Species composition of Culicoides (Diptera: Ceratopogonidae) in the Ridge and Valley region of Tennessee, USA

Biting midges in the genus Culicoides Latreille (Diptera: Ceratopogonidae) are known to transmit many pathogens of veterinary and medical concern. Although much work has been done globally and in certain regions of North America, Culicoides spp. research in rural Appalachia is limited. To begin characterizing the distribution and community structure of Culicoides spp. in Appalachia, we surveyed 2 distinct sites in the Ridge and Valley ecoregion of northeastern Tennessee, USA, from April 2021-September 2021. Culicoides spp. were sampled using 2 methods: Centers for Disease Control ultraviolet LED light traps and potential larval habitat substrate collection (coupled with water chemistry values). Site 1 was dominated by natural features, and Site 2 was a beef cattle operation. During 96 trap nights, a total of 1,568 Culicoides were collected, representing 24 species. Site 1 yielded the highest diversity, with 24 species, while Site 2 yielded 12 species. Overall, the most abundant species in light traps were C. stellifer Coquillett (44%), C. bergi Cochrane (18%), C. haematopotus Malloch (12%), and C. debilipalpis Lutz (11%). From substrate sampling, 8 species were identified. Culicoides haematopotus was the most abundant and was collected during each sampling period. Water chemistry values taken at the time of substrate collection were not significantly related to which Culicoides spp. emerged from a given substrate. Our results indicate a diverse community of Culicoides spp. in our study area, however, further work is needed to identify Culicoides species composition across a variety of landscapes in Appalachia and inform research on vector presence and associated vector disease dynamics.

Diphenhydramine-involved Fatal and Nonfatal Drug Overdoses in Tennessee, 2019-2022

BACKGROUND

Diphenhydramine (DPH), known as the brand name Benadryl, is an over-the-counter medication associated with accidental ingestion leading to nonfatal overdoses. Additionally, DPH has been used in tandem with illicit substances leading to fatal drug overdoses.

OBJECTIVE

In response to DPH being seized with illicit drugs as an adulterant, as well as its growing intentional misuse, we sought to explore its recent involvement in fatal and nonfatal drug overdoses in the state of Tennessee.

METHODS

We conducted a statewide cross-sectional study to determine the characteristics of DPH-involved fatal and nonfatal overdoses in Tennessee during 2019-2022 using data from the State Unintentional Drug Overdose Reporting System, the Electronic Surveillance System for the Early Notification of Community-based Epidemics, and the National Forensic Laboratory Information System Public Data Query System. Frequencies were generated to compare demographic characteristics, circumstances, and toxicology between fatal and nonfatal DPH-involved overdoses.

RESULTS

We identified 143 suspected nonfatal DPH and 409 fatal DPH-involved overdoses in Tennessee from 2019 to 2022. Nonfatal overdoses remained consistent while fatal overdoses peaked in 2021. Most nonfatal overdoses were under 18 (63.4%), while most fatal overdoses were between 18 and 64 years of age (95.7%). For fatal overdoses, fentanyl was the most prevalent substance on toxicology followed by prescription opioids.

CONCLUSION

Nonfatal overdoses remained consistent while fatal overdoses peaked in 2021 in Tennessee. Use of DPH among other illicit substances lends to evidence suggesting its use as an adulterant. Monitoring of DPH-involved fatal and nonfatal overdoses is critical to inform harm reduction initiatives.

Mycobacterium senegalense Infection in Kidney Transplant Patient with Diabetes, Memphis, Tennessee, USA

Fewer than 30 cases of Mycobacterium senegalense infection have been reported. We report a complicated case of M. senegalense infection in Memphis, Tennessee, in the southeastern United States. The patient's comorbidities of past organ transplant and insulin-dependent diabetes required delicate consideration of those health conditions to guide treatment.

Exploring trends in benzodiazepine-positive fatal drug overdoses in Tennessee, 2019-2021

BACKGROUND

Benzodiazepine-positive overdoses increased between 2019 and 2021 in Tennessee. We sought to determine the changes in the number and characteristics of prescription and illicit benzodiazepine-positive fatal drug overdoses during this period.

MATERIALS AND METHODS

A statewide study was conducted to determine changes in the number and characteristics of benzodiazepine-positive drug overdose decedents using 2019-2021 data from the Tennessee State Unintentional Drug Overdose Reporting System. The analyses were limited to Tennessee residents aged ≥ 18 years. A benzodiazepine-positive overdose was defined as any benzodiazepine on toxicology, regardless of the presence of other substances. Frequencies were generated to compare demographics, circumstances, prescription history, and toxicology between 2019 and 2021 for illicit and prescription benzodiazepine-positive fatal overdoses.

RESULTS

Between 2019 and 2021, 1666 benzodiazepine-positive unintentional or undetermined fatal drug overdoses out of 5916 total overdoses that occurred among adult Tennessee residents with available toxicological information. Prescription benzodiazepines were identified in 80.7% of deaths, whereas illicit benzodiazepines were identified in 12.0% of deaths. Many decedents had an anxiety disorder (45.5%), while over half of all decedents had a history of substance use disorder (52.3%). Most benzodiazepine-positive overdoses involved fentanyl (71.3%).

CONCLUSIONS

This analysis can inform local and regional public health workers to implement focused prevention and intervention efforts for people with co-occurring mental health conditions and substance use disorders to curb overdose epidemics among persons using benzodiazepines in Tennessee. Public health campaigns should focus on educating people on appropriate prescription medication use and the dangers of obtaining substances illicitly. Given the high proportion of opioids in this population, further education also is needed on the dangers of polysubstance drug use. The differences between prescription and illicit benzodiazepine-positive fatal overdoses indicate the need to develop substance-specific prevention and treatment strategies.

Perceptions of the impact of COVID-19 in Tennessee, USA: a retrospective study

Background

Despite high incidence and mortality risks associated with COVID-19 during the pandemic, stay-at-home orders and vaccination recommendations were met with varying levels of acceptance in Tennessee. Understanding perceptions of individuals regarding the health and economic impacts of COVID-19 is necessary to address public concerns while ensuring appropriate public health response. Therefore, the objectives of this study were to (a) investigate differences in opinions among residents of Tennessee regarding the impacts of COVID-19; and (b) identify socioeconomic and demographic predictors/determinants of these opinions.

Methods

This retrospective cross-sectional study was conducted using survey data collected in nine waves during 2020. Distributions of survey-weighted sociodemographic characteristics and respondent perceptions of the impact of COVID-19 were computed. Weighted logistic models were used to investigate predictors of a number of perceptions: whether the health or economic impact was greater, concern for respondent's health, concern for family's health, and willingness to accept COVID-19 vaccine.

Results

The study included a total of 9,754 survey respondents. Approximately equal percentages considered COVID-19 to have a greater economic (48.4%) versus health impact (51.6%). Just 40.1% of the respondents reported that they would definitely accept a COVID-19 vaccine. Age group, race, educational attainment, and household composition were significant (p < 0.05) predictors of all investigated perceptions regarding COVID-19. Lack of prior infection was the strongest predictor of the perception of COVID-19 having a greater impact on health (OR = 2.40, p < 0.001), concern for respondent's health (OR = 1.86, p = 0.002), and concern for family members' health (OR = 1.90, p = 0.001). Compared to males, females had higher odds of identifying the health impact of COVID-19 as greater (OR = 1.09, p = 0.041) and reporting concern for family health (OR = 1.14, p = 0.003). However, they had lower odds (OR = 0.63, p < 0.001) of willingness to accept vaccine than males.

Conclusion

These findings improve our understanding of the drivers of health behaviors, including vaccine hesitancy, and are useful for guiding public health outreach/education programs.

Association between chronic disease and substance use among older adults in Tennessee

Background

Substance use and misuse have a negative impact on health care outcomes, specifically in the older adult population. Older adults are at risk due to several factors occurring toward the end of life such as changing family dynamics, loss of friends and loved ones, and chronic diseases. Substance use in older adults with chronic diseases in rural areas remains poorly studied. This study examines older adults greater than 55 of age in the state of Tennessee, U.S.A.

Design and methods

Data was extracted from the 2019 National Behavioral Risk Factor Surveillance System (BRFSS) with a subsample for the State of Tennessee (N = 6242) and individuals over age 55 (N = 3389).

Results

At least 33.7% (N = 1143) of older adults have a chronic disease, and 24.4% (N = 828) have at least two or more chronic diseases. Alcohol use in the past month was reported in 29.4% of older adults; however, chronic disease status was not associated with alcohol use. Marijuana use and smoking in the past month were significant for older adults with two or more chronic diseases. Low income and less high school education were associated with chronic disease and smoking.

Conclusions

Marijuana use and smoking were found to be significant in older adults with chronic disease, but not with alcohol use. Preventative measures such as screening tools, education, and providing resources to patients should be targeted to populations at risk to promote overall health outcomes.

MORTALITY, SURVIVAL, AND SEROLOGIC RESULTS FOR ELK (CERVUS CANADENSIS) IN THE CUMBERLAND MOUNTAINS OF TENNESSEE, USA

Comprehensive disease surveillance has not been conducted in elk (Cervus canadensis) in Tennessee, US, since their reintroduction to the state 20 yr ago. We identified causes of death, estimated annual survival, and identified pathogens of concern in elk at the North Cumberland Wildlife Management Area (NCWMA), Tennessee, US. In 2019 and 2020, we captured 29 elk (21 females, eight males) using chemical immobilization and fitted individuals with GPS collars with mortality sensors. Elk that died between February 2019 and February 2022 were necropsied to identify causes of death; these included disease associated with meningeal worm (Parelaphostrongylus tenuis; n=3), poaching (n=1), vehicular collision (n=1), legal hunter harvest (n=1), and unknown due to carcass degradation (n=3). Using data from GPS collars and known-fate survival models, we estimated an average yearly survival rate of 80.2%, indicating that survival had not significantly increased from soon after elk reintroduction (79.9%). We collected blood, tissue, feces, and ectoparasites opportunistically from anesthetized elk for health surveillance. We identified lone star ticks (Amblyomma americanum; n=53, 85.5%; 95% confidence interval [CI], 73.72-92.75), American dog ticks (Dermacentor variabilis; n=8, 12.9%; 95% CI, 6.13-24.40), and black-legged ticks (Ixodes scapularis; n=1, 1.6%; 95% CI, 0.08-9.83). We detected evidence of exposure to Anaplasma marginale (100%; 95% CI, 84.50-100.00), Leptospira interrogans (70.4%; 95% CI, 49.66-85.50), Toxoplasma gondii (55.6%; 95% CI, 35.64-73.96), epizootic hemorrhagic disease virus (51.9%; 95% CI, 32.35-70.84), and Theileria cervi (25.9%; 95% CI, 11.78-46.59). Johne's disease (Mycobacterium avium subsp. paratuberculosis) is potentially established within the population, but has not been previously documented in eastern elk populations. Disease associated with P. tenuis was a primary cause of death, and more research is needed to understand its ecology and epidemiology. Research to determine population implications of other detected pathogens at the NCWMA is warranted.

COVID-19 Vaccine Hesitancy and Uptake among Minority Populations in Tennessee

COVID-19 vaccine hesitancy and uptake among Southern states in the US has been problematic throughout the pandemic. To characterize COVID-19 vaccine hesitancy and uptake among medically underserved communities in Tennessee. We surveyed 1482 individuals targeting minority communities in Tennessee from 2 October 2021 to 22 June 2022. Participants who indicated that they did not plan to receive or were unsure whether to receive the COVID-19 vaccine were considered vaccine-hesitant. Among participants, 79% had been vaccinated, with roughly 5.4% not likely at all to be vaccinated in the next three months from the date that the survey was conducted. When focusing particularly on Black/AA people and white people, our survey results revealed a significant association between race (Black/AA, white, or people of mixed Black/white ancestry) and vaccination status (vaccinated or unvaccinated) (p-value = 0.013). Approximately 79.1% of all participants received at least one dose of a COVID-19 vaccine. Individuals who were concerned with personal/family/community safety and/or wanted a return to normalcy were less likely to be hesitant. The study found that the major reasons cited for refusing the COVID-19 vaccines were distrust in vaccine safety, concerns about side effects, fear of needles, and vaccine efficacy.

Using Natural Language Processing to Predict Fatal Drug Overdose From Autopsy Narrative Text: Algorithm Development and Validation Study

BACKGROUND

Fatal drug overdose surveillance informs prevention but is often delayed because of autopsy report processing and death certificate coding. Autopsy reports contain narrative text describing scene evidence and medical history (similar to preliminary death scene investigation reports) and may serve as early data sources for identifying fatal drug overdoses. To facilitate timely fatal overdose reporting, natural language processing was applied to narrative texts from autopsies.

OBJECTIVE

This study aimed to develop a natural language processing-based model that predicts the likelihood that an autopsy report narrative describes an accidental or undetermined fatal drug overdose.

METHODS

Autopsy reports of all manners of death (2019-2021) were obtained from the Tennessee Office of the State Chief Medical Examiner. The text was extracted from autopsy reports (PDFs) using optical character recognition. Three common narrative text sections were identified, concatenated, and preprocessed (bag-of-words) using term frequency-inverse document frequency scoring. Logistic regression, support vector machine (SVM), random forest, and gradient boosted tree classifiers were developed and validated. Models were trained and calibrated using autopsies from 2019 to 2020 and tested using those from 2021. Model discrimination was evaluated using the area under the receiver operating characteristic, precision, recall, F1-score, and F2-score (prioritizes recall over precision). Calibration was performed using logistic regression (Platt scaling) and evaluated using the Spiegelhalter z test. Shapley additive explanations values were generated for models compatible with this method. In a post hoc subgroup analysis of the random forest classifier, model discrimination was evaluated by forensic center, race, age, sex, and education level.

RESULTS

A total of 17,342 autopsies (n=5934, 34.22% cases) were used for model development and validation. The training set included 10,215 autopsies (n=3342, 32.72% cases), the calibration set included 538 autopsies (n=183, 34.01% cases), and the test set included 6589 autopsies (n=2409, 36.56% cases). The vocabulary set contained 4002 terms. All models showed excellent performance (area under the receiver operating characteristic ≥0.95, precision ≥0.94, recall ≥0.92, F1-score ≥0.94, and F2-score ≥0.92). The SVM and random forest classifiers achieved the highest F2-scores (0.948 and 0.947, respectively). The logistic regression and random forest were calibrated (P=.95 and P=.85, respectively), whereas the SVM and gradient boosted tree classifiers were miscalibrated (P=.03 and P<.001, respectively). "Fentanyl" and "accident" had the highest Shapley additive explanations values. Post hoc subgroup analyses revealed lower F2-scores for autopsies from forensic centers D and E. Lower F2-score were observed for the American Indian, Asian, ≤14 years, and ≥65 years subgroups, but larger sample sizes are needed to validate these findings.

CONCLUSIONS

The random forest classifier may be suitable for identifying potential accidental and undetermined fatal overdose autopsies. Further validation studies should be conducted to ensure early detection of accidental and undetermined fatal drug overdoses across all subgroups.

FIRST RECORD OF A PARASITE, DACTYLOGYRUS CF. SKRJABINI (MONOGENOIDEA: DACTYLOGYRIDAE), INFECTING INVASIVE SILVER CARP, HYPOPHTHALMICHTHYS MOLITRIX (VALENCIENNES, 1844) (CYPRINIFORMES: XENOCYPRIDIDAE) IN NORTH AMERICA

The parasites infecting invasive carps in North America (all Cypriniformes: Xenocyprididae: grass carp, Ctenopharyngodon idella [Valenciennes, 1844]; silver carp, Hypophthalmichthys molitrix [Valenciennes, 1844]; bighead carp, Hypophthalmichthys nobilis [Richardson, 1845]; and black carp, Mylopharyngodon piceus [Richardson, 1846]) are little studied, and no parasite has been reported from silver carp there. We herein surveyed silver carp from Barkley Reservoir and Cheatham Reservoir (Cumberland River, Tennessee; June and December 2021) and the White River (Arkansas; May 2022) and collected numerous monogenoid specimens infecting the pores on the outer face of the gill raker plate. We heat-killed, formalin-fixed, and routinely stained some specimens for morphology and preserved others in 95% ethanol for DNA extraction and sequencing of the large subunit ribosomal DNA (28S). We identified our specimens as Dactylogyrus cf. skrjabini because they had a dorsal anchor deep root that is much longer than the superficial root, an approximately parallel penis and accessory piece, and a relatively large marginal hook pair V. No type specimen of Dactylogyrus skrjabiniAkhmerov, 1954 (type host and locality is silver carp, Amur River, Russia) is publicly available, but we borrowed several vouchers (NSMT-Pl 6393) that infected the gill rakers of silver carp captured in the Watarase River, Japan. The original description of D. skrjabini was highly stylized and diagrammatical, differing from the specimens we studied from North America and Japan by the dorsal anchor having a superficial root and shaft that comprise a strongly C-shaped hook (the superficial root curves toward the dorsal anchor point) (vs. superficial root straight, at ∼45° angle to deep root and directed away from the dorsal anchor point), a single, much reduced transverse bar that is narrow for its entire breadth (vs. dorsal and ventral transverse bars robust and broad, having an irregular outline), an accessory piece that lacks digitiform projections (vs. accessory piece with 4 digitiform projections), and an accessory piece that lacks a half cardioid-shaped process (vs. accessory piece having a half cardioid-shaped process). Our 28S sequences (generated from 4 specimens of D. cf. skrjabini: 2 from Tennessee [763 base pairs (bp)] and 2 from Arkansas [776 bp]) were identical to 1 ascribed to D. skrjabini from Japan. The present study is the first verifiable and credible report of a parasite from silver carp in North America and the first nucleotide information for a parasite from silver carp in North America.

Vaccine Confidence and Uptake of the Omicron Bivalent Booster in Tennessee: Implications for Vulnerable Populations

The COVID-19 Omicron variant and its subvariants are now the dominant variants circulating in the US. Therefore, the original COVID-19 vaccine cannot offer full protection. Instead, vaccines that target the spike proteins of the Omicron variants are warranted. Hence, the FDA recommended the development of a bivalent booster. Unfortunately, despite the safety and immunogenicity of the Omicron bivalent boosters from Pfizer and Moderna, uptake in the US has been poor. At this time, only 15.8% of individuals in the US aged five and older have received the Omicron bivalent booster (OBB). The rate is 18% for those aged 18 and older. Poor vaccine confidence and booster uptake are often fueled by misinformation and vaccine fatigue. These result in more problems associated with vaccine hesitancy, which are particular prevalent in Southern states in the US. In Tennessee, the OBB vaccination rate for eligible recipients is only 5.88% at time of writing (16 February 2023). In this review, we discuss (1) the rationale for developing the OBBs; (2) the efficacy and safety of the bivalent boosters; (3) the adverse events associated with these boosters; (4) vaccine hesitancy associated with the OBBs uptake in Tennessee; (5) implications for vulnerable populations, disparities in uptake of OBBs in Tennessee, and strategies to improve vaccine confidence and OBB uptake. In support of public health, it is essential that we continue to provide education, awareness, and vaccine access to the vulnerable and medically underserved populations in Tennessee. Receiving the OBBs is the most effective method to date of protecting the public against severe COVID disease, hospitalization, and death.

Clinical characteristics and outcomes of children with single or co-detected rhinovirus-associated acute respiratory infection in Middle Tennessee

BACKGROUND

Rhinovirus (RV) is one of the most common etiologic agents of acute respiratory infection (ARI), which is a leading cause of morbidity and mortality in young children. The clinical significance of RV co-detection with other respiratory viruses, including respiratory syncytial virus (RSV), remains unclear. We aimed to compare the clinical characteristics and outcomes of children with ARI-associated RV-only detection and those with RV co-detection-with an emphasis on RV/RSV co-detection.

METHODS

We conducted a prospective viral surveillance study (11/2015-7/2016) in Nashville, Tennessee. Children < 18 years old who presented to the emergency department (ED) or were hospitalized with fever and/or respiratory symptoms of < 14 days duration were eligible if they resided in one of nine counties in Middle Tennessee. Demographics and clinical characteristics were collected by parental interviews and medical chart abstractions. Nasal and/or throat specimens were collected and tested for RV, RSV, metapneumovirus, adenovirus, parainfluenza 1-4, and influenza A-C using reverse transcription quantitative polymerase chain reaction assays. We compared the clinical characteristics and outcomes of children with RV-only detection and those with RV co-detection using Pearson's χ² test for categorical variables and the two-sample t-test with unequal variances for continuous variables.

RESULTS

Of 1250 children, 904 (72.3%) were virus-positive. RV was the most common virus (n = 406; 44.9%), followed by RSV (n = 207; 19.3%). Of 406 children with RV, 289 (71.2%) had RV-only detection, and 117 (28.8%) had RV co-detection. The most common virus co-detected with RV was RSV (n = 43; 36.8%). Children with RV co-detection were less likely than those with RV-only detection to be diagnosed with asthma or reactive airway disease both in the ED and in-hospital. We did not identify differences in hospitalization, intensive care unit admission, supplemental oxygen use, or length of stay between children with RV-only detection and those with RV co-detection.

CONCLUSION

We found no evidence that RV co-detection was associated with poorer outcomes. However, the clinical significance of RV co-detection is heterogeneous and varies by virus pair and age group. Future studies of RV co-detection should incorporate analyses of RV/non-RV pairs and include age as a key covariate of RV contribution to clinical manifestations and infection outcomes.

Developing and Validating a Novel Tool to Enhance Functional Status Assessment: The Tennessee Functional Status Questionnaire (TFSQ)

PURPOSE

Functional status is a major contributor to overall health and reflects both daily activity level (performance) and maximum attainable activity level (capacity). Existing assessment tools evaluate only 1 domain of function and do not provide insight into contributors to functional decline. We addressed these deficiencies by developing the Tennessee Functional Status Questionnaire (TFSQ), which reports activity levels in metabolic equivalents (METs) and evaluates 5 key areas: performance, capacity, activity, pain, and acute care. We validated the activity levels reported by the TFSQ against the Duke Activity Status Index (DASI).

METHODS

In this prospective, observational study, 120 patients completed both the TFSQ and the DASI. TFSQ-reported functional performance and capacity was correlated with DASI-calculated METs.

RESULTS

Pearson correlation between TFSQ-reported capacity and DASI-calculated METs was r = 0.69, P < .001. TFSQ capacity was significantly lower in patients who reported recently decreased activity, pain affecting function, or recent acute care exposure.

CONCLUSIONS

The TFSQ is a brief and efficient assessment of patient function, standardized to METs and validated against the DASI. Our study suggests that many patients may have the functional reserve to increase daily physical activity and that factors such as changes in activity, pain, and recent acute care interaction may lower functional capacity.

Biodiversity of Nearctic inland water: discovery of the genus Heterorotula (Porifera, Spongillida, Spongillidae) in the Appalachian Mountains, with biogeographical implications and description of new species

This paper reports the discovery of a small population of sponges in the Pigeon River of eastern Tennessee, USA, which were morphologically distinct from Spongillida of North America. A morphological comparative analysis resulted in the first Nearctic record of the genus Heterorotula with the description of a new species Heterorotulalucasi sp. nov. diverging from all other known species by its unique combinations of diagnostic morphotraits of spicules and gemmules. The new record enlarges the geographic range of the genus which has been known until now only from Australia, New Zealand, New Caledonia, Japan (as an alien species), and from subequatorial Brazil (as subfossil remains). The discovery of a biogeographic enclave of Heterorotula in the southeastern United States contributes to the understanding of Porifera inland water biodiversity, biogeographic patterns, and adaptive morphotraits in the Nearctic and globally. Data confirm that the Appalachian region (Ordovician-Permian origin) of Tennessee and, in general, of North America have high levels of diversity and endemicity.

isolated from canine specimens submitted to a diagnostic laboratory in Tennessee, USA: a descriptive study

Background

Multidrug- and methicillin-resistant staphylococci are both veterinary and public health concerns due to their zoonotic potential. Therefore, the objective of this study was to investigate patterns of antimicrobial, multidrug, and methicillin resistance among four Staphylococcus spp. commonly isolated from canine clinical specimens submitted to the Clinical Bacteriology Laboratory at the University of Tennessee College of Veterinary Medicine (UTCVM).

Methods

Results of antimicrobial susceptibility testing and mecA polymerase chain reaction (PCR) for isolates of four common Staphylococcus spp. isolates were obtained from the Bacteriology Laboratory at the UTCVM between 01/01/2006 and 12/31/2017. Cochran-Armitage trend test was used to assess temporal trends of antimicrobial resistance (AMR), multidrug resistance (MDR), and methicillin resistance. Kappa test of agreement was used to assess agreement between the results of PCR and disk diffusion tests.

Results

Most of the 7805 isolates were S. pseudintermedius (6453 isolates), followed by S. coagulans (860), S. aureus (330), and S. schleiferi (162). Among S. pseudintermedius isolates, 45.5% were MDR, and 30.8% were methicillin-resistant (MRSP). There was a significant temporal increase in MRSP (p = 0.017). Chloramphenicol resistance increased among both MRSP and methicillin-susceptible (MSSP) isolates (p <  0.0001). Among S. aureus isolates, 40.9% were MDR, 37.4% were methicillin-resistant (MRSA), and the proportion of MRSA isolates increased significantly (p = 0.0480) over time. There was an increasing temporal trend in the proportion of MDR isolates among MSSP (p = 0.0022), but a decrease among MRSP (p <  0.0001) and MRSA (p = 0.0298). S. schleiferi had the highest percentage (56.9%) of methicillin-resistant isolates. Oxacillin disk diffusion was superior to cefoxitin for the detection of mecA-mediated resistance and had almost perfect agreement with mecA PCR assay for S. pseudintermedius (95.4% agreement, kappa (κ) = 0.904; p <  0.0001), S. coagulans (95.6%, κ = 0.913; p <  0.0001) and S. schleiferi (97.7%, κ = 0.945; p <  0.0001). However, cefoxitin disk diffusion was superior to oxacillin disk diffusion and had almost perfect agreement with mecA PCR assay for S. aureus (95.3%, κ = 0.834; p <  0.0001).

Conclusions

The levels of resistance and increasing temporal trends are concerning. These findings have implications for treatment decisions and public health due to the zoonotic potential of staphylococci. Continued surveillance and use of antibiograms to guide clinical decisions will be critical.

Rural Hospital Closures in Tennessee: Centering Community Residents' Voices to Identify Public Health Ethical Issues and Inform Policy Strategies

The US is witnessing rapid hospital closures in rural communities, with devastating consequences for community residents beyond decreased access to health care services. Hospital closures have been associated with outmigration of younger generations due to loss of employment opportunities and economic decline, and with creating uncertainty and a sense of powerlessness among residents. While great efforts have been undertaken to document the effects of hospital closures on health care access, particularly during the COVID-19 epidemic, limited attention has been given to the public health ethics associated with dismantling health care for populations in greatest need. Drawing on the narratives of community stakeholders and residents, several themes evolved around processes, structures, and spillover effects of hospital closures on their daily lives, including decision making processes of when and how to close hospitals. Concerns arose regarding lack of transparency and disregard for alternative health care services to meet the needs of rural communities. The researchers analyzed participants' stories using the six core values of the American Public Health Association's code of ethics to determine the extent to which the multilevel crisis emerging from rural hospital closures contradicts the public health ethical responsibility of ensuring access to health care in rural communities. Centering the voices of rural community stakeholders and residents is critical to inform and guide public health strategies and in turn address health care needs of rural communities.

COVID-19 Incidence and Mortality in Long-Term Care Facilities in Tennessee

Background

Coronavirus Disease 2019, COVID-19, a viral infection, responsible for the latest pandemic has been shown to particularly affect the older population. Older adults, those aged 65 years and older, and individuals with serious underlying medical conditions are at a higher risk for severe illness from COVID-19 with a greater likelihood for hospitalization, admittance to the intensive care unit (ICU), and mortality. In this article, we describe the incidence and mortality rate found in Long Term Care facilities (LTCFs) and delineate any variations observed across varying types of LTCFs in the state of Tennessee (TN).

Methods

Using aggregated data from the Tennessee (TN) Department of Health on COVID-19 Cases and Deaths from June 2020 to November 2021, we compare and contrast the incidence and fatality of COVID-19 among Long Term Care Facilities (LTCFs) in TN and describe the trends observed in these settings.

Results

Our study indicates that there were major variations in COVID-19 prevalence rates in Nursing Homes (NHs) - 49% versus Assisted Care Living Facilities (ACLFs) in TN -16%. Although COVID-19 prevalence rates differed for NH and ACLFs, 12% of infected residents died in NHs while 13% of infected residents died in ACLFs. (Odds Ratio [OR]: 1.08 95% Confidence Interval [CI]: 0.93 -1.3, z-score: 1.37, p value: 0.085). Cases were more prevalent in five counties namely Davidson, Shelby, Hamilton, Knox, and Rutherford, majority of which were Metropolitan.

Conclusion

As new variants continue to appear, counties with higher prevalence of COVID-19 should take continued effort to protect both resident and staff members especially in NHs settings and Metropolitan cities, where prevalence rate of the illness is higher.

Sociodemographic and Geographic Disparities of Prostate Cancer Treatment Delay in Tennessee: A Population-Based Study

The relationship of social determinants of health, Appalachian residence, and prostate cancer treatment delay among Tennessee adults is relatively unknown. We used multivariate logistic regression on 2005–2015 Tennessee Cancer Registry data of adults aged ≥18 diagnosed with prostate cancer. The outcome of treatment delay was more than 90 days without surgical or nonsurgical intervention from date of diagnosis. Social determinants in the population-based registry were race (White, Black, Other) and marital status (single, married, divorced/separated, widow/widower). Tennessee residence was classified as Appalachian versus non-Appalachian (urban/rural). Covariates include age at diagnosis (18–54, 54–69, ≥70), health insurance type (none, public, private), derived staging of cancer (localized, regional, distant), and treatment type (non-surgical/surgical). We found that Black and divorced/separated patients had 32% (95% confidence interval [CI]: 1.22–1.42) and 15% (95% CI: 1.01–1.31) increased odds to delay prostate cancer treatment. Patients were at decreased odds of treatment delay when living in an Appalachian county, both urban (odds ratio [OR] = 0.89, 95% CI: 0.82–0.95) and rural (OR = 0.83, 95% CI: 0.78–0.89), diagnosed at ≥70 (OR = 0.59, 95% CI: 0.53–0.66), and received surgical intervention (OR = 0.72, 95% CI: 0.68–0.76). Our study was among the first to comprehensively examine prostate cancer treatment delay in Tennessee, and while we do not make clinical recommendations, there is a critical need to further explore the unique factors that may propagate disparities. Prostate cancer treatment delay in Black patients may be indicative of ongoing health and access disparities in Tennessee, which may further affect quality of life and survivorship among this racial group. Divorced/separated patients may need tailored interventions to improve social support.

Targeting COVID Vaccine Hesitancy in Rural Communities in Tennessee: Implications for Extending the COVID-19 Pandemic in the South

Approximately 40% of Tennesseans are vaccinated fully, due mainly to higher vaccination levels within urban counties. Significantly lower rates are observed in rural counties. Surveys suggest COVID-19 vaccine hesitancy is entrenched mostly among individuals identifying as white, rural, Republican, and evangelical Christian. Rural counties represent 70 of the total 95 counties in Tennessee, and vaccine hesitancy signifies an immediate public health crisis likely to extend the COVID-19 pandemic. Tennessee is a microcosm of the pandemic’s condition in the Southern U.S. Unvaccinated communities are the greatest contributors of new COVID-19 infections, hospitalizations, and deaths. Rural Tennesseans have a long history of cultural conservatism, poor health literacy, and distrust of government and medical establishments and are more susceptible to misinformation and conspiracy theories. Development of novel strategies to increase vaccine acceptance is essential. Here, I examine the basis of COVID-19 following SARS-CoV-2 infection and summarize the pandemic’s extent in the South, current vaccination rates and efforts across Tennessee, and underlying factors contributing to vaccine hesitancy. Finally, I discuss specific strategies to combat COVID-19 vaccine hesitancy. We must develop novel strategies that go beyond financial incentives, proven ineffective toward vaccinations. Successful strategies for vaccine acceptance of rural Tennesseans could increase acceptance among unvaccinated rural U.S. populations.

Sensitivity of Phytophthora capsici from Tennessee to Mefenoxam, Fluopicolide, Oxathiapiprolin, Dimethomorph, Mandipropamid, and Cyazofamid

Phytophthora blight is a destructive disease caused by the oomycete Phytophthora capsici, which affects vegetable production throughout the state of Tennessee and worldwide. Fungicides are a primary control method used in managing Phytophthora blight, but in some cases the efficacy of these products has been reduced or lost in the field. In 2018 and 2019, the efficacy of six fungicides was tested in vitro on 184 P. capsici isolates collected in Tennessee using radial growth assays. The fungicides included in the study were mefenoxam, fluopicolide, oxathiapiprolin, dimethomorph, mandipropamid, and cyazofamid. Seven isolates were resistant to mefenoxam, 86 were resistant to fluopicolide, one was resistant to oxathiapiprolin, and 13 were resistant to cyazofamid. None were resistant to dimethomorph or mandipropamid. Of the 86 isolates resistant to fluopicolide, five were also resistant to mefenoxam. Resistance to fluopicolide and cyazofamid was widespread in Tennessee, and it was more localized for mefenoxam and oxathiapiprolin. The results of this study show that fungicide resistance is widespread in P. capsici in Tennessee, and the implications for Phytophthora blight management are discussed.

Characteristics, Comorbidities, and Data Gaps for Coronavirus Disease Deaths, Tennessee, USA

As of March 2021, coronavirus disease (COVID-19) had led to >500,000 deaths in the United States, and the state of Tennessee had the fifth highest number of cases per capita. We reviewed the Tennessee Department of Health COVID-19 surveillance and chart-abstraction data during March 15‒August 15, 2020. Patients who died from COVID-19 were more likely to be older, male, and Black and to have underlying conditions (hereafter comorbidities) than case-patients who survived. We found 30.4% of surviving case-patients and 20.3% of deceased patients had no comorbidity information recorded. Chart-abstraction captured a higher proportion of deceased case-patients with >1 comorbidity (96.3%) compared with standard surveillance deaths (79.0%). Chart-abstraction detected higher rates of each comorbidity except for diabetes, which had similar rates among standard surveillance and chart-abstraction. Investing in public health data collection infrastructure will be beneficial for the COVID-19 pandemic and future disease outbreaks.

Methicillin-Resistant Staphylococcus aureus Bloodstream Infections and Injection Drug Use, Tennessee, USA, 2015-2017

Rising injection drug use associated with these infections highlights the need for targeted interventions.

Recently, Tennessee, USA, has seen an increase in the use of commonly injected drugs, such as heroin and fentanyl. Injection drug use (IDU) practices can lead to life-threatening methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs) and other serious diseases. We matched MRSA BSIs identified through the National Healthcare Safety Network to the Tennessee Hospital Discharge Data System to characterize the prevalence, demographics, and clinical characteristics associated with IDU in this disease population. Of the 7,646 MRSA BSIs identified during 2015–2017, we found that 1,839 (24.1%) were IDU-related. IDU-related BSIs increased by 118.9%; the greatest rise occurred among emergency department–onset infections (197.4%). IDU was more often associated with white, female, 18–49-year-old, and uninsured persons (p<0.001). We found >1 additional IDU-related diagnoses in 84.2% of IDU-related BSIs. Targeted harm reduction strategies for persons at high risk of IDU are necessary to reduce MRSA BSIs in acute care settings.

Dark Heritage in the New South: Remembering Convict Leasing in Southern Middle Tennessee through Community Archaeology

Despite playing a central role in establishing our current racialized prison system, Southern convict leasing has been largely forgotten by American society. The Lone Rock Stockade Project is carrying out excavations at the site of an 1870s convict stockade in order to illuminate the depravity of convict leasing and acknowledge the sacrifices of the convicts who were forced to work without pay in Tennessee's industries. While the project works to identify descendant communities and manage the dangers of COVID-19, the project's public outreach is focused on establishing the site's narrative as dark heritage, rather than industrial triumph, within the local community.

Revisiting the Fetal Assault Law in Tennessee: Implications and the Way Forward

The rising prevalence of opioid use disorder (OUD) among those living in the United States has demanded a collaborative response from health care and policy spheres. Addressing OUD among pregnant women is especially difficult, given the controversies surrounding the medical and ethical balance between meeting maternal versus fetal/newborn needs. Most medical organizations discourage the criminalization of drug use in pregnancy due to the adverse public health outcomes of such an approach. Despite this recommendation, many states continue to use punitive law to address drug use in pregnancy. In 2014, the Fetal Assault Law in Tennessee (TN) became the first law in the United States to directly allow women to be prosecuted for drug use in pregnancy. Since its expiration in 2016, this law has been re-introduced several times to the TN legislature in support of permanent implementation. This article outlines the impact of the initial Fetal Assault Law on maternal/newborn health in TN and provides alternative immediate, short-term, and long-term health policy strategies through which health care providers and legislators can better advocate for the well-being of both mothers with OUD and their infants.

Retrospective investigation of Echinococcus canadensis emergence in translocated elk (Cervus canadensis) in Tennessee, USA, and examination of canid definitive hosts

BACKGROUND

Few reports of Echinococcus spp. have been described in the USA; however, the geographical distribution of Echinococcus spp. in wild hosts is increasing consequent to human activities. In the early 2000's, 253 elk (Cervus canadensis) originating from Alberta, Canada were released into the Great Smoky Mountains National Park and North Cumberland Wildlife Management Area in an effort to re-establish their historical range.

METHODS

We investigated the prevalence of Echinococcus spp. in re-established elk populations in the North Cumberland Wildlife Management Area and the Great Smoky Mountains National Park via a retrospective analysis of banked elk tissues and helminth examinations on intestinal contents from coyotes (Canis latrans) from the North Cumberland Wildlife Management Area.

RESULTS

Four elk were PCR and sequence positive for E. canadensis. Each sequence had 98% or greater coverage and identity to multiple E. canadensis genotypes on GenBank. Adult Echinococcus spp. were not detected in any of the coyotes examined in this study.

CONCLUSIONS

Continued surveillance of this disease in susceptible species in these areas is warranted, and these data further underscore the risk of zoonotic pathogen introduction secondary to wildlife translocation.

A Qualitative Study to Explore Perception of Impacts of Preemption of Tobacco Regulation on Counties in Appalachian Tennessee

Bottom-up processes, starting at the local government level, are valuable for more-stringent tobacco control measures. The existence of industry-backed state-level tobacco control preemption in states has impeded policy progress within the state and localities/communities. A national public health goal under Healthy People 2020 is to eliminate state-level preemption across the United States. This study explored individual-level perceptions of the impact of state-level preemption in Appalachian Tennessee-a high-smoking, low-income region. During 2015-2016, a community-engagement project to develop a Population Health Improvement Plan (PHIP) involving over 200 stakeholders and 90 organizations was conducted in Appalachian Tennessee to identify policies/programs to address tobacco use. Using a multifaceted framework approach that focused on prevention, protection, and cessation, interviews and meeting discussions were audio-recorded and transcribed. Content analysis using NVivo 11 was conducted to generate themes. Although the central focus of the PHIP was not preemption, the issue emerged naturally in the discussions as a major concern among participants. Cultural and normative factors in Appalachian Tennessee were identified as key rationales for participants' aversion to state preemption. Thus, repealing preemption would facilitate culturally tailored and region-specific policies/programs to the high tobacco use among Appalachian Tennessee communities where statewide/nationwide policies/programs have not had the intended impacts.

Assessment of hematologic and corticosterone response in free-living eastern box turtles (Terrapene carolina carolina) at capture and after handling

Hematology is a common tool for wildlife health assessments. Manual leukocyte counts are required in reptiles, however, disagreement between quantification methods has been observed in some chelonians. This study determined agreement between two methods of leukocyte quantification, eosinophilic leukopet, and blood film white blood cell (WBC) estimates, in free-living eastern box turtles (Terrapene carolina carolina). Simultaneously, we assessed the impact of handling duration on both leukocyte quantity and corticosterone levels. We collected blood at capture (<2 min from disturbance) and again before release 30-150 min later from 92 box turtles at six sites in Illinois and Tennessee. Constant and proportional error was present in the leukopet results for WBC, lymphocytes, and basophils compared to the estimate method. Both methods were in agreement for heterophils, monocytes, and eosinophils. Agreement between the methods was significantly more likely at WBC counts below 23,241/µl. All hematologic parameters were significantly higher at the final blood draw compared to the initial blood draw using both WBC determination methods, except relative eosinophil and basophil counts. Corticosterone levels varied with time, with maximum concentrations reached at 54 min postcapture, followed by a rapid return to baseline levels. Corticosterone level was not significantly associated with any hematologic parameter or sex. This study provides a framework for understanding the effects of animal handling methodology and diagnostic modality when evaluating hematologic health in box turtles.

Implications of Tennessee's Opioid Legislation for Neonatal Abstinence Syndrome

Opioid use during pregnancy is on the rise in the United States. Neonatal abstinence syndrome (NAS), also known as newborn drug withdrawal, is a public health epidemic. Between 2004 and 2014, Tennessee experienced a fivefold increase in NAS hospitalizations, from 1.5 to 8.0 per 1,000 live births. Soaring increases in the number of newborns with NAS nationwide have caught the attention of many federal and state lawmakers, especially given the unknown burdens associated with medical and social services needed by those affected over time. Tennessee opioid-related regulations and laws enacted between 2000 and 2018 were systematically reviewed and analyzed to identify each law's purpose; effects on families and individuals; pros and cons in terms of social, practical, and legal factors; and implications for nursing practice. Our findings were that Tennessee's laws are intended to decrease the number of opioids prescribed, ensure access to continued prenatal care and substance abuse management for mothers with substance use disorders, and reduce the ease of obtaining opioids. We also found that Tennessee lawmakers have enacted laws and regulations aimed at decreasing the abuse of opioids, but not reducing the incidence of NAS. As new laws are considered, it is critical that health care providers and lawmakers work together to ensure that the developed and enacted laws strike a balance between safely managing the care of both pregnant women and their newborns without producing negative outcomes.

A singular case of advanced caries sicca in a pre-Columbian skull from East Tennessee

OBJECTIVE

Documentation of an advanced case of tertiary stage treponemal disease.

MATERIALS

The well-preserved cranium and mandible of an adult male (Burial G) from the Early Woodland period (900 BCE-200 CE) Wilhoite site (40GN10) from east Tennessee.

METHODS

Macroscopic examination of the cranio-facial periostosis on Burial G for pathognomonic indicators of treponemal disease.

RESULTS

There are extensive contiguous nodular lesions on the frontal, parietals, temporals, and occipital bones. The frontal squama additionally exhibits radial scaring and circumvallate cavitating lesions. Radial scars are also present on both zygomatic bones and the endocranial surface of the calotte. There is rounding of the nasal margins in addition to periostosis on the palate.

CONCLUSIONS

Burial G unequivocally exhibits the pathognomonic reactive changes of caries sicca, radial scarring, and cavitating lesions.

SIGNIFICANCE

The Early Woodland date in combination with the advanced degree of pathognomonic reactive change is exceptional, and to date, without parallel in the pre-Columbian archaeological record of North America. Any case approaching the severity displayed here is invariably late prehistoric.

LIMITATIONS

The absence of postcrania does not permit assessment of frailty or synergism of secondary conditions.

SUGGESTIONS FOR FURTHER RESEARCH

More comprehensive documentation of pre-Columbian treponemal cases is merited.

Comparing landowner support for wild hog management options in Tennessee

Wild hogs (Sus scrofa) are an invasive, non-native species quickly gaining ground on private, as well as public, lands in Tennessee and much of the United States. Wildlife management personnel may benefit from assessing stakeholders' views towards various management options to control and eradicate wild hogs. A statewide mail survey of 5000 randomly selected landowners in Tennessee counties known to have wild hogs yielded 1620 completed responses (33% response rate). Using this dataset, an index of potential for conflict among landowner groups was computed for each of eleven management options, which varied from leaving the wild hogs alone, to both lethal and non-lethal options. Results indicate varying levels of potential for conflict depending on hunter status, wild hog hunter status, presence of wild hogs on land, percent of income derived from land, and amount of land damage caused by wild hogs. Overall, three management options including leaving the wild hogs alone, allowing sale of wild hogs, and capturing and relocating were found unacceptable whereas many other options including capturing and killing, providing technical assistance to landowners and educating people on preventing damage were found to have high level of acceptability and most consensus among landowner subgroups. Findings will be useful in understanding how support for wild hog control options vary across population segments, and which options are likely to see more or less resistance from certain landowners.

Intention to Try Tobacco Among Middle School Students in a Predominantly Rural Environment of Central Appalachia

BACKGROUND

Disparities in tobacco use exist across regions in the United States. The Central Appalachian region carries some of the very high rates of tobacco use prevalence but research on tobacco use initiation is sparse.

OBJECTIVE

To investigate the intention to try tobacco and its associated factors among nonsmoking youth.

METHOD

Data were obtained from school-based tobacco surveys (n = 539) conducted in 11 middle schools (6th-8th grades; aged 10-15 years) in Northeast Tennessee in 2015-2016. Nonsmoking participants without firm commitment to abstain from trying tobacco in the next year were considered to have an intention to try tobacco. The Full Information Maximum Likelihood estimation (FIML) method in Mplus was employed to conduct a multivariable logistic regression analysis to delineate correlates of intention to try tobacco.

RESULTS

Overall, 20.0% of participants had intention to try tobacco. Among participants with intention to try tobacco, 53.7% owned tobacco-branded item(s), 86.1% believed that tobacco users have more friends, and 88.9% lived with tobacco users. In the adjusted logistic model, ever use of tobacco products, home smoking rules, owning tobacco-branded item(s), living with tobacco users, believing that tobacco users have more friends, and perception of easy access to tobacco products were significantly associated with intention to try tobacco (p < .02).

CONCLUSION

This study suggests that individual, interpersonal, and community level factors influence intention to try tobacco in this environment where tobacco pre-emption laws impede development of local tobacco control policies and regulations. Thus, efforts should focus on tobacco use initiation preventive programs, including school-based tobacco control programs.

Increasing Prevalence of Borrelia burgdorferi sensu stricto-Infected Blacklegged Ticks in Tennessee Valley, Tennessee, USA

In 2017, we surveyed forests in the upper Tennessee Valley, Tennessee, USA. We found Ixodes scapularis ticks established in 23 of 26 counties, 4 of which had Borrelia burgdorferi sensu stricto–infected ticks. Public health officials should be vigilant for increasing Lyme disease incidence in this region.

Stauratostoma shelleyi n. gen., n. sp. (Nematoda: Rhabditida: Thelastomatidae) from Appalachian Polydesmid Millipedes (Polydesmida: Xystodesmidae)

Stauratostoma shelleyi n. gen., n. sp. is described from the midgut and hindgut of nine species of the millipede family Xystodesmidae collected in the southern Appalachian regions of North Carolina, Tennessee and Alabama. Specimens of S. shelleyi were morphologically examined with differential interference contrast, phase contrast, and scanning electron microscopy. The head of S. shelleyi differs from other thelastomatid nematodes in having a head region mushroom-shaped in profile; cruciform stomatal opening formed from four flaps; greatly expanded labial disc; and eight-sectored annule-like column supporting the labial disc. Thirteen nematodes from various hosts were sequenced for 28S LSU rDNA and compared with other millipede-inhabiting nematodes. Stauratostoma shelleyi is the sister group to the few Thelastoma spp. that have been molecularly characterized using the D2-D3 expansion segments of the 28S LSU rDNA.

Mammalian Pathogenesis and Transmission of Avian Influenza A(H7N9) Viruses, Tennessee, USA, 2017

Infections with low pathogenicity and highly pathogenic avian influenza A(H7N9) viruses affected poultry in 4 states in the southeastern United States in 2017. We evaluated pathogenicity and transmission of representative viruses in mouse and ferret models and examined replication kinetics in human respiratory tract cells. These viruses can cause respiratory infections in mammalian models.

Angiostrongylus cantonensis Eosinophilic Meningitis in an Infant, Tennessee, USA

Angiostrongylus cantonensis, the rat lungworm, is the most common infectious cause of eosinophilic meningoencephalitis worldwide. This parasite is endemic to Southeast Asia and the Pacific Islands, and its global distribution is increasing. We report A. cantonensis meningoencephalitis in a 12-month-old boy in Tennessee, USA, who had not traveled outside of southwestern Tennessee or northwestern Mississippi.

Black Americans' Perspectives of Barriers and Facilitators of Community Screening for Kidney Disease

BACKGROUND AND OBJECTIVES

Incidence of ESKD is three times higher in black Americans than in whites, and CKD prevalence continues to rise among black Americans. Community-based kidney disease screening may increase early identification and awareness of black Americans at risk, but it is challenging to implement. This study aimed to identify participants' perspectives of community kidney disease screening. The Health Belief Model provides a theoretic framework for conceptualization of these perspectives and optimization of community kidney disease screening activities.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Researchers in collaboration with the Tennessee Kidney Foundation conducted three focus groups of adults in black American churches in Nashville, Tennessee. Questions examined views on CKD information, access to care, and priorities of kidney disease health. Content analysis was used. Guided by the Health Belief Model, a priori themes were generated, and additional themes were derived from the data using an inductive approach.

RESULTS

Thirty-two black Americans completed the study in 2014. Participants were mostly women (79%) with a mean age of 56 years old (range, 24-78). Two major categories of barriers to kidney disease screening were identified: (1) participant factors, including limited kidney disease knowledge, spiritual/religious beliefs, emotions, and culture of the individual; and (2) logistic factors, including lack of convenience and incentives and poor advertisement. Potential facilitators of CKD screening included provision of CKD education, convenience of screening activities, and use of culturally sensitive and enhanced communication strategies. Program recommendations included partnering with trusted community members, selecting convenient locations, tailored advertising, and provision of compensation.

CONCLUSIONS

Findings of this study suggest that provider-delivered culturally sensitive education and stakeholder engagement are critical to increase trust, decrease fear, and maximize participation and early identification of kidney disease among black Americans considering community screening.

A decade of health assessments in Appalachia

Purpose The purpose of this paper is to describe standardized clinical process of care and quality performance metrics at Roane Medical Center (RMC) and compare data from 2005 to 2015. Design/methodology/approach Information was extracted from a nationwide sample of short-term acute care hospitals using the Hospital Quality Alliance (HQA) database, evaluating multiple parameters measured at RMC. HQA data from RMC were matched against state and national benchmarks; findings were also compared with similar reports from the same facility in 2005. Findings Information collected by HQA expanded substantially in ten years and queried different parameters over time, thus exact comparisons between 2005 and 2015 cannot be easily calculated. Nevertheless, analysis of process of care data for 2015 placed RMC at or above state- and national-average performance in 64.9 percent (24 of 37) and 56.5 percent (26 of 46) categories, respectively. RMC registered superior process of care scores in heart failure care, pneumonia care, thrombus prevention and care, as well as stroke care. While RMC continues to perform favorably against state and national reference groups, the differences between RMC vs state and RMC vs national averages using current reporting metrics were both statistically smaller in 2015 compared to 2005 ( p<0.05). Research limitations/implications Perhaps the most significant interval health event for the RMC service area since 2005 was a coal ash spill at the nearby Tennessee Valley Authority facility in December 2008. Although reports on environmental and health effects following one of the largest domestic industrial toxin releases reached a number of important conclusions, the consequences for RMC in terms of potential added clinical burden on emergency services and impact on chronic health conditions have not been specifically studied. This could explain data reported on emergency department services at RMC but additional research will be needed to establish causality. Practical implications While tracking of care processes at all US hospitals will be facilitated by refinements in HQA tools, longitudinal evaluations for any specific unit will be more meaningful if the assessment instrument undergoes limited change over time. Social implications Appalachia remains one of several regions in the USA often identified as medically underserved. Hospitals here have confronted the challenge of diminished reimbursement, high expenses, limited staffing and other financial hardships in a variety of ways. Since the last published report on RMC, a particularly severe global recession has placed additional stress on organizations offering crucial health services in the region. Originality/value As a follow-up study to track potential changes which have been registered in the decade 2005-2015, this is the first report to provide original, longitudinal analysis on RMC, an institution operating in a rural and underserved area.

Persistent Infections with Diverse Co-Circulating Astroviruses in Pediatric Oncology Patients, Memphis, Tennessee, USA

Human astroviruses are a major cause of pediatric gastroenteritis, especially in immunocompromised children. We conducted a retrospective study to demonstrate that diverse astrovirus genotypes can co-circulate in pediatric oncology patients. A subset of cases is associated with long-term virus shedding (range 17–183 days).

A new slider turtle (Testudines: Emydidae: Deirochelyinae: Trachemys) from the late Hemphillian (late Miocene/early Pliocene) of eastern Tennessee and the evolution of the deirochelyines

Trachemys (Testudines: Emydidae) represents one of the most well-known turtle genera today. The evolution of Trachemys, while being heavily documented with fossil representatives, is not well understood. Numerous fossils from the late Hemphillian Gray Fossil Site (GFS) in northeastern Tennessee help to elucidate its evolution. The fossil Trachemys at the GFS represent a new species. The new taxon, Trachemys haugrudi, is described, and currently represents the most thoroughly described fossil emydid species known. A phylogenetic analysis, including 31 species, focusing on the subfamily Deirochelyinae is performed that includes the new fossil species, along with numerous other modern and fossil deirochelyine species, representing the first phylogenetic analysis published that includes several fossil deirochelyines. The phylogenetic analysis, utilizing morphological evidence, provides monophyletic clades of all modern deirochelyines, including Chrysemys, Deirochelys, Pseudemys, Malaclemys, Graptemys, and Trachemys. A strict consensus tree finds the recently described fossil species Graptemys kerneri to be part of a clade of Graptemys + Malaclemys. Three fossil taxa, including one previously referred to Pseudemys (Pseudemys caelata) and two to Deirochelys (Deirochelys carri and Deirochelys floridana) are found to form a clade with modern Deirochelys reticularia reticularia, with D. floridana sister to the other members of the clade. Chrysemys is found to be part of a basal polytomy with Deirochelys in relation to other deirochelyine taxa. Two fossil taxa previously referred to Chrysemys (Chrysemys timida and Chrysemys williamsi) form a paraphyly with the modern Chrysemys picta picta and Deirochelys, and may be referable to distinct genera. Additionally, fossil taxa previously attributed to Trachemys (Trachemys hillii, Trachemys idahoensis, Trachemys inflata, and Trachemys platymarginata) and T. haugrudi are found to form a clade separate from clades of northern and southern Trachemys species, potentially suggesting a distinct lineage of Trachemys with no modern survivors. Hypotheses of phylogenetic relationships mostly agree between the present study and previous ones, although the inclusion of fossil taxa provides further clues to the evolution of parts of the Deirochelyinae. The inclusion of more fossil taxa and characters may help resolve the placement of some taxa, and further elucidate the evolution of these New World turtles.

Changes in Childhood Pneumonia Hospitalizations by Race and Sex Associated with Pneumococcal Conjugate Vaccines

Introduction of pneumococcal conjugate vaccines in the childhood immunization schedule was associated with decreases in all-cause pneumonia hospitalizations among black and white children in Tennessee, USA. Although racial disparities that existed before introduction of these vaccines have been substantially reduced, rates remain higher in boys than in girls among young children.

First Record of Culex coronator In Shelby County, Tennessee

Culex coronator has been identified in Shelby County, TN, for the first time as an established species. This is an important discovery since the range of Cx. coronator is unknown in Tennessee and it has been found positive for West Nile virus. Larvae and an adult were discovered during routine surveillance. Larvae were collected at 9 different locations, while the 1 adult captured was at the 10th isolated location.

Highly Pathogenic Avian Influenza A(H7N9) Virus, Tennessee, USA, March 2017

In March 2017, highly pathogenic avian influenza A(H7N9) was detected at 2 poultry farms in Tennessee, USA. Surveillance data and genetic analyses indicated multiple introductions of low pathogenicity avian influenza virus before mutation to high pathogenicity and interfarm transmission. Poultry surveillance should continue because low pathogenicity viruses circulate and spill over into commercial poultry.

Prevalence of Tritrichomonas foetus in tennessee bulls

The prevalence of bovine trichomonosis (BT) in TN bulls was estimated through both active screening of bulls and review of previous laboratory records. During the active bull screening, preputial smegma specimens were collected from 458 TN beef bulls at 2 cattle slaughterhouses and 2 stockyards, which serve most beef bulls in TN, between March 2014 and June 2015. Each specimen was cultured for Tritrichomonas foetus (T. foetus) as well as evaluated microscopically every other day for seven days for any protozoa resembling T. foetus. An aliquot of the culture media from each specimen was used for DNA extraction and subsequent qPCR testing. Two specimens were considered suspect on microscopic evaluation, but all specimens were negative for T. foetus on qPCR. This suggests that the 2 specimens were most likely contaminated by fecal trichomonads. Retrospectively, 1979 T. foetus test records from 2 major TN diagnostic laboratories were reviewed between October 2013 and September 2016. True prevalence of BT in TN beef bulls was estimated at <0.01% from the laboratory records, although the county prevalence differed in 2 TN counties (Marshal: 0.09% and Bedford: 0.5%). Overall, the prevalence of BT in TN is low, and the current screening efforts to help control BT disease in TN are acceptable. Future efforts should focus on educating cattle stakeholders on the importance of optimal specimen collection and handling as well as routine testing for BT before cattle movement. In addition, cattle producers should be reminded of leading risk factors associated with BT in cattle.

Tennessee: Individual Market Just Barely Viable-For Now

Those who say the ACA is collapsing often point to Tennessee as evidence. And Gov. Bill Haslam has called it "ground zero" for plans pulling out of the ACA marketplaces. To give just one example, UnitedHealthcare left the individual market in the state at the end of 2016.

Socioeconomic Disparities and Influenza Hospitalizations, Tennessee, USA

We examined population-based surveillance data from the Tennessee Emerging Infections Program to determine whether neighborhood socioeconomic status was associated with influenza hospitalization rates. Hospitalization data collected during October 2007-April 2014 were geocoded (N = 1,743) and linked to neighborhood socioeconomic data. We calculated age-standardized annual incidence rates, relative index of inequality, and concentration curves for socioeconomic variables. Influenza hospitalizations increased with increased percentages of persons who lived in poverty, had female-headed households, lived in crowded households, and lived in population-dense areas. Influenza hospitalizations decreased with increased percentages of persons who were college educated, were employed, and had health insurance. Higher incidence of influenza hospitalization was also associated with lower neighborhood socioeconomic status when data were stratified by race.

Comparative sequence analyses of La Crosse virus strain isolated from patient with fatal encephalitis, Tennessee, USA

We characterized a La Crosse virus (LACV) isolate from the brain of a child who died of encephalitis-associated complications in eastern Tennessee, USA, during summer 2012. We compared the isolate with LACV sequences from mosquitoes collected near the child's home just after his postmortem diagnosis. In addition, we conducted phylogenetic analyses of these and other sequences derived from LACV strains representing varied temporal, geographic, and ecologic origins. Consistent with historical findings, results of these analyses indicate that a limited range of LACV lineage I genotypes is associated with severe clinical outcomes.

La Crosse Encephalitis Virus Infection in Field-Collected Aedes albopictus, Aedes japonicus, and Aedes triseriatus in Tennessee

La Crosse virus (LACV) is a mosquito-borne virus and a major cause of pediatric encephalitis in the USA. La Crosse virus emerged in Tennessee and other states in the Appalachian region in 1997. We investigated LACV infection rates and seasonal abundances of the native mosquito vector, Aedes triseriatus, and 2 recently introduced mosquito species, Ae. albopictus and Ae. japonicus, in an emerging disease focus in Tennessee. Mosquitoes were collected using multiple trapping methods specific for Aedes mosquitoes at recent human case sites. Mosquito pools were tested via reverse transcriptase-polymerase chain reaction (RT-PCR) of the S segment to detect multiple Bunyamwera and California serogroup viruses, including LACV, as well as real-time RT-PCR of the M segment. A total of 54 mosquito pools were positive, including wild-caught adult females and laboratory-reared adults, demonstrating transovarial transmission in all 3 species. Maximum likelihood estimates (per 1,000 mosquitoes) were 2.72 for Ae. triseriatus, 3.01 for Ae. albopictus, and 0.63 for Ae. japonicus. We conclude that Ae. triseriatus and Ae. albopictus are important LACV vectors and that Ae. japonicus also may be involved in virus maintenance and transmission.

Morphological and molecular variation in the least madtom Noturus hildebrandi (Siluriformes: Ictaluridae), a Mississippi Embayment endemic: evidence for a cryptic lineage in the Hatchie River

Sheared principal component analysis of 40 morphometric characteristics measured for 146 individuals and relative frequencies of pigmentation patterns scored for 980 individuals of the least madtom Noturus hildebrandi, a diminutive catfish endemic to eastern lowland drainages of the Mississippi Embayment region of North America, suggested a clinal pattern of morphological variation extending across the range from north to south. DNA sequence data representing 90 individuals from the mitochondrial gene cytochrome b (cytb) analysed using Bayesian phylogenetic methods recovered four major haplotype clades, suggestive of a high degree of isolation by drainage. Individual gene trees of cytb and four additional nuclear loci as well as trees based on concatenated datasets of these genes consistently recovered a cryptic lineage of individuals from the Hatchie River drainage that is morphologically indistinguishable from surrounding populations. Gene-tree analyses failed to recover a monophyletic N. hildebrandi with respect to Noturus baileyi. A coalescence-based species tree analysis, however, did recover N. hildebrandi monophyly with high support, suggesting that relationships reflected in individual gene trees and concatenated datasets are in part artefacts of incomplete lineage sorting or an ancient introgressive event. Results are consistent with the hypothesis of an ancient connection between the Hatchie and Tennessee River systems. Current subspecific designations are of limited utility as they reflect morphological variation and are not entirely consistent with phylogeny. Discrepancies between the pattern of variation observed in the morphological and molecular data may be explained by recent local adaptation to individual stream conditions that masks deeper evolutionary divergences.

Tennessee health plan tobacco cessation coverage

OBJECTIVE

To evaluate the smoking cessation coverage available from public and private Tennessee health plans.

DESIGN AND SAMPLE

Cross-sectional study. The sampling frame for private plans was a register of licensed plans obtained from the Tennessee Commerce Department. Government websites and reports provided TennCare data.

MEASURES

Data were abstracted from plan manuals and formularies for benefit year 2012. Classification of coverage included comprehensive-all seven recommended medications plus individual and group counseling; moderate-at least two forms of nicotine replacement therapy (NRT) plus bupropion and varenicline and one form of counseling; inadequate-at least one treatment, or none-no medications or counseling, or coverage only for pregnant women.

RESULTS

Of nine private plans, one provided comprehensive coverage; two, moderate coverage; four, inadequate coverage, as did TennCare; and two plans provided no coverage. Over 362,800 smokers had inadequate access to cessation treatments under TennCare, while 119,094 smokers had inadequate or no cessation coverage under private plans.

CONCLUSION

In 2012, Tennessee fell short of Healthy People goals for total managed care and comprehensive TennCare coverage of smoking cessation. If Tennessee mandates that all health plans provide full coverage, 481,900 smokers may immediately be in a better position to quit.