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We highlight the paradoxical implications of decadal reclassification of U.S. counties (and America's population) from nonmetropolitan to metropolitan status between 1960 and 2017. Using data from the U.S. Census Bureau, we show that the reclassification of U.S. counties has been a significant engine of metropolitan growth and nonmetropolitan decline. Over the study period, 753-or nearly 25% of all nonmetropolitan counties-were redefined by the Office of Management and Budget (OMB) as metropolitan, shifting nearly 70 million residents from nonmetropolitan to metropolitan America by 2017. All the growth since 1970 in the metropolitan share of the U.S. population came from reclassification rather than endogenous growth in existing metropolitan areas. Reclassification of nonmetropolitan counties also had implications for drawing appropriate inferences about rural poverty, population aging, education, and economic growth. The paradox is that these many nonmetropolitan "winners"-those experiencing population and economic growth-have, over successive decades, left behind many nonmetropolitan counties with limited prospects for growth. Our study provides cautionary lessons regarding the commonplace narrative of widespread rural decline and economic malaise but also highlights the interdependent demographic fates of metropolitan and nonmetropolitan counties.Esophageal bypass surgery is an effective treatment strategy for esophageal cancer with esophago-tracheobronchial fistula. We herein report an esophageal cancer patient with esophago-pulmonary fistula who achieved a long-term survival but died suddenly because of cardiac tamponade. A 70-year-old male patient with esophago-pulmonary fistula due to esophageal tumor invasion underwent definitive chemoradiotherapy as the initial treatment. Esophageal bypass surgery followed by additional chemotherapy was performed, and the patient survived for a long time. Four years and six months later, a small abscess in an esophago-pulmonary fistula was visualized on computed tomography. One month later, he suffered suddenly severe dyspnea and died. An autopsy suggested that the direct cause of death had been cardiac tamponade due to atrio-pericardial fistula. selleck kinase inhibitor Definitive therapy for esophageal cancer with fistula after esophageal bypass is an effective treatment, but close special attention must be paid to the possibility of irradiation-related late toxicity.Past firefighting water additives were found to contain perfluorinated compounds that could persist in the environment resulting in potential adverse effects to biota. Since this revelation, manufacturers have introduced alternative firefighting water additives that are fluorine free, but few studies have investigated the fate and effects in the environment of these new additives. Firefighting water additives could enter aquatic ecosystems through run-off, leaching or direct application. Therefore, there is a need to investigate the potential effect that firefighting water additives could have on aquatic biota. This study investigated the toxicity of six firefighting water additives Eco-Gel™, Thermo-Gel™, FireAde™, Fire-Brake™, Novacool Foam™, and F-500™ to aquatic biota. The toxicities of firefighting water additives to Lemna minor (duckweed), Daphnia magna (water flea), Hexagenia spp. larvae (mayfly), Lampsilis fasciola (wavy-rayed lampmussel) and Oncorhynchus mykiss (rainbow trout) were investigated through acute and chronic static and semi-static tests to estimate LC50 values for survival and EC50 values for immobility and/or reproduction endpoints. A large variation in toxicities among the firefighting water additives and among the test species was observed. Based on a worst-case exposure scenario of direct application, several firefighting water additives were found to pose a hazard to aquatic organisms. An exposure rate representative of a direct overhead application by a water bomber during a forest fire was used in the hazard assessment. For example, the hazard quotients determined for the D. magna acute toxicity tests ranged from 0.20 for Eco-Gel to 317 for F-500 in the forest pool (15 cm) scenario. This study presents the first deterministic risk assessment of firefighting water additives in aquatic ecosystems.

To analyze the use of alvimopan, a peripheral mu-opioid receptor antagonist, in expediting gastrointestinal recovery after benign abdominal urinary tract reconstruction. Alvimopan use has been well defined in the management of radical cystectomy and urinary diversion for oncologic indications. It has not been studied in benign abdominal genitourinary reconstruction.

Patients who underwent urinary reconstruction utilizing harvested bowel segments for benign conditions from 12/2014-7/2019 were retrospectively reviewed. From 5/2018-7/2019 our institution approved the use of perioperative alvimopan in the aforementioned patients (N = 11), who were paired 12 with patients from a cohort of alvimopan-eligible patients who did not receive the drug (N = 22). Patients were paired by (1) type of reconstruction and (2) presence of neurogenic bowel-bladder (NBB).

Of the 70 patients who underwent urinary reconstruction during the study period, 46 patients (66%) were eligible to receive alvimopan. Length of stay was shorter for the alvimopan group compared to the non-alvimopan group (median 5days [IQR 4-5days] vs. 8days [IQR 6-11days]; P = 0.002). Time to first bowel movement was shorter for the alvimopan group (median 4days [IQR 3-4days] vs. 6days [IQR 4-7], P = 0.001). No patient treated with alvimopan required a nasogastric (NG) tube for post-operative ileus compared to 7 (32%) patients in the non-treatment group (P = 0.035). Post-operative complications and 30-day readmissions were similar between the two groups.

The use of perioperative alvimopan in benign abdominal urinary tract reconstruction expedited return of bowel function and decreased length of stay compared to a matched cohort of untreated patients.

The use of perioperative alvimopan in benign abdominal urinary tract reconstruction expedited return of bowel function and decreased length of stay compared to a matched cohort of untreated patients.