Conclusions: PE-related concussions had the second highest incidence rate after organized sports. A significant gender difference was observed in PE class. Awareness about concussions and methods to reduce the risk of concussion is suggested for PE classes.Background: Concussions are one of the most common head injuries acquired within the pediatric population. While sport-related concussions are well documented, concussions within other aspects of a child’s life are not as well researched. The purpose of this study is to examine the incidence of a large pediatric concussion population in a broad range of daily activities. Methods: Patients’ gender and nature of injury were extracted from 1408 medical records of patients who were diagnosed with a concussion at Saint Peter’s Sports Medicine Institute. Statistical analyses were conducted for activities and environmental settings using chi-squared tests. Results: Concussions were most prevalent in organized sports (53.3%), followed by injuries within the following settings: school (16.5%), recreational (6.7%), motor vehicle collisions (6.6%), home (5.5%), and other (11.3%). Specifically, soccer (12.9%), school physical education (PE) class (10.6%), and football (9.8%) subcategories recorded the most incidences of concussion. For the PE class cohort ( Concussion is a common traumatic head injury that is most often associated with contact sports or battlefield injuries ,2. PreviThe diagnosis of concussion is on the rise, and the exact epidemiology is still not completely understood. Many studies report that females have a greater incidence of sports-related concussion compared to males in organized sports ,11,12,13The study design was retrospective, and methods will be discussed in terms of concussion population sample, classification of concussions, rationale for concussion incidence groupings, and statistical analyses. The Saint Peter’s University Hospital Ethics Committee for the Protection of Human Subjects in Research approved this retrospective study, in accordance with the United States Code of Federal Regulations 21CFR 56.110.n = 790) were female.The data were extracted from records of pediatric concussion participants by one of the authors (A.G.), a pediatric sports medicine physician, who diagnosed all the participants with a concussion. The concussion setting (nature of activity when a concussion was acquired) and the gender of the patient were collected. The data presented in this study represents all the participants that sought treatment at the Saint Peter’s University Hospital (SPUH) Sports Medicine Institute (SMI) in Somerset, New Jersey, between 15 September 2014 and 31 May 2018 (~4 years). SMI is located in Central New Jersey and is easily accessible to at least a third of the state’s population of 2 million pediatric-age individuals [The primary variables were mechanism of injury and gender. Incidences of concussion were organized into five primary categories: organized sports, school setting, home setting, motor vehicle collisions, and recreational activities. Concussions that were not categorized into the prior five categories were grouped as “other”. All mechanism of injury and gender data were classified within a single category. No data were included in two or more categories. The categories of organized sports and school setting were subdivided into subcategories for an analysis of specific concussion incidences. The following subcategories are included under organized sports: soccer; football; basketball; lacrosse; cheerleading; combat sports, which includes mixed martial arts (MMA); boxing and wrestling; ice hockey; field hockey; softball; and other organized sports. The sports squash, tennis, golf, ultimate frisbee, etc., were grouped into the “other organized sports” subcategory of organized sports. The concussions resulting from a school setting were analyzed with two methods. One analysis for the school setting cohort examined incidence of concussion, investigating gender as a function of the child’s type of school—specifically, primary, middle, or high schools. The other analysis for the school-setting cohort examined incidences of concussions in physical education (PE) classes as a function of gender. This sub-category includes the study of all activities within PE class, such as PE basketball and PE volleyball. No data were classified in more than one sub-category or cohort.The motor vehicle collisions (MVC) cohort includes concussions acquired while inside a motor vehicle (either as a driver or passenger), or an impact by a motor vehicle as a pedestrian. The home-setting cohort includes all injuries and collisions which lead to a concussion diagnosis within a patient’s home. These injuries range from falling in the shower, slipping on ice near the home, or a blunt injury to the head while colliding with a door, to what many patient’s parents described as “horsing around”. The recreational cohort includes head injuries while bicycling, skateboarding/hoverboarding, snowboarding, sledding, tubing, ice skating, trampolining, ziplining, horseback riding, alcohol related injuries, and injuries acquired in amusement parks. Finally, the following activities and settings are examples that could not be grouped into any of the five primary categories, and were listed within the “other” cohort: tripping while casually walking, slipping on ice (not near the home such as a shopping area), fainting, head injury while entering a car, being involved in a physical altercation, and having objects  thrown at subject.The criteria for the diagnosis of a concussion included the following: (1) patient sustained a direct impact to the head, face, neck, or elsewhere on the body that could result in an impulsive force transmitted to the head; and (2) the presentation of at least one symptom  within 24 h of sustaining the injury during cognitive or physical exertion. Participants who had sustained a head injury but were (1) symptom-free the following day, (2) could read for longer than 30 min, (3) could do homework for two or more hours, and (4) could perform moderate to heavy physical exertion without symptoms were not diagnosed with a concussion. These subjects were excluded from this analysis.p-value) of less than 0.05 for the chi-squared test. The significance p-value was corrected with Bonferroni’s correction for multiplicity of tests, in order to avoid Type I errors. Since a total of 10 statistical comparisons were performed, the significance p-value was lowered to 0.005 to correct for multiple comparisons. Gender differences were computed in the following cohorts, due to the expectation that male and female participation was about equivalent: all organized sports, PE for schooling levels , organized soccer, and organized basketball, as well as the high school setting, middle school setting, primary school setting, home setting, recreational activities, and motor vehicle collisions. There were no missing data to account for within this study. Statistical analyses were computed utilizing IBM SPSS Statistics 20 package.Statistical power for an effect size between 0.1 and 0.2, with 80% power and alpha = 0.05, yields a sample size between 392 and 1568 participants . With 14The following findings will be presented: incidences of all recorded concussions from the primary and sub-categories, concussion percentages in each category, top-five categories of activities where concussions were observed, and an incidence rate of concussion as a function of gender comparison.n = 751). The remaining concussions were attributed to concussions within the school setting , recreational activities , motor vehicle collisions , and the home setting . A few  of the concussions did not fall into any of the five primary categories, and are listed as “other”.The numbers and percentages of concussions recorded in each cohort are reported in n = 182), within the organized sports cohort (n = 751). Football and basketball followed at 18.4% (n = 138) and 11.1% (n = 83), respectively. These three sports accounted for approximately 54% of all organized sports-related concussions. Lacrosse , cheerleading , and combat sports  had the next three highest incidences of sports-related concussions. The combat sports of wrestling, boxing, and MMA were grouped together because of the similar nature of the activities. The final three sports to have the highest incidence of concussions were ice hockey (n = 33), softball (n = 29), and field hockey (n = 26), at approximately 2% each. Other organized sports-related concussions accounted for the remaining 6.5% (n = 91) of the concussions in this category.Soccer was observed to have the highest number of concussions, at 24.2% (n = 232), there were two different types of subcategorizations of the data performed (see n = 100) of all concussions in a school setting. Middle  and primary schools  had comparatively lower incidence of concussions. For the second analysis, concussions from PE class accounted for 64.2% (n = 149) of all concussions that were recorded in a school setting. PE basketball  and PE volleyball  accounted for the highest number of incidents of concussions in a school setting; this translates to 23% and 18% of all recorded PE incidences of concussions, respectively.For the school setting primary category (rmed see . The firn = 136), 89% (n = 41), 82% (n = 27), and 64% (n = 39), respectively, when compared to their female counterparts. Conversely, sports with traditionally higher female participation in the state of New Jersey, United States such as cheerleading, field hockey, and softball had a female concussion incidence rate of 100%. In the remaining sports of soccer and basketball, where male and female participation is assumed to be similar, females had higher incidence of concussions at 57% (n = 103) and 59% (n = 49), respectively. These higher observed female incidences of concussion in soccer  and basketball  are, however, not statistically different from the gender proportions of the entire study population. The total number of males who experienced a sport-related concussion in the more popular organized sports (n = 356) was compared to the number of females who experiences a sport-related concussion in the more popular organized sports (n = 304). When these rates were compared to the gender proportions of the entire study population (expected outcome), the higher incidence of male concussions was statistically different .Gender differences among the organized sports category are reported within n = 182) as an organized sport. The second highest incidence of concussions were documented in a school setting, specifically, during PE class, accounting for 10.6% (n = 149) of all the concussions. Any physical activity that was part of the PE curriculum, which included an array of diverse physical activities, including soccer, basketball, volleyball, etc., was pooled into the “school PE” cohort. The only other organized sport in the top five was football , in third place. The fourth and fifth highest incidence of concussion were recorded by participants who incurred a concussion while performing recreational activities  and those involved in motor vehicle collisions .n = 40), home setting , and motor vehicle collisions , all had higher female incidences of concussion compared to males. However, the higher rate of female concussions was only statistically significant in motor vehicle collisions , and not the other two categories.n = 152) of all concussions that incurred in a school setting. When examining the individual school levels, females only have a statistically higher proportion of concussions  in high school . Middle schools had a higher rate of female concussions , while primary schools showed a higher incidence of male concussions ; however, neither difference showed statistical significance . Females, additionally, have a higher proportion of concussions  when investigating the cohort of concussions reported during PE class  when all three school levels were examined. The two PE sports that had the highest incidence of concussions, PE volleyball and PE basketball, also had higher female incidence of concussion at 85% (n = 23) and 77% (n = 27), respectively.The trend of higher female concussion incidence follows in the school setting. Females accounted for 66% (p < 0.001) than the number of female concussions when compared to the total gender proportion of the study. This difference, however, could be a false positive, as there simply could have been more male athletes compared to females. This false positive could also be attributed to the larger number of sports that have predominately male participants, such as football, combat sports, and ice hockey.The results of this retrospective study are mostly consistent with previous studies in relation to gender differences in the incidence of concussions ,10,17,18p > 0.5) from gender proportions of the total study population. It is possible that females are getting concussed more frequently than males; however, due to the scope of this study, only comparison of the observed incidences with the study population’s proportions can be conducted. Many prior studies have shown that females have higher proportions of concussions in soccer and basketball [The analysis of organized sports that are presumed to have equal gender participation would reduce the false positive rate. As anticipated, sports that are considered to have predominately male participants, such as football, lacrosse, combat sports , and ice hockey, had higher incidences of male concussions. Conversely, sports with traditionally predominant female participation in New Jersey, such as cheerleading, field hockey, and softball, had higher incidences of female concussions. However, when sports with equal male and female participation, such as soccer (57%) and basketball (59%), were examined, females were observed to have a higher incidence of concussions; however, these higher female observations were not statistically different .Sports-related concussions in organized sports was the largest cause of concussions, as observed in this study, accounting for 53% of all recorded concussions. However, the second leading cause was previously unclear, and is shown in this study to occur in a school setting for pediatric and adolescent age groups. Injuries in a school setting were those that occurred either during PE class, in a classroom, during recess, or in the hallway. Consistent with the general trend of the highest proportion of concussions being sports-related, most of the concussions in the school were also sports-related; specifically, during PE (64% of the school setting cohort). The incidences of concussion during school PE accounted for 11% of the total study’s concussions—whereas organized soccer accounted for 13% of the total concussions, and organized football accounted for only 10% of the total concussions, which is fewer than school PE. Additionally, unlike in organized sports, females in PE were diagnosed with a concussion significantly more often than males , but not at the middle (p = 0.58) or primary (p = 0.02) school levels. A potential explanation for this difference could be the rate at which males and females differentiate in their growth in high school between the ages of 13 and 18.Only one other previous study, conducted by Nelson et al.  between p < 0.001) showed a statistically higher proportion of female concussions. Most prior studies on the epidemiology of concussions do not examine these other aspects of life where concussions can occur. These concussions may not always be preventable, as they are occurring during everyday activities. It is important to record them and make the information available to everyone. This will hopefully change the perception of concussions being only from a battlefield or athletic trauma, to resulting from everyday injury as well. Concussions can be incurred in a school setting or during everyday activities for the pediatric population, such as taking a skateboard down the street or while at an amusement park.After organized sports-related concussions and school-related concussions, the highest number of concussions were reported in participants who were participating in recreational activities (7%), involved in motor vehicle collisions (7%), and finally while participants were home (6%). Although injuries in the home setting and during recreational activities showed no statistical differences in gender, MVCs (Studies from other regions throughout the world are needed to determine whether the trends observed here generalize to other populations. The trends and gender differences observed in this study, such as the higher prevalence of female concussions during school PE and motor vehicle collisions, have the potential to be observed in other regions as well. This knowledge could potentially raise awareness and make the general population more vigilant, hopefully leading to fewer concussions in the future and encouraging more people to seek treatment after a suspected concussion. It is important to keep track of the incidences of concussions during organized sports, but it should be equally as important to track concussions in all other aspects of life. Although organized soccer and basketball did not yield gender differences that were statistically significant, a longitudinal study that does not rely on expected outcomes could yield results consistent with previous studies showing higher rates of female concussions.


One hundred fifteen Americans die every day from opioid overdose. These overdose fatalities have been augmented by the increased availability of potent synthetic opioids, such as fentanyl and its derivatives. The death rate of synthetic opioids, other than methadone, increased by 72.2% from 2014 to 2015, and doubled from 2015 to 2016, situating the USA in the midst of an opioid overdose epidemic. The analytical identification of these opioids in postmortem samples and the correct toxicological data interpretation is critical to identify and implement preventive strategies. This article reviews the current knowledge of postmortem toxicology of synthetic opioids and the chemical and pharmacological factors that may affect drug concentrations in the different postmortem matrices and therefore, their interpretation. These factors include key chemical properties, essential pharmacokinetics parameters (metabolism), postmortem redistribution and stability data in postmortem samples. Range and ratios of concentrations reported in traditional and non-traditional postmortem specimens, blood, urine, vitreous humor, liver and brain, are summarized in tables. The review is focused on fentanyl and derivatives  and non-traditional opioid agonists . All of these data are critically compared to postmortem data, and chemical and pharmacological properties of natural opioids (morphine), semi-synthetic , and synthetic opioids (methadone and buprenorphine). The interpretation of drug intoxication in death investigation is based on the available published literature. This review serves to facilitate the evaluation of cases where synthetic opioids may be implicated in a fatality through the critical review of peer reviewed published case reports and research articles. Opioid overdose deaths continue to increase in the United States, killing more than 42,000 people in 2016. The opioids detected in these cases, in increasing order, were methadone, natural and semi-synthetic opioids , heroin and synthetic opioids . Synthetic opioids (excluding methadone) and heroin deaths specifically experienced a sharp increase from 2015 to 2016   reducing the intensity of pain and showing a high addiction potential. These opioid receptor agonists also induce dose-dependent respiratory depression  and the new generation synthetic opioids  have a chemical core structure totally different from morphine, a naturally occurring opioid from Synthetic opioids are widely regulated by the United States Controlled Substances Act of 1970 (CSA) in order to control their use and distribution. As new compounds arise and threaten public safety, compounds can be emergency scheduled by the DEA to slow production and use of these harmful substances and aid in prosecution of drug diverters for a temporary period until the formal procedures have gone through , the lack of reference databases, the presence of other substances , opioid tolerance, and postmortem phenomena (postmortem redistribution and drug instability) complicates the interpretation of the analytical findings. Pichini et al.  and ZawiThe present review is focused on fentanyl derivatives and new generation opioids due to the limited knowledge concerning these substances and their high prevalence in opioid-overdose related cases. This work complements the previously published literature reviewing the current knowledge of postmortem toxicology of synthetic opioids and the chemical and pharmacological factors that may affect drug concentrations in the different matrices and therefore, their interpretation in postmortem samples. These factors include key chemical properties, essential pharmacokinetics parameters, postmortem redistribution and stability data in postmortem samples. All of these data are critically compared to postmortem data of natural opioids (morphine), semi-synthetic , and synthetic opioids (methadone and buprenorphine). The interpretation of drug intoxication in death investigation is based on the available published literature. This review serves to facilitate the evaluation of cases where synthetic opioids may be implicated in a fatality through the review of peer reviewed published case reports and research articles.https://pubchem.ncbi.nlm.nih.gov/) and DrugBank (https://www.drugbank.ca/drugs).PubMed, Scopus and Google Scholar were searched for appropriate articles. Forensic case-reports and research articles of natural, semi-synthetic and synthetic opioids were reviewed up to May 2018. All articles were manually reviewed for content and references in each manuscript were further queried. Included articles were limited to peer-reviewed journals indexed by the Institute for Scientific Information (ISI) and published in English. Chemical properties were retrieved from the public databases PubChem . Figure P values (0.8–2). Fentanyl and analogs show a log P between 1.5 and 4.3. The high lipophilicity of fentanyl and its analogs enables rapid diffusion through membranes, including the blood-brain barrier. Also, this lipophilicity along with their basic characteristics make these group of drugs candidates to undergo postmortem redistribution. Table Chemically, opioids are predominantly basic drugs with pKa ranging from 7.5 to 10.9. The chemical parameter log P, the decimal logarithm of the partition coefficient Kp, is a useful indication of the lipophilicity of a compound. In the case of opioids, log P range is wide, from 0.8 (oxymorphone) to 5 (methadone). Morphine and related compounds show the lowest log Volume of distribution (Vd) and protein binding also help to predict the drugs that may exhibit postmortem redistribution. Vd is defined as the volume into which the total amount of the drug would have to be uniformly distributed to reach the concentrations measured in plasma. It is expressed in L/kg of body weight (amount of drug in the body divided by the plasma drug concentration). Drugs highly bound to plasma proteins but not to tissue components would be expected to have a small Vd, while those drugs which distribute into muscle, adipose tissue and other intracellular components will have a high Vd. Drugs with a Vd greater than 3 L/kg are considered to have a greater potential to undergo postmortem redistribution. Table One of the critical issues related to fentanyl, its derivatives and the new synthetic opioids, is the low concentrations expected in the biological samples (ng to pg/mL or ng to pg/g range) due to their high potency. However, the potency of these type of drugs varies considerably within this group, and therefore the concentrations reported show a wide range, depending on the drug. Table The identification and quantification of metabolites in postmortem samples may improve the interpretation of the analytical results. The determination of metabolites may extend the window of detection, and also can be employed to calculate metabolite-to-parent ratios in urine and other biological samples to differentiate acute or delayed death. In certain cases, as it happens in morphine and buprenorphine, metabolites can be pharmacologically active. Although this type of information is limited in the case of the synthetic opioids, fentanyl, sufentanil, and alfentanil's metabolites are inactive in the opioid system  were desmethyl and di-desmethyl AH-7921. Together with the glucuronidated metabolites, they were recommended as suitable analytical targets for documenting AH-7921 intake ; acrylfentanyl 0.3 ng/mL (n = 1); butyrfentanyl 14.9, 0.3–58 ng/mL (n = 4); carfentanil 0.08, 0.05–0.1 ng/mL (n = 2); fentanyl 8.2, 1.1–38 ng/mL (n = 14); furanyl fentanyl 1.7, 0.6–6.1 ng/mL (n = 4) and U-47700 17 ng/mL (n = 1).In several cases, multiple synthetic opioids were detected. Acetylfentanyl and fentanyl were frequently found together , and suicides were reported in 7 cases.In all of the reports mentioned in Table Postmortem changes in drug concentrations can happen via postmortem redistribution (PMR) from tissues of a higher to a lower concentration. Physicochemical and pharmacological properties of the analytes, such as pKa, log P, volume of distribution (Vd) and protein binding, may indicate drugs that experience this postmortem phenomenon. Lipophilic basic drugs with a Vd > 3 L/kg, such as fentanyl, may undergo PMR. Fentanyl has been reported to undergo extensive PMR , were stable in urine samples stored at −20°C or below for at least 2 months. However, remifentanil in urine samples decreased by approximately 90% within 1 week at room temperature and by more than 50% in samples stored for 1 week at 4°C. Because of the instability of that analyte, the authors recommended to analyze the primary metabolite, remifentanil acid (Wang and Bernert, Fentanyl, norfentanyl, acetyl fentanyl and acetyl norfentanyl spiked into whole blood were stable after three freeze-thaw cycles and at room temperature for 72 h (Poklis et al., Regarding the new synthetic opioids not related to fentanyl, U-47700 was stable in blood refrigerated for up to 30 days (Mohr et al., We performed a critical review of the currently available literature to assist in the toxicological interpretation of synthetic opioids postmortem cases. Synthetic opioids constitute a heterogenous group of compounds related or not to fentanyl, mostly basic and lipophilic, with a wide range of potencies related to morphine, from 1 to 10,000. Research has been conducted in the investigation of metabolic pathways and identification of target metabolites of fentanyl derivatives and non-structurally related synthetic opioids, showing similarities and differences from fentanyl depending on the compound. Postmortem concentrations seemed to correlate with their potency, although the presence of other CNS depressants, such as ethanol and benzodiazepines has to be taken into account. Further research is guaranteed to investigate postmortem redistribution phenomena of this class of compounds, and stability issues in postmortem samples.MC and GC contributed conception and design of the review. MC, RC, and JP searched, organized, reviewed and analyzed the case reports and research articles. MC wrote the first draft of the manuscript. All authors contributed to manuscript revision, read and approved the submitted version.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.


PCOS patients demonstrated lower muscle, glycogen and protein masses , along with a lower bone mineral content and mass  than their healthy counterparts, while total and abdominal fat masses were similar between the two groups. PCOS patients also exhibited increased extracellular body water  and decreased intracellular water, compatible with low-grade inflammation and cellular dehydration. Key differences in body composition between women with PCOS and controls demonstrated an osteosarcopenic body composition phenotype in PCOS patients. A confirmation of these findings in larger studies may render osteosarcopenia management a targeted adjunct therapy in women with PCOS.Scarce data exist on the body composition of lean women with polycystic ovary syndrome (PCOS) on treatment with metformin and oral contraceptives (OCs). Thirty-four lean (body mass index 18.5–24.9 kg/m Polycystic ovary syndrome (PCOS) is a multifarious endocrinopathy affecting up to 15% of reproductive-aged women worldwide . The synA bioelectrical impedance (bio-impedance) analysis (BIA) provides an assessment of body composition based on the varying bioelectric resistance of different tissues . It is sLately, evidence has accumulated about the effect of stress and, consequently, about subclinical, low-grade inflammation on body composition ,13. AddiIncreased salivary cortisol and α-amylase concentrations have been reported in PCOS patients which, compared with healthy counterparts, demonstrated a sustained low-grade inflammation status ,19,20. PThere are few bio-impedance studies that have assessed body composition in lean women with PCOS ,28, exhiThe study was approved by the Athens University Medical School Ethics Committee and was in accordance with the Helsinki Declaration of the World Medical Association for human studies (Repository number: 345/28-8-2012). All participants gave informed consent after an explanation of the purpose and nature of every study procedure. The study took place at the Unit of Translational and Clinical Research in Endocrinology of the National and Kapodistrian University of Athens (‘study site’) in one academic year period (from September 2013 to June 2014).2) females of reproductive age (18–40 years) with polycystic ovary syndrome (PCOS group) and clinically healthy age- and BMI-matched females (control group). The PCOS group included women with an established diagnosis of PCOS according to the Rotterdam criteria  [Study participants included a convenience sample of lean ], adipose tissue in kilograms [AT (Kg)], adipose tissue as a percentage of weight [AT (%Weight)], and the presence of sarcopenia [Sarcopenia].The body composition bio-impedance analysis was performed with a BIA-ACC device  ,33. ThisThe possibility of selection bias was addressed by the similarity in the recruitment of both groups.p-value < 0.05 was considered significant in all analyses. Data normality was examined using the Shapiro–Wilk test. Descriptive statistics are presented by median values and by 25th and 75th percentiles. Due to the asymmetry of distributions and the small number of participants, Mann–Whitney U-tests were used to test the statistical significance of differences between the two groups. Kendall’s tau tests were used to evaluate correlations.A two-sided An effect size r calculation was also performed by dividing the z value by the squared root of the number of the total sample. The Holm’s method was used for adjusting the alpha level , using tA total of 102 women were initially screened, of which 52 were eligible to be included in the study. From these, 17 patients with PCOS and an equal number of clinically healthy controls, matched for age and BMI, agreed to participate.The baseline characteristics of the participants of the study did not differ between the two groups, as shown in 2 = 17.486, df = 33, p < 0.001) with a low skeletal muscle mass measured both in kilograms  and as a percentage of fat free mass . On the other hand, the fat free mass (FFM), in kilograms (kg) was also lower in patients with PCOS than controls, but the size effect was moderate . The glycogen mass as a percentage of FFM and in kilograms was significantly decreased in the PCOS group compared to those of the control group , along with decreased total body protein measured in kg and as a percentage of the fat free mass when compared with the control group . Appendicular lean soft tissue in kg and as %FFM was also decreased in the PCOS patients vs. controls , as shown in ns, r = 0.063) and the abdominal fat mass  did not differ significantly between the two groups.The PCOS group demonstrated sarcopenia , as shown in p = 0.026, r = 0.378; p < 0.001, r = 0.799; p = 0.0025, r = 0.52, respectively) compared with the control group.The bone mineral content and bone mass were decreased in the PCOS group compared with the control group . A statistically significant difference in the phase angle was also observed between the two groups, with the PCOS group demonstrating lower degrees .Extracellular body water, expressed as a percentage of total body water, was increased in the PCOS group  , a decreDolfing et al., with the use of a BIA, compared lean PCOS patients with matched controls and found similar lean body masses between the two groups. However, the results of this study were based on a very small sample . PCOS isVgontzas et al. reported a significant increase of circulating interleukin-6 , while CThus, it seems that PCOS, apart from other characteristics, is a disorder of low-grade inflammation, as reflected in the body composition of women in this study and in accordance with recent studies ,13. It iRecent data suggest the contribution of hepatic disorders, such as the non-alcoholic fatty liver disease (NAFLD), to PCOS phenotypes ,50. The In several studies ,54,55,562) did not differ between the two groups in this study. Visceral adiposity is a marker of additional metabolic risk in polycystic ovary syndrome; however, this feature may be more evident in overweight and/or obese PCOS patients [No statistically significant differences were found in the fat mass between the PCOS and the control groups of this study. Similarly, Durmus et al. found a higher visceral adiposity in overweight and/or obese PCOS patients compared to peer controls and non-obese PCOS patients . Lean wopatients , which wpatients ,43,64 anpatients .Hyperandrogenism and hyperinsulinemia, well-recognized characteristics of PCOS, may influence bone mineral density and biochemical markers of bone turnover. Bone formation markers were found to be decreased in younger PCOS patients compared with healthy controls . It has Women with PCOS in this study exhibited shifts in body water compartments. They were overall ’dehydrated,’ but also had an augmented extracellular water compartment. Again, several studies have reported low-grade inflammation in PCOS ,73,74, eA statistically significant difference in the phase angle was also observed between the two groups of our study. The phase angle represents the angle between the electric reactance and resistance, as it depends on cell membrane integrity and body cell mass. A low-phase angle is consistent with low reactance, associated with either cell death or breakdown in the selective permeability of the cell membrane. Generally, a phase angle is lower in disease than in health, increasing with an improvement of the clinical status. A high level of inflammatory and oxidative stress in our patients associated with their low-grade inflammation might explain the findings related to the phase angle .The limitations of the study include the small sample size , the croWe demonstrated a decreased muscle mass, major shifts of the water compartments, and an overall “osteosarcopenic” phenotype of our lean PCOS patients under a six month treatment with metformin and OCs. All the elements of the disturbed body composition in osteosarcopenic PCOS patients may be future targets of therapeutic interventions, like the GLP-1 agonists . Further


Little is known about the long-term shifts in distributions of three abdominal-obesity-related indicators, waist circumference (WC), waist-to-hip ratio (WHpR) and waist-to-height ratio (WHtR) among Chinese adults. Traditional mean regression models used in the previous analyses were limited in their ability to capture cross-distribution among effects. The current study aims to describe the shift in distribution of WC, WHpR, and WHtR over a period of 18 years (1993–2011) in China, and to reveal quantile-specific associations of the three indicators with key covariates.Longitudinal data from seven waves of the China Health and Nutrition Surveys (CHNS) in 1993, 1997, 2000, 2004, 2006, 2009 and 2011 were analyzed. The LMS method was used to illustrate the gender-specific quantile curves of WC, WHtR and WHpR over age. Separate gender-stratified longitudinal quantile regressions were employed to investigate the effect of important factors on the trends of the three indicators.A total of 11,923 participants aged 18–65 years with 49,507 observations were included in the analysis. The density curves of WC, WHtR and WHpR shifted to right and became wider. The three outcomes all increased with age and increased more at upper percentiles. From the multivariate quantile regression, physical activity was negatively associated in both genders; smoking only had a negative effect on male indicators. Education and drinking behavior both had opposite effects on the three indicators between men and women. Marital status and income were positively associated with the shifts in WC, WHtR and WHpR in male and female WC, while urbanicity index had a positive effect on three outcomes in men but inconsistent effect among female outcomes..The abdominal-obesity related indicators of the Chinese adults experienced rapid growth according to our population-based, age- and gender-specific analyses. Over the 18-year study period, major increases in WC, WHtR and WHpR were observed among Chinese adults. Specifically, these increases were greater at upper percentiles and in men. Age, physical activity, energy intake, drinking, smoking, education, income and urbanicity index were associated with elevated abdominal obesity indicators, and the effects differed among percentiles and between gendersThe online version of this article (10.1186/s12889-019-6927-6) contains supplementary material, which is available to authorized users. However, one major drawback of BMI is that it fails to consider the distribution of fat throughout the body. Abdominal fat, i.e., that around the heart, liver and kidneys, has been found by no means to be less pathogenic than general obesity, but rather has more significant relationship with heavy disease burden [Obesity has become a serious problem that threatens public health. Body mass index (BMI), which is defined as weight divided by the square of the height , waist-to-hip ratio (WHpR) and waist-to-height ratio (WHtR). Significant increases in these indicators have been reported in developed countries. An Australian 12-year cohort study reported increases of 4.32 cm and 6.25 cm in WC from 1999 to 2011 for men and women, respectively .More importantly, accumulating evidence has shown the positive correlation of abdominal obesity indicators with the risk of chronic diseases. For example, WC alone or WC combined with BMI is more predictive than BMI alone for hypertension  and obesThe past decades witnessed great development in China. The popularizing of mass education and the process of urbanization had a dramatic influence on people’s health. The health status of Chinese population was challenged by changes in dietary pattern and lifestyle. Studies also reported the important association between socioeconomic status and obesity , 17. TheTraditionally, a general linear regression model was frequently performed to study the effect of obesity-related covariates on the conditional mean of the dependent variable. However, this method is not suitable if the effect of explanatory variables differs at different levels of the outcome, and cannot make full use of the overall distribution. By contrast, quantile regression builds an array of equations that are regressed to defined quantiles without extra hypotheses in distribution. Thus, it is more robust against outliers or skewness to the response variable than is ordinary linear regression . MeanwhiIn the current study, we aim to describe the secular shift of abdominal obesity in adults, as depicted by WC, WHtR and WHpR, and to explore the relationships between covariates and changes of indicators at each quantile. Our results provide new perspectives on the population health and may encourage researchers and policy makers to control, prevent and decrease the epidemic of abdominal obesity.Data for this study was derived from the China Health and Nutrition Surveys (CHNS), a large-scale longitudinal survey designed to cover key public health risk factors and health outcomes and, demographic, socioeconomic factors at the individual, household and community levels. The CHNS aimed to examine the effects of social and economic change across time on public health. The sample of this large-scale survey was selected randomly from eight provinces in the first wave in 1989. Within each province, stratified sampling was used to select cities and counties. In later survey years, more provinces were involved, and more data was collected. Detailed information is available in the profile .In the current study, adults aged 18 to 65 from the seven latest waves in 1993, 1997, 2000, 2004, 2006, 2009 and 2011 were analyzed. Due to the longitudinal nature of our study, only subjects with more than one records were considered as qualified participants. We excluded subjects without measurements of WC, height or HC and participants whose WC was outside the range of 45 to 150 cm, whose HC was outside the range of 55 to 150 cm, or whose height was outside the range of 120 to 200 cm were also excluded as extreme outliers. Missing values were imputed with multiple imputation method. A total of 11,923 individuals with 49,507 records were involved in our final analysis.The outcomes of interest were WC, WHtR and WHpR. WC, HC and height were collected by physical measurements methods. WC was taken at a midpoint between the bottom of the rib cage and the top of the iliac crest at the end of exhalation. HC was taken at the level of maximal gluteal protrusion. Both WC and HC were measured using a SECA tape to the nearest 0.1 cm. Height was measured without shoes to the nearest 0.2 cm using a portable stadiometer. WHtR and WHpR were computed as WC divided by height and HC, respectively.Categorical covariates included sex , educational level , smoking status , drinking status  and marital status . Continuous covariates included age, energy intake, total physical activity, per capita family annual income, and urbanicity level.Data of smoking, drinking, energy intake, physical activity, educational level, marital status and income was collected by questionnaires and dietary survey. Variables were defined as follows:average daily energy intake for each individual, calculated based on the data of detailed food consumption during three consecutive days at both the household and individual level.indicated by average metabolic equivalents of task (MET) hours per day in a week, estimated from four aspects: occupational, domestic, active leisure and travel. The MET is defined as the ratio of a person’s working metabolic rate (and therefore the rate of energy consumption) to his or her basal metabolic rate. One MET is defined as 1 kcal/kg-hour of energy cost.average individual income, calculated based on reported gross annual household income and was inflated to 2011 values using the Consumer Price Index  and cateA total score at the community level to describe the characteristics and degree of urbanization, calculated by a multicomponent continuous scale developed specifically for the CHNS . Each coThe demographic, socioeconomic and lifestyle features in each wave were described in Table λ, μ and σ were chosen to maximize a penalized log-likelihood in the VGAM package in R version 3.3.2 .To illustrate the shifts of WC, WHtR and WHpR between 1993 and 2011, kernel density plots were used to display distributions. To illustrate the age-specific smoothed quantile curves for these three indicators, LMS  quantile regression were constructed, in which the parameters lqmm package: Model 1 only included year, and the coefficient measured the crude yearly change of the outcome; Model 2 adjusted individual-level features, including age, energy intake, PA, smoking status and drinking status, educational level, marital status and per capita annual income, so the coefficient reflected the yearly change conditional on individual-level covariates; Model 3 controlled a community-level urbanicity index based on Model 2. Thus, in Model 3, the coefficient of time indicated the effect of time-varying factors or unavailable or unmeasurable covariates like culture, environment and social policy, after controlling individual level and community level covariates. A quadratic term of age was included in Model 2 and Model 3.Finally, gender-stratified longitudinal analyses were conducted to investigate the time trend of abdominal obesity measures and influencing factors. Due to limited space, we multiplied both WHtR and WHpR by 100 to avoid the regression coefficients close to zero. Longitudinal quantile regression models with fixed effects for each outcome of interest were built in three steps using the The individual-, household-, and community-level characteristics of the studied samples are presented in Table For both genders, from 1993 to 2011, the density curves all shifted to right and became wider, which meant that the proportion of subjects with high WC, WHtR and WHpR increased with time  and 0.236 cm  with an additional 100 MET-hour of physical activity per day at 10th and 90th percentiles, respectively; female 100-fold WHtR and WHpR decreased 0.145  and 0.167  respectively at 10th percentile, and 0.105  and 0.124  respectively at 90th percentile, with an additional 10,000 MET-hour of physical activity per day. Smoking only significantly associated with male WC and WHtR. WC in male smokers tended to be 1.061 cm  smaller than that in nonsmokers at 10th percentile, and 1.044 cm  at 90th percentile. WHtR in male smokers was also smaller, and the negative effect of smoking was stronger at lower percentiles.Interestingly, drinking and educational level had completely opposite effects on the three outcomes between sexes. Drinking caused a significant increase in all percentiles of WC, WHtR and WHpR among men. While female non-drinkers with media value of WC were prone to have 0.599 cm  larger WC, as well as larger WHtR and WHpR, but significance was only shown in WC. Higher educational level tended to cause larger WC and WHtR in men, but smaller WC, WHtR and WHpR in women. The effects of education at upper percentiles were stronger than at lower percentiles in men, but weaker in women. For instance, men receiving senior schooling or above had approximately 1.775 cm  more of WC at 10th percentiles and 1.790 cm  at 90th percentile, compared with those with no or primary schooling. For women with senior schooling or above, WC at 10th percentile was 2.257 cm  and at 90th percentile was 2.250 cm  smaller than those least-educated.Compared with never-married men and women, the married had notably larger outcomes, and the effects of marriage on three indicators were stronger in men than in women. WC in married men and women were around 2.116 cm  and 1.651 cm , respectively larger than that in unmarried men and women. Higher level of income was positively associated with three indicators in men, but the association was inconsistent among three outcomes in women. For example, men with relatively high income had 1.913 cm  lager WC at 10th percentiles and 1.926 cm  at 90th percentile. In women, high level of income contributed to an increase by 0.603 cm  in WC but a decrease in WHpR. For men, urbanicity index had a positive effect which was stronger at upper percentiles on the WC, WHtR and WHpR. Living in a community with high urbanicity index resulted in an increment of 1.651 cm  in WC at 10th percentile in men and 1.667 cm  at 90th percentile, compared with men living in a community with low urbanicity index. Similar results were also found in women for WC, but not WHtR and WHpR.To the best of our knowledge, the current study is the first age- and gender-specific analysis in a Chinese population to explore the secular trends of three indicators of abdominal obesity and their relation with potential risk factors. We found the three indicators increased more in men and at upper percentiles over a period of 18 years.Previous studies using CHNS data showed that WC and the prevalence of abdominal obesity had increased greatly from 1993 to 2009 in both sexes , especiaGender-related differences in the shifting patterns of the three indicators can be summarized from two aspects: on the one hand, the extent of increment is greater in men. For example, with WC, the percentile curves in 2011 were much higher than those in 1993 in men, but the extent of the increase in women was not as remarkable as that in men. On the other hand, the age-specific increase is different. Again, taking WC as an example, percentile curves for men started to decrease after 50 years of age, but the curves were still climbing in women. It has been confirmed that gender is an important factor influencing body composition and the accumulation and distribution of body fat due to the effect of sex hormones ; it may In the multivariate quantile regression analyses, the opposite effects of education level on the indicators among genders have been noted. Such a divergence has also been reported in other population , 28. A sThe positive association between marital status and obesity or abdominal obesity has been reported , 32. It Our study had several limitations. Detailed information regarding eating, drinking and smoking behaviors, as well as variables like occupation were not included in our database. Limitations also stem from the sample attrition. However, the rate of lost to follow-up was low relative to the large sample size and data was collected from fixed regions, so we assumed the missing data were uninformative. Sensitive analyses with imputed data were also conducted, providing results that were similar to those of our study. Despite these limitations, our study has several strengths. The longitudinal nature of variables at the individual, household and community levels was considered, and the effects on changes were analyzed in a comprehensive way. Moreover, the use of quantile regression allowed a more detailed and robust investigation of the distributions and trends of the indicators.Over the 18-year study period, rapid increases in abdominal-obesity related measurements, WC, WHtR and WHpR were observed among Chinese adults. Specifically, these increases were greater at upper percentiles and greater in men. Age, physical activity, energy intake, drinking, smoking, educational level, income level and community-level urbanicity were associated with elevated abdominal obesity indicators, and the effects differed among percentiles and between genders. Regardless of which indicator is used, the remarkable increase of abdominal obesity in China is worthy of great attention. Furthermore, the increase is very likely to continue after 2011 accompanied with the ongoing processes of urbanicity and modernization. Therefore, effective strategies for preventing and controlling the epidemic of abdominal obesity are needed to diminish the negative effects on public health.Additional file 1:Figure S1. depicts the shifts in distributions of WC, WHtR and WHpR for Chinese adults in each wave. Figure S2-S4. show the quantile curves by age of WC, WHtR and WHpR respectively for adults in each wave. Table S1-S3. provide the coefficients and standard errors from multivariate quantile regression for 10th, 25th, 50th, 75th and 90th percentiles of WC, WHtR and WHpR, respectively. (DOCX 11252 kb)This file contains 4 figures and 3 tables that present additional results obtained in the study that we consider important to publish.


The increasing public demand for efficient, sustainably produced poultry meat with simultaneous optimization of animal welfare is calling for amendments in meat production. A starting point to meet this demand consists of complete diets for broilers with reduced crude protein content, supplemented with higher amounts of crystalline amino acids. This ensures sufficient nutritional supply and decreased nitrogen excretion for environmental relief. To optimize the performance and health, despite the drastically reduced protein content (~17.5% finisher diet), the present study compared different methionine sources  in slightly higher dosages than found in practice, in comparison to a diet meeting the methionine requirements using methionine hydroxy analog. Methionine is the first limiting amino acid and has a significant influence on the health and growth of the animals. The results of the feeding trial showed no differences concerning general health, ileal histology, and performance data of broilers before slaughter. However, the composition of the breast meat differed significantly (highest protein content and lowest fat content in the L-methionine group), and thus provides the impetus for further research.®), groups “L” and “DL” the respective Met source in equivalent concentrations each exceeding the nutritional recommendations. “R-MHA” (“R” for “reduced”) received the minimum required level (using MHA as Met source). Performance exceeded performance goals without differences between the groups. The average feed conversion ratio (FCR) amounted to 1.35. The carcass/body weight ratio of R-MHA was significantly lower (0.782) compared to DL (0.808) and L (0.809). Breast meat of R-MHA contained significantly more fat (144 g/kg dry matter (DM)) compared to L (104 g/kg DM) and significantly lower CP content . The results indicated possible improvement in slaughter yield by protein-reduced diets supplemented with L-Met, thus recommending further research focusing on the Met influence.Sustainably produced poultry meat with consideration of animal health poses a challenge for broiler production. Low protein diets with high amounts of synthetic amino acids (AAs) like methionine (Met) are the consequence. In a five-week feeding trial, 360 broilers (Ross 308) assigned to four feeding groups were offered protein-reduced complete diets (starter: 20% crude protein (CP); grower: 18.5% CP; finisher: 17.5% CP), supplemented with essential AAs. The “MHA” group received DL-2-hydroxy-4-(methylthio) butanoic acid (DL-HMTBA; trade name: MHA The demand for poultry meat has been growing globally for years. Due to increments in intensive poultry production and the resulting negative effects on the environment ,2,3, seaThe present study concentrated, besides the protein reduction in feed, which was already successful in a first trial , now onMet deficiency has significant negative effects, such as a reduced feed conversion ratio (FCR) in broilers, which results in retarded growth ,30 and aDue to the additional elimination of animal products in the feed , the animals are not sufficiently supplied with cysteine as well, so synthetic Met needs to be supplemented. However, L-Met was not commercially available for animal production until it’s registration as a feed additive in 2014 (Commission Implementing Regulation (EU) No 852/2014 of 5 August 2014). Therefore, the racemate DL-Met or MHA butanoic acid (DL-HMTBA), but in the following, the short trade name MHA is applied) was mainly used, which has a biological availability of 99% or 84%, respectively ,33. In order for these analogs to be available for the metabolism, they must be converted into the directly metabolizable L-Met, after being absorbed in the small intestine . The D-iThere is controversy in studies, confirming the sufficiency of these analogs  ,38. It iDue to its important role, Met is generally used in practice above the recommended dose range ,40,41. IAnimal Protection Act  was required for this experiment. Two dissections were carried out: the first one on day 7 and the second on day 35 so that the number of animals per box was reduced to 10 after the first week of the trial. For the exclusive use of their organs or tissues for scientific purposes, the animals were killed in accordance with Animal Protection Act.The experiment took place, conforming to German regulations. The Animal Welfare Officer of the University of Veterinary Medicine Hannover, Germany (reference: TVT-2018-V-102), approved the experiments. Since no interventions had been carried out on the broilers before dissection, no notification or approval in accordance with the For the trial, a common line for fattening of broilers was used . The 360 one-day-old broiler chickens of both sexes were divided into four groups . During the first two weeks, animals from a reserve group replaced impaired or deceased broilers. Thereafter, no animal was replaced anymore. The animals were randomly separated into 24 boxes  at the start of the experiment. The four feeding groups with their replicates were evenly distributed in the stable so that the box location had no influence on the experimental results.®, Goldspan GmbH & Co. KG, Goldenstedt, Germany) served as litter, which covered the floor with at least 1 cm. One side of each box served as a scratching area, optically divided by the drinking line , with two drinking nipples per box, from the feeding area, equipped with one hanging-type feeder . Ventilation of the stable was provided by a vacuum ventilation system, which was installed on both long sides of the stable above the boxes. The environmental temperature was controlled daily and kept at an adequate range through space heating, and the red lamps above each compartment or additional ventilation (switched on at temperatures above 29 °C) as the weather became hotter during the summer. In each box, 1 kg of wood shavings  and 8 h of darkness with dimmed night lighting until the end of the experiment.Feed was offered ad libitum. In total, four different feeding approaches were prepared, containing four different starter diets, four grower diets, and four finisher diets. All diets were pelleted. In order to maximize the comparability of the final diets, the same supplementary feed  was used at 80% in all 12 diets. It contained vitamins, minerals, and coccidiostats (narasin/nicarbacin). To complete the respective diets, the remaining 20% were supplemented with equal proportions of soybean meal, AAs  and minerals, such as limestone, monocalcium phosphate, salt, sodium bicarbonate see Table A1The three feeds adapted to the respective growth phase were fed to all groups in the following periods: starter: d 1–7, grower: d 8–14, finisher: d 15–35. The animals received a complete diet with a protein content oriented towards the protein levels in a previous experiment , which hEssential AA levels were equal in all diets by adding the following crystalline AAs (in addition to Met) in different concentrations: lysine, threonine, valine, isoleucine, arginine  was done once a week on the same weekday. Exceptions were the first and the last week, in which the interval had to be shortened by one day for technical reasons (six days). At the box level, which corresponds to the replicate level, the feed intakes (FI), water intakes (WI), as well as the animal losses had been determined. Additionally, conspicuous behavior deviating from regular one  was documented. The calculation of the FCR was based on the collected feed intake and body mass increase at the box level.To measure the DM content of the litter, samples were taken weekly at three defined spots along a diagonal line through each box. A cup was used (5 cm diameter) to punch out a sample from the full depth of the bedding, at each collection point. Additionally, the nitrogen (N) content of the samples was tested during the first and last weeks, respectively. In contrast, the samples of the last week were obtained as follows: At the end of the experiment, the bedding material of all boxes was collected separately. To obtain a uniform sample, 10 kg from each box bedding was separated and homogenized (rotating machine). From this material, an aliquot was taken and used for the last DM and N analysis.The footpads of the animals were scored with a scoring system from 0 to 7 designed by Mayne et al. : score 0Scoring footpads, as the essential welfare indicator in practice, was carried out weekly. If necessary, the feet were carefully washed with a wet cloth to remove slightly adhering debris and to facilitate the examination. The first dissection took place after seven days, where 120 animals (n = 30 per group) were examined; the second one after 35 days, where 72 broilers were dissected (n = 18 per group). In both dissections, a percussive blow to the head was used as anesthesia or rather stunning method in accordance with Annex I of Council Regulation (EC) No. 1099/2009, Chapter I, Methods, 2 was removed from the ileum  and fixed in 4% formaldehyde for 48 h. After fixation, tissue samples were embedded in paraffin using standard techniques [Lamina muscularis mucosae). The relation of the villus height to the depth of the crypt was computed at the end [In order to determine the size of the villi and crypts in the ileum, as established indicators of intestinal health ,46,47, t the end . Measure® Type 911 pH, Knick, Germany), a glass electrode  and a temperature sensor in combination, measurements were taken at the Musculi pectorales superficiales (MPS) 24 h post mortem (p.m.). After the same storage time, the drip loss measurements were carried out. The value of the drip loss was obtained by subtracting the pectoral muscle weight after 24 h and the weight after 48 h storage at 4 °C. Therefore, the respective pectoral muscle piece was dabbed dry and stored cool in a plastic box. With a portable electrical conductivity (EC) meter with two parallel stainless steel electrodes , the EC was measured. Shear force: after determining the boiling loss, the shear force was determined using the Warner–Bratzler shear force method with the Texture Analyzer TA.TXplus . On a fresh cut in MPS, the CIE  color values (L* (lightness), a* (redness), b* (yellowness)) were measured with a colorimeter . All parameters were measured three times, from which the mean values were calculated, respectively.In addition to the usual carcass parameters , the breast meat quality traits were analyzed at the Institute for Food Quality and Food Safety . For thThe various diets were analyzed in accordance with the official methods of the VDLUFA . The DM ® Enterprise Guide®, version 9.3 . For all parameters, mean values, as well as the standard deviation (SD) of the mean, were calculated. Feed intake, water intake, the N content, etc. were analyzed at the box level. For parameters, such as BW, FPD scores, and the histological values, the individual animals were the basis of the calculation. The mean of the FPD scores was determined by forming the mean of the scores of both feet of each animal. In general, a one-way-ANOVA for independent samples and mixed models was performed for repeated parameters, i.e., BW, histological measurements, and the DM and N content in the litter. For parameters, which were not distributed normally, a non-parametric one-way-ANOVA was used. The p < 0.05 was the basis of a statistical significance for all statements concerning the results of the analysis. The statistical analysis was performed using the Statistical Analysis System for Windows the SASAnimal losses were limited to a total of six of 360 animals from the third week onwards . In general, the experiments ran without complications and the use of antibiotics or other therapeutic interventions. Controlling the temperature in the stable was significantly more difficult, due to the high outside temperatures. It was gradually reduced from about 33 °C for the one-day-old birds to about 25.2 °C by day 21, rising again to an average of 30.1 °C by day 35.In No significant differences were observed concerning the water/feed (w/f) intake ratio per day and animal, except week 3 see Table A2At the beginning of the trial, the DM content of the litter was 919 g/kg DM. During the trial, there were no statistical differences in DM content between the groups . This lep-value, the MHA-diets (first and last group) had the wettest litter at the first and the last week. Nevertheless, the N contents were almost identical in all groups  showed no significant differences. Regardless of the l groups . In geneThe carcass/body weight ratio showed significant differences : R-MHA hAnalyzing the composition of breast meat  revealedThe analyses of the breast meat conducted by the Institute for Food Quality and Food Safety showed no significant differences whatsoever .Neither in the first nor the second round of dissections were significant differences detectable concerning the sizes of the measured villi , althougThe intestinal wall of the ileum showed no alterations .There were no incidents during the implementation of the project. Animal losses were very low  from day 14 onwards. The performance parameters exceeded the performance goals of the breeding company . In geneScoring the footpads was carried out as an essential welfare indicator and to verify whether the different Met sources influence the pathogenesis of FPD. As Chavez and Kratzer found out, MHA is supposed to be less effective in preventing FPD . The posConcerning the N content in the litter, there were no differences between the groups. However, the general N excretion of the animals could be further reduced. Also, in comparison to the preceding study   had a significantly higher fat content (144 g/kg DM), especially compared to L (104 g/kg DM), significantly lower CP content  and phosphorus content . As lean meat is in demand as a protein supplier, the supplementation of L-Met also offers an advantage here. The fact that increased dietary Met levels are beneficial is supported, inter alia, by the findings of Hickling et al. , who achThe mentioned studies were related to the general volatile increase of Met in the feed . There were no differences in the comparison of Met sources . HoweverIn the present study, the influence of feed on the immune system was not focused on, but it would be worthwhile to continue research in this direction, especially regarding the aforementioned lack of d-amino-oxidase in young broilers.In summary, even when feeding drastically protein-reduced diets, the animals could still achieve high performance through an optimized AA supply. However, the different Met sources seemed to have no influence on parameters, such as FI and BWG, in the present study, contrary to the parameters of the breast meat analyses, such as a decreased fat content in the pectoral muscle through the use of L-Met (compared to R-MHA). Especially regarding consumers’ increasing desire for low-fat meat, these results are certainly interesting and provide impetus for further research into optimized AA supply with an influence on animal health and resource efficiency.Since the trial took place under optimal husbandry conditions, the Met supply was above the assumed demand , and the diets differed only by one AA, it is difficult to expect great differences between the groups. On the other hand, the conditions in practice are continuously improving and thus are becoming more similar to the ones in the trial, so that our findings are actually related to practical conditions. The effects of different Met sources on performance  and protein reduction leave much to be desired. However, the results of the pectoral muscle analysis are interesting. These provide first indications of significant differences in the composition of the muscle when MHA, L-, and DL-Met (except for MHA in minimum required levels) are used in common dosages. Although the number of samples was limited, the findings provide an opportunity for further research into the influence of Met with a sharply reduced CP content in the feed. If one also considers the significantly lower N excretion, inter alia, due to the strong CP reduction, a remarkable improvement results, concerning the environmental impact of poultry production.These meticulously balanced, protein-reduced diets, considering the Met availability, comprise interesting benefits when it comes to sustainability in animal production.


Background: The Overall Depression Severity and Impairment Scale (ODSIS) is a self-report scale designed to evaluate the severity and functional impairment associated with depression.Objective: This study evaluated the psychometric properties of the online version of the ODSIS in Spanish outpatients with depression and anxiety disorders.Method: Patients with a main diagnosis of a depressive (n = 283) or anxiety disorder (n = 191) and a mean age of 38.15 (SD = 12.06) were evaluated with a clinical diagnostic interview and measures assessing depression, anxiety, positive and negative affect, and quality of life. Factorial structure, internal consistency, convergent, and discriminant validity and cutoff scores were analyzed.Results: Consistent with previous validations of the instrument, Confirmatory Factor Analysis showed a unidimensional factor structure. Furthermore, the results obtained supported the internal consistency and construct validity of the ODSIS scores. A score of 5 was found to meet the criteria used in this study for the optimal cutoff score.Conclusion: The results obtained in this study show that the Spanish version of the ODSIS delivered online is an adequate tool to assess the depression-related severity and impairment in a brief and easy fashion. Among the emotional disorders, the most prevalent lifetime syndrome is a major depressive episode , 2. It iWith the increasing interest in the identification and dissemination of evidence-based treatments for psychological problems, the need for evidence-based assessment strategies is greater than ever before. It is crucial for researchers to develop assessment instruments with good psychometric properties resulting in their reliable evaluation. Furthermore, because research on Internet-based interventions has grown exponentially in recent years, it is also necessary to validate online assessment scales with good psychometric properties , 15.As mentioned above, depression is among the most prevalent and disabling psychological disorders worldwide. Currently, a variety of well-validated measures exist to assess different aspects of depression, such as the Patient Health Questionnaire-9 , the CeThe literature shows that it is essential to assess the severity and impairment associated with depression because these factors influence whether or not individuals may benefit from treatment . Thus, bThe Overall Depression Severity and Impairment Scale (ODSIS) is a 5-item assessment instrument to evaluate severity and functional impairment due to depressive symptoms, such as the frequency and intensity of depression and its interference with work, school, social life, and relationships. Furthermore, it also assesses the impairment caused by depression-related loss of interest and difficulty engaging in activities . All of To date, only two validation studies of the ODSIS have been published. The first validation of the ODSIS was conducted in a North American sample , whereasTo the best of our knowledge, no study has evaluated the psychometric properties of the online version of the ODSIS in a sample of adults with depression and anxiety disorders in the Spanish population. In addition, although an online validation of the ODSIS has already been carried out , the dian = 283) and a subsample with a principal diagnosis of anxiety (n = 191). Thus, we formulated the following objectives: (a) to examine how the scale performs in patients with depressive vs. anxiety disorders; (b) to examine the scale's internal structure, reliability, and validity of the test scores; and (c) to obtain a cutoff score.In a previous study published by the current authors, the psychometric properties of the Overall Anxiety Severity and Impairment Scale (OASIS) were analyzed . SimilarThe procedure in the present study was the same than in the recently published study regarding the Spanish validation of the OASIS . Before SD = 12.06; range: 18–68 years), and women made up the majority of the sample . Most participants were married or had partners , and about half had completed university studies . In all, 283 participants had a main diagnosis of a depressive disorder , and 191 had a main diagnosis of an anxiety disorder. The sample had a high comorbidity rate, with more than half of the participants (57.81%) presenting with at least one comorbid anxiety and/or depressive disorder. A total of 474 individuals participated in the study. As aforementioned, we included the same participants that took part in the recent Spanish validation of the OASIS. However, the number of participants in the present study is lower because a portion of the sample did not answer the ODSIS. The average age was 38.15 . The sum of the scores is used to obtain the total score, which can be a maximum of 20. The measure has shown excellent internal consistency  and good convergent/discriminant validity . In the The BDI-II is one of the most widely used scales for the assessment of depressive symptoms. The scale is made up of 21 items, rated from 0 to 3, about the different symptoms characterizing major depression disorder. The sum of the scores is used to obtain the total score, which can be a maximum of 63 points. The BDI-II has shown good internal consistency (α = 0.76–0.95). The Spanish validation has also demonstrated high internal consistency for both general (α = 0.87) and clinical populations (α = 0.89) . In the The BAI is a 21-item self-reported questionnaire that evaluates anxiety symptoms in a past week timeframe. Each item is rated from 0  to 3 (“severely”), and scores can range between 0 and 63 points. The BAI has shown good to excellent internal consistency in previous validations , as well as adequate convergent and divergent validity . In the The OASIS is a 5-item self-reported scale that assesses the severity, impairment , and behavioral avoidance caused by anxiety symptoms. Previous studies have shown good internal consistency (α = 0.80), test-retest reliability, and convergent and discriminant validity –31. The The PANAS is a scale that evaluates two independent dimensions of affect: positive affect (PANAS-P) and negative affect (PANAS-N). Each subscale is made up of 10 items with descriptors , and individuals have to select the degree to which they have experienced each of them in the past week on a 5-point Likert scale, with total scores ranging from 10 to 50 points. This measure has shown excellent convergent and divergent validity, as well as high reliability indexes , 33. In The QLI is a 10-item self-reported scale assessing the following areas regarding quality of life: psychological well-being, physical well-being, self-care and independent functioning, occupational functioning, interpersonal functioning, emotional and social support, community and service support, self-realization, spiritual satisfaction, and a global assessment of quality of life. Previous psychometric evaluations of the QLI have found good internal consistency and test-retest reliability , 35. In We followed the same statistical procedures for the analyses of data as in González-Robles et al. . First, 2), the comparative fitness index (CFI), standardized root mean residuals (SRMR), and the root mean square error or approximates (RMSEA). The following cutoff scores were used to determine good fit: CFI and TLI above 0.90 (better if above 0.95) and RMSEA below.08 , depression (BDI-II), positive and negative affect (PANAS-P and PANAS-N) and quality of life (QLI). To interpret the correlation values, Cohen's  recommenAUC) were calculated. A 95% confidence interval for the AUC and its statistical significance were also calculated (PPV), and Negative Predictive Value (NPV) were obtained for each ODSIS cutoff point around the range of scores. In order to identify the optimal cutoff point on ODSIS scores to offer the best balance between sensitivity and specificity, four different methods were applied to each ODSIS cutoff point: Youden index (J), Index of Union (IU), Closest to  Criterion, and Concordance Probability Method (CZ)  . The ODShod (CZ) .http://vassarstats.net/clin1.html. The remaining analyses were performed through the software SPSS Statistics, version 22.0.The following software was employed for the analyses. CFA was calculated using the software EQS (version 6). The sensitivity, specificity, PPV, NPV, and their 95% confidence intervals were calculated using the web application SD = 4.90) for the total sample (n = 474), 7.94 (SD = 4.98) for females (n = 342), and 7.53 (SD = 4.67) for the male participants (n = 132). Means and standard deviations for each item and the total score on the ODSIS are shown in d = 0.08) and marital status (Eta2 = 0.012). A slight but significant correlation between age and the ODSIS scores was observed . The scores on the ODSIS in the depression sample were significantly higher than those in the anxiety sample . Additionally, statistically significant differences in the ODSIS scores were found as a function of education level . Sidak's post-hoc tests showed significant differences in depression levels in patients with medium studies compared to those with university studies, with lower levels of depression in the latter (p < 0.01). Significant differences were also found depending on the principal diagnosis  and number of comorbid disorders . Sidak's post-hoc tests showed that patients with MDD as the principal diagnosis were significantly more depressed than patients with PD/AG as the principal diagnosis (p < 0.01). Additionally, post-hoc tests revealed that patients with 3 or more comorbid diagnoses had significantly higher levels of depression than those without any comorbid disorder (p < 0.05).The mean ODSIS score was 7.83 (2(4) = 16.08, p > 0.001; SRMR = 0.03, RMSEA = 0.08, 90% CI ; CFI = 0.99. All items were strongly related to this factor, as shown by the factor loadings, with values that ranged from 0.84 to 0.88.Adequate model fit was found for a single-factor model, with the following values: χCronbach's alpha for the five items on the ODSIS was 0.92. r = 0.67, p < 0.01). Furthermore, medium and positive correlations were observed between the ODSIS and the anxiety measures (OASIS and BAI), with values ranging between 0.37 and 0.47 (p < 0.01). In addition, the ODSIS correlated negatively but highly with the PANAS-P , and positively but moderately with the PANAS-N . Finally, a large and positive correlation was observed between the ODSIS and the QLI .The ODSIS significantly correlated with all the measures. A positive and large correlation between the ODSIS and the BDI-II was found, as expected (p < 0.001). A ROC curve was calculated in the sample of 136 participants. Not all the participants of the sample completed the BDI-II measure at pre-test. For this reason, we did the analysis with 136 participants. The scores on the BDI-II were used as criterion, such that participants with scores ≥ 14 on the BDI-II were classified as suffering from mild, moderate or severe depressive symptoms, whereas participants with scores below 14 were classified as suffering from zero or minimal depressive symptoms . The AUCThe aim of this study was to analyze the psychometric properties of the ODSIS administered online in a Spanish sample of patients with depression and anxiety disorders. The literature has shown the high comorbidity rates between depressive and anxiety disorders ; therefoFirst, preliminary analyses showed no significant differences based on gender or marital status. However, patients with medium studies were significantly more depressed than those with university studies. In addition, a slight but significant correlation was observed between age and the ODSIS scores. By contrast, the original validation did not find significant differences with regard to any sociodemographic or clinical variable . Second,With regard to reliability, the ODSIS demonstrated excellent internal consistency in the Spanish clinical sample , consistent with previous validation studies , 21. FinRegarding cutoff scores, a cutoff point of 5 was found to meet three of the four criteria used to select the optimal cutoff point . Thus, these outcomes suggest that this score can be used as a cutoff point to discriminate patients with clinical depressive symptoms from those with no clinical depressive symptoms. These data might be useful, for instance, for selecting patients with depressive symptoms for clinical trials. The results obtained in this study using ROC analysis are not consistent with prior validations of the instrument in clinical populations because Bentley et al.  obtainedThe analysis of construct validity of the test scores yielded evidence for relation with all other variables. As anticipated, positive and relevant correlations were found between the ODSIS and measures of negative affect, depressive symptoms, and anxiety. Large and significant correlations between the ODSIS and the BDI-II were interpreted as evidence of convergent validity. Moreover, correlations between the ODSIS with anxiety  and affect (PANAS-P and PANAS-N) of lower magnitude than with depression (BDI) were interpreted as evidence of discriminant validity. Additionally, the positive and large correlation observed between the ODSIS and the QLI suggests the strong association between high levels of depression and poorer quality of life. Overall, the results obtained in this study support the construct validity of the ODSIS scores.The strengths of this study are highlighted in the following lines. First, this is the first study to evaluate the psychometric properties of the ODSIS delivered online in a Spanish clinical population. In clinical settings, the time that the clinicians have available to assess patients is usually very limited. Brief instruments like the ODSIS can help in the evaluation of the severity and impairment caused by depression, making this task simpler. Second, as mentioned above, depression is characterized by high comorbidity rates , especiaThis study has limitations that should be mentioned. First, even though the BDI-II is a well-established measure and one of the more widespread scales for the assessment of depression , 48, we To conclude, the results obtained in this study support the internal consistency, factorial structure, and construct validity of the ODSIS delivered online in a Spanish clinical sample with a range of depressive and anxiety disorders, consistent with those obtained in prior validations of the scale , 18.Future validations of the ODSIS in Spanish clinical patients are warranted to more precisely explore cutoff scores in a sample of healthy control individuals. In addition, because there is disparity between the cutoff scores obtained in this study (ODSIS = 5) and those obtained in previous validations of the ODSIS, more research is needed to replicate these findings. Another important aspect is that, given that the ODSIS focuses on depression-related severity and impairment, main targets of any psychological or psychiatric intervention, future studies should analyze the scale's sensitivity to change, i.e., how the scale performs as a treatment outcome measure. Finally, although the sample used in this study was rather heterogeneous, it was restricted to patients with depressive and anxiety disorders. Therefore, further research is warranted to analyze the validity and reliability of the ODSIS in more severe patients .This study was carried out in accordance with the recommendations of Ethics Committee of Jaume I University with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Ethics Committee of Jaume I University.AM drafted the original manuscript and participated in the conceptualization and methodology. AG-R was involved in the conceptualization, writing and reviewing the manuscript. CM and AD-G were involved in the data curation and participated in writing the original draft, GM collaborated in the data curation and methology of the study. AG-P, JB-L, and SQ were involved in the conceptualization, supervision, and the revision of the manuscript. RB and CB were involved in the conceptualization, funding acquisition, supervision, writing, and review.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.


For the OOP expenses, rural patients were experiencing increasing risk of having OOP expenses, with the ORs of 0.159, 0.573, 1.278, 1.281, 1.65. The coefficients for the log-linear models in the five years were 0.075 (p = 0.352), 0.61, 0.565, 0.439, 0.46 . Policy makers in China should notice and narrow the gap of health outcomes between rural and urban patients.Rural-urban disparity in China attracts special international attention in view of the imbalance of economic development between rural and urban areas. However, few studies used patient level data to explore the disparity of health outcomes between rural and urban patients. This study aims to evaluate the trend of health outcomes between rural and urban patients hospitalized with acute myocardial infarction (AMI) in China. Using an electronic medical records (EMRs) database in Shanxi, China, we identified 87,219 AMI patients hospitalized between 2013 and 2017. We used multivariable binary logistic regressions and two-part models to estimate the association between region of origin  and two outcomes, in-hospital mortality and out-of-pocket (OOP) expenses. Rural patients were associated with lower in-hospital mortality and the adjusted Odds Ratios (ORs) were 0.173, 0.34, 0.605, 0.522, 0.556 ( Health inequality between rural and urban areas has been a widely studied topic in the field of public health all over the world ,5,6,7,8.Rural-urban disparity with regards to health outcomes in China is an established field of debate ,13,14. OSince the Chinese national medical reform was implemented in 2009, the healthcare coverage and accessibility have been greatly improved in both rural and urban areas of China ,19. HoweTo understand the trend of rural-urban disparity in China, studies with a longer sampling period are usually preferred. Several studies have presented the changing patterns of this disparity over a period of time ,24,25,26This study was based on the electronic medical records provided by the Health and Family Planning Commission in Shanxi, China. This database was standardized by the former Ministry of Health in 2011, and it was then required as a part of health information systems in hospitals in the entire country. The database includes over 200 patient level variables, with each patient hospitalization counting as a unique observation. These variables included patients’ demographic characteristics , length of stay in hospital, up to 10 secondary diagnoses coded using the International Classification of Disease, Tenth Revision (ICD-10), up to seven procedures coded using the International Classification of Disease, Ninth Revision (ICD-9), gravity of disease , and outcomes upon discharge . All patient unique identifiers such as names and ID card numbers were excluded prior to the authors’ access.Using patients’ primary diagnosis codes (ICD-10 code: I21), we identified 87,219 AMI patients hospitalized in Shanxi between 2013 and 2017. We also excluded patients who were less than 18 years old and those with key variables missing. This study focused on AMI patients for three reasons. First, AMI is a very commonly diagnosed disease and leads to hospitalization. It has been reported as the major cause of death among cardiovascular disease patients all over the world . Second,The two outcomes of interest in this study were in-hospital mortality and out-of-pocket costs for AMI patients. In-hospital mortality was defined as all-cause death during the patient’s hospitalization, which was a proxy of the medical quality of that hospital. Out-of-pocket expense was defined as the direct financial expenses of the patient to the hospital, which was a proxy of the patient’s direct financial burden.We identified patients’ region of origin  using a two-stage classification method. In the first stage, we used their insurance types to identify their region of origin. Patients with the insurance type of the New Cooperative Medical Scheme (NCMS) were classified as rural patients, while those with the Urban Resident-based Basic Medical Insurance Scheme (URBMI) or the Urban Employee-based Basic Medical Insurance scheme (UEBMI) were classified as urban residents. In the Chinese healthcare system, these three types of insurance are government-based and they cover over 95% of residents. URBMI and UEBMI are only available to urban residents while NCMS only covers rural residents. Therefore, these three insurance types are the golden standards to identify whether the patients were from rural or urban areas. In this first stage, we identified 83.9% of all patients’ region of origin.In the second stage, we used regular expressions to identify the key words in patients’ current residency address. Patients whose current residency address contained county, town or village were classified as rural residents, while those whose current address contained city and district were classified as urban patients. In contrast to the first stage, this stage was a suboptimal method of classification. Some immigrant workers who came from rural areas may live and work in the urban areas, but they may not be covered by the three government-based medical insurance. For these patients, our two-stage classification method will misclassify them as urban residents. However, this bias is minimized since the first stage identified 83.9% of all patients and Shanxi province is not famous for immigrant workers.A total of 96.7% of patients’ region of origin in this study were identified using this two-stage classification method. The patients whose region of origin were not identifiable using this classification method were excluded from this study.Patient level covariates included age, gender, marital status, occupation, length of stay, gravity of disease, whether percutaneous coronary intervention (PCI) was conducted, and Elixhauser score. Hospital level covariate included whether the hospital was tertiary or not. Patients’ ages were categorized into four groups , with the 18–45 years as the reference group. Marital status was categorized into married, unmarried, widowed, divorced and other, with married as the reference. Occupation was categorized into public institution, private institution, farmer, unemployed, retired and other, with public institution as the reference. The length of stay in hospitals was categorized using the quartiles, with the lowest quartile as the reference. The gravity of disease had three categories, normal (Reference), severe and dangerous. PCIs were identified using the ICD-9 procedure codes 36.01, 36.02, 36.05, 36.06 or 36.07. Comorbidity scores have been widely applied in risk adjustment and predicting the outcomes of hospitalized patients. In this study, we used the Elixhauser comorbidity score updated by the Agency for Healthcare Research and Quality (AHRQ) in 2017 . This coWe used multivariable logistic regressions with binary mortality outcome in this study. In terms of patient’s OOP expense, since it was extremely right skewed and had mass density at zero, we adopted a two-part model as suggested by Deb and Norton . In the Since each independent variable may have different effects on the patients’ outcomes across the five years, we conducted the regression models separately for each year’s data. All data management, statistical modeling and data visualization were conducted in statistical computing environment R 3.4.1 .A total of 87,219 hospital patient records with the primary diagnosis of AMI were identified in this study. These patients were admitted in 168 hospitals in Shanxi between 2013 and 2017, resulting in an average of 519.2 discharged patients in each hospital. It was to be noted that the proportion of rural patients continuously increased from 45.3% in 2013 to 58.6% in 2015. The proportion remained stable at 58% between 2015 and 2017 .As As shown in In contrast to the in-hospital mortality, the coefficients for OOP expenses experienced more fluctuations. The administrative hospitalized AMI patient data in this study indicated that the disparity of health outcomes between rural and urban patients have been reduced from 2013 to 2017. Despite the closing gap, the in-hospital mortality rates of rural patients were consistently lower than those of urban patients after adjusting for a set of patient and hospital level variables. Rural AMI patients had an increasing risk of having OOP expenses compared with their urban counterparts. The adjusted non-zero OOP expenses of rural AMI patients had been consistently higher than urban patients. In view of the fact that cardiovascular disease is the leading cause of death globally and in China ,33, thesOur results highlighted that urban patients had higher in-hospital mortality rates after controlling for the covariates. These results agree with several previous studies ,34,35. FThere are multiple reasons for the result that rural patients had lower adjusted in-hospital mortality rates than urban patients. First, high pollution level and unhealthy lifestyle in urban areas may explain this disparity. With rapid economic development in recent years, urban residents are subject to higher air and water pollution compared with rural residents . Second,The probability that rural AMI patients had OOP expenses revealed an unceasingly increasing pattern compared to urban patients. This trend agrees with several studies from other developing countries. For example, Garg and Karan reported that residents in rural areas had a higher proportion of OOP expenditure than their urban counterparts in India . AnotherThe other interesting result in this study is the level of hospitals. The ORs of tertiary hospitals maintained a growing trend and it exceeded 1 in 2017, which indicated that tertiary hospitals had higher adjusted mortality rates than secondary hospitals. Similar results have been revealed in other studies ,45. TertWe noticed that the number of AMI patients experienced an expansion between 2013 and 2015, but the trend seemed to disappear after 2015. This is because the EMR system in Shanxi was initiated and piloted in a few large medical centers in 2013, and the number of hospitals applying this EMR system continued to increase until 2015, when the EMR system was applied to hospitals in the entire province. Although the number of AMI patients in 2013 and 2014 was relatively small compared with that in 2015, 2016 and 2017, the study team could still have sufficient statistical power to make inference about the parameters of rural-urban disparity with thousands of patient records.This study has several limitations. First, since this study is based on administrative medical records, it does not contain information of patients’ follow-ups. Patient outcomes can only be observed during their hospitalization, and we do not have their follow-ups after discharge. Second, the patients were divided into rural or urban regions according to their insurance status and current residency address. However, the second stage classification may lead to misclassification bias. The second stage was a suboptimal method of classification since some immigrant workers who came from rural areas may live and work in the urban areas, but they may not be covered by the insurance mentioned in this paper. For these patients, our two-stage classification method will misclassify them as urban residents. A more robust method may be using the patients’ registry information, which were not collected in our database. Third, as an observational study, this study is subject to omitted variable bias. Door-to-balloon time is a crucial variable that can influence the outcomes of patients , but it The disparities with regard to in-hospital mortality and OOP expenses between rural and urban patients are shrinking in China. The adjusted in-hospital mortality rates of rural patients were significantly lower than those of urban patients, but the adjusted OOP expenses of rural patients were significantly higher than those of urban patients. Policy makers are recommended to narrow the gap of health outcomes between rural and urban patients.