The Effects of a Health Promotion Program on Rural, West Virginia Adults

This health promotion project is a 12-week program for adults in a rural West Virginia community with a body mass index (BMI) of 25 or greater. The goals of this project were to facilitate learning through modules focusing on activity and nutrition, increase knowledge of healthy activity and nutrition, and improve weight and BMI. Each 12-week session provided evidenced-based information regarding obesity, physical activity, and nutrition. Participants completed pre- and postprogram and 1-month follow-up survey/questionnaire. Results were compared for changes in activity, nutrition, and BMI. The program resulted in positive changes: increase in activity and nutritional consumption and a decrease in BMI.

The association of alcohol consumption patterns with self-rated physical health and psychiatric distress among Afghanistan- and Iraq-era U.S. veterans

Alcohol misuse is associated with negative mental and physical health outcomes, which presents a public health concern in veterans. However, less is known regarding outcomes among veterans with low to moderate alcohol consumption. This study included veterans with military service in Iraq and/or Afghanistan (N = 1083) who resided in the VA Mid-Atlantic region catchment area (North Carolina, Virginia, and parts of West Virginia). Participants completed a mailed survey that inquired about demographics, past-year alcohol consumption, self-rated physical health, and psychiatric symptoms. Logistic regression was used to evaluate associations between alcohol consumption and posttraumatic stress disorder (PTSD), depression, and self-rated physical health. In both bivariate results and adjusted models, non-drinkers and hazardous drinkers were more likely to endorse clinically significant PTSD and depression symptoms than moderate drinkers. Moderate drinkers were also less likely to report fair/poor health, after adjusting for demographics and psychiatric symptoms. Results overall showed a U-shaped curve, such that moderate alcohol use was associated with lower rates of mental health problems and fair/poor health. While the VA routinely screens for alcohol misuse, current results suggest that non-drinkers are also at risk for poor mental and physical health.

Personal responsibility within health policy: unethical and ineffective

This paper argues against incorporating assessments of individual responsibility into healthcare policies by expanding an existing argument and offering a rebuttal to an argument in favour of such policies. First, it is argued that what primarily underlies discussions surrounding personal responsibility and healthcare is not causal responsibility, moral responsibility or culpability, as one might expect, but biases towards particular highly stigmatised behaviours. A challenge is posed for proponents of taking personal responsibility into account within health policy to either expand the debate to also include socially accepted behaviours or to provide an alternative explanation of the narrowly focused discussion. Second, a critical response is offered to arguments that claim that policies based on personal responsibility would lead to several positive outcomes including healthy behaviour change, better health outcomes and decreases in healthcare spending. It is argued that using individual responsibility as a basis for resource allocation in healthcare is unlikely to motivate positive behaviour changes, and is likely to increase inequality which may lead to worse health outcomes overall. Finally, the case of West Virginia's Medicaid reform is examined, which raises a worry that policies focused on personal responsibility have the potential to lead to increases in medical spending overall.

Can brook trout survive climate change in large rivers? If it rains

We provide an assessment of thermal characteristics and climate change vulnerability for brook trout (Salvelinus fontinalis) habitats in the upper Shavers Fork sub-watershed, West Virginia. Spatial and temporal (2001-2015) variability in observed summer (6/1-8/31) stream temperatures was quantified in 23 (9 tributary, 14 main-stem) reaches. We developed a mixed effects model to predict site-specific mean daily stream temperature from air temperature and discharge and coupled this model with a hydrologic model to predict future (2016-2100) changes in stream temperature under low (RCP 4.5) and high (RCP 8.5) emissions scenarios. Observed mean daily stream temperature exceeded the 21°C brook trout physiological threshold in all but one main-stem site, and 3 sites exceeded proposed thermal limits for either 63- and 7-day mean stream temperature. We modeled mean daily stream temperature with a high degree of certainty (R²=0.93; RMSE=0.76°C). Predicted increases in mean daily stream temperature in main-stem and tributary reaches ranged from 0.2°C (RCP 4.5) to 1.2°C (RCP 8.5). Between 2091 and 2100, the average number of days with mean daily stream temperature>21°C increased within main-stem sites under the RCP 4.5 (0-1.2days) and 8.5 (0-13) scenarios; however, no site is expected to exceed 63- or 7-day thermal limits. During the warmest 10years, ≥5 main-stem sites exceeded the 63- or 7-day thermal tolerance limits under both climate emissions scenarios. Years with the greatest increases in stream temperature were characterized by low mean daily discharge. Main-stem reaches below major tributaries never exceed thermal limits, despite neighboring reaches having among the highest observed and predicted stream temperatures. Persistence of thermal refugia within upper Shavers Fork would enable persistence of metapopulation structure and life history processes. However, this will only be possible if projected increases in discharge are realized and offset expected increases in air temperature.

Comparative analytical and toxicological assessment of methylcyclohexanemethanol (MCHM) mixtures associated with the Elk River chemical spill

On January 9, 2014, a chemical mixture containing crude methylcyclohexanemethanol (MCHM) contaminated the water supply of Charleston, West Virginia. Although the mixture was later identified as a mix of crude MCHM and stripped propylene glycol phenyl ethers, initial risk assessment focused on 4-MCHM, the predominant component of crude MCHM. The mixture's exact composition and the toxicity differences between 4-MCHM, crude MCHM, and the tank mixture were unknown. We analyzed the chemical composition of crude MCHM and the tank mixture via GC/MS and, based on identified spectra, found that crude MCHM and the tank mixture differed in chemical composition. To evaluate acute developmental toxicity, zebrafish embryos were exposed to 0, 1, 6.25, 12.5, 25, 50, or 100 parts per million (ppm; mg/L) of 4-MCHM, crude MCHM, or the tank mixture. The percent mortality and percent hatch, larval morphology alterations, and larval visual motor response test were used to establish toxicity profiles for each of the chemicals or mixtures. The acute toxicity differed between 4-MCHM, crude MCHM and the tank mixture with significant differences in survival, hatching, morphology, and locomotion at levels as low as the short-term screening level of 1 ppm, suggesting a need for further research into human health risks. This study is the first to evaluate the developmental toxicity of the tank mixture and highlights that studies evaluating risk should not assume the effects of 4-MCHM or crude MCHM are representative of the Tank 396 mixture.

Degradation of Crude 4-MCHM (4-Methylcyclohexanemethanol) in Sediments from Elk River, West Virginia

In January 2014, approximately 37 800 L of crude 4-methylcyclohexanemethanol (crude MCHM) spilled into the Elk River, West Virginia. To understand the long-term fate of 4-MCHM, we conducted experiments under environmentally relevant conditions to assess the potential for the 2 primary compounds in crude MCHM (1) to undergo biodegradation and (2) for sediments to serve as a long-term source of 4-MCHM. We developed a solid phase microextraction (SPME) method to quantify the cis- and trans-isomers of 4-MCHM. Autoclaved Elk River sediment slurries sorbed 17.5% of cis-4-MCHM and 31% of trans-4-MCHM from water during the 2-week experiment. Sterilized, impacted, spill-site sediment released minor amounts of cis- and up to 35 μg/L of trans-4-MCHM into water, indicating 4-MCHM was present in sediment collected 10 months post spill. In anoxic microcosms, 300 μg/L cis- and 150 μg/L trans-4-MCHM degraded to nondetectable levels in 8-13 days in both impacted and background sediments. Under aerobic conditions, 4-MCHM isomers degraded to nondetectable levels within 4 days. Microbial communities at impacted sites differed in composition compared to background samples, but communities from both sites shifted in response to crude MCHM amendments. Our results indicate that 4-MCHM is readily biodegradable under environmentally relevant conditions.

Implementation of a skills practical to first-year pharmacy students

BACKGROUND AND PURPOSE

Objective structured clinical examinations (OSCEs) are being implemented in pharmacy schools across the country. As part of a new curriculum, a practical with an OSCE component was implemented for the first time at the West Virginia University School of Pharmacy.

EDUCATIONAL ACTIVITY AND SETTING

A practical with an OSCE component was developed for first-year professional pharmacy students in a foundational pharmacy skills course. The OSCE component assessed insulin and inhaler counseling and blood pressure skills. A written exam covered material from throughout the semester.

FINDINGS

A total of 76 students completed the practical. The average grade was a 27.8 out of 30 points. A total of 62 faculty hours were needed for the implementation of this OSCE.

DISCUSSION AND SUMMARY

An OSCE that assessed a variety of foundational pharmacy skills was designed and implemented to first year pharmacy students using limited faculty time and resources.

Advance Care Planning and Shared Decision-Making: An Interprofessional Role-Playing Workshop for Medical and Nursing Students

Introduction

Advance care planning (ACP) is an essential discussion between a health care provider and a patient about their future care during serious illness. In clinical practice, high-quality ACP may be addressed with an interprofessional approach. Role-playing is an ideal method to practice both ACP and shared decision-making before having these conversations with patients.

Methods

This asynchronous role-playing workshop is prefaced with two prerecorded 25-minute videos for faculty and student preparation with one introducing ACP concepts, and one depicting a patient-physician ACP discussion. During the 2-hour workshop, students complete four role-play ACP scenarios with the following roles: patient, family member, nurse, nurse practitioner, and physician. Students rotate through different roles guided by scripts, and have a fact sheet for each scenario detailing prognostic information for disease processes. The role-play works optimally with three nursing students, three medical students, and one faculty facilitator per group. Facilitators are provided with a timeline, a guide for debriefing, and an evaluation rubric.

Results

The survey data from 85 students spread over four course offerings were summarized. When asked both if learning objectives were met, and to reflect on the clinical relevance, teaching effectiveness, and the overall workshop experience, most participants reported a good to excellent rating.

Discussion

This role-play activity allows students to practice ACP and shared decision-making, both with patient and family presence, and in premeeting rounds with the health care team. ACP exposure during student training helps trainees recognize the impact of high-quality interprofessional conversations on the care patients want and ultimately receive.

Ultrasound and histological measurements of dividing membrane thickness in twin gestations

OBJECTIVE

To determine how prenatal ultrasound measurements of dividing membrane thickness correlate with postnatal histological measurements and chorionicity in twin gestations.

METHODS

This was a prospective, longitudinal cohort study of twin gestations. Dividing membrane thickness was measured by transabdominal ultrasound, with the insonation beam both parallel and perpendicular to the membrane, in the second or third trimester, depending on when care was established. Ultrasound examinations were performed every 4 weeks following initial assessment until delivery. Measurements of membrane thickness from the first ultrasound examination were compared with histological measurements after delivery.

RESULTS

A total of 45 twin pregnancies (32 dichorionic, 13 monochorionic) were included. Mean gestational age at initial ultrasound examination was 24.1 ± 7.3 weeks. Parallel ultrasound measurements of membrane thickness were 1.6 ± 0.8 mm for monochorionic and 2.5 ± 0.9 mm for dichorionic gestations (P = 0.001). Perpendicular ultrasound measurements were 1.6 ± 0.3 mm for monochorionic and 2.2 ± 0.8 mm for dichorionic gestations (P = 0.009). Inter- and intraobserver reliability of ultrasound measurements were 0.847 and 0.950, respectively. Parallel and perpendicular ultrasound measurements correlated better with each other (R = 0.807, P < 0.001) than with histological measurements of membrane thickness (R_parallel  = 0.538, P < 0.001; R_{perpendicular}  = 0.529, P < 0.001). Receiver-operating characteristics curve analyses to predict histological membrane thickness > 50^th percentile resulted in an area under the curve (AUC) of 0.828 for parallel (P < 0.001) and 0.874 for perpendicular (P < 0.001) measurements with a cut-off value of 1.9 mm for both approaches. The AUCs for parallel and perpendicular measurements to predict dichorionicity were 0.892 (P < 0.001) and 0.823 (P < 0.001) with cut-off values of 1.9 and 1.8 mm, respectively.

CONCLUSION

Prenatal ultrasound measurement of twin dividing membrane thickness is positively correlated with postnatal histological measurement. Dichorionicity can be determined by a magnified dividing membrane thickness ≥ 1.9 mm. Measurements with the ultrasound beam parallel to the dividing membrane may be more accurate than perpendicular measurements. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Fire Blight Resistance in Wild Accessions of Malus sieversii

Fire blight (Erwinia amylovora) is a devastating bacterial disease in apple that results in severe economic losses. Epidemics are becoming more common as susceptible cultivars and rootstocks are being planted, and control is becoming more difficult as antibiotic-resistant strains develop. Resistant germplasm currently being utilized by breeding programs tend to have small fruit size and poor flavor characteristics. Malus sieversii, a progenitor species of domestic apple, is notable for its relatively large, palatable fruit and some accessions have been reported to be resistant to fire blight. In this study, nearly 200 accessions of M. sieversii and appropriate controls were inoculated with E. amylovora in both Washington and West Virginia to identify fire blight resistant accessions. Twelve accessions were identified with resistance comparable to highly resistant and resistant controls. Several accessions exhibited a unique resistance response, not previously reported in domestic apple (M. × domestica), characterized by low incidence of infection but high severity once infection was initiated. Several of these M. sieversii accessions will be used as parents in future crosses in the Washington State University apple breeding program.

Relationship Between Adherence to Individual Goals Within the 5-2-1-0 Guidelines for Obesity Prevention and Number of PACER Laps in Adolescents

BACKGROUND

The purpose of this study was to evaluate the relationship between adolescents' adherence to the 5-2-1-0 goals and the number of completed Progressive Cardiovascular Endurance Run (PACER) laps.

METHODS

Participants included 1792 students aged 10 to 16 years who were randomly selected across 9 data collection periods between 2012 and 2014. The Survey of Physical Activity and Nutrition was used to measure time spent in physical activity and sedentary behavior, and dietary intake and the dependent variable was the number of PACER laps achieved. The Kruskal-Wallis test and pairwise post hoc comparisons were conducted.

RESULTS

Only 0.95% (N = 17) participants met all 4 goals outlined within the 5-2-1-0 guidelines. Whereas 10.04% met 3 (N = 180), 41.63% met 2 (N = 746), 34.99% met 1 (N = 627), and 12.39% did not meet any goals (N = 222). Pairwise comparisons indicated there were significant differences: between groups not meeting any of the 5-2-1-0 goals and other groups (meeting one goal [p = .000], 2 goals [p = .000], 3 goals [p = .000], and all 4 [p = .008]).

CONCLUSIONS

The positive relationship between PACER laps and adherence to the 5-2-1-0 goals suggests targeted and sequential behavioral changes may have positive implications on adolescents' cardiovascular fitness and body mass index.

A Free Clinic Continuity Experience During Residency Is Associated With Practice in Underserved Areas

BACKGROUND

Exposure to underserved areas during training may increase residents' likelihood of practice in these settings. The Marshall University Family Medicine Residency offers a supplemental continuity experience at a local free clinic to interested residents.

OBJECTIVE

We assessed the association of such an experience with graduate practice choices.

METHODS

We evaluated all residency graduates (N = 138) who completed our family medicine program from 1997 through 2014 and compared participants in the free clinic experience to nonparticipants. Various characteristics and outcome measures were collected retrospectively from resident records maintained for program accreditation.

RESULTS

A total of 43 residents participated in the free clinic experience compared with 95 nonparticipants. Postgraduation practice in an area of need was seen for 56% (24 of 43) of participants compared with 31% (29 of 95) of nonparticipants (P = .005). The 53 graduates practicing in areas of need were nearly twice as likely to have taken part in the free clinic experience (45% [24 of 53] versus 22% [19 of 85], P = .005). Participants were more likely to practice in rural areas (63%, 27 of 43) than residents who did not participate (43% [41 of 95], P = .033). Board certification rates were high for both free clinic participants (98%, 42 of 43) and nonparticipants (95% [90 of 95], P = .43).

CONCLUSIONS

Resident participation in a supplemental continuity experience at a free clinic was associated with practicing in areas of need and rural communities after graduation.

The Characterization of Ozone Exposures in Rural West Virginia and Virginia

Ozone (O3) is suspected of being the most significant air pollutant affecting vegetation in the United States. Ozone concentrations measured at Bearden Knob and Parsons, located in a remote forested region of northcentral West Virginia, were characterized and compared with exposures experienced at other sites in the region. From 1988 to 1992, 1988 was one of the highest O3 exposure years in the region, while 1992 was the lowest. At almost all sites in 1992, few hourly average concentrations were > or = 0.10 ppm, while in 1988 several sites had more than 100 hourly average concentrations > or = 0.10 ppm. These instances occurred at both high- and low-elevation sites. In 1992, the high-elevation Bearden Knob site experienced a flat-type diurnal pattern, while the nearby low-elevation Parsons site experienced a changing diurnal pattern, indicative of scavenging. Using several indices, O3 exposures at Parsons were less than those at Bearden Knob. Evaluation of hourly averaged data for all sites in the region from 1988 to 1992 showed that Horton Station experienced the highest W126 O3 exposures. Horton Station is a high-elevation site in the mountains of southwestern Virginia. Square-wave exposures have been used under artificial conditions in vegetation experiments. If square-wave exposures are observed under ambient conditions, then the vegetation data collected under artificial conditions may be relevant for predictive purposes. Square-wave exposures were characterized for two high-elevation sites. In 1992, Horton Station experienced 25 episodes for which the hourly average concentrations remained near 0.05 ppm for eight hours or longer; there were 18 episodes for which the hourly average concentrations remained near 0.06 ppm, and three episodes for which the concentrations remained near 0.07 ppm. Bearden Knob experienced 31 episodes of eight hours or longer for hourly average concentrations near 0.05 ppm, 13 episodes at or near 0.06 ppm, and three episodes at or near 0.07 ppm. Until experiments are performed to determine the relative importance of hourly average concentrations above 0.03 ppm for assessing vegetation effects, using single-parameter exposure indices to predict effects may produce inconsistent results.

Creating a More Perennial Problem? Mountaintop Removal Coal Mining Enhances and Sustains Saline Baseflows of Appalachian Watersheds

Mountaintop removal coal mining (MTM) is a form of surface mining where ridges and mountain tops are removed with explosives to access underlying coal seams. The crushed rock material is subsequently deposited in headwater valley fills (VF). We examined how this added water storage potential affects streamflow using a paired watershed approach consisting of two sets of mined and unmined watersheds in West Virginia. The mined watersheds exported 7-11% more water than the reference watersheds, primarily due to higher and more sustained baseflows. The mined watersheds exported only ~1/3 of their streamflow during storms, while the reference watersheds exported ~2/3 of their annual water yield during runoff events. Mined watersheds with valley fills appear to store precipitation for considerable periods of time and steadily export this alkaline and saline water even during the dry periods of the year. As a result, MTMVFs in a mixed mined/unmined watershed contributed disproportionately to streamflow during baseflow periods (up to >90% of flow). Because MTMVFs have both elevated summer baseflows and continuously high concentrations of total dissolved solids, their regional impact on water quantity and quality will be most extreme and most widespread during low flow periods.

Disparities in Rural Breast Cancer Care: Factors Affecting Choice of Breast Reconstruction in a West Virginia Tertiary Care Hospital

The decision to pursue immediate postmastectomy breast reconstruction (IBR) is not uniform across all groups of women in the United States. We sought to investigate if the challenges of caring for a socioeconomically and geographically challenged rural population affected the incidence of IBR and to identify predictive factors of IBR in this population. Using our institution's cancer registry, we conducted a 10-year review of women with early-stage, unilateral breast cancer who received mastectomy. Demographics, insurance status, comorbidities, and surgeon graduation year were compared for patients receiving IBR versus no reconstruction. Variables with P < 0.05 on univariate analysis were included into a multivariate logistic regression model to determine independent predictors of IBR. From 2006 to 2015, 53/423 (12.5%) patients underwent IBR. On multivariate analysis, three factors independently predicted the decision to undergo IBR: age (P = 0.004), insurance type (P = 0.034), and use of contralateral prophylactic mastectomy (CPM, P < 0.001). Our data indicate that age, insurance type, and utilization of CPM influence the decision to pursue reconstruction. Additionally, the rate of IBR was found to be much lower in our West Virginia population than reported nationally, suggesting disparities in the care of women with early-stage, unilateral breast cancer in a rural population, even in a tertiary care environment.

Factors Affecting Choice of Treatment for Early-Stage Breast Cancer in West Virginia: A 10-Year Experience from a Rural Tertiary Care Center

Recent literature shows changing trends in use of breast conservation surgery (BCS), mastectomy, and contralateral prophylactic mastectomy (CPM) in women with early-stage breast cancer (ESBC). We analyzed factors associated with selection of these treatment modalities in a rural West Virginia tertiary care hospital. We conducted a 10-year analysis of women treated for ESBC at our institution from the institutional cancer registry. Variables were compared between patients choosing BCS versus mastectomy. In women who chose mastectomy, predictors for choice of CPM were also examined. Variables with P < 0.05 on univariate analysis were entered into a multivariate logistic regression model to define independent predictors of treatment choice. The mastectomy rate increased from 18.0 per cent in 2006 to 40.2 per cent in 2013. On multivariate analysis, insurance status (P < 0.001), comorbidities (P = 0.001), and surgeon graduation after 1987-a surrogate for surgeon age-(P = 0.010) predicted receipt of mastectomy. Of those receiving mastectomy, 106 (25.1%) elected CPM. CPM rates increased from 8.0 per cent in 2006 to 45.0 per cent in 2013. Younger age at diagnosis (P < 0.001) and use of preoperative MRI (P = 0.012) independently predicted use of CPM versus unilateral mastectomy. Rates of mastectomy and CPM in ESBC have increased in West Virginia over time. Independent predictors of selecting mastectomy over BCS included insurance status, surgeon age, and associated comorbidities. Younger patients and patients receiving preoperative MRI were more likely to choose CPM. Awareness of these factors will aid in counseling women with ESBC and allow clinicians to address potential biases or disparities that may affect treatment choices. Further prospective study of these findings is warranted.

Osteopathic Medical Students Entering Family Medicine and Attitudes Regarding Osteopathic Manipulative Treatment: Preliminary Findings of Differences by Sex

Context

Factors distinguishing osteopathic physicians from their allopathic counterparts include the use of osteopathic manipulative treatment (OMT), application of osteopathic principles and practice (OPP), and a greater likelihood of entering primary care, specifically family medicine (FM). In the United States, the percentage of entering osteopathic medical students who were female rose from 14.3% in fall 1977 to 44.3% in fall 2015.

Objectives

To investigate the perspectives of female osteopathic medical students as they relate to osteopathic distinctiveness.

Methods

Students at the West Virginia School of Osteopathic Medicine who were eligible to participate in graduation exercises in 2014 or 2015 were asked to complete the school's standard Exit Survey. The research team chose 5 items from the survey to include in the current analysis. Sex had been self-identified at admission, and residency in first postgraduate year was categorized as FM or other specialty. Graduates entering a transitional year or traditional internship were removed from analysis.

Results

Analysis was conducted for 308 of the 375 students (82%) expected to graduate in 2014 or 2015. χ2 analysis found no difference by sex in the number of graduates entering FM residencies vs other specialties (P=.727). Statistically significant differences were found in 2 survey items: "Use of OMT will enhance my practice" (P=.005) and "What emphasis do you believe OMT will have in your practice?" (P<.001). Graduating female students responded more favorably to OMT on both items. For the latter item, 91.4% of female and 80.3% of male students indicated OMT would have at least some role in their practices. Sex differences remained after statistically controlling for entry into FM.

Conclusion

Female graduating osteopathic medical students were more likely to report that OMT will have at least some role in their practices. Future studies of the attitudes and practice patterns of osteopathic physicians should analyze for differences by sex.

Predicting water filter and bottled water use in Appalachia: a community-scale case study

A questionnaire survey was conducted in order to assess residents' perceptions of water quality for drinking and recreational purposes in a mid-sized city in northcentral West Virginia. Two logistic regression analyses were conducted in order to investigate the factors that influence bottle use and filter use. Results show that 37% of respondents primarily use bottled water and that 58% use a household filter when drinking from the tap. Respondents with lower levels of environmental concern, education levels, and lower organoleptic perceptions were most likely to perceive health risks from tap water consumption, and were most likely to use bottled water. Income, age, and organoleptic perceptions were predictors of water filter use among respondents. Clean water for recreational purposes was not found to be significant with either of these models. Our results demonstrate that bottle use and filter use are explained differently. We argue that more education and better communication about local tap water quality would decrease the use of bottled water. We demonstrate that household filters could be used as an alternative to bottled water.

Anatomical and technical predictors of perioperative clinical outcomes after carotid artery stenting

BACKGROUND

A few other studies have reported the effects of anatomical and technical factors on clinical outcomes of carotid artery stenting (CAS). This study analyzed the effect of these factors on perioperative stroke/myocardial infarction/death after CAS.

METHODS

This was a retrospective analysis of prospectively collected data of 409 of 456 patients who underwent CAS during the study period. A logistic regression analysis was used to determine the effects of anatomical and technical factors on perioperative stroke, death, and myocardial infarction (major adverse events [MAEs]).

RESULTS

The MAE rate for the entire series was 4.7% (19 of 409), and the stroke rate was 2.2% (9 of 409). The stroke rate for asymptomatic patients was 0.46% (1 of 218; P = .01). The MAE rates for patients with transient ischemic attack (TIA) were 7% (11 of 158) vs 3.2% (8 of 251) for other indications (P = .077). The stroke rates for heavily calcified lesions were 6.3% (3 of 48) vs 1.2% (4 of 332) for mildly calcified/noncalcified lesions (P = .046). Differences in stroke and MAE rates regarding other anatomical features were not significant. The stroke rate for patients with percutaneous transluminal angioplasty (PTA) before embolic protection device (EPD) insertion was 9.1% (2 of 22) vs 1.8% (7 of 387) for patients without (P = .07) and 2.6% (9 of 341) for patients with poststenting PTA vs 0% (0 of 68) for patients without. The MAE rate for patients with poststenting PTA was 5.6% (19 of 341) vs 0% (0 of 68) for patients without (P = .0536). The MAE rate for patients with the ACCUNET (Abbott, Abbott Park, Ill) EPD was 1.9% (3 of 158) vs 6.7% (16 of 240) for others (P = .029). The differences between stroke and MAE rates for other technical features were not significant. A regression analysis showed that the odds ratio for stroke was 0.1 (P = .031) for asymptomatic indications, 13.7 (P = .014) for TIA indications, 6.1 (P = .0303) for PTA performed before EPD insertion, 1.7 for PTA performed before stenting, and 5.4 (P = .0315) for heavily calcified lesions. The MAE odds ratio was 0.46 (P = .0858) for asymptomatic indications, 2.1 for PTAs performed before EPD insertion, 2.2 for poststent PTAs, and 2.2 (P = .1888) for heavily calcified lesions. A multivariate analysis showed that patients with TIA had an odds ratio of stroke of 11.05 (P = .029). Patients with PTAs performed before EPD insertion had an OR of 6.15 (P = .062). Patients with heavily calcified lesions had an odds ratio of stroke of 4.25 (P = .0871). The MAE odds ratio for ACCUNET vs others was 0.27 (P = .0389).

CONCLUSIONS

Calcific lesions and PTA before EPD insertion or after stenting were associated with higher stroke or MAE rates, or both. The ACCUNET EPD was associated with lower MAE rates. There was no correlation between other anatomical/technical variables and CAS outcome.

Right TraC™ Post-Hospitalization Care Transitions Program to Reduce Readmissions for Hemodialysis Patients

BACKGROUND

Hemodialysis (HD) patients have high hospitalization rates. This nonrandomized trial tested the effect of a bundle of renal-specific "Right TraC™" strategies on 30-day all-cause readmission rates and, secondarily, 90-day readmissions and overall admissions among HD patients.

METHODS

Twenty-six Fresenius clinics in West Virginia, Ohio, and Kentucky participated in the interventions. Eighteen matched clinics served as controls; intervention clinics also served as their own controls. We deployed the intervention in 3 incremental phases focused on patient information exchange, post-hospital follow-up, and telephonic case management. Thirty-day hospital readmissions per patient year (ppy) were calculated by dividing the total number of readmissions within 30 days of index admission by the total number of patient-years in baseline (2012) and remeasurement (2014) periods. We also compared readmission rates from 2010 to 2015. We used repeated measures Poisson regression to compare outcomes between groups and time periods.

RESULTS

From 2012 to 2014, 30-day all-cause readmissions ppy declined for Right TraC clinics (from 0.88 to 0.66 [p < 0.001]; for controls, from 0.73 to 0.61 [p = 0.16]). Difference in change between groups was nonsignificant (p = 0.26). Overall admissions ppy declined: for Right TraC clinics from 2.51 to 1.97 (p < 0.001); for controls from 2.14 to1.92 (p = 0.21); difference in change between groups was significant (p = 0.01). For 2010, 2011, and 2012, Right TraC clinic 30-day readmissions ppy were unchanged: 0.89, 1.00, 0.88 (p = 0.61 and p = 0.49); they declined to 0.66 (p < 0.001) in 2014 (intervention year); rose to 0.70 (p = 0.06) in 2015 (interventions discontinued).

CONCLUSION

We conclude that Right TraC interventions may have been helpful in reducing hospital readmission rates.

Private well groundwater quality in West Virginia, USA-2010

The Centers for Disease Control and Prevention (CDC), in collaboration with the West Virginia Bureau of Public Health (BPH), initiated an investigation to characterize private well water quality in West Virginia. The objective was to better characterize private well water across various aquifer geologies by testing household drinking water samples and comparing them to EPA's National Primary Drinking Water Standards. The BPH selected ten counties representing three regions to capture geologically diverse areas that represent varying aquifer geology. We collected well-water samples from participating households and analyzed all water samples for 20 constituents currently monitored in public drinking-water systems. We calculated geometric means for each constituent and compared metal concentrations to EPA maximum and secondary contaminant levels by the geologic age of the rock surrounding the aquifer where the sample was obtained. All participating households (n=139) provided a water sample. We detected arsenic at levels higher than the EPA maximum contaminant level in 10 (7.2%) samples. We detected elevated radon-222 in 48 (34.5%) samples. Geologic age of the region was indicative of whether arsenic and radon-222 were present at levels that exceeded current EPA drinking water standards. We found arsenic and radon concentrations were higher in Permian aquifers compared to those of other geologic ages. Homeowners with private wells in areas with Permian aged aquifers could benefit from targeted public health messaging about potentially harmful constituent concentrations in the well water. This may help ensure proper testing and maintenance of private wells and reduce exposure to these constituents.

A pilot study to assess residential noise exposure near natural gas compressor stations

BACKGROUND

U.S. natural gas production increased 40% from 2000 to 2015. This growth is largely related to technological advances in horizontal drilling and high-volume hydraulic fracturing. Environmental exposures upon impacted communities are a significant public health concern. Noise associated with natural gas compressor stations has been identified as a major concern for nearby residents, though limited studies exist.

OBJECTIVES

We conducted a pilot study to characterize noise levels in 11 homes located in Doddridge County, West Virginia, and determined whether these levels differed based on time of day, indoors vs. outdoors, and proximity of homes to natural gas compressor stations. We also compared noise levels at increasing distances from compressor stations to available noise guidelines, and evaluated low frequency noise presence.

METHODS

We collected indoor and outdoor 24-hour measurements (Leq, 24hr) in eight homes located within 750 meters (m) of the nearest compressor station and three control homes located >1000m. We then evaluated how A-weighted decibel (dBA) exposure levels differed based on factors outlined above.

RESULTS

The geometric mean (GM) for 24-hour outdoor noise levels at homes located <300m (Leq,24hr: 60.3 dBA; geometric standard deviation (GSD): 1.0) from the nearest compressor station was nearly 9 dBA higher than control homes (Leq,24hr: 51.6 dBA; GSD: 1.1). GM for 24 hour indoor noise for homes <300m (Leq,24hr: 53.4 dBA; GSD: 1.2) from the nearest compressor station was 11.2 dBA higher than control homes (Leq,24hr: 42.2 dBA; GSD: 1.1). Indoor average daytime noise for homes <300m of the nearest compressor stations were 13.1 dBA higher than control homes, while indoor nighttime readings were 9.4 dBA higher.

CONCLUSIONS

Findings indicate that living near a natural gas compressor station could potentially result in high environmental noise exposures. Larger studies are needed to confirm these findings and evaluate potential health impacts and protection measures.

In vitro cytotoxicity assessment of a West Virginia chemical spill mixture involving 4-methylcyclohexanemethanol and propylene glycol phenyl ether

Thousands of gallons of industrial chemicals, crude 4-methylcyclohexanemethanol (MCHM) and propylene glycol phenyl ether (PPh), leaked from industrial tanks into the Elk River in Charleston, West Virginia, USA, on January 9, 2014. A considerable number of people were reported to exhibit symptoms of chemical exposure and an estimated 300,000 residents were advised not to use or drink tap water. At the time of the spill, the existing toxicological data of the chemicals were limited for a full evaluation of the health risks, resulting in concern among those in the impacted regions. In this preliminary study, we assessed cell viability and plasma membrane degradation following a 24-h exposure to varying concentrations (0-1000 μM) of the two compounds, alone and in combination. Evaluation of different cell lines, HEK-293 (kidney), HepG2 (liver), H9c2 (heart), and GT1-7 (brain), provided insight regarding altered cellular responses in varying organ systems. Single exposure to MCHM or PPh did not affect cell viability, except at doses much higher than the estimated exposure levels. Certain co-exposures significantly reduced metabolic activity and increased plasma membrane degradation in GT1-7, HepG2, and H9c2 cells. These findings highlight the importance of examining co-exposures to fully understand the potential toxic effects.

Deltamethrin-Incorporated Nets as an Integrated Pest Management Tool for the Invasive Halyomorpha halys (Hemiptera: Pentatomidae)

Long-lasting insecticide nets (LLINs), which have insecticide incorporated within the fibers, have been widely used for control of malaria and other insect-vectored diseases. Only recently have researchers begun exploring their use for control of agricultural pests. In this study, we evaluated the toxicity of a deltamethrin-incorporated LLIN, ZeroFly (Vestergaard-Frandsen, Washington, DC) for control of the brown marmorated stink bug, Halyomorpha halys (Stål). In the lab, exposure to the ZeroFly net for 10 s resulted in >90% mortality of H. halys nymphs and >40% mortality of H. halys adults. Longer exposure to the net resulted in higher mortality. In another experiment, a 15-cm2 sheet of ZeroFly net placed inside of the stink bug trap provided long-lasting kill of H. halys adults equal to or better than standard dichlorvos kill strip. Potential for the use of ZeroFly nets for H. halys IPM is discussed.

Temporal and Directional Patterns of Nymphal Halyomorpha halys (Hemiptera: Pentatomidae) Movement on the Trunk of Selected Wild and Fruit Tree Hosts in the Mid-Atlantic Region

Halyomorpha halys (Stål) (Hemiptera: Pentatomidae) is an invasive and polyphagous herbivore that has been problematic in Mid-Atlantic fruit orchards, many of which are adjacent to woodlands containing its wild hosts. Our tree census in woodlands bordering 15 Mid-Atlantic apple orchards revealed 47 species of deciduous trees and shrubs, 76.6% of which were recorded hosts of H. halys. Tree of heaven was most common and abundant overall. Halyomorpha halys nymphs have a substantial walking dispersal capacity, and their fitness is enhanced by feeding on multiple hosts. Directional and temporal patterns of nymphal H. halys movement on selected wild hosts and apple and peach trees at the orchard-woodland interface were monitored in 2014 and 2015 using passive traps to capture nymphs walking up and down tree trunks. Weekly captures from mid-May to late September or mid-October were compared among hosts across both seasons. Despite higher total nymphal captures in 2014 than 2015, the seasonal trends for both years were similar and indicated bivoltine H. halys populations. In both years, more nymphs were intercepted while walking up than down and captures of upward- and downward-walking nymphs varied significantly among the hosts. All instars were captured, but captures of second instars predominated. Captures reflected seasonal changes in instar distribution and consisted predominantly of younger and older nymphs, early and later in the season, respectively. Results are discussed in relation to host and seasonal effects on the movement of nymphs at the orchard-woodland interface, and the implications for H. halys management.