Disparities in Opioid Overdose Death Trends by Race/Ethnicity, 2018-2019, From the HEALing Communities Study.

Objectives. To examine trends in opioid overdose deaths by race/ethnicity from 2018 to 2019 across 67 HEALing Communities Study (HCS) communities in Kentucky, New York, Massachusetts, and Ohio. Methods. We used state death certificate records to calculate opioid overdose death rates per 100 000 adult residents of the 67 HCS communities for 2018 and 2019. We used Poisson regression to calculate the ratio of 2019 to 2018 rates. We compared changes by race/ethnicity by calculating a ratio of rate ratios (RRR) for each racial/ethnic group compared with non-Hispanic White individuals. Results. Opioid overdose death rates were 38.3 and 39.5 per 100 000 for 2018 and 2019, respectively, without a significant change from 2018 to 2019 (rate ratio = 1.03; 95% confidence interval [CI] = 0.98, 1.08). We estimated a 40% increase in opioid overdose death rate for non-Hispanic Black individuals (RRR = 1.40; 95% CI = 1.22, 1.62) relative to non-Hispanic White individuals but no change among other race/ethnicities. Conclusions. Overall opioid overdose death rates have leveled off but have increased among non-Hispanic Black individuals. Public Health Implications. An antiracist public health approach is needed to address the crisis of opioid-related harms. (Am J Public Health. 2021;111(10):1851-1854. https://doi.org/10.2105/AJPH.2021.306431).

Geographic Coverage and Verification of Trauma Centers in a Rural State: Highlighting the Utility of Location Allocationfor Trauma System Planning.

BACKGROUND: Care at verified trauma centers has improved survival and functional outcomes, yet determining the appropriate location of potential trauma centers is often driven by factors other than optimizing system-level patient care. Given the importance of transport time in trauma, we analyzed trauma transport patterns in a rural state lacking an organized trauma system and implemented a geographic information system to inform potential future trauma center locations. STUDY DESIGN: Data were collected on trauma ground transport during a 3-year period (2014 through 2016) from the Statewide Incident Reporting Network database. Geographic information system mapping and location-allocation modeling of the best-fit facility for trauma center verification was computed using trauma transport patterns, population density, road network layout, and 60-minute emergency medical services transport time based on current transport protocols. RESULTS: Location-allocation modeling identified 2 regional facilities positioned to become the next verified trauma centers. The proportion of the Vermont population without access to trauma center care within 60 minutes would be reduced from the current 29.68% to 5.81% if the identified facilities become verified centers. CONCLUSIONS: Through geospatial mapping and location-allocation modeling, we were able to identify gaps and suggest optimal trauma center locations to maximize population coverage in a rural state lacking a formal, organized trauma system. These findings could inform future decision-making for targeted capacity improvement and system design that emphasizes more equitable access to trauma center care in Vermont.

Exploring the neighbourhood-level correlates of Covid-19 deaths in London using a difference across spatial boundaries method.

This paper explores neighbourhood-level correlates of the Covid-19 deaths in London during the initial rise and peak of the pandemic within the UK - the period March 1 to April 17, 2020. It asks whether the person-level predictors of Covid-19 that are identified in reports by Public Health England and by the Office of National Statistics also hold at a neighbourhood scale, remaining evident in the differences between neighbours. In examining this, the paper focuses on localised differences in the number of deaths, putting forward an innovative method of analysis that looks at the differences between places that share a border. Specifically, a difference across spatial boundaries method is employed to consider whether a higher number of deaths in one neighbourhood, when compared to its neighbours, is related to other differences between those contiguous locations. It is also used to map localised 'hot spots' and to look for spatial variation in the regression coefficients. The results are compared to those for a later period, April 18 - May 31. The findings show that despite some spatial diffusion of the disease, a greater number of deaths continues to be associated with Asian and Black ethnic groups, socio-economic disadvantage, very large households (likely indicative of residential overcrowding), and fewer from younger age groups. The analysis adds to the evidence showing that age, wealth/deprivation, and ethnicity are key risk factors associated with higher mortality rates from Covid-19.

Sulfate Deficiency as a Risk Factor for Autism.

This is a study of water and beverages consumed during pregnancy by mothers of children with autism. Materials included vials for water samples and a survey to describe the water and beverages. Samples were tested for sulfate and surveys evaluated for average daily levels. Results were stratified for selected regions of the United States. Areas with the highest rates of autism showed a trend toward lower levels of sulfate compared to areas with low rates of autism (28% sulfate, n = 45, p = 0.059). Severe autism was associated with low sulfate levels while mild symptoms were associated with higher levels of sulfate (- 0.32 correlation, n = 86, p < 0.01). The results suggest that sulfate may be helpful in reducing both the incidence and severity of autism.

Regional incidence of and reconstructive management patterns in melanoma and nonmelanoma skin cancer of the head and neck: A 3-year analysis in the inpatient setting.

INTRODUCTION: Currently, there is limited literature on reconstructive trends for inpatient head and neck skin cancer. Rather, studies have focused primarily on patients treated on an outpatient basis. To gain a better understanding of the effect that reconstructive correction of complex skin cancer defects has on the healthcare system, we examined the existing incidence and reconstructive trends of head and neck melanoma and nonmelanoma skin cancer (NMSC) in the inpatient setting. METHOD: We performed the analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database (NIS) for the years 2012-2014 of the United States (US). Adults diagnosed with melanoma skin cancer or NMSC of the head and neck region were included. Patient characteristics, reconstructive modality, surgical specifics, and outcomes were retrieved. Trends with time for reconstruction techniques were analyzed. RESULTS: In total, 41,185 patients with a diagnosis of skin malignancy were identified, of whom 5,480 (13.3%) underwent reconstruction. Most patients were white (90.0%), male (71.6%), and had a diagnosis of NMSC (79.2%). An increase in flap reconstruction (p < 0.001) was observed. After population adjustment, the highest incidence of skin malignancy was found in the Northeast. CONCLUSION: There has been a trending increase in inpatient NMSC and melanoma skin cancer of the head and neck region, correlating to an increase in the reconstructive procedures performed, and greater cost burden. Resources may be allocated toward early identification and treatment for skin cancer to help control the current rise in complex skin cancer cases necessitating inpatient admission.

Spatial patterning and correlates of self-harm in Manchester, England.

AIMS: To investigate the spatial distribution of self-harm incidence rates, their socioeconomic correlates and sex/age differences using data on self-harm presentations to emergency departments from The Manchester Self-Harm Project (2003-2013). METHODS: Smoothed standardised incidence ratios for index self-harm episodes (n = 14 771) and their associations with area-level socioeconomic factors across 258 small areas (median population size = 1470) in the City of Manchester municipality were estimated using Bayesian hierarchical models. RESULTS: Higher numbers and rates of self-harm were found in the north, east and far southern zones of the city, in contrast to below average rates in the city centre and the inner city zone to the south of the centre. Males and females aged 10-24, 25-44 and 45-64 years showed similar geographical patterning of self-harm. In contrast, there was no clear pattern in the group aged 65 years and older. Fully adjusted analyses showed a positive association of self-harm rates with the percentage of the unemployed population, households privately renting, population with limiting long-term illness and lone-parent households, and a negative association with the percentage of ethnicity other than White British and travel distance to the nearest hospital emergency department. The area-level characteristics investigated explained a large proportion (four-fifths) of the variability in area self-harm rates. Most associations were restricted to those aged under 65 years and some associations (e.g. with unemployment) were present only in the youngest age group. CONCLUSIONS: The findings have implications for allocating prevention and intervention resources targeted at high-risk groups in high incidence areas. Targets for area-based interventions might include tackling the causes and consequences of joblessness, better treatment of long-term illness and consideration of the accessibility of health services.

How context matters: Demonstrating microgeographical differences in social capital and its implications for mental wellbeing in pregnancy with a novel bubble diagram technique.

There has been limited exploration of social capital at the contextual level in relation to maternal health, and in particular with the "obstetric transition" and associated mental health problems. In the North Central Province of Sri Lanka, with socio-culturally diverse communities, and a recent history of major conflict, the leading cause of maternal death is suicide. The objective of this study was to identify contextual patterns of social capital constructs that lead to poor maternal mental wellbeing, using a novel bubble visualisation technique, to demonstrate the use of data derived from qualitative approaches. We conducted a qualitative study of pregnant women based on diary entries (n = 41) and interviews (n = 38) in eight different communities of the Anuradhapura district of Sri Lanka. Bubble diagrams were constructed to visualize each context using the frequency and weight of responses given in diaries. Marital, family and neighbourhood cohesion were not homogenous in the district and the bubble diagrams displayed clear microgeographical patterns in which women living in specific communities had poorer mental wellbeing. Such techniques can be used to convey complex social capital implications in digestible way for policy makers and planners to enact locally specific strategies addressing health inequalities.

Coastal proximity and mental health among urban adults in England: The moderating effect of household income.

After adjusting for covariates, self-reported general health in England is higher among populations living closer to the coast, and the association is strongest amongst more deprived groups. We explored whether similar findings were present for mental health using cross-sectional data for urban adults in the Health Survey for England (2008-2012, N ≥25,963). For urban adults, living ≤1 km from the coast, in comparison to >50 km, was associated with better mental health as measured by the GHQ12. Stratification by household income revealed this was only amongst the lowest-earning households, and extended to ≤5 km. Our findings support the contention that, for urban adults, coastal settings may help to reduce health inequalities in England.

Disparities of infant and neonatal mortality trends in Greece during the years of economic crisis by ethnicity, place of residence and human development index: a nationwide population study.

OBJECTIVE: To study trends of infant mortality rate (IMR) and neonatal mortality rate in Greece during the period 2004-2016 and explore the role of sociodemographic factors in the years of crisis. DESIGN: Nationwide individual data for live births and infant (0-11 months) deaths provided by the Hellenic Statistical Authority were examined using Poisson, joinpoint regression and interrupted time series (ITS) analyses. SETTING: Greece. PARTICIPANTS: All infant deaths (n=4862) over the 13-year period, of which 87.2% were born to Greek mothers, and respective live births. MAIN OUTCOME MEASURES: Evolution of IMR (0-364 days), early (<7 days) neonatal mortality rate (ENMR), late (7-27 days) neonatal mortality rate (LNMR) and post neonatal (28-364 days) mortality rate (PNMR) trends, by maternal nationality, place of residence and Human Development Index (HDI). RESULTS: By Poisson regression, overall, during the study period, among infants of Greek mothers, IMR and PNMR declined significantly (-0.9%; 95% CI -1.7% to -0.1% and -1.6%; -3.0% to -0.2% annually, respectively), although differentially by place of residence (IMRurban: -2.1%; -2.9% to -1.3%, IMRrural: +10.6%; 7.6% to 13.6%). By contrast, among infants of non-Greek mothers, the low starting IMR/ENMR/LNMR/PNMR increased significantly (max ENMR:+12.5%; 8.6% to 16.5%) leading to a non-significant time-trend pattern overall in Greece. The inverse associations of HDI with IMR, ENMR and PNMR were restricted to Greek mothers' infants. Joinpoint regression analyses among Greek mothers' infants indicated non-significant increasing trends of IMR and ENMR following the crisis (+9.3%, 2012-2016, p=0.07 and +10.2%, 2011-2016, p=0.06, respectively). By contrast, the high (+17.1%; 8.1% to 26.9%, p=0.002) IMR increases among non-Greek infants were restricted to 2004-2011 and equalised to those of Greek mothers' infants thereafter. ITS analyses in preset years (2008, 2010, 2012) identified significantly increasing trends in IMR, LNMR and PNMR after 2012, and in ENMR after 2010, among Greek mothers' infants. CONCLUSIONS: HDI and rural residence were significantly associated with IMR. The strongly decreasing IMR trends among Greek-mothers' infants were stagnated after a lag time of ~4 years of crisis approximating the previously sharply increasing trends among non-Greeks.

Socio-economic inequality in health service utilisation: Does accounting for seasonality in health-seeking behaviour matter?

Seasonal variation exists in disease incidence. The variation could occur across the different regions in a country. This paper argues that using national household data that are not adjusted for seasonal and regional variations in disease incidence may not be directly suitable for assessing socio-economic inequality in annual outpatient service utilisation, including for cross-country comparison. In fact, annual health service utilisation may be understated or overstated depending on the period of data collection. This may lead to miss-estimation of socio-economic inequality in health service utilisation depending, among other things, on how health service utilisation, across geographical areas, varies by socio-economic status. Using a nationally representative dataset from South Africa, the paper applies a seasonality index that is constructed from the District Health Information System, an administrative dataset, to annualise public outpatient health service visits. Using the concentration index, socio-economic inequality in health service visits, after accounting for seasonal variations, was compared with that when seasonal variations are ignored. It was found that, in some cases, socio-economic inequality in outpatient health service visits depends on the socio-economic distribution of the seasonality index. This may justify the need to account for seasonal and geographical variations.

Concurrent psychiatry for patients enrolled in opioid agonist treatment: a propensity score matched cohort study in Ontario Canada.

OBJECTIVE: The objective was to characterize the relationship between geography, concurrent psychiatric services, all-cause mortality, and acute health care use for individuals enrolled in Opioid Agonist Treatment, in Ontario, Canada. METHODS: We conducted a propensity score matching study of patients enrolled in Opioid Agonist Treatment in Ontario for the first time between January 1, 2011, and December 31, 2015. We first compared outcomes between patients who were actively engaged and patients who were not actively engaged in Opioid Agonist Treatment. We created treatment and a control groups on the basis of an individual's access to psychiatric care within an episode of Opioid Agonist Treatment. Relative risk and number needed to treat were calculated to determine the correlation between psychiatric care and health outcomes among patients enrolled in Opioid Agonist Treatment at two time points within an episode of care and for two geographic regions in Ontario (north and south). RESULTS: During the first year of Opioid Agonist Treatment, concurrent psychiatric care was associated with a reduction in all-cause mortality in southern Ontario (RR 0.80, 95% CI, 0.73-0.87), a reduction in emergency department visits in both northern and southern Ontario (north: RR = 0.76, 95% CI, 0.72-0.81; south: RR = 0.87, 95% CI, 0.86-0.88), and a reduction in hospitalizations (north: RR = 0.88, 95% CI. 0.82-0.94, south: RR = 0.92, 95% CI, 0.91-0.93). CONCLUSION: Our findings have significant clinical and political implications for health system planning highlighting the need for integrated mental health and addiction services for individuals with Opioid Use Disorder.

Density of Medical Marijuana Dispensaries and Current Marijuana Use among Young Adult Marijuana Users in Los Angeles.

Background: While tobacco and alcohol studies have focused on density of outlets as a determinant of consumption, research has begun examining the effects of medical marijuana (MM) dispensaries on marijuana use. Objectives: Examine the relationship between density of MM dispensaries and frequency of marijuana use among young adult medical marijuana patients (MMP) and nonpatient users (NPU). Methods: Young adult marijuana users (n = 329) aged 18- to 26-year old were sampled in Los Angeles in 2014-2015 and separated into MMP (n = 198) and NPU (n = 131). In 2014, 425 operational MM dispensaries were identified within the City of Los Angeles. Sequential multilevel Poisson random effect models examined density of MM dispensaries per square mile and 90 d marijuana use among MMP and NUP at the ZIP code level while controlling for demographic, behavioral, and community characteristics. Results: Density of MM dispensaries was not related to 90 d use of marijuana (days of use or hits per day) among either MMP or NPU. MMP reported significantly greater days of marijuana use in the past 90 d compared to NPU but no differences were found for hits per day. African-Americans reported significantly greater hits per day compared to whites. Hispanics reported significantly fewer hits per day compared to non-Hispanics. Conclusion: Concentration of MM dispensaries surrounding young adult marijuana users in Los Angeles was unrelated to days of marijuana use irrespective of having a MM recommendation or not. Rather, individual factors related to consumer choices and behaviors were more important in determining recent marijuana use among MMP and NPU.

Latitude continues to be significantly associated with the prevalence of multiple sclerosis: an updated meta-analysis.

OBJECTIVES: Previous studies have demonstrated a strong latitudinal gradient in multiple sclerosis (MS) prevalence. Herein, we present a meta-analysis of the latitudinal gradient of MS prevalence including studies published since our 2011 review, seeking to assess the latitudinal gradient and whether it has changed since our previous analysis. METHODS: Studies published up to December 2018 were located via Embase, Web of Knowledge and PubMed, using standardised search terms; data were extracted from peer-reviewed studies and these studies added to those from our previous analysis. Where age-specific data were available, prevalence estimates were age-/sex-standardised to the 2009 European population. Prevalence estimates were adjusted for study prevalence year and ascertainment methods. The latitudinal association with MS prevalence was assessed by meta-regression. RESULTS: A total of 94 studies met inclusion criteria, yielding 230 new prevalence points and 880 altogether with those from the prior study. There was a significant positive gradient in time-corrected MS prevalence with increasing latitude (5.27/100 000 per degree latitude), attenuating slightly to 4.34/100 000 on age-standardisation, these associations persisting on adjustment for ascertainment method. Of note, the age-standardised gradient was consistently significantly enhanced from our previous study, regardless of whether it was as-measured, time-corrected or adjusted for ascertainment methods. Certain areas, such as the Scandinavian and Atlantic Coast/Central Europe regions, showed changes in MS prevalence gradient over time, but other regional gradients were similar. CONCLUSIONS: This new meta-analysis confirms that MS prevalence is still strongly positively associated with increasing latitude and that the gradient is increasing, suggesting that potentially modifiable environmental factors, such as sun exposure, are still strongly associated with MS risk.

Assessing Spatial Relationships between Prescription Drugs, Race, and Overdose in New York State from 2013 to 2015.

Over the last decade, New York State has experienced one of the greatest increases in opioid overdose deaths in the United States, particularly from heroin and synthetic opioids. This study investigated spatial patterns in the distribution of county-level rates of overdose deaths in New York State and associations between prescriptions for opioid pain relievers, race, and overdose deaths from 2013-2015. Global and local Moran's I tests for spatial autocorrelation examined Bayesian smoothed rates of overdose for clusters of counties with high and low rates of overdose mortality. Getis Ord* analyses identified local hotspots of high and low clusters of overdose. Model performance indicators selected the best-fitting spatial regression model to examine associations between prescriptions for opioid pain relievers, race/ethnicity (non-Hispanic White, Black, and Hispanic) after adjusting for spatial dependence in the data. Socio-demographic characteristics of clusters were examined. Findings suggest rates of opioid overdose deaths are clustered in New York. Rates of prescription opioids were associated with rates of overdose from any opioid, prescription pain relievers, and synthetic opioids. Greater populations of African Americans were associated with greater rates of heroin overdose death rates. Findings from this study inform public health opioid overdose prevention interventions and policies.

Fentanyl shock: The changing geography of overdose in the United States.

BACKGROUND: Rapid increases in drug overdose deaths in the United States since 2014 have been highly regionally stratified, with the largest increases occurring in the eastern and northeastern states. By contrast, many western states saw overdose deaths plateau. This paper shows how the differential influx of fentanyl and fentanyl analogues in the drug supply has reshaped the geography and demography of the overdose crisis in the United States. METHODS: Using all state lab drug seizures obtained by Freedom of Information Act request, I analyze the regionally distinctive presence of fentanyl in the US drug supply with descriptive plots and statistical models. Main analyses explore state-year overdose trends using two-way fixed effects ordinary least squares (OLS) regression and two-stage least squares regression (2SLS) instrumenting for fentanyl exposure with state-longitude times a linear trend. RESULTS: First, fentanyl exposure is highly correlated with geography and only weakly explained by overdose rates prior to 2014. States in the east (higher degrees longitude) are much more heavily affected. Second, fentanyl exposure exhibits a statistically significant and important effect on overdose mortality, with model-predicted deaths broadly consistent with official death statistics. Third, fentanyl exposure explains most of the variation in increased overdose mortality between 2011 and 2017. Consequently, the epicenter of the overdose crisis shifted towards the eastern United States over these years. CONCLUSION: These findings shed light on the "third-wave" of the overdose epidemic, characterized by rapid and geographically disparate changes in drug supply that heighten the risk of overdose. Above all, they underscore the urgency of adopting evidence-based policies to combat addiction in light of the rapidly changing drug environment.

Opioid overdose deaths and potentially inappropriate opioid prescribing practices (PIP): A spatial epidemiological study.

INTRODUCTION: Opioid overdose deaths quintupled in Massachusetts between 2000 and 2016. Potentially inappropriate opioid prescribing practices (PIP) are associated with increases in overdoses. The purpose of this study was to conduct spatial epidemiological analyses of novel comprehensively linked data to identify overdose and PIP hotspots. METHODS: Sixteen administrative datasets, including prescription monitoring, medical claims, vital statistics, and medical examiner data, covering >98% of Massachusetts residents between 2011-2015, were linked in 2017 to better investigate the opioid epidemic. PIP was defined by six measures: ≥100 morphine milligram equivalents (MMEs), co-prescription of benzodiazepines and opioids, cash purchases of opioid prescriptions, opioid prescriptions without a recorded pain diagnosis, and opioid prescriptions through multiple prescribers or pharmacies. Using spatial autocorrelation and cluster analyses, overdose and PIP hotspots were identified among 538 ZIP codes. RESULTS: More than half of the adult population (n = 3,143,817, ages 18 and older) were prescribed opioids. Nearly all ZIP codes showed increasing rates of overdose over time. Overdose clusters were identified in Worcester, Northampton, Lee/Tyringham, Wareham/Bourne, Lynn, and Revere/Chelsea (Getis-Ord Gi*; p < 0.05). Large PIP clusters for ≥100 MMEs and prescription without pain diagnosis were identified in Western Massachusetts; and smaller clusters for multiple prescribers in Nantucket, Berkshire, and Hampden Counties (p < 0.05). Co-prescriptions and cash payment clusters were localized and nearly identical (p < 0.05). Overlap in PIP and overdose clusters was identified in Cape Cod and Berkshire County. However, we also found contradictory patterns in overdose and PIP hotspots. CONCLUSIONS: Overdose and PIP hotspots were identified, as well as regions where the two overlapped, and where they diverged. Results indicate that PIP clustering alone does not explain overdose clustering patterns. Our findings can inform public health policy decisions at the local level, which include a focus on PIP and misuse of heroin and fentanyl that aim to curb opioid overdoses.

Socioeconomic and geographical disparities in prescription and illicit opioid-related overdose deaths in Orange County, California, from 2010-2014.

Background: Reports indicate a geographic effect of socioeconomic inequalities on the occurrence of opioid-related fatal overdoses. This study aims to (1) estimate the rates of opioid-related overdoses, (2) estimate the association of benzodiazepine co-ingestion with opioid-related deaths, (3) estimate associations between socioeconomic indicators and opioid-related deaths, and (4) map the distribution of fatal overdoses, in Orange County (OC), California. Methods: An ecologic study was conducted of all opioid- related deaths (1205 total) from 2010 to 2014 obtained from the OC Coroner Division database (1065 OC residents, 55 nonresidents, 85 OC homeless) (analyzed 2016-2017). Rates of opioid overdose, benzodiazepine co-ingestion prevalence, and associations with socioeconomic status (SES; education, poverty, median income) using ZIP code analysis in the residential and homeless communities were calculated. Results: Of 1205 deaths, 904 involved prescription-type opioids, 223 involved heroin, 39 involved both, and 39 not stated; 973 were classified unintentional overdoses, 180 suicides, and 52 undetermined; 49% of cases involved benzodiazepines. Prescription-type opioid and heroin death rates for residents were 5.4/ 100,000 person-years (95% confidence interval [CI]: 5.0-5.8) and 1.2/100,000 person-years (95% CI: 1.0-1.4), respectively. Males, age group 45-54, and Caucasian race had the highest rate (13.6/100,000) of opioid mortality. The highest death rates were seen in homeless adults, at 136/100,000 person-years for prescription-type opioids (95% CI: 99.0-185.5) and 156/100,000 person-years for heroin (95% CI: 116.8-209.5). Conclusions: The burden of prescription-type opioid-related deaths in OC affects all demographics and levels of SES; there is a disproportionately high rate of opioid-related deaths in the OC homeless population.

Latitude, Vitamin D, Melatonin, and Gut Microbiota Act in Concert to Initiate Multiple Sclerosis: A New Mechanistic Pathway.

Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS). While the etiology of MS is still largely unknown, scientists believe that the interaction of several endogenous and exogenous factors may be involved in this disease. Epidemiologists have seen an increased prevalence of MS in countries at high latitudes, where the sunlight is limited and where the populations have vitamin D deficiency and high melatonin levels. Although the functions and synthesis of vitamin D and melatonin are contrary to each other, both are involved in the immune system. While melatonin synthesis is affected by light, vitamin D deficiency may be involved in melatonin secretion. On the other hand, vitamin D deficiency reduces intestinal calcium absorption leading to gut stasis and subsequently increasing gut permeability. The latter allows gut microbiota to transfer more endotoxins such as lipopolysaccharides (LPS) into the blood. LPS stimulates the production of inflammatory cytokines within the CNS, especially the pineal gland. This review summarizes the current findings on the correlation between latitude, sunlight and vitamin D, and details their effects on intestinal calcium absorption, gut microbiota and neuroinflammatory mediators in MS. We also propose a new mechanistic pathway for the initiation of MS.

Regional variation in hospitalizations and outpatient appointments for diverticular disease in Norway: a nationwide cross-sectional study.

OBJECTIVE: To investigate the use of specialized health care services for diverticular disease in different hospital referral regions in Norway. MATERIALS AND METHODS: Nationwide cross-sectional study with data from the Norwegian Patient Registry and Statistics Norway. All Norwegian inhabitants aged 40 years and older in the years 2012-16 (2,517,938) were included. We obtained the rates (n/100,000 population) for hospitalizations, outpatient appointments, and surgery for diverticular disease for the population in each hospital referral region. We also quantified the use of lower gastrointestinal (LGI) endoscopy in hospitalizations and outpatient appointments for diverticular disease and the use of LGI endoscopy performed on any indication. RESULTS: There were 131 hospitalizations and 381 outpatient appointments for diverticular disease per 100,000 population annually. Hospitalization rates varied 1.9-fold across regions from 94 to 175. Outpatient appointment rates varied 2.5-fold across regions from 258 to 655. Outpatient appointments were strongly correlated to hospitalizations (rs=0.75, p < .001) and outpatient LGI endoscopy for any indication (rs=0.67, p < .001). Hospitalization and surgery rates remained stable over the study period, while outpatient appointment rates increased by 37%. Concurrently, rates of outpatient LGI endoscopy performed on any indication increased by 35%. CONCLUSION: There was considerable regional variation in both hospitalizations and outpatient appointments for diverticular disease. The extent of variation and the correlation with diagnostic intensity of LGI endoscopy indicate that the regional variation in health care utilization for diverticular disease to a large extent can be explained by regional differences in clinical practice rather than disease burden.