Shared and distinct interactions of type 1 and type 2 Epstein-Barr Nuclear Antigen 2 with the human genome.

BACKGROUND: There are two major genetic types of Epstein-Barr Virus (EBV): type 1 (EBV-1) and type 2 (EBV-2). EBV functions by manipulating gene expression in host B cells, using virus-encoded gene regulatory proteins including Epstein-Barr Nuclear Antigen 2 (EBNA2). While type 1 EBNA2 is known to interact with human transcription factors (hTFs) such as RBPJ, EBF1, and SPI1 (PU.1), type 2 EBNA2 shares only ~ 50% amino acid identity with type 1 and thus may have distinct binding partners, human genome binding locations, and functions. RESULTS: In this study, we examined genome-wide EBNA2 binding in EBV-1 and EBV-2 transformed human B cells to identify shared and unique EBNA2 interactions with the human genome, revealing thousands of type-specific EBNA2 ChIP-seq peaks. Computational predictions based on hTF motifs and subsequent ChIP-seq experiments revealed that both type 1 and 2 EBNA2 co-occupy the genome with SPI1 and AP-1 (BATF and JUNB) hTFs. However, type 1 EBNA2 showed preferential co-occupancy with EBF1, and type 2 EBNA2 preferred RBPJ. These differences in hTF co-occupancy revealed possible mechanisms underlying type-specific gene expression of known EBNA2 human target genes: MYC (shared), CXCR7 (type 1 specific), and CD21 (type 2 specific). Both type 1 and 2 EBNA2 binding events were enriched at systemic lupus erythematosus (SLE) and multiple sclerosis (MS) risk loci, while primary biliary cholangitis (PBC) risk loci were specifically enriched for type 2 peaks. CONCLUSIONS: This study reveals extensive type-specific EBNA2 interactions with the human genome, possible differences in EBNA2 interaction partners, and a possible new role for type 2 EBNA2 in autoimmune disorders. Our results highlight the importance of considering EBV type in the control of human gene expression and disease-related investigations.

Improving measurement-based care implementation in adult ambulatory psychiatry: a virtual focus group interview with multidisciplinary healthcare professionals.

BACKGROUND: Measurement-Based Care (MBC) is an evidence-based practice shown to enhance patient care. Despite being efficacious, MBC is not commonly used in practice. While barriers and facilitators of MBC implementation have been described in the literature, the type of clinicians and populations studied vary widely, even within the same practice setting. The current study aims to improve MBC implementation in adult ambulatory psychiatry by conducting focus group interviews while utilizing a novel virtual brainwriting premortem method. METHODS: Semi-structured focus group interviews were conducted with clinicians (n = 18) and staff (n = 7) to identify their current attitudes, facilitators, and barriers of MBC implementation in their healthcare setting. Virtual video-conferencing software was used to conduct focus groups, and based on transcribed verbatin, emergent barriers/facilitators and four themes were identified. Mixed methods approach was utilized for this study. Specifically, qualitative data was aggregated and re-coded separately by three doctoral-level coders. Quantitative analyses were conducted from a follow-up questionnaire surveying clinician attitudes and satisfaction with MBC. RESULTS: The clinician and staff focus groups resulted in 291 and 91 unique codes, respectively. While clinicians identified a similar number of barriers (40.9%) and facilitators (44.3%), staff identified more barriers (67%) than facilitators (24.7%) for MBC. Four themes emerged from the analysis; (1) a description of current status/neutral opinion on MBC; (2) positive themes that include benefits of MBC, facilitators, enablers, or reasons on why they conduct MBC in their practice, (3) negative themes that include barriers or issues that hinder them from incorporating MBC into their practice, and (4) requests and suggestions for future MBC implementation. Both participant groups raised more negative themes highlighting critical challenges to MBC implementation than positive themes. The follow-up questionnaire regarding MBC attitudes showed the areas that clinicians emphasized the most and the least in their clinical practice. CONCLUSION: The virtual brainwriting premortem focus groups provided critical information on the shortcomings and strengths of MBC in adult ambulatory psychiatry. Our findings underscore implementation challenges in healthcare settings and provide insight for both research and clinical practice in mental health fields. The barriers and facilitators identified in this study can inform future training to increase sustainability and better integrate MBC with positive downstream outcomes in patient care.

Outbreak of Acute Respiratory Illness Associated With Human Adenovirus Type 4 at the United States Coast Guard Academy, 2019.

BACKGROUND: Although a human adenovirus (HAdV) vaccine is available for military use, officers-in-training are not routinely vaccinated. We describe an HAdV-associated respiratory outbreak among unvaccinated cadets at the US Coast Guard Academy and its impact on cadet training. METHODS: We defined a case as a cadet with new onset cough or sore throat during August 1-October 4, 2019. We reviewed medical records and distributed a questionnaire to identify cases and to estimate impact on cadet training. We performed real-time polymerase chain reaction testing on patient and environmental samples and whole genome sequencing on a subset of positive patient samples. RESULTS: Among the 1072 cadets, 378 (35%) cases were identified by medical records (n = 230) or additionally by the questionnaire (n = 148). Of the 230 cases identified from medical records, 138 (60%) were male and 226 (98%) had no underlying conditions. From questionnaire responses, 113 of 228 (50%) cases reported duty restrictions. Of cases with respiratory specimens, 36 of 50 (72%) were HAdV positive; all 14 sequenced specimens were HAdV-4a1. Sixteen (89%) of 18 environmental specimens from the cadet dormitory were HAdV-positive. CONCLUSIONS: The HAdV-4-associated outbreak infected a substantial number of cadets and significantly impacted cadet training. Routine vaccination could prevent HAdV respiratory outbreaks in this population.

Epidemiologic and Clinical Characteristics of Monkeypox Cases - United States, May 17-July 22, 2022.

Monkeypox, a zoonotic infection caused by an orthopoxvirus, is endemic in parts of Africa. On August 4, 2022, the U.S. Department of Health and Human Services declared the U.S. monkeypox outbreak, which began on May 17, to be a public health emergency (1,2). After detection of the first U.S. monkeypox case), CDC and health departments implemented enhanced monkeypox case detection and reporting. Among 2,891 cases reported in the United States through July 22 by 43 states, Puerto Rico, and the District of Columbia (DC), CDC received case report forms for 1,195 (41%) cases by July 27. Among these, 99% of cases were among men; among men with available information, 94% reported male-to-male sexual or close intimate contact during the 3 weeks before symptom onset. Among the 88% of cases with available data, 41% were among non-Hispanic White (White) persons, 28% among Hispanic or Latino (Hispanic) persons, and 26% among non-Hispanic Black or African American (Black) persons. Forty-two percent of persons with monkeypox with available data did not report the typical prodrome as their first symptom, and 46% reported one or more genital lesions during their illness; 41% had HIV infection. Data suggest that widespread community transmission of monkeypox has disproportionately affected gay, bisexual, and other men who have sex with men and racial and ethnic minority groups. Compared with historical reports of monkeypox in areas with endemic disease, currently reported outbreak-associated cases are less likely to have a prodrome and more likely to have genital involvement. CDC and other federal, state, and local agencies have implemented response efforts to expand testing, treatment, and vaccination. Public health efforts should prioritize gay, bisexual, and other men who have sex with men, who are currently disproportionately affected, for prevention and testing, while addressing equity, minimizing stigma, and maintaining vigilance for transmission in other populations. Clinicians should test patients with rash consistent with monkeypox,† regardless of whether the rash is disseminated or was preceded by prodrome. Likewise, although most cases to date have occurred among gay, bisexual, and other men who have sex with men, any patient with rash consistent with monkeypox should be considered for testing. CDC is continually evaluating new evidence and tailoring response strategies as information on changing case demographics, clinical characteristics, transmission, and vaccine effectiveness become available.§.

Epidemiologic and Clinical Features of Children and Adolescents Aged <18 Years with Monkeypox - United States, May 17-September 24, 2022.

Data on monkeypox in children and adolescents aged <18 years are limited (1,2). During May 17­September 24, 2022, a total of 25,038 monkeypox cases were reported in the United States,† primarily among adult gay, bisexual, and other men who have sex with men (3). During this period, CDC and U.S. jurisdictional health departments identified Monkeypox virus (MPXV) infections in 83 persons aged <18 years, accounting for 0.3% of reported cases. Among 28 children aged 0­12 years with monkeypox, 64% were boys, and most had direct skin-to-skin contact with an adult with monkeypox who was caring for the child in a household setting. Among 55 adolescents aged 13­17 years, most were male (89%), and male-to-male sexual contact was the most common presumed exposure route (66%). Most children and adolescents with monkeypox were non-Hispanic Black or African American (Black) (47%) or Hispanic or Latino (Hispanic) (35%). Most (89%) were not hospitalized, none received intensive care unit (ICU)­level care, and none died. Monkeypox in children and adolescents remains rare in the United States. Ensuring equitable access to monkeypox vaccination, testing, and treatment is a critical public health priority. Vaccination for adolescents with risk factors and provision of prevention information for persons with monkeypox caring for children might prevent additional infections.

Effects of COVID-19 on Patients in Adult Ambulatory Psychiatry: Using Patient-Rated Outcome Measures and Telemedicine.

Introduction: To examine the effects of coronavirus disease 2019 (COVID-19) on patients in an academic psychiatric ambulatory clinic, data from a measurement-based care (MBC) system were analyzed to evaluate impacts on psychiatric functioning in patients using telemedicine. Psychiatric functioning was evaluated for psychological distress (brief adjustment scale [BASE]-6), depression (patient health questionnaire [PHQ]-9), and anxiety (generalized anxiety disorder [GAD]-7), including initial alcohol (U.S. alcohol use disorders identification test) and substance use (drug abuse screening test-10) screening. Methods: This observational study included MBC data collected from November 2019 to March 2021. Patient-Reported Outcome Measures (PROMs) were examined to determine changes in symptomatology over the course of treatment, as well as symptom changes resulting from the pandemic. Patients were included in analyses if they completed at least one PROM in the MBC system. Results: A total of 2,145 patients actively participated in the MBC system completing at least one PROM, with engagement ranging from 35.07% to 83.50% depending on demographic factors, where completion rates were significantly different for age, payor status, and diagnostic group. Average baseline scores for new patients varied for the GAD-7, PHQ-9, and BASE-6. Within-person improvements in mental health before and after the pandemic were statistically significant for anxiety, depression, and psychological adjustment. Discussion: MBC is a helpful tool in determining treatment progress for patients engaging in telemedicine. This study showed that patients who engaged in psychiatric services incorporating PROMs had improvements in mental health during the COVID-19 pandemic. Additional research is needed exploring whether PROMs might serve as a protective or facilitative factor for those with mental illness during a crisis when in-person visits are not possible.

Automated Digital Notification of COVID-19 Diagnoses Through Text and Email Messaging - North Carolina, December 2020-January 2021.

During October 3, 2020-January 9, 2021, North Carolina experienced a 400% increase in daily reported COVID-19 cases (1). To handle the increased number of cases and rapidly notify persons receiving a positive SARS-CoV-2 test result (patients), North Carolina state and local health departments moved from telephone call notification only to telephone call plus automated text and email notification (digital notification) beginning on December 24, 2020. Overall, among 200,258 patients, 142,975 (71%) were notified by telephone call or digital notification within the actionable period (10 days from their diagnosis date)* during January 2021, including at least 112,543 (56%) notified within 24 hours of report to North Carolina state and local health departments, a significantly higher proportion than the 25,905 of 175,979 (15%) notified within 24 hours during the preceding month (p<0.001). Differences in text notification by age, race, and ethnicity were observed. Automated digital notification is a feasible, rapid and efficient method to support timely outreach to patients, provide guidance on how to isolate, access resources, inform close contacts, and increase the efficiency of case investigation staff members.

COVID-19 Vaccine Administration, by Race and Ethnicity - North Carolina, December 14, 2020-April 6, 2021.

COVID-19 has disproportionately affected non-Hispanic Black or African American (Black) and Hispanic persons in the United States (1,2). In North Carolina during January-September 2020, deaths from COVID-19 were 1.6 times higher among Black persons than among non-Hispanic White persons (3), and the rate of COVID-19 cases among Hispanic persons was 2.3 times higher than that among non-Hispanic persons (4). During December 14, 2020-April 6, 2021, the North Carolina Department of Health and Human Services (NCDHHS) monitored the proportion of Black and Hispanic persons* aged ≥16 years who received COVID-19 vaccinations, relative to the population proportions of these groups. On January 14, 2021, NCDHHS implemented a multipronged strategy to prioritize COVID-19 vaccinations among Black and Hispanic persons. This included mapping communities with larger population proportions of persons aged ≥65 years among these groups, increasing vaccine allocations to providers serving these communities, setting expectations that the share of vaccines administered to Black and Hispanic persons matched or exceeded population proportions, and facilitating community partnerships. From December 14, 2020-January 3, 2021 to March 29-April 6, 2021, the proportion of vaccines administered to Black persons increased from 9.2% to 18.7%, and the proportion administered to Hispanic persons increased from 3.9% to 9.9%, approaching the population proportion aged ≥16 years of these groups (22.3% and 8.0%, respectively). Vaccinating communities most affected by COVID-19 is a national priority (5). Public health officials could use U.S. Census tract-level mapping to guide vaccine allocation, promote shared accountability for equitable distribution of COVID-19 vaccines with vaccine providers through data sharing, and facilitate community partnerships to support vaccine access and promote equity in vaccine uptake.

Anhydrous Ammonia Chemical Release - Lake County, Illinois, April 2019.

On April 25, 2019, a farm tractor towing two 2-ton ammonia tanks on a county road in Lake County, Illinois, experienced a mechanical failure that resulted in the release of anhydrous ammonia, a colorless, pungent, irritating gas that can cause severe respiratory and ocular damage (1). Approximately 80% of anhydrous ammonia produced in the United States is used as a fertilizer in agriculture (1). Eighty-three persons, including first responders, motorists, and neighborhood residents, were evaluated at area hospitals because of exposure to the gas. Two weeks after the release, the Agency for Toxic Substances and Disease Registry (ATSDR) and CDC's National Center for Environmental Health (NCEH) collaborated with the Lake County Health Department and the Illinois Department of Public Health on an investigation using ATSDR's Assessment of Chemical Exposures program to describe the release, review the emergency response, and determine health effects associated with the exposure. First responders, community residents, and hospital personnel reported communication challenges related to the nature of the gas release and effective protective measures. Among the 83 persons evaluated at six area hospitals for effects of the chemical release, 14 (17%) were hospitalized, including eight (10%) who were admitted to the intensive care unit (ICU), seven (8%) of whom required endotracheal intubation and mechanical ventilation; no deaths occurred. In addition, ICU health care providers experienced symptoms of secondary exposure. The National Institute for Occupational Safety and Health's Emergency Responder Health Monitoring and Surveillance Program has specific recommendations and tools to protect responders during all phases of a response (2). Hospitals also need to review institutional policies and procedures for chemical mass casualty events, including decontamination (3). Prompt and correct identification of hazardous material (hazmat) events, and clear communication among responding entities, including on-scene and hospital responders, is important to ensure effective response after a chemical release.

Physical Activity Facilitators and Barriers Among Retired Women in North Carolina: A Qualitative Study.

BACKGROUND Women are less likely than men to be physically active and more likely to reduce their physical activity as they age. The objective of this research was to understand barriers that might prevent North Carolina women from being physically active after retirement as well as aspects of retirement that might facilitate a more physically active lifestyle to inform intervention strategies applicable to retired women.METHOD Semi-structured interviews were conducted with 15 recently retired women living in North Carolina. Interviews were recorded and transcribed. Content analysis was used to identify themes related to barriers and facilitators of physical activity after retirement.RESULTS Six themes were identified. One theme was the development of leisure-time physical activity habits over the lifespan. Five other themes described how physical activity after retirement was influenced by prior occupational physical activity, concurrent life transitions (e.g., becoming a caregiver), health, social support, and the community environment.LIMITATIONS Women in this study were active participants in community organizations, which might make their experiences unique from those of women who are not engaged with their communities. However, similarities in themes in this and other qualitative studies corroborate the broader transferability of findings.CONCLUSION Interventions to promote physical activity among retired North Carolina women should consider emphasizing health benefits of physical activity and improving walking environments and access to physical activity facilities. Local residents should be involved in intervention design to address unique barriers among women who retire from physically demanding jobs or become caregivers.

Sepsis Attributed to Bacterial Contamination of Platelets Associated with a Potential Common Source - Multiple States, 2018.

During May-October 2018, four patients from three states experienced sepsis after transfusion of apheresis platelets contaminated with Acinetobacter calcoaceticus-baumannii complex (ACBC) and Staphylococcus saprophyticus; one patient died. ACBC isolates from patients' blood, transfused platelet residuals, and two environmental samples were closely related by whole genome sequencing. S. saprophyticus isolates from two patients' blood, three transfused platelet residuals, and one hospital environmental sample formed two whole genome sequencing clusters. This whole genome sequencing analysis indicated a potential common source of bacterial contamination; investigation into the contamination source continues. All platelet donations were collected using apheresis cell separator machines and collection sets from the same manufacturer; two of three collection sets were from the same lot. One implicated platelet unit had been treated with pathogen-inactivation technology, and two had tested negative with a rapid bacterial detection device after negative primary culture. Because platelets are usually stored at room temperature, bacteria in contaminated platelet units can proliferate to clinically relevant levels by the time of transfusion. Clinicians should monitor for sepsis after platelet transfusions even after implementation of bacterial contamination mitigation strategies. Recognizing adverse transfusion reactions and reporting to the platelet supplier and hemovigilance systems is crucial for public health practitioners to detect and prevent sepsis associated with contaminated platelets.

Temporal heterogeneity increases with spatial heterogeneity in ecological communities.

Heterogeneity is increasingly recognized as a foundational characteristic of ecological systems. Under global change, understanding temporal community heterogeneity is necessary for predicting the stability of ecosystem functions and services. Indeed, spatial heterogeneity is commonly used in alternative stable state theory as a predictor of temporal heterogeneity and therefore an early indicator of regime shifts. To evaluate whether spatial heterogeneity in species composition is predictive of temporal heterogeneity in ecological communities, we analyzed 68 community data sets spanning freshwater and terrestrial systems where measures of species abundance were replicated over space and time. Of the 68 data sets, 55 (81%) had a weak to strongly positive relationship between spatial and temporal heterogeneity, while in the remaining communities the relationship was weak to strongly negative (19%). Based on a mixed model analysis, we found a significant but weak overall positive relationship between spatial and temporal heterogeneity across all data sets combined, and within aquatic and terrestrial data sets separately. In addition, lifespan and successional stage were negatively and positively related to temporal heterogeneity, respectively. We conclude that spatial heterogeneity may be a predictor of temporal heterogeneity in ecological communities, and that this relationship may be a general property of many terrestrial and aquatic communities.

Species reordering, not changes in richness, drives long-term dynamics in grassland communities.

Determining how ecological communities will respond to global environmental change remains a challenging research problem. Recent meta-analyses concluded that most communities are undergoing compositional change despite no net change in local species richness. We explored how species richness and composition of co-occurring plant, grasshopper, breeding bird and small mammal communities in arid and mesic grasslands changed in response to increasing aridity and fire frequency. In the arid system, grassland and shrubland plant and breeding bird communities were undergoing directional change, whereas grasshopper and small mammal communities were stable. In the mesic system, all communities were undergoing directional change regardless of fire frequency. Despite directional change in composition in some communities, species richness of all communities did not change because compositional change resulted more from reordering of species abundances than turnover in species composition. Thus, species reordering, not changes in richness, explains long-term dynamics in these grass and shrub dominated communities.

Press-pulse interactions: effects of warming, N deposition, altered winter precipitation, and fire on desert grassland community structure and dynamics.

Global environmental change is altering temperature, precipitation patterns, resource availability, and disturbance regimes. Theory predicts that ecological presses will interact with pulse events to alter ecosystem structure and function. In 2006, we established a long-term, multifactor global change experiment to determine the interactive effects of nighttime warming, increased atmospheric nitrogen (N) deposition, and increased winter precipitation on plant community structure and aboveground net primary production (ANPP) in a northern Chihuahuan Desert grassland. In 2009, a lightning-caused wildfire burned through the experiment. Here, we report on the interactive effects of these global change drivers on pre- and postfire grassland community structure and ANPP. Our nighttime warming treatment increased winter nighttime air temperatures by an average of 1.1 °C and summer nighttime air temperature by 1.5 °C. Soil N availability was 2.5 times higher in fertilized compared with control plots. Average soil volumetric water content (VWC) in winter was slightly but significantly higher (13.0% vs. 11.0%) in plots receiving added winter rain relative to controls, and VWC was slightly higher in warmed (14.5%) compared with control (13.5%) plots during the growing season even though surface soil temperatures were significantly higher in warmed plots. Despite these significant treatment effects, ANPP and plant community structure were highly resistant to these global change drivers prior to the fire. Burning reduced the cover of the dominant grasses by more than 75%. Following the fire, forb species richness and biomass increased significantly, particularly in warmed, fertilized plots that received additional winter precipitation. Thus, although unburned grassland showed little initial response to multiple ecological presses, our results demonstrate how a single pulse disturbance can interact with chronic alterations in resource availability to increase ecosystem sensitivity to multiple drivers of global environmental change.

Park characteristics, use, and physical activity: A review of studies using SOPARC (System for Observing Play and Recreation in Communities).

The System for Observing Play and Recreation in Communities (SOPARC) can obtain information on park users and their physical activity using momentary time sampling. We conducted a literature review of studies using the SOPARC tool to describe the observational methods of each study, and to extract public park use overall and by demographics and physical activity levels. We searched PubMed, Embase, and SPORTDiscus for full-length observational studies published in English in peer-reviewed journals through 2014. Twenty-four studies from 34 articles were included. The number of parks observed per study ranged from 3 to 50. Most studies observed parks during one season. The number of days parks were observed ranged from 1 to 16, with 16 studies observing 5 or more days. All studies included at least one weekday and all but two included at least one weekend day. Parks were observed from 1 to 14times/day, with most studies observing at least 4 times/day. All studies included both morning and afternoon observations, with one exception. There was a wide range of park users (mean 1.0 to 152.6 people/park/observation period), with typically more males than females visiting parks and older adults less than other age groups. Park user physical activity levels varied greatly across studies, with youths generally more active than adults and younger children more active than adolescents. SOPARC was adapted to numerous settings and these review results can be used to improve future studies using the tool, demonstrate ways to compare park data, and inform park promotions and programming.

Physical Activity-Related Policy and Environmental Strategies to Prevent Obesity in Rural Communities: A Systematic Review of the Literature, 2002-2013.

INTRODUCTION: Health disparities exist between rural and urban residents; in particular, rural residents have higher rates of chronic diseases and obesity. Evidence supports the effectiveness of policy and environmental strategies to prevent obesity and promote health equity. In 2009, the Centers for Disease Control and Prevention recommended 24 policy and environmental strategies for use by local communities: the Common Community Measures for Obesity Prevention (COCOMO); 12 strategies focus on physical activity. This review was conducted to synthesize evidence on the implementation, relevance, and effectiveness of physical activity-related policy and environmental strategies for obesity prevention in rural communities. METHODS: A literature search was conducted in PubMed, PsycINFO, Web of Science, CINHAL, and PAIS databases for articles published from 2002 through May 2013 that reported findings from physical activity-related policy or environmental interventions conducted in the United States or Canada. Each article was extracted independently by 2 researchers. RESULTS: Of 2,002 articles, 30 articles representing 26 distinct studies met inclusion criteria. Schools were the most common setting (n = 18 studies). COCOMO strategies were applied in rural communities in 22 studies; the 2 most common COCOMO strategies were "enhance infrastructure supporting walking" (n = 11) and "increase opportunities for extracurricular physical activity" (n = 9). Most studies (n = 21) applied at least one of 8 non-COCOMO strategies; the most common was increasing physical activity opportunities at school outside of physical education (n = 8). Only 14 studies measured or reported physical activity outcomes (10 studies solely used self-report); 10 reported positive changes. CONCLUSION: Seven of the 12 COCOMO physical activity-related strategies were successfully implemented in 2 or more studies, suggesting that these 7 strategies are relevant in rural communities and the other 5 might be less applicable in rural communities. Further research using robust study designs and measurement is needed to better ascertain implementation success and effectiveness of COCOMO and non-COCOMO strategies in rural communities.

Disparities in physical activity resource availability in six US regions.

OBJECTIVE: We conducted an ecological study to determine physical activity resource availability overall and by sociodemographic groups in parts of six states (CA, IL, MD, MN, NC, NY). METHODS: Data on parks and recreational facilities were collected from 3 sources in 2009-2012. Three measures characterized park and recreational facility availability at the census tract level: presence of ≥1 resource, number of resources, and resource kernel density. Associations between resource availability and census tract characteristics (predominant racial/ethnic group, median income, and proportion of children and older adults) were estimated using linear, binomial, and zero-inflated negative binomial regression in 2014. Pooled and stratified analyses were conducted. RESULTS: The study included 7139 census tracts, comprising 9.5% of the 2010 US population. Overall the availability of parks and recreational facilities was lower in predominantly minority relative to non-Hispanic white census tracts. Low-income census tracts and those with a higher proportion of children had an equal or greater availability of park resources but fewer recreational facilities. Stratification revealed substantial variation in resource availability by site. CONCLUSION: The availability of physical activity resources varied by sociodemographic characteristics and across regions. Improved knowledge of resource distribution can inform strategies to provide equitable access to parks and recreational facilities.

Validity of hospital discharge diagnosis codes for stroke: the Atherosclerosis Risk in Communities Study.

BACKGROUND AND PURPOSE: Characterizing International Classification of Disease 9th Revision, Clinical Modification (ICD-9-CM) code validity is essential given widespread use of hospital discharge databases in research. Using the Atherosclerosis Risk in Communities (ARIC) Study, we estimated the accuracy of ICD-9-CM stroke codes. METHODS: Hospitalizations with ICD-9-CM codes 430 to 438 or stroke keywords in the discharge summary were abstracted for ARIC cohort members (1987-2010). A computer algorithm and physician reviewer classified definite and probable ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Using ARIC classification as a gold standard, we calculated the positive predictive value (PPV) and sensitivity of ICD-9-CM codes grouped according to the American Heart Association/American Stroke Association (AHA/ASA) 2013 categories and an alternative code grouping for comparison. RESULTS: Thirty-three percent of 4260 hospitalizations were validated as strokes (1251 ischemic, 120 intracerebral hemorrhage, 46 subarachnoid hemorrhage). The AHA/ASA code groups had PPV 76% and 68% sensitivity compared with PPV 72% and 83% sensitivity for the alternative code groups. The PPV of the AHA/ASA code group for ischemic stroke was slightly higher among blacks, individuals <65 years, and at teaching hospitals. Sensitivity was higher among older individuals and increased over time. The PPV of the AHA/ASA code group for intracerebral hemorrhage was higher among blacks, women, and younger individuals. PPV and sensitivity varied across study sites. CONCLUSIONS: A new AHA/ASA discharge code grouping to identify stroke had similar PPV and lower sensitivity compared with an alternative code grouping. Accuracy varied by patient characteristics and study sites.

Adenocarcinoma of the distal esophagus and esophageal-proventricular junction in a yellow-naped parrot.

A 57-y-old male yellow-naped parrot (Amazona auropalliata) was presented because of lethargy, inappetence, and weight loss. Hematology and serum biochemistry were unremarkable, and imaging revealed a mass in the distal esophagus at the coelomic inlet. The luminal diameter of the esophagus was reduced in this area, and passage of ingesta was limited. Following gavage feeding, the patient died and was submitted for autopsy. At postmortem examination, the noted mass effect was a thickening of the distal esophagus with adherent, coalescing, soft, pale-tan plaques on the mucosal surface. Additional gross findings included pale-tan, opaque feed material oozing from the dorsum of the lungs and covering the cranial air sacs. Histology of the esophagus, esophageal-proventricular junction, and proximal proventriculus revealed an unencapsulated, infiltrative, transmural neoplasm that extended from the mucosal surface deep into the muscularis, almost to the adventitia. The neoplasm was composed of cuboidal cells arranged in islands and tubules, consistent with an adenocarcinoma, a rarely reported entity in the esophagus of psittacine birds and to our knowledge not reported previously at the esophageal-proventricular junction.