweight or obese (percent change: 1.58%, 95% CI: 0.88, 2.28) and those with serum cotinine levels ≥ 1 ng/mL (percent change: 1.14%, 95% CI: 0.49, 1.80)., Conclusion: Our findings indicated that increased Sb exposure may correlate with higher HbA1c levels, especially in male adolescents. More studies are needed to further explore and validate the potential mechanisms., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Feng, Tang, He, Peng, Mo, Zhu and Wei.)

Background: This study aimed to elucidate the scope and nature of adverse events (AEs) associated with Yasmin., Methods: Among the 17,035,572 AE reports collected from the Food and Drug Administration Adverse Event Reporting System (FAERS) database between January 2004 and September 2023, 25,949 reports involved Yasmin. The demographic details, clinical outcomes, and sources of reports were extracted, and four algorithms were used to evaluate adverse drug reactions., Results: The majority of the AE reports involved females aged 18-45 years. Hospitalization was the most frequently reported serious outcome (46.84 %), with death occurring in 292 patients (1.82 %). The highest number of reports originated from the United States. Adverse reactions spanned across 24 system organ categories (SOCs), and hepatobiliary, vascular, and psychiatric disorders were the most frequently reported AEs. A total of 229 Preferred Terms (PTs) were identified for adverse reactions, with high signal strength observed for conditions such as post-cholecystectomy syndrome. In addition, fear of disease, which has not been previously identified as an AE related to Yasmin, was also identified as a high signal strength side effect., Conclusion: The findings of the present study underscore the importance of monitoring and identifying potential AEs in patients receiving Yasmin, including those not currently listed in the medication instructions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: This research aims to assess the demographic characteristics, prevalence, outcomes, and complications in chronic kidney disease (CKD) patients following mandible fractures in the United States using a nationally representative database., Methods: We analyzed data from the National Inpatient Sample from 2010 to 2019 in the United States. Patients with mandible fractures were categorized into three groups based on the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9-CM and ICD-10-CM): end-stage renal disease (ESRD), non-ESRD CKD, and healthy kidney function. Chi-squared tests and analysis of variance (ANOVA) were used to compare these groups. Additionally, multivariate regression analysis was performed to determine whether CKD is an independent risk factor for complications in patients with mandible fractures., Results: A total of 38,481 patients in the United States were estimated to have experienced mandible fractures between 2010 and 2019. The incidence rate of non-ESRD CKD in patients with mandible fractures significantly increased over time, while the prevalence of ESRD remained stable during the ten-year period. Compared to the healthy kidney function group, patients with chronic kidney disease exhibited higher hospital costs, longer hospitalization durations, and higher in-hospital mortality rates. Additionally, they had greater odds ratios for most of the investigated complications., Conclusions: This study revealed a steady annual increase in the morbidity rate of non-ESRD CKD among patients with mandible fractures, while ESRD prevalence remained stable over ten years. We observed a close association between chronic kidney disease and the prognosis of patients with mandible fractures. Clinicians should prioritize preventive measures and appropriate management of mandibular fractures in patients with CKD., (© 2024. The Author(s).)

Background: Patients undergoing maintenance hemodialysis face heightened vulnerability during disasters like tropical cyclones, yet there is sparse research on their treatment-related challenges and countermeasures. This scoping review aims to highlight the issues maintenance hemodialysis patients encounter following tropical cyclones., Methods: A systematic scoping review of 19 articles from 2000 to 2023 was conducted, evaluating eligibility against predefined criteria., Results: Hemodialysis patients encounter substantial challenges during and after tropical cyclones in the United States, Puerto Rico, Australia, and Taiwan. Thematic analysis identified 3 themes related to "challenges" (Hemodialysis health-related challenges, socially relevant challenges, and challenges of management inefficiencies). "Recommendations" comprised 4 themes and 4 phases across the "mitigation phase" (fortifying healthcare infrastructure and mobilizing community-focused risk mitigation initiatives), "preparedness" (emergency plan development, training, and patient education), "response" (activation of emergency plans and providing emergency healthcare services), and "recovery" (intersectoral collaboration for recovery and rebuilding)., Conclusion: This scoping review underscores challenges confronted by patients undergoing maintenance hemodialysis post-tropical cyclones, highlighting the urgent need for targeted strategies to ensure the continuity of dialysis care during and after such disasters.

Purpose: This study aimed to assess the drug risk of drug-related keratitis and track the epidemiological characteristics of drug-related keratitis., Methods: This study analyzed data from the U.S. Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database from January 2004 to December 2023. A disproportionality analysis was conducted to assess drug-related keratitis with positive signals, and drugs were classified and assessed with regard to their drug-induced timing and risk of drug-related keratitis., Results: A total of 1606 drugs were reported to pose a risk of drug-related keratitis in the FAERS database, and, after disproportionality analysis and screening, 17 drugs were found to significantly increase the risk of drug-related keratitis. Among them, seven were ophthalmic medications, including dorzolamide (reporting odds ratio [ROR] = 3695.82), travoprost (ROR = 2287.27), and brimonidine (ROR = 2118.52), and 10 were non-ophthalmic medications, including tralokinumab (ROR = 2609.12), trazodone (ROR = 2377.07), and belantamab mafodotin (ROR = 680.28). The top three drugs having the highest risk of drug-related keratitis were dorzolamide (Bayesian confidence propagation neural network [BCPNN] = 11.71), trazodone (BCPNN = 11.11), and tralokinumab (BCPNN = 11.08). The drug-induced times for non-ophthalmic medications were significantly shorter than those for ophthalmic medications (mean days, 141.02 vs. 321.96, respectively; P < 0.001). The incidence of drug-related keratitis reached its peak in 2023., Conclusions: Prevention of drug-related keratitis is more important than treatment. Identifying the specific risks and timing of drug-induced keratitis can support the development of preventive measures., Translational Relevance: Identifying the specific drugs related to medication-related keratitis is of significant importance for drug vigilance in the occurrence of drug-related keratitis.

Purpose and Design: This study aimed to evaluate the risk of drug-related dry eye using real-world data, underscoring the significance of tracing pharmacological etiology for distinct clinical types of dry eye., Methods: Analyzing adverse event reports in the Food and Drug Administration Adverse Event Reporting System (FAERS) from January 2004 to September 2023, we employed disproportionality analysis and the Bayesian confidence propagation neural network algorithm. The analysis involved categorizing drugs causing dry eye, assessing risk levels, and conducting segmental assessments based on the time of onset of drug-related dry eye adverse reactions., Results: In the FAERS database, adverse reactions related to dry eye were linked to 1160 drugs. Disproportionality analysis identified 33 drugs with significant risk, notably in ophthalmic (brimonidine, bimatoprost), oncology (tisotumab vedotin, erdafitinib), and other medications (isotretinoin, oxymetazoline). The top three drugs with the highest risk of drug-related dry eye are isotretinoin (Bayesian confidence propagation neural network (BCPNN) = 6.88), tisotumab vedotin (BCPNN = 6.88), and brimonidine (BCPNN = 6.77). Among different categories of drugs, respiratory medications have the shortest mean onset time for drug-related dry eye, averaging 50.99 days. The prevalence skewed towards females (69.9 %), particularly in menopausal and elderly individuals (45-70 years old, mean age 54.7 ± 18.2). Reports of drug-related dry eye adverse reactions showed an annual increase., Conclusion: Informed clinical decision-making is crucial for preventing drug-related dry eye. Assessing the risk of dry eyes associated with both local and systemic medications helps optimize treatment and provide necessary cautionary information., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

One of the challenges associated with understanding environmental impacts on cancer risk and outcomes is estimating potential exposures of individuals diagnosed with cancer to adverse environmental conditions over the life course. Historically, this has been partly due to the lack of reliable measures of cancer patients' potential environmental exposures before a cancer diagnosis. The emerging sources of cancer-related spatiotemporal environmental data and residential history information, coupled with novel technologies for data extraction and linkage, present an opportunity to integrate these data into the existing cancer surveillance data infrastructure, thereby facilitating more comprehensive assessment of cancer risk and outcomes. In this paper, we performed a landscape analysis of the available environmental data sources that could be linked to historical residential address information of cancer patients' records collected by the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The objective is to enable researchers to use these data to assess potential exposures at the time of cancer initiation through the time of diagnosis and even after diagnosis. The paper addresses the challenges associated with data collection and completeness at various spatial and temporal scales, as well as opportunities and directions for future research., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Injection-equipment-sharing networks play an important role in hepatitis C virus (HCV) transmission among people who inject drugs (PWID). Direct-acting antiviral (DAA) treatments for HCV infection and interventions to prevent HCV transmission are critical components of an overall hepatitis C elimination strategy, but how they contribute to the elimination outcomes in different PWID network settings are unclear., Methods: We developed an agent-based network model of HCV transmission through the sharing of injection equipment among PWID and parameterized and calibrated the model with rural PWID data in the United States. We modeled curative and preventive interventions at annual coverage levels of 12.5 %, 25 %, or 37.5 % (cumulative percentage of eligible individuals engaged), and two allocation approaches: random vs targeting PWID with more injection partners (hereafter 'degree-based'). We compared the impact of these intervention strategies on prevalence and incidence of HCV infections. We conducted sensitivity analysis on key parameters governing the effects of curative and preventive interventions and PWID network characteristics., Results: Combining curative and preventive interventions at 37.5 % annual coverage with degree-based allocation decreased prevalence and incidence of HCV infection by 67 % and 70 % over two years, respectively. Curative interventions decreased prevalence by six to 12 times more than preventive interventions, while curative and preventive interventions had comparable effectiveness on reducing incidence. Intervention impact increased with coverage almost linearly across all intervention strategies, and degree-based allocation was always more effective than random allocation, especially for preventive interventions. Results were sensitive to parameter values defining intervention effects and network mean degree., Conclusion: DAA treatments are effective in reducing both prevalence and incidence of HCV infection in PWID, but preventive interventions play a significant role in reducing incidence when intervention coverage is low. Increasing coverage, including efforts in reaching individuals with the most injection partners, preventing reinfection, and improving compliance and retention in preventive services can substantially improve the outcomes. PWID network characteristics should be considered when designing hepatitis C elimination programs., Competing Interests: Declaration of competing interest The authors declare there is no conflict of interests., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Aims: Patients affected by functional mitral regurgitation represent an increasingly high-risk population. Edge-to-edge mitral valve repair (TEER) has emerged as a promising treatment option for these patients. However, there is limited research on the comparative outcomes of TEER versus surgical mitral valve repair (SMVr). This study seeks to compare the demographics, complications, and outcomes of TEER and SMVr based on a real-world analysis of the National Inpatient Sample (NIS) database., Methods and Results: In the NIS database, from the years 2016 to 2018, a total of 6233 and 2524 patients who underwent SMVr and TEER were selected, respectively. The mean ages of the patients were 65.68 years (SMVr) and 78.40 years (TEER) (p < 0.01). The mortality rate of patients who received SMVr was similar to that of patients who were treated with TEER (1.7% vs. 1.9%, p = 0.603). Patients who underwent SMVr more likely suffered from perioperative complications including cardiogenic shock (2.3% vs. 0.4%, p < 0.001), cardiac arrest (1.7% vs. 1.1%, p = 0.025), and cerebrovascular infarction (0.9% vs. 0.4%, p = 0.013). The average length of hospital stay was longer (8.59 vs. 4.13 days, p < 0.001) for SMVr compared to TEER; however, the average cost of treatment was higher ($218 728.25 vs. $215 071.74, p = 0.031) for TEER compared to SMVr. Multiple logistic regression analysis showed that SMVr was associated with worse adjusted cardiogenic shock (OR, 7.347 [95% CI, 3.574-15.105]; p < 0.01) and acute kidney injury (OR, 2.793 [95% CI, 2.356-3.311]; p < 0.01)., Conclusion: Patients who underwent TEER demonstrated a notable decrease in postoperative complications and a shorter hospitalization period when compared to those who underwent SMVr., (© 2024 The Author(s). Clinical Cardiology published by Wiley Periodicals LLC.)

Background: Recent data reveal a marked rise in the detection and mortality rates of Desmoplastic Malignant Melanoma (DMM). This trend underscores the imperative for an in-depth analysis of DMM's epidemiology, which is crucial for the formulation of precise medical and public health strategies. This investigation seeks to elucidate the variations in the incidence and mortality of DMM over a 15-year period (2005-2019)., Methods: Data on DMM patients was sourced from the Surveillance, Epidemiology, and End Results (SEER) database. Both incidence and incidence-based mortality rates (IBM) were directly extracted from the SEER database. Joinpoint regression was used to analyze and calculate the average annual percent change (AAPC) and its 95% confidence interval (CI)., Results: Between 2005 and 2019, 3,384 DMM cases were identified, boasting an age-adjusted incidence rate of 36.3 cases per 1000,000 person-years (95% CI 3.51-3.76) and an IBM of 1.65cases per 1000,000 person-years (95% CI 1.57-1.74). Of these, 2,353 were males (69.53%) and 1,031 were females (30.47%). There were 1894 patients (55.97%) who were over 70 years old. Predominantly, DMM lesions manifested in exposed areas: Limbs (955, 28.22%), Face (906, 26.77%), and Scalp and Neck (865, 25.56%). The incidence of DMM increased significantly at a rate of APC = 0.9% during 2005-2019, while the incidence-based mortality showed a significant upward trend (APC = 7%) during 2005-2012, and slowly increasing trend (APC = 0.6%) during 2012-2019. In contrast to the modest upward trajectory in female incidence and mortality, male incidence initially surged, later declining, while male mortality peaked and stabilized post-2012. The primary sites for incidence and mortality were chronically sun-exposed areas: Face, Scalp and Neck, and Limbs., Conclusions: In recent years, the incidence and incidence-based mortality of DMM have significantly increased. Each subgroup analysis has different trends, and these trends can provide better support for our exploration of DMM., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To assess patient satisfaction within pediatric ophthalmology and identify trends in patient sentiment., Methods: Pediatric ophthalmologists in the United States were identified using the American Association for Pediatric Ophthalmology and Strabismus member directory. Demographic data were recorded using publicly available websites. Online written reviews and Stars ratings were obtained from Healthgrades.com. A sentiment analysis package, Valence Aware Dictionary for Sentimental Reasoning (VADER), was used to generate a compound score of reviews, and word frequency analyses were applied., Results: A total of 377 pediatric ophthalmologists (2,640 online reviews) were evaluated. Physicians received an average of 4.22/5 Stars and a compound sentiment score of 0.56, indicating positive sentiment. No differences in scores were observed by gender or location, although physicians with fewer years in practice had higher Stars ratings compared to peers ( P < .001). The three most common words in the word frequency analysis of all reviews were "surgery," "staff," and "time," with heavy emphasis on bedside manner and addressing patient concerns., Conclusions: This study demonstrates overall high patient satisfaction in pediatric ophthalmology care, with differences in sentiment based on physician demographic features. The study highlights that patient perspective is influenced by non-clinical features of care. These data may be used by pediatric ophthalmologists seeking to improve health care delivery. [ J Pediatr Ophthalmol Strabismus . 2024;61(3):211-218.] .

Background: Pragmatic trials are gaining popularity as a cost-effective way to examine treatment effectiveness and generate timely comparative evidence. Incorporating supplementary real-world data is recommended for robust outcome monitoring. However, detailed operational guidelines are needed to inform effective use and integration of heterogeneous databases., Objective: Lessons learned from the Veterans Affairs (VA) Diuretic Comparison Project (DCP) are reviewed, providing adaptable recommendations to capture clinical outcomes from real-world data., Methods: Non-cancer deaths and major cardiovascular (CV) outcomes were determined using VA, Medicare, and National Death Index (NDI) data. Multiple ascertainment strategies were applied, including claims-based algorithms, natural language processing, and systematic chart review., Results: During a mean follow-up of 2.4 (SD = 1.4) years, 907 CV events were identified within the VA healthcare system. Slight delays (∼1 year) were expected in obtaining Medicare data. An additional 298 patients were found having a CV event outside of the VA in 2016 - 2021, increasing the CV event rate from 3.5 % to 5.7 % (770 of 13,523 randomized). NDI data required ∼2 years waiting period. Such inclusion did not increase the number of deaths identified (all 894 deaths were captured by VA data) but enhanced the accuracy in determining cause of death., Conclusion: Our experience supports the recommendation of integrating multiple data sources to improve clinical outcome ascertainment. While this approach is promising, hierarchical data aggregation is required when facing different acquisition timelines, information availability/completeness, coding practice, and system configurations. It may not be feasible to implement comparable applications and solutions to studies conducted under different constraints and practice. The recommendations provide guidance and possible action plans for researchers who are interested in applying cross-source data to ascertain all study outcomes., Competing Interests: Declaration of competing interest This study was supported by the Veterans Affairs Cooperative Studies Program through a grant to the Diuretic Comparison Project (DCP).The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Inc.)

The triglyceride-glucose (TyG) index is an accessible and reliable surrogate indicator of insulin resistance and is strongly associated with diabetes. However, its relationship with diabetic retinopathy (DR) remains controversial. This meta-analysis aimed to assess the relationship between the TyG index and the prevalence of DR. Initial studies were searched from PubMed, Embase, Web of Science, and China National Knowledge Infrastructure (CNKI) electronic databases. The retrieval time range was from the establishment of the database to June 2023. Pooled estimates were derived using a random-effects model and reported as odds ratio (OR) with 95% confidence intervals (CIs). Two researchers independently assessed the methodological quality of the included studies. The Newcastle-Ottawa Quality Scale (NOS) was utilized to assess cohort studies or case-control studies. The Agency for Healthcare Research and Quality (AHRQ) methodology checklist was applied to assess cross-sectional studies. Ten observational studies encompassing 13716 patients with type 2 diabetes were included in the meta-analysis. The results showed that a higher TyG index increased the risk of DR compared with a low TyG index (OR: 2.34, 95% CI: 1.31-4.19, P < 0.05). When the index was analyzed as a continuous variable, consistent results were observed (OR: 1.48, 95% CI: 1.12-1.97, P < 0.005). There was no significant effect on the results of the sensitivity analyses excluding one study at a time (P all < 0.05). A higher TyG index may be associated with an increased prevalence of DR in patients with type 2 diabetes. However, high-quality cohort or case-control studies are needed to further substantiate this evidence., Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023432747., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Zhou, Zhu and Li.)

Circular RNAs are involved in intervention strategies for treating ischemic stroke (IS). However, circCNOT6L (hsa&#95;circ&#95;0006168) has not yet been reported in IS. Thus, we aimed to explore the potential role of circCNOT6L and its molecular mechanism in IS. In this study, we first found that the expression of both exosomal circCNOT6L (P = 0.0006) and plasma circCNOT6L (P = 0.0054) was down-regulated in IS patients compared with controls. Clinically, a negative correlation was observed between the relative expression level of circCNOT6L and the National Institutes of Health Stroke Scale (NIHSS) score and infarct volume of the brain. Simultaneously, the relative expression level of circCNOT6L was negatively associated with multiple risk factors for IS, such as mean platelet volume (MPV), red cell distribution width (RDW), very low-density lipoprotein (VLDL), and serum potassium, whereas it was positively correlated with high-density lipoprotein (HDL). In vitro, circCNOT6L silencing blocked cell viability and proliferation, while it promoted cell apoptosis of astrocytes undergoing oxygen-glucose deprivation/reperfusion (OGD/R) treatment. Mechanistically, the RNA antisense purification (RAP) assay and luciferase reporter assay revealed that circCNOT6L acts as a miRNA sponge to absorb miR-99a-5p and then regulates the expression of serine proteinase inhibitor (SERPINE1). In the further rescue experiment, overexpressing SERPINE1 could rescue the cell apoptotic signals due to circCNOT6L depletion. In conclusion, CircCNOT6L attenuated the cell apoptotic signal of astrocytes via the miR99a-5p/SERPINE1 axis and then alleviated injury after hypoxia induced by ischemic stroke., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Cadmium is a heavy metal that is exceedingly hazardous to humans and can enter the body through tainted food or drink, causing severe harm. It is critical to develop a technology for detecting cadmium in food and water that is sensitive and accurate. One such approach, which employs nucleases, is uncommon. A cadmium(II) turn-on biosensor was successfully created in this work using repetitive cleavage of certain specific nucleases for signal conversion and sophisticated stem-loop qPCR (quantitative polymerase chain reaction) for quick signal amplification and output. The method has strong selectivity and sensitivity for precise quantification, with a detection limit of 6 nmol L -1 , i.e. 0.948 g L -1 , which is far lower than the 5.0 g L -1 set by the United States Environmental Protection Agency, and it also operates well in retail rice samples., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: To investigate the effect of Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors on the incidence of early neurological deterioration during the treatment of branch atheromatous disease (BAD). Methods: A retrospective analysis of 297 BAD patients admitted to the Department of Neurology in Zhengzhou People's Hospital from January 2020 to April 2023 was made. According to whether to use PCSK9 inhibitor treatment, they were divided into PCSK9 inhibitor group (81 cases) and control group (216 cases). Propensity score matching (PSM) method was used to eliminate the general situation difference between PCSK9 inhibitor group and control group. Seventy-two cases were successfully matched in each group. The early neurological deterioration (END) and low-density lipoprotein cholesterol (LDL-C) were compared. END was defined as the National Institutes of Health Stroke Scale (NIHSS) score increase≥2 points within 72 hours after stroke. Suspicious influencing factors leading to END were screened for multivariate logistic regression model analysis. Results: After PSM matching, among the 144 patients, 90 were male and 54 were female, aged (61.2±9.6) years. After matching, The hospital stay[ M ( Q 1 , Q 3 )] [9(7, 11)d vs 10(8, 13)d] in PCSK9 and NIHSS score at discharge [2(1, 3) vs 3(1, 4) points] were significantly different from those in the control group (all P <0.05). In addition, the incidence of END was reduced in the PCSK9 inhibitor group [12.5%(9/72) vs 31.9%(23/72), P <0.05]. Multivariate logistic regression analysis found that C-reactive protein (CRP)( OR =1.119,95% CI : 1.010-1.240, P <0.05) and PCSK9 inhibitor ( OR =0.298, 95% CI : 0.117-0.755, P <0.05) were factors associated with the development of END. Conclusion: The use of PCSK9 inhibitors in the treatment of patients with BAD can reduce the incidence of END.

Introduction: Roxadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor approved in several regions for the treatment of anemia of chronic kidney disease (CKD). ASPEN evaluated the efficacy, safety, and feasibility of roxadustat in patients with anemia of CKD in US dialysis organizations., Methods: This open-label, single-arm study (NCT04484857) comprised a 6-week screening period, followed by 24 weeks of treatment (with optional extension ≤1 year) and a 4-week follow-up. Patients aged ≥18 years, receiving chronic dialysis, with hemoglobin (Hb) 9.0-12.0 g/dL if converting from erythropoiesis-stimulating agents (ESAs), or <10.0 g/dL if receiving ESAs for <6 weeks, received oral roxadustat three times weekly in-center. Primary efficacy endpoints included proportion of patients with mean Hb ≥10 g/dL, averaged over weeks 16-24, and mean Hb change from baseline to the average over weeks 16-24. Safety was also assessed., Findings: Overall, 283 patients were enrolled and treated, 282 (99.6%) were included in the full analysis set, and 216 (76.3%) continued into the extension period. Most patients enrolled were from DaVita sites (71%), with the rest from US Renal Care sites (29%). Mean (standard deviation [SD]) baseline Hb was 10.6 (0.7) g/dL. Nearly all patients were prior ESA users (n = 274; 97.2%). The proportion of patients with mean Hb ≥10 g/dL during weeks 16-24 was 83.7% (95% confidence interval 78.9-88.6). Mean (SD) Hb increase from baseline to the average over weeks 16-24 was 0.2 (1.0) g/dL. During the treatment period, 82 (29.0%) patients reported treatment-emergent serious adverse events (TESAEs). The most common TESAEs were COVID-19 pneumonia (n = 10; 3.5%), acute respiratory failure (n = 9; 3.2%), COVID-19 (n = 7; 2.5%), acute myocardial infarction (n = 7; 2.5%), and fluid overload (n = 6, 2.1%)., Discussion: Roxadustat was effective in maintaining Hb in patients with anemia of CKD on dialysis in large, community-based dialysis organizations., (© 2023 The Authors. Hemodialysis International published by Wiley Periodicals LLC on behalf of International Society for Hemodialysis.)

Background: People who are incarcerated are at high risk of developing tuberculosis. We aimed to estimate the annual global, regional, and national incidence of tuberculosis among incarcerated populations from 2000 to 2019., Methods: We collected and aggregated data for tuberculosis incidence and prevalence estimates among incarcerated individuals in published and unpublished literature, annual tuberculosis notifications among incarcerated individuals at the country level, and the annual number of incarcerated individuals at the country level. We developed a joint hierarchical Bayesian meta-regression framework to simultaneously model tuberculosis incidence, notifications, and prevalence from 2000 to 2019. Using this model, we estimated trends in absolute tuberculosis incidence and notifications, the incidence and notification rates, and the case detection ratio by year, country, region, and globally., Findings: In 2019, we estimated a total of 125 105 (95% credible interval [CrI] 93 736-165 318) incident tuberculosis cases among incarcerated individuals globally. The estimated incidence rate per 100 000 person-years overall was 1148 (95% CrI 860-1517) but varied greatly by WHO region, from 793 (95% CrI 430-1342) in the Eastern Mediterranean region to 2242 (1515-3216) in the African region. Global incidence per 100 000 person-years between 2000 and 2012 among incarcerated individuals decreased from 1884 (95% CrI 1394-2616) to 1205 (910-1615); however, from 2013 onwards, tuberculosis incidence per 100 000 person-years was stable, from 1183 (95% CrI 876-1596) in 2013 to 1148 (860-1517) in 2019. In 2019, the global case detection ratio was estimated to be 53% (95% CrI 42-64), the lowest over the study period., Interpretation: Our estimates suggest a high tuberculosis incidence rate among incarcerated individuals globally with large gaps in tuberculosis case detection. Tuberculosis in incarcerated populations must be addressed with interventions specifically tailored to improve diagnoses and prevent transmission as a part of the broader global tuberculosis control effort., Funding: National Institutes of Health., Competing Interests: Declaration of interests We declare no competing interests., (This is an Open Access article published under the CC BY 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.)

Objective: To explore the efficacy of intravenous thrombolysis with tenecteplase (TNK) in the treatment of branch atheromatous disease (BAD). Methods: A total of 148 BAD patients hospitalized in the stroke center of Zhengzhou People's Hospital from January 2020 to March 2023 were retrospectively included. According to whether TNK was used for treatment, the patients were divided into the TNK group (52 cases) and the control group (96 cases). The propensity score matching (PSM) method was used to eliminate baseline differences between the two groups, and 46 pairs were successfully matched. Early neurological deterioration (END) was defined as an increase in the national Institutes of Health Stroke Scale (NIHSS) scores within 7 days of stroke≥2. The 90-day modified Rankin Scale (mRS) was used to compare the long-term efficacy between the two groups. A binary logistic regression model was used to analyze the influencing factors of clinical outcomes in patients with BAD. Results: Among the 92 patients, 62 were males and 30 were females, with an average age of (61.0±9.5) years. After PSM, there were statistically significant differences in NIHSS score at discharge [2 (0, 4) vs 4 (3, 8)] and length of hospital stay [9 (6, 13) d vs 11 (9, 14) d] (both P <0.05) between the two groups. The proportion of mRS 0-2 in TNK group was higher than that in the control group [82.6%(38/46) vs 60.8%(28/46)], while the proportion of END and mRS≥4 was lower than that in the control group [10.8%(5/46) vs 30.4%(14/46); 8.7%(4/46) vs 26.0%(12/46)], with statistically significant differences ( P <0.05). The 90-day mortality in the control group was 2.2% (1/46), while no death was detected in the TNK group. Conclusion: Intravenous thrombolysis therapy with TNK can not only increase the proportion of 90-day mRS 0-2 in BAD patients, but also reduce the incidence of END.

Cholangiocarcinoma is characterized by a poor prognosis with limited treatment and management options. Chemotherapy using gemcitabine with cisplatin is the only available first-line therapy for patients with advanced cholangiocarcinoma, although it offers only palliation and yields a median survival of < 1 year. Recently there has been a resurgence of immunotherapy studies focusing on the ability of immunotherapy to inhibit cancer growth by impacting the tumor microenvironment. Based on the TOPAZ-1 trial, the US Food and Drug Administration has approved the combination of durvalumab and gemcitabine with cisplatin as the first-line treatment of cholangiocarcinoma. However, immunotherapy, like immune checkpoint blockade, is less effective in cholangiocarcinoma than in other types of cancer. Although several factors such as the exuberant desmoplastic reaction are responsible for cholangiocarcinoma treatment resistance, existing literature on cholangiocarcinoma cites the inflammatory and immunosuppressive environment as the most common factor. However, mechanisms activating the immunosuppressive tumor microenvironment contributing to cholangiocarcinoma drug resistance are complicated. Therefore, gaining insight into the interplay between immune cells and cholangiocarcinoma cells, as well as the natural development and evolution of the immune tumor microenvironment, would provide targets for therapeutic intervention and improve therapeutic efficacy by developing multimodal and multiagent immunotherapeutic approaches of cholangiocarcinoma to overcome the immunosuppressive tumor microenvironment. In this review, we discuss the role of the inflammatory microenvironment-cholangiocarcinoma crosstalk and reinforce the importance of inflammatory cells in the tumor microenvironment, thereby highlighting the explanatory and therapeutic shortcomings of immunotherapy monotherapy and proposing potentially promising combinational immunotherapeutic strategies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Yu, Zhu, Wang and Chen.)

Purpose: Gastrointestinal perforation (GIP) is a fatal adverse event (AE). The AE of GIP induced by novel antineoplastic agents has attracted attention recently. We aimed to explore the AE signals of GIP related to novel antineoplastic agents comprehensively based on the FDA Adverse Event Reporting System (FAERS). Methods: The FAERS database containing 71 quarters of records was used for analysis. Reporting odds ratio (ROR), information component (IC), and empirical Bayesian geometric mean (EBGM) were utilized to evaluate the signals of GIP associated with novel antineoplastic drugs. Standardization of drug names was by employing MedEx-UIMA software and Python. Data analysis and visualization were performed using MySQL Workbench and R software. Results: After cleaning and handling the data, 5226 GIP cases were identified that were associated with new antineoplastic medications, where these agents were the main suspected contributors. A total of 37 novel antineoplastic drugs were detected with signals of GIP for ROR and IC. Only 22 drugs showed statistically significant signals for EBGM. We found the GIP signals of 22 novel antineoplastic drugs overlapped for the 3 indicators, including anti-vascular endothelial growth factor/vascular endothelial growth factor receptor, anti-endothelial growth factor receptor, immune checkpoint inhibitors, and so on. Conclusion: The potential risk of GIP associated with several novel antineoplastic agents was identified through data mining, which provided valuable information on the safety risks associated with GIP among these drugs. The potential threat of GIP should be recognized and managed properly when using these novel antineoplastic agents., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Yu, Zhu, Chen, Zhu and Liao.)

Increasing evidence demonstrates that an online Diabetes Prevention Program (DPP) can delay the onset of type 2 diabetes. However, little has been done for Chinese Americans. This study, using Community-Based Participatory Research and Intervention Mapping approaches, describes a formative research process in the development of a culturally and linguistically tailored online DPP program among Chinese Americans with prediabetes living in New York City. Using a triangulation approach, data were collected to inform the development of an online DPP curriculum through (1) a literature review, (2) three focus groups (n = 24), and (3) a community advisory board meeting among 10 key informants knowledgeable in community needs, diabetes care, and lifestyle interventions. Participants indicated online DPPs would be very useful and easily accessible. However, key barriers including low computer skills/literacy and technology self-efficacy were identified. In addition, taking meal photos and tracking pedometer steps daily were found to be acceptable self-motoring tools for sustaining a healthy lifestyle. Furthermore, the integration of features such as text message reminders and the creation of social support groups into the online DPP curriculum was proposed to minimize attrition. This theory-based formative research to develop a culturally and linguistically appropriate web-based DPP curriculum was well-received by Chinese Americans and warrants testing in future intervention studies.

The reporting and analysis of population-based cancer statistics in the United States has traditionally been done for counties. However, counties are not ideal for analysis of cancer rates, due to wide variation in population size, with larger counties having considerable sociodemographic variation within their borders and sparsely populated counties having less reliable estimates of cancer rates that are often suppressed due to confidentiality concerns. There is a need and an opportunity to utilize zone design procedures in the context of cancer surveillance to generate coherent, statistically stable geographic units that are more optimal for cancer reporting and analysis than counties. To achieve this goal, we sought to create areas within each US state that are: 1) similar in population size and large enough to minimize rate suppression; 2) sociodemographically homogeneous; 3) compact; and 4) custom crafted to represent areas that are meaningful to cancer registries and stakeholders. The resulting geographic units reveal the heterogeneity of rates that are hidden when reported at the county-level while substantially reducing the need to suppress data. We believe this effort will facilitate more meaningful comparative analysis of cancer rates for small geographic areas and will advance the understanding of cancer burden in the United States., (Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2022.)

Background: Obesity is associated with polycystic ovary syndrome (PCOS). We aimed to elucidate the research status and explore research trends and future directions of research on obesity and PCOS., Methods: A bibliometric analysis of the published papers in the field of obesity and PCOS between 2012 and 2022 was conducted on the basis of the Web of Science Core Collection database. The collaboration networks, research trends, literature sources, citation analysis, co-citation analysis, and keywords analysis were statistically analyzed and visualized using the VOSviewer software., Results: We retrieved 2843 records from 681 journals by 12307 authors from 2942 institutes in 99 countries. The number of published papers and citations had a roughly increasing trend annually. The United States and China contributed the majority of the records. Monash University, Shanghai Jiaotong University, Aristotle University of Thessaloniki, Karolinska Institute, University of São Paulo, and Tehran University of Medical Sciences were the biggest nodes in their cluster of the collaboration network map, and Moran LJ, Teede HJ, Joham AE, Escobar-Morreale HF, and Macut D were prolific authors. Research trends and hotspots were identified and visualized in the field of obesity and PCOS. Research hotspots in this field focused on insulin resistance (IR), metabolic syndrome, metformin, and inflammation. Bariatric surgery, mitochondrial dysfunction, binding globulins, and comorbidities may be the frontiers of future research., Conclusions: We concluded the research status and trends in the field of obesity and PCOS. A better understanding of collaboration patterns, research hotspots, and frontiers may be useful for researchers., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Luo, Li, Li, Wang, Li, Song, Sun, Fu, Zhou, Yi, Zhu and Zhu.)

BACKGROUND: The prevalence of major depressive disorder (MDD) continues to rise year over year, resulting in significant economic implications. However, when patients are treated with contemporary standard-of-care antidepressant pharmacotherapies, a suboptimal response is often attained, resulting in frequent treatment changes. OBJECTIVE: To compare health care resource utilization (HCRU) and all-cause medical and pharmacy costs between commercially insured patients with an MDD diagnosis and matched non-MDD patients and explore treatment patterns among patients with MDD initiating antidepressant pharmacotherapy. METHODS: This was a retrospective, observational analysis of IBM MarketScan US commercial claims data. Adults aged 18 years and older with continuous enrollment 12 or more months before and after the patient's first MDD diagnosis from 2017 to 2018 were included in the analysis. HCRU and all-cause medical and pharmacy costs were compared among patients with MDD and a 1:1 exact-matched cohort of non-MDD patients during the same period (Objective 1). Treatment patterns (persistence, discontinuation, switch, combination, and augmentation) were analyzed for patients with MDD starting first-line antidepressant monotherapy for up to 12 months following their antidepressant initiation index date (Objective 2). Time to first treatment change or discontinuation was calculated and treatment patterns were graphically displayed in Sankey diagrams. RESULTS: 625,272 patients with MDD were matched 1:1 to a cohort of non-MDD patients in Objective 1. Patients with MDD had statistically significantly greater all-cause medical (20.4 vs 9.4; P < 0.0001), outpatient (19.5 vs 9.0; P < 0.0001), emergency department (0.51 vs 0.23; P < 0.0001), inpatient (0.35 vs 0.11; P < 0.0001), and any mental health-related (7.7 vs 0.58; P < 0.0001) visits compared with non-MDD patients. Mean all-cause medical costs were $6,809 ( P < 0.0001) higher among patients with MDD than among patients without MDD ($13,183 vs $6,374, respectively). In Objective 2, 44,485 patients with MDD who received antidepressant monotherapy as their first-line MDD treatment were examined. Among the first treatment patterns observed following initiation, 19.3% of patients persisted with their first-line therapy, 56.2% discontinued antidepressant therapy, 24.5% experienced a treatment change (switching, adding a second antidepressant, or augmenting their existing therapy). The median days until first treatment change were 65 days for those discontinuing and 47 days for those switching antidepressants. Among the 24.5% of patients with a treatment change, 50.0% experienced another change in therapy within 30 days. CONCLUSIONS: The HCRU and costs accrued for patients with MDD is significantly greater than those for non-MDD patients. A large proportion of patients with MDD experienced treatment changes shortly after initiating their first-line antidepressant therapy. The results of this study highlight the need for reevaluation of the current MDD treatment paradigm. DISCLOSURES: Drs Zhu and Namjoshi are employees of Biogen Inc. and may hold stock. Dr Ferries and Ms Suthoff are employees of Sage Therapeutics, Inc., and may hold stock and/or stock options. Dr Bera has no potential conflicts of interest to disclose. This research was funded by Sage Therapeutics and Biogen. Manuscript editorial services were provided by Boston Strategic Partners, Inc., funded by Sage Therapeutics and Biogen. This work was supported by Sage Therapeutics, Inc., and Biogen. The authors had full editorial control of the manuscript and provided final approval on all content.

Reduced availability of agricultural water has spurred increased interest in using recycled irrigation water for U.S. food crop production. However, there are significant knowledge gaps concerning the microbiological quality of these water sources. To address these gaps, we used 16S rRNA gene and metagenomic sequencing to characterize taxonomic and functional variations (e.g., antimicrobial resistance) in bacterial communities across diverse recycled and surface water irrigation sources. We collected 1 L water samples ( n = 410) between 2016 and 2018 from the Mid-Atlantic (12 sites) and Southwest (10 sites) U.S. Samples were filtered, and DNA was extracted. The V3-V4 regions of the 16S rRNA gene were then PCR amplified and sequenced. Metagenomic sequencing was also performed to characterize antibiotic, metal, and biocide resistance genes. Bacterial alpha and beta diversities were significantly different ( p < 0.001) across water types and seasons. Pathogenic bacteria, such as Salmonella enterica , Staphylococcus aureus , and Aeromonas hydrophilia were observed across sample types. The most common antibiotic resistance genes identified coded against macrolides/lincosamides/streptogramins, aminoglycosides, rifampin and elfamycins, and their read counts fluctuated across seasons. We also observed multi-metal and multi-biocide resistance across all water types. To our knowledge, this is the most comprehensive longitudinal study to date of U.S. recycled water and surface water used for irrigation. Our findings improve understanding of the potential differences in the risk of exposure to bacterial pathogens and antibiotic resistance genes originating from diverse irrigation water sources across seasons and U.S. regions.

This paper examines the effects of the COVID-19 pandemic (measured by total cases and deaths per 100K people) on the early-stage entrepreneurship activity (measured by the Kauffman Early-Stage Entrepreneurship indicators) in the United States. The empirical analyses are based on the panel dataset of 51 States between 2020 and 2021. The findings show that the COVID-19 pandemic negatively affects early-stage entrepreneurship activity. Further analyses indicate the positive impact of the COVID-19 pandemic on the startup's early survival rate. However, new entrepreneurs' rate and opportunity share are negatively affected by the COVID-19 pandemic. Implications for the post-COVID-19 era are also discussed., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Kang, Guo, Lu and Zhu.)

Background: Emerging evidence suggests heterologous prime-boost COVID-19 vaccination as a superior strategy than homologous schedules. Animal experiments and clinical observations have shown enhanced antibody response against influenza variants after heterologous vaccination; however, whether the inoculation order of COVID-19 vaccines in a prime-boost schedule affects antibody response against SARS-CoV-2 variants is not clear., Methods: We conducted immunological analyses in a cohort of health care workers (n = 486) recently vaccinated by three types of inactivated COVID-19 vaccines under homologous or heterologous prime-boost schedules. Antibody response against ancestral SARS-CoV-2 (Wuhan-Hu-1) was assessed by total antibody measurements, surrogate virus neutralization tests, and pseudovirus neutralization assays (PNA). Furthermore, serum neutralization activity against SARS-CoV-2 variants of concern was also measured by PNA., Findings: We observed strongest serum neutralization activity against the widely circulating SARS-CoV-2 variant B.1.617.2 among recipients of heterologous BBIBP-CorV/CoronaVac and WIBP-CorV/CoronaVac. In contrast, recipients of CoronaVac/BBIBP-CorV and CoronaVac/WIBP-CorV showed significantly lower B.1.617.2 neutralization titers than recipients of reverse schedules. Laboratory tests revealed that neutralizing activity against common variants but not the ancestral SARS-CoV-2 was associated with the inoculation order of heterologous prime-boost vaccines. Multivariable regression analyses confirmed this association after adjusting for known confounders., Conclusions: Our data provide clinical evidence of inoculation order-dependent expansion of neutralizing breadth against SARS-CoV-2 in recipients of heterologous prime-boost vaccination and call for further studies into its underlying mechanism., Funding: National Key R&D Program of China, National Development and Re-form Commission of China, National Natural Science Foundation of China, Shenzhen Science and Technology Innovation Commission, and US Department of Veterans Affairs., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Non-Hispanic Asians (NHA) in USA have been reported with higher arsenic (As), lead (Pb), cadmium (Cd), mercury (Hg) and their specific species levels, comparing with non-NHA. This study aimed to investigate the associations of these metal/metalloid levels with blood pressure levels and prevalence of hypertension among general NHA using the 2011-2018 National Health and Nutrition and Examination Survey (NHANES) data., Methods: The study included participants aged 20 years and older with determinations of As, Dimethylarsinic acid (DMA), Pb, Cd, Hg and methyl-Hg (MeHg) in blood (n = 10, 177) and urine (n = 5, 175). These metals/metalloid levels were measured by inductively coupled plasma mass spectrometry. Systolic (SBP) and diastolic blood pressure (DBP) levels were examined through a standardized protocol. Censored normal regression model and logistic regression model were employed to explore the associations of As, DMA, Pb, Cd, Hg and MeHg levels with blood pressure levels and prevalence of hypertension respectively, and potential confounders were adjusted in these regression models. Quantile-based g-computation approach was used to analysis joint effect of metals mixture on blood pressure level and hypertension., Results: For NHA, urinary As and Hg levels were associated with increased DBP level; Higher blood Hg and MeHg levels were related to increased blood pressure levels and hypertension; However, negative association was observed between urinary Cd and SBP level; Blood metals mixture (including blood Pb, Cd and Hg) was associated with increased DBP level, but not for hypertension. For non-NHA, urinary As and DMA levels were associated with increased SBP level, but not DBP level and prevalence of hypertension; Urinary Pb level was associated with decreased DBP level; Nevertheless, positive associations were observed between blood Pb levels and SBP and prevalence of hypertension; Blood Hg level was associated with decreased DBP level and prevalence of hypertension; Furthermore, blood MeHg level was associated with decreased DBP level; Positive association was observed between blood metals mixture and increased SBP level among non-NHA., Conclusions: Highly exposed to Hg level among NHA was associated with increased blood pressure levels and prevalence of hypertension. Urinary As level was associated with increased DBP level among NHA. Furthermore, blood metals mixture was related to increased DBP level among NHA. Further prospective studies with larger sample size should be performed to warrant the results., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate whether there is a correlation between the METS-IR index and asthma among Americans., Methods: In an attempt to establish the relationship between the METS-IR index and asthma prevalence and age at first onset of asthma, we conducted a logistic regression analysis, subgroup analysis, and dose-response curve analysis using the National Health and Nutrition Examination Survey (NHANES) database., Results: In model 3, each unit increase in METS-IR index led to 1.5% increase in asthma prevalence (OR= 1.015, 95% CI: 1.012, 1.018) and an earlier age of onset of asthma by 0.057years (β= -0.057, 95% CI: -0.112, -0.002).Stratified analysis determined that an increase in METS-IR index was associated with asthma prevalence in almost all subgroups, except in the group where it was not known whether a blood relative had asthma, and a positive linear relationship was found between METS-IR index and asthma prevalence, as well as a linear negative relationship with age at asthma onset., Conclusion: Despite the fact that a direct causal relationship cannot be demonstrated, a higher METS-IR index is positively related to asthma prevalence and correspondingly may result in asthma onset at younger ages., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Chen, Yang, Han, Wang, Zhuang, Zhu and Chen.)

Purpose: Patients with cancer often have compromised immune system which can lead to worse COVID-19 outcomes. The purpose of this study is to assess the association between COVID-19 outcomes and existing cancer-specific characteristics., Patients and Methods: Patients aged 18 or older with laboratory-confirmed COVID-19 between June 1, 2020, and December 31, 2020, were identified (n = 314 004) from the Optum® de-identified COVID-19 Electronic Health Record (EHR) derived from more than 700 hospitals and 7000 clinics in the United States. To allow sufficient observational time, patients with less than one year of medical history in the EHR dataset before their COVID-19 tests were excluded (n = 42 365). Assessed COVID-19 outcomes including all-cause 30-day mortality, hospitalization, ICU admission, and ventilator use, which were compared using relative risks (RRs) according to cancer status and treatments., Results: Among 271 639 patients with COVID-19, 18 460 had at least one cancer diagnosis: 8034 with a history of cancer and 10 426 with newly diagnosed cancer within one year of COVID-19 infection. Patients with a cancer diagnosis were older and more likely to be male, white, Medicare beneficiaries, and have higher prevalences of chronic conditions. Cancer patients had higher risks for 30-day mortality (RR 1.07, 95% CI 1.01-1.14, P = 0.028) and hospitalization (RR 1.04, 95% CI 1.01-1.07, P = 0.006) but without significant differences in ICU admission and ventilator use compared to non-cancer patients. Recent cancer diagnoses were associated with higher risks for worse COVID-19 outcomes (RR for mortality 1.17, 95% CI 1.08-1.25, P<0.001 and RR for hospitalization 1.10, 95% CI 1.06-1.14, P<0.001), particularly among recent metastatic (stage IV), hematological, liver and lung cancers compared with the non-cancer group. Among COVID-19 patients with recent cancer diagnosis, mortality was associated with chemotherapy or radiation treatments within 3 months before COVID-19. Age, black patients, Medicare recipients, South geographic region, cardiovascular, diabetes, liver, and renal diseases were also associated with increased mortality., Conclusions and Relevance: Individuals with cancer had higher risks for 30-day mortality and hospitalization after SARS-CoV-2 infection compared to patients without cancer. More specifically, patients with a cancer diagnosis within 1 year and those receiving active treatment were more vulnerable to worse COVID-19 outcomes., Competing Interests: The authors have declared that no competing interests exist.

Colorectal cancer (CRC) is one of the most predominant cancers in the USA and ranks third among all cancers in incidence and mortality. Vietnamese Americans exhibit persistently lower screening rates compared to the general U.S. population, due to cultural, economic, and environmental barriers. The impact of environmental factors in particular is not well known, and lack of geographical access may be a significant barrier to accessing screening. This study aims to elucidate build and neighborhood environmental factors affecting CRC screening rates among Vietnamese Americans. A total of 517 Vietnamese Americans 50 years and older residing in Philadelphia County were included in the study. Surveys were collected to determine CRC screening behavior and sociodemographic characteristics. Individual neighborhood characteristics, which included the Walk Score, was obtained based on the participant's address. Neighborhood characteristics were calculated using census-tract level data for the social deprivation index, ethnic composition, and presence of hospitals or federally qualified health centers (FQHC). The generalized linear mixed model revealed that residing in an ethnically dense neighborhood was negatively associated with CRC screening (β = -0.67, SE = 0.29, p = .01), while social deprivation (β = 0.30, SE = 0.27, p = .27) and presence of FQHCs or hospitals (β = 0.16, SE = 0.30, p = .58) were not. Individual neighborhood characteristics including the Walk Score (β = 0.21, SE = 0.26, p = .43) was not associated with CRC screening behavior. Neighborhood characteristics, specifically ethnic density is associated with lower uptake of screening in this population. Future interventions should aim to target specific Vietnamese American and other Asian ethnic neighborhoods that may experience disparities in screening., (© Society of Behavioral Medicine 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The efficacy of plant-based antimicrobials against Salmonella Newport and Listeria monocytogenes on melon rinds was evaluated. Four cantaloupe and 3 honeydew melon varieties grown in Georgia, Arizona, Texas, North Carolina, Indiana and California were tested. Melon rinds (10 g pieces) were inoculated with 5-6 log CFU/10 g rind of S. Newport or L. monocytogenes. Samples were then immersed in 5 % olive extract or 0.5 % oregano oil antimicrobial solution and gently agitated for 2 min. Samples were stored at 4 °C and surviving populations of both bacteria were enumerated at days 0 and 3. Plant-based antimicrobials reduced S. Newport and L.monocytogenes population on all rind samples, regardless of the melon types, varieties or growing locations. Compared to the control, antimicrobial treatments caused up to 3.6 and 4.0 log reductions in populations of Salmonella and L. monocytogenes, respectively. In most cases, plant-based antimicrobial treatments reduced pathogen populations to below the detection limit (1 log CFU/g) at day 3. In general, oregano oil had better antimicrobial activity than olive extract and the antimicrobial treatments were more effective on Salmonella than on L. monocytogenes. The plant-based antimicrobial treatments exhibited better microbial reductions on honeydews than on cantaloupes. These antimicrobials could potentially be used as sanitizers for decontaminating melons., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: The American Cancer Society (ACS) and the NCI collaborate every 5 to 8 years to update the methods for estimating the numbers of new cancer cases and deaths in the current year for the U.S. and individual states. Herein, we compare our current projection methodology with the next generation of statistical models., Methods: A validation study was conducted comparing current projection methods (vector autoregression for incidence; Joinpoint regression for mortality) with the Bayes state-space method and novel Joinpoint algorithms. Incidence data from 1996-2010 were projected to 2014 using two inputs: modeled data and observed data with modeled where observed were missing. For mortality, observed data from 1995 to 2009, 1996 to 2010, 1997 to 2011, and 1998 to 2012, each projected 3 years forward to 2012 to 2015. Projection methods were evaluated using the average absolute relative deviation (AARD) between observed counts (2014 for incidence, 2012-2015 for mortality) and estimates for 47 cancer sites nationally and 21 sites by state., Results: A novel Joinpoint model provided a good fit for both incidence and mortality, particularly for the most common cancers in the U.S. Notably, the AARD for cancers with cases in 2014 exceeding 49,000 for this model was 3.4%, nearly half that of the current method (6.3%)., Conclusions: A data-driven Joinpoint algorithm had versatile performance at the national and state levels and will replace the ACS's current methods., Impact: This methodology provides estimates of cancer data that are not available for the current year, thus continuing to fill an important gap for advocacy, research, and public health planning., (©2021 American Association for Cancer Research.)

Background: Men who have sex with men (MSM) experience high rates of gonococcal infection at extragenital (rectal and pharyngeal) anatomic sites, which often are missed without asymptomatic screening and may be important for onward transmission. Implementing an express pathway for asymptomatic MSM seeking routine screening at their clinic may be a cost-effective way to improve extragenital screening by allowing patients to be screened at more anatomic sites through a streamlined, less costly process., Methods: We modified an agent-based model of anatomic site-specific gonococcal infection in US MSM to assess the cost-effectiveness of an express screening pathway in which all asymptomatic MSM presenting at their clinic were screened at the urogenital, rectal, and pharyngeal sites but forewent a provider consultation and physical examination and self-collected their own samples. We calculated the cumulative health effects expressed as gonococcal infections and cases averted over 5 years, labor and material costs, and incremental cost-effectiveness ratios for express versus traditional scenarios., Results: The express scenario averted more infections and cases in each intervention year. The increased diagnostic costs of triple-site screening were largely offset by the lowered visit costs of the express pathway and, from the end of year 3 onward, this pathway generated small cost savings. However, in a sensitivity analysis of assumed overhead costs, cost savings under the express scenario disappeared in the majority of simulations once overhead costs exceeded 7% of total annual costs., Conclusions: Express screening may be a cost-effective option for improving multisite anatomic screening among US MSM., Competing Interests: Conflict of Interest and Sources of Funding: The authors do not report any conflicts of interest. This work was supported by the US Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Epidemiologic and Economic Modeling Agreement (5NU38PS004644)., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

This paper uses the daily seasonally-adjusted data for net revenues and openings of small businesses in the accommodation, food services, leisure, and hospitality sectors in the United States from January 10, 2020, to June 24, 2021. The results from the Dorta-Sanchez bootstrap unit-root test for a random walk with drift show that the COVID-19 crisis has significantly affected revenues and openings of small leisure and hospitality firms. Moreover, the results remain valid when the data for the national level and 51 states are considered., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Lu, Shang and Zhu.)

Today, there are more than 16.9 million cancer survivors in the United States; this number is projected to grow to 22.2 million by 2030. Although much progress has been made in describing cancer survivors' needs and in improving survivorship care since the seminal 2006 Institute of Medicine report "From Cancer Patient to Cancer Survivor: Lost in Transition," there is a need to identify evidence gaps and research priorities pertaining to cancer survivorship. Thus, in April 2019, the National Cancer Institute convened grant-funded extramural cancer survivorship researchers, representatives of professional organizations, cancer survivors, and advocates for a 1-day in-person meeting. At this meeting, and in a subsequent webinar aimed at soliciting input from the wider survivorship community, evidence gaps and ideas for next steps in the following 6 areas, identified from the 2006 Institute of Medicine report, were discussed: surveillance for recurrence and new cancers, management of long-term and late physical effects, management of long-term and late psychosocial effects, health promotion, care coordination, and financial hardship. Identified evidence gaps and next steps across the areas included the need to understand and address disparities among cancer survivors, to conduct longitudinal studies as well as longer-term (>5 years postdiagnosis) follow-up studies, to leverage existing data, and to incorporate implementation science strategies to translate findings into practice. Designing studies to address these broad evidence gaps, as well as those identified in each area, will expand our understanding of cancer survivors' diverse needs, ultimately leading to the development and delivery of more comprehensive evidence-based quality care., (Published by Oxford University Press 2021. This work is written by US Government employees and is in the public domain in the US.)

Background: The American Cancer Society (ACS) and the NCI collaborate every 5-8 years to update the methods for estimating numbers of new cancer cases and deaths in the current year in the United States and in every state and the District of Columbia. In this article, we reevaluate the statistical method for estimating unavailable historical incident cases which are needed for projecting the current year counts., Methods: We compared the current county-level model developed in 2012 (M0) with three new models, including a state-level mixed effect model (M1) and two state-level hierarchical Bayes models with varying random effects (M2 and M3). We used 1996-2014 incidence data for 16 sex-specific cancer sites to fit the models. An average absolute relative deviation (AARD) comparing the observed with the model-specific predicted counts was calculated for each site. Models were also cross-validated for six selected sex-specific cancer sites., Results: For the cross-validation, the AARD ranged from 2.8% to 33.0% for M0, 3.3% to 31.1% for M1, 6.6% to 30.5% for M2, and 10.4% to 393.2% for M3. M1 encountered the least technical issues in terms of model convergence and running time., Conclusions: The state-level mixed effect model (M1) was overall superior in accuracy and computational efficiency and will be the new model for the ACS current year projection project., Impact: In addition to predicting the unavailable state-level historical incidence counts for cancer surveillance, the updated algorithms have broad applicability for disease mapping and other activities of public health planning, advocacy, and research., (©2021 American Association for Cancer Research.)

Purpose: Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer, more commonly diagnosed among black women than other subgroups. TNBC varies geographically, but little is known about area-level characteristics associated with elevated incidence., Methods: We generated 2011-2013 age-adjusted TNBC incidence rates for state economic areas (SEAs) in 43 states using data from North American Association of Central Cancer Registries. For cases missing data on molecular markers, we imputed TNBC status using cross-marginal proportions. We linked these data to SEA covariates from national sources. Using linear ecological regression, we examined correlates of TNBC incidence rates for the overall population and for age (< 50 years or 50 + years)- or race (white or black)-specific subgroups., Results: The mean annual incidence of TNBC across SEAs was 13.7 per 100,000 women (range = 4.5-26.3), with especially high and variable rates among African American women (mean = 20.5, range 0.0-155.1). TNBC incidence was highest in South Atlantic and East South Central Census Divisions and lowest in Mountain Division. Overall TNBC incidence was associated with SEA sociodemographics (e.g., percent of females age 45 + who are non-Hispanic black: coefficient estimate [est.] = 1.62), healthcare characteristics (e.g., percent of population without health insurance: est. = - 0.52), and health behaviors (e.g., prevalence of obesity among women: est. = 0.72) (all p < 0.05). Other variables related to TNBC incidence included density of obstetrician/gynecologists and prevalence of smoking., Conclusion: TNBC incidence varied across SEAs in the U.S., particularly for African American women. Identifying areas with elevated TNBC incidence can facilitate research and interventions on area- and individual-level correlates of TNBC.

Background: Colorectal cancer (CRC) disproportionately affects Vietnamese Americans, especially those with low income and were born outside of the United States. CRC screening tests are crucial for prevention and early detection. Despite the availability of noninvasive, simple-to-conduct tests, CRC screening rates in Asian Americans, particularly Vietnamese Americans, remain suboptimal. The purpose of this study was to evaluate the interplay of multilevel factors - individual, interpersonal, and community - on CRC screening behaviors among low-income Vietnamese Americans with limited English proficiency., Methods: This study is based on the Sociocultural Health Behavior Model, a research-based model that incorporates 6 factors associated with decision-making and health-seeking behaviors that result in health care utilization. Using a community-based participatory research approach, we recruited 801 Vietnamese Americans from community-based organizations. We administered a survey to collect information on sociodemographic characteristics, health-related factors, and CRC screening-related factors. We used structural equation modeling (SEM) to identify direct and indirect predictors of lifetime CRC screening., Results: Bivariate analysis revealed that a greater number of respondents who never screened for CRC reported limited English proficiency, fewer years of US residency, and lower self-efficacy related to CRC screening. The SEM model identified self-efficacy (coefficient = 0.092, P < .01) as the only direct predictor of lifetime CRC screening. Educational attainment (coefficient = 0.13, P < .01) and health beliefs (coefficient = 0.040, P < .001) had a modest significant positive relationship with self-efficacy. Health beliefs (coefficient = 0.13, P < .001) and educational attainment (coefficient = 0.16, P < .01) had significant positive relationships with CRC knowledge., Conclusions: To increase CRC screening uptake in medically underserved Vietnamese American populations, public health interventions should aim to increase community members' confidence in their abilities to screen for CRC and to navigate associated processes, including screening preparation, discussions with doctors, and emotional complications.

Aim: A nomogram was constructed to forecast the overall survival (OS) of patients with mycosis fungoides/Sezary syndrome. Patients & methods: The clinicopathological information of patients was obtained from the Surveillance, Epidemiology and End Results (SEER) database. A model was established based on the independent prognostic factors. Predictive ability of the model was evaluated with the concordance index and calibration curves. Risk stratification was conducted for patients with similar tumor node metastasis (TNM) stages. Results: The model included 1997 eligible patients and seven prognostic factors for OS. The concordance index of the nomogram was 0.84 in the training and external validation cohorts, which indicated good predictive ability of the model and reliability of the results. The high agreement between the model predictions and actual observations was identified by calibration curves, which demonstrated the prediction accuracy of the model. Risk stratification displayed significant differences for patients with similar TNM stages, which suggested that the OS of patients with similar TNM stages could be further distinguished. Conclusion: We established a reliable nomogram to predict the OS of patients with mycosis fungoides/Sezary syndrome, which highlighted the advantages of nomograms over the conventional TNM staging system and promoted the application of individualized therapeutic strategies.

Background: The opioid epidemic has been associated with an increase in hepatitis C virus (HCV) infections. Federally qualified health centers (FQHCs) have a high burden of hepatitis C disease and could serve as venues to enhance testing and treatment., Methods: We estimated clinical outcomes and the cost-effectiveness of hepatitis C testing and treatment at US FQHCs using individual-based simulation modeling. We used individual-level data from 57 FQHCs to model 9 strategies, including permutations of HCV antibody testing modality, person initiating testing, and testing approach. Outcomes included life expectancy, quality-adjusted life-years (QALY), hepatitis C cases identified, treated and cured; and incremental cost-effectiveness ratios., Results: Compared with current practice (risk-based with laboratory-based testing), routine rapid point-of-care testing initiated and performed by a counselor identified 68% more cases after (nonreflex) RNA testing in the first month of the intervention and led to a 17% reduction in cirrhosis cases and a 22% reduction in liver deaths among those with cirrhosis over a lifetime. Routine rapid testing initiated by a counselor or a clinician provided better outcomes at either lower total cost or at lower cost per QALY gained, when compared with all other strategies. Findings were most influenced by the proportion of patients informed of their anti-HCV test results., Conclusions: Routine anti-HCV testing followed by prompt RNA testing for positives is recommended at FQHCs to identify infections. If using dedicated staff or point-of-care testing is not feasible, then measures to improve immediate patient knowledge of antibody status should be considered., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Evidence regarding the association between blood lead levels (BLL) and hyperhomocysteinemia (HHcy) in US adults was limited. We aimed to investigate the association of BLL with the risk of HHcy, and to examine possible effect modifiers using US National Health and Nutrition Examination Survey (NHANES) database. We performed a cross-sectional study using data from up to 9,331 participants aged ≥ 20 years of NHANES from 2001 to 2006. BLL was measured by atomic absorption spectrometry. HHcy was defined as plasma homocysteine level > 15 µmol/L. The weighted prevalence of HHcy was 6.87%. The overall mean BLL was 1.9 μg/dL. Overall, there was a nonlinear positive association between Ln-transformed BLL (LnBLL) and the risk of HHcy. The Odds ratios (95% CI) for participants in the second (0.04-0.49 μg/dL), third (0.5-0.95 μg/dL) and fourth quartiles (> 0.95 μg/dL) were 1.12 (95% CI: 0.71, 1.76), 1.13 (95% CI: 0.73, 1.77), and 1.67 (95% CI: 1.07, 2.61), respectively, compared with those in quartile 1. Consistently, a significantly higher risk of HHcy (OR: 1.49; 95% CI: 1.19, 1.88) was found in participants in quartile 4 compared with those in quartiles 1-3. Furthermore, a strongly positive association between LnBLL and HHcy was observed in participants with estimated glomerular filtration rate (eGFR) < 60 mL/min -1 /1.73 m -2 . Our results suggested that a higher level of BLL (LnBLL > 0.95 μg/dL) was associated with increased risk of HHcy compared with a lower level of BLL (LnBLL ≤ 0.95 μg/dL) among U.S. adults, and the association was modified by the eGFR.

Nonsyndromic cleft lip with or without cleft palate (NSCLP) is a common birth defect for which only ~ 20% of the underlying genetic variation has been identified. Variants in noncoding regions have been increasingly suggested to contribute to the missing heritability. In this study, we investigated whether variation in craniofacial enhancers contributes to NSCLP. Candidate enhancers were identified using VISTA Enhancer Browser and previous publications. Prioritization was based on patterning defects in knockout mice, deletion/duplication of craniofacial genes in animal models and results of whole exome/whole genome sequencing studies. This resulted in 20 craniofacial enhancers to be investigated. Custom amplicon-based sequencing probes were designed and used for sequencing 380 NSCLP probands (from multiplex and simplex families of non-Hispanic white (NHW) and Hispanic ethnicities) using Illumina MiSeq. The frequencies of identified variants were compared to ethnically matched European (CEU) and Los Angeles Mexican (MXL) control genomes and used for association analyses. Variants in mm427/MSX1 and hs1582/SPRY1 showed genome-wide significant association with NSCLP (p ≤ 6.4 × 10 -11 ). In silico analysis showed that these enhancer variants may disrupt important transcription factor binding sites. Haplotypes involving these enhancers and also mm435/ABCA4 were significantly associated with NSCLP, especially in NHW (p ≤ 6.3 × 10 -7 ). Importantly, groupwise burden analysis showed several enhancer combinations significantly over-represented in NSCLP individuals, revealing novel NSCLP pathways and supporting a polygenic inheritance model. Our findings support the role of craniofacial enhancer sequence variation in the etiology of NSCLP.

Aim: To investigate whether endoscopic treatment is applicable to American patients and explores the predictors of lymph node metastasis (LNM) in early gastric cancer (EGC)., Methods: Patients with EGC confined to either mucosa (T1a, n  = 1799) and submucosa (T1b, n  = 1689) were identified from the Surveillance, Epidemiology, and End Result database. Multivariate logistic regression, Kaplan-Meier method, and univariate/multivariate Cox regression were used to assess the correlation between invasion depth and LNM or prognosis. A nomogram for predicting LNM was constructed and internally validated., Results: EGC limited to T1a exhibited a 2.4% incidence of LNM, which increased to 11.1% when the depth invaded T1b.LNM was present at 1.4%, 5.2%, and 5.0% for sizes ≤2, 2-5, and >5cm of low-grade T1a EGC, respectively, ( p = .019) and at 4.8%, 12.4%, and 28.6% of T1b EGC, respectively ( p   < .001).The multivariate logistic model revealed that older age, T1b invasion, larger tumor size, and high-grade lesions were associated with a higher risk of LNM. Moreover, the T1a EGC patients had better cancer-specific survival (OS) and overall survival(CSS) compared with the T1b EGC patients (5-year OS: 77.2% versus 67.4%, p  < .001; 5-year CSS: 90.6% versus 81.4%, p  < .001). The discrimination of the prediction model was 0.745., Conclusions: Endoscopic treatment may only be suitable for patients in the US population who have low-grade T1a lesions of less than 2 cm in size. Patients with T1a lesions of greater than 2 cm in size, lesions with high-grade, and all T1b lesions may benefit from radical surgical resection with lymphadenectomy.

Background: Effective medical record documentation is required to support accurate capture of diagnoses, patient acuity (case mix index [CMI]), and justify resource utilization for reimbursement. Billing code complexity and a lack of formal documentation education in training programs have created a need for academic medical centers to incorporate training for trainees (residents, fellows, and new nurse practitioners). We hypothesized that standardized stroke note templates, trainee education, and feedback from chart audits would improve documentation accuracy., Purpose: To improve the accurate/complete capture of expected (E) length of stay (LOS) and CMI by designing/implementing ischemic and hemorrhagic stroke templates containing high-frequency complication and comorbidity diagnoses with the greatest impact on stroke populations, combined with trainee education and chart audits., Methods: Descriptive statistics were used for outcomes before/after implementation of the templates. Primary outcomes include ELOS and CMI. Wilcoxon rank-sum test or chi-square test was used for group comparison., Results: The post-template group demonstrated a significant improvement in ELOS from 5.84 to 8.27 days (p < .0001). Case mix index increased (1.73-1.75; p < .0001) in the post-template group., Conclusions: Stroke-specific templates, trainee education, and chart audits were associated with significant improvement in documentation accuracy and an improved business model of stroke care in our hospital.