Pediatric Gender Care in Primary Care Settings in West Virginia: Provider Knowledge, Attitudes, and Educational Experiences

PURPOSE

Pediatric primary care providers (PPCPs) often care for gender diverse youth (GDY), particularly in rural areas, but little is known about their relevant knowledge, attitudes, or educational experiences regarding caring for this population.

METHODS

This study surveyed PPCPs throughout the rural state of West Virginia using an online survey assessing 1) demographics, 2) knowledge, 3) attitudes, and 4) educational experiences. Knowledge and attitude scores were calculated and proportion-tests and t-tests were used to compare these scores by PPCP characteristics including age, time in practice, and training background.

RESULTS

In total, 51 PPCPs from throughout the state completed the survey and 82% had cared for GDY in the prior year. Younger providers (

DISCUSSION

PPCPs in a rural state reported caring for GDY, but knowledge and attitudes related to this care varied by age, time in practice, and relevant educational experiences. More research is needed to determine best strategies for providing education to PPCPs, particularly those who are older and have been in practice longer, and to better understand the impacts of legislation limiting evidence-based gender-affirming care on PPCP knowledge, attitudes, and access to educational experiences.

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Key Words

• LGBTQ
• Pediatrics
• Primary care
• Rural health

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MESH Headings

• Humans
• West Virginia
• Female
• Male
• Health Knowledge, Attitudes, Practice
• Adult
• Primary Health Care
• Surveys and Questionnaires
• Attitude of Health Personnel
• Middle Aged
• Pediatrics/education
• Adolescent

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Grants

• U54 GM104942 NIGMS NIH HHS

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Affiliation(s)

Kacie M Kidd Division of Adolescent Medicine, Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia.
Alana Slekar West Virginia University, Morgantown, West Virginia
Gina M Sequeira Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
Nicole F Kahn Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
Lisa M Costello Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
Isabela Negrin Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
Sara Farjo WVU Urgent Care, West Virginia University School of Medicine, Morgantown, West Virginia
Savannah Lusk Department of Family Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
Snehalata Huzurbazar Department of Mathematics and Data Science, West Virginia University, Morgantown, West Virginia
Janani Narumanchi Department of Pediatrics, University of Tennessee School of Medicine, Memphis, Tennessee

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"Fighting demons": Stigma and shifting norms in explicit mention of overdose in obituaries, 2010-2019

Obituaries are often the only published record of an individual's life and elicit community reactions, including stigmatization. Because obituaries are typically written by the bereaved, their content reflects the writer's perceptions of mores governing the social context of the next-of-kin and decedent. When a cause of death is stigmatized, it can influence the way the bereaved write the obituary. However, what constitutes a stigmatized cause of death may change as larger societal discourses of morality shift and conditions or events become framed differently. Using a sample of obituaries (N = 210) from obituary aggregator Legacy.com of "off-time," or premature, deaths in West Virginia from 2010, 2015, 2017, and 2019, this article explores whether the presentation of overdose deaths in obituaries changes alongside the shift in the public framing of the opioid crisis as medical rather than criminal. I find obituaries including terms associated with drug use and overdose become both more common and explicit over the course of the study period. This suggests that the shift in public framing of the opioid crisis from criminalization to medicalization corresponds with a decrease in drug stigmatization in obituaries. Obituary analysis can be a useful means of exploring the stigmatization of other controversial causes of death, such as suicide, cirrhosis, and lung cancer.

Microbial profile of broiler carcasses processed at a university scale mobile poultry processing unit

Chicken and chicken products have been associated with foodborne pathogens such as Salmonella, Campylobacter, and Escherichia coli (E. coli). Poultry comprises an important segment of the agricultural economy (75 million birds processed as of 2019) in West Virginia (WV). The risk of pathogens on processed chickens has risen with the increased popularity of mobile poultry processing units (MPPUs). This study evaluated the microbial safety of broilers processed in a MPPU in WV. This study assessed aerobic plate counts (APCs), E. coli counts and the presence/absence of Salmonella and Campylobacter on 96 broiler carcasses following each MPPU step of scalding, eviscerating, and chilling. Samples were either chilled in ice water only (W) or ice water with 5 ppm chlorine (CW). The highest number of bacteria recovered from carcasses were APCs (4.21 log10CFU/mL) and E. coli (3.77 log10CFU/mL; P = 0.02). A total reduction of 0.30 (P = 0.10) and 0.63 (P = 0.01) log10CFU/mL for APCs and E. coli, respectively, occurred from chilling carcasses in CW. Overall, results show that E. coli, Salmonella, and Campylobacter were significantly (P < 0.05) reduced from the initial scalding to the chilling step. However, Salmonella frequency doubled (15.63-34.38%) after the evisceration step, indicating that washing carcasses after evisceration may be a critical control point in preventing cross-contamination by Salmonella. Proper chilling is also an important microbial mitigation step in MPPU processing. Results indicate that Campylobacter was more resistant to chilling than Salmonella. Campylobacter was not completely inactivated until carcasses were chilled in CW, whereas W was sufficient to reduce Salmonella on carcasses. The results led to the conclusion that although 5 ppm chlorine (Cl2) achieved more bacterial reductions than water alone, the reductions were not always significant (P > 0.05). Further MPPU studies are needed to verify more effective chilling and processing strategies.

Guaranteed Cash Incentives Boosted COVID-19 Vaccinations Of Young Adults: Evidence From West Virginia

Guaranteed small cash incentives were widely employed by policy makers during the COVID-19 vaccination campaign, but the impact of these programs has been largely understudied. We were the first to exploit a statewide natural experiment of one such program implemented in West Virginia in 2021 that provided a $100 incentive to fully vaccinated adults ages 16-35. Using individual-level data from the Census Bureau's Household Pulse Survey, we isolated the policy effect through a difference-in-discontinuities design that exploited the discontinuity in incentive eligibility at age thirty-five. We found that the $100 incentive was associated with a robust increase in the proportion of people ever vaccinated against COVID-19 and the proportion who completed or intended to complete the primary series of COVID-19 vaccines. The policy effects were also likely to be more pronounced among people with low incomes, those who were unemployed, and those with no prior COVID-19 infection. The guaranteed cash incentive program may have created more equitable access to vaccines for disadvantaged populations. Additional outreach may also be needed, especially to unvaccinated people with prior COVID-19 infections.

Fish in a Dish: Using Zebrafish in Authentic Science Research Experiences for Under-represented High School Students from West Virginia

Early research experiences positively affect students' interest in STEM careers, and develop practical science and critical thinking skills. However, outreach opportunities are not equally accessible for all students. In states like West Virginia, where many students live in rural Appalachian communities, opportunities for engaging in STEM experiences are limited. In addition, rural teachers may not be equipped to provide authentic research experiences for students due to lack of resources or support. For many students in West Virginia, the Health Sciences and Technology Academy (HSTA) is a major opportunity for STEM engagement. Since its inception in 1998, HSTA has spread to 26 of 55 counties in West Virginia. The program recruits first-generation, low-socioeconomic status, rurally living, and African American high school students who are under-represented in STEM fields. Our research laboratory partnered with HSTA to implement an innovative, hands-on research camp using zebrafish for students participating in their annual junior-level biomedical sciences summer camp. Our camp was held in-person and adapted to an online format during the Covid-19 pandemic. We used pre-post surveys in both camps to assess impacts on science confidence and to collect information about general perceptions of zebrafish, research, and STEM fields. We found that students participating in the in-person and online camps experienced similar overall gains in science confidence. We also identified strong interest in zebrafish, research, and STEM degrees among online students. Online students did not prefer virtual learning experiences; however, they still enjoyed our camp. We also surveyed high school teachers volunteering for HSTA to identify factors that would encourage use of zebrafish in classrooms. The most prominent needs include classroom supplies, experience, and funding. Our successful science-education partnership demonstrates that zebrafish research experiences foster positive outcomes for under-represented students, and can inform future outreach efforts and collaborations with teachers.

The influence of transformations in supply on methamphetamine initiation among people injecting opioids in the United States

BACKGROUND

Co-use of methamphetamine (MA) and opioids (pharmaceutical pills, heroin and fentanyls) has increased in the United States and is represented in rising mortality. Although coinciding with the import of low cost, high potency and purity methamphetamine, the relationship between supply and demand in propelling this polydrug use is not well understood. We consider the influence of macro changes in supply on the uptake of opioid and methamphetamine co-use by injection at the level of individual drug and injection initiation in West Virginia, a state which leads the US in drug overdose mortality.

METHOD

We recruited n = 30 people for semi-structured interviews who self-reported injecting heroin/fentanyl and using methamphetamine by any route at a West Virginia syringe service program and through snowball sampling. Interviews were recorded and transcripts analyzed using a thematic approach. Ethnographic observation was also conducted and recorded in fieldnotes. Sequence of substance and mode of use initiation and use trajectories for opioids and stimulants were charted for each participant.

RESULTS

A clear pattern of individual drug initiation emerged that matched each successive supply wave of the US overdose epidemic: 25 participants had initiated opioid use with pills, followed by heroin, often mixed with/replaced by fentanyl, and subsequently added methamphetamine use. For participants, the supply and consumption of opioid analgesics had set in motion a series of steps leading to the addition of stimulant injection to existing opioid injecting repertoires. Unlike other studies that have found a birth cohort effect in patterns of initiation, participants showed the same sequence across age groups. Considerations of economy, availability, dependence, tolerance and the erosion of taboos that marked transitions from opioid pills to heroin injection influenced these subsequent trajectories in novel ways. The form, timing and extent of opioid and stimulant consumption was influenced by four stages of the changing drug supply, which in turn reflected back on demand.

CONCLUSION

Transformations in the social meaning and supply of methamphetamine enabled these transitions while other desired, non-injectable drugs were difficult to obtain. We discuss policy implications of injectable drugs' market dominance at this location and possible interventions.

Concentrations of 45 Per- and Polyfluoroalkyl Substances in North American River Otters (Lontra canadensis) from West Virginia, USA

North American river otters (Lontra canadensis) are top predators in riverine ecosystems and are vulnerable to per- and polyfluoroalkyl substance (PFAS) exposure. Little is known about the magnitude of exposure and tissue distribution of PFAS in river otters. We measured 45 PFAS in various tissues of 42 river otters collected from several watersheds in the state of West Virginia, USA. The median concentrations of ∑All (sum concentration of 45 PFAS) varied among tissues in the following decreasing order: liver (931 ng/g wet weight) > bile > pancreas > lung > kidney > blood > brain > muscle. Perfluoroalkylsulfonates (PFSAs) were the predominant compounds accounting for 58-75% of the total concentrations, followed by perfluoroalkyl carboxylates (PFCAs; 21-35%). 8:2 fluorotelomer sulfonate (8:2 FTS), 10:2 FTS, and 6:2 chlorinated polyfluoroalkyl ether sulfonate were frequently found in the liver (50-90%) and bile (96-100%), whereas hexafluoropropylene oxide dimer acid (HFPO-DA) was rarely found. The hepatic concentrations of ∑All in river otters collected downstream of a fluoropolymer production facility located along the Ohio River were 2-fold higher than those in other watersheds. The median whole body burden of ∑All was calculated to be 1580 μg. PFOS and perfluorooctanoic acid (PFOA) concentrations in whole blood of some river otters exceeded the human toxicity reference values, which warrant further studies.

Comparing the effects of decreasing prescription opioid shipments and the release of an abuse deterrent OxyContin formulation on opioid overdose fatalities in WV: an interrupted time series study

INTRODUCTION

The 2010 release of an abuse deterrent formulation (ADF) of OxyContin, a brand name prescription opioid, has been cited as a major driver for the reduction in prescription drug misuse and the associated increasing illicit opioid use and overdose rates. However, studies of this topic often do not account for changes in supplies of other prescription opioids that were widely prescribed before and after the ADF OxyContin release, including generic oxycodone formulations and hydrocodone. We therefore sought to compare the impact of the ADF OxyContin release to that of decreasing prescription opioid supplies in West Virginia (WV).

METHODS

Opioid tablet shipment and overdose data were extracted from The Washington Post ARCOS (2006-2014) and the WV Forensic Drug Database (2005-2020), respectively. Locally estimated scatterplot smoothing (LOESS) was used to estimate the point when shipments of prescription opioids to WV began decreasing, measured via dosage units and morphine milligram equivalents (MMEs). Interrupted time series analysis (ITSA) was used to compare the impact LOESS-identified prescription supply changes and the ADF OxyContin release had on prescription (oxycodone and hydrocodone) and illicit (heroin, fentanyl, and fentanyl analogues) opioid overdose deaths in WV. Model fit was compared using Akaike Information Criteria (AIC).

RESULTS

The majority of opioid tablets shipped to WV from 2006 to 2014 were generic oxycodone or hydrocodone, not OxyContin. After accounting for a 6-month lag from ITSA models using the LOESS-identified change in prescription opioid shipments measured via dosage units (2011 Q3) resulted in the lowest AIC for both prescription (AIC = -188.6) and illicit opioid-involved overdoses (AIC = -189.4), indicating this intervention start date resulted in the preferred model. The second lowest AIC was for models using the ADF OxyContin release as an intervention start date.

DISCUSSION

We found that illicit opioid overdoses in WV began increasing closer to when prescription opioid shipments to the state began decreasing, not when the ADF OxyContin release occurred. Similarly, the majority of opioid tablets shipped to the state for 2006-2014 were generic oxycodone or hydrocodone. This may indicate that diminishing prescription supplies had a larger impact on opioid overdose patterns than the ADF OxyContin release in WV.

Quantitatively Identifying Messaging Topics to Encourage West Virginia nurses' COVID-19 Vaccination

Nurses are particularly influential to others as it relates to COVID-19 vaccination decision-making and are at higher risk of COVID-19 themselves. Yet, nurses' COVID-19 vaccination remains suboptimal. This study combines communication science frameworks with a novel conceptualize of identity-identity fusion-to explore why nurses may not vaccinate and what strategies might encourage them to protect themselves from COVID-19. Practicing nurses recruited from the West Virginia Nurses Association (N = 328) were asked about their nursing identity, COVID-19 threat perceptions, vaccination efficacy perceptions, vaccination social norms, and both vaccination and information seeking plans. Findings show that social norms may have particular influence over nurses' vaccination intentions, though this is unique to nurses who do not view themselves as completely "fused" with the nursing identity. "Fully fused" nurses, on the other hand, may respond well to information conveying their particular risk for COVID-19. Data suggest information on one's self-efficacy or ability to get vaccinated should be avoided, as it might discourage some nurses'vaccination. Findings are discussed in terms of how identity may influence vaccination.

Transplantation, Waitlist Status, and County Indices of Economic Health in West Virginia

Key Points

Patients with ESKD coming from impoverished counties are less likely to be waitlisted or transplanted. Insurance status modified the relationship between county poverty rates and waitlisting/transplant.

Background

Kidney transplantation is the optimal treatment for patients with ESKD. Given lower rates of kidney transplant in West Virginia (WV), we searched for potential predictors, focusing on the indices of economic health.

Methods

Data on the initiation of RRT, being waitlisted for, and receiving a kidney transplant between 1965 and 2020 were collected from United States Renal Data System. Data on county poverty rate (PR) and economic distress were collected from the Appalachian Regional Commission.

Results

Of the 23,055 WV patients identified, 2999 (13%) were transplanted compared with 514,050 (15.3%) for the rest of the United States (P < 0.001). Patients who never received a kidney transplant were from counties with higher PRs (17.95%) compared with transplanted patients (17.44%; P < 0.001). Waitlisted patients (2,375) came from counties with lower PRs than those who were never waitlisted (17.48 versus 17.94%; P < 0.001). Waitlisted patients were less likely to be from distressed or at-risk counties (32 versus 34.3%; P = 0.05) than patients who were never waitlisted. In multivariable logistic regression, county PR remained an independent predictor of being transplanted (odds ratio, 0.91; 95% confidence interval, 0.85 to 0.97; P = 0.008) or waitlisted (odds ratio, 0.9; 95% confidence interval, 0.84 to 0.96; P = 0.001) per 5% increase in PR after adjusting for age, sex, body mass index, alcohol use, functional status, and comorbid medical conditions. Group/employer health insurance seemed to modify the relationship between PR and waitlist, where PR remained an independent predictor of waitlisting among patients with insurance.

Conclusions

Waitlisted patients and transplant recipients from WV were more likely to hail from counties with lower PRs and those in better economic health.

Investigation of Sources of Fluorinated Compounds in Private Water Supplies in an Oil and Gas-Producing Region of Northern West Virginia

Per- and polyfluoroalkyl substances (PFASs) are a class of toxic organic compounds that have been widely used in consumer applications and industrial activities, including oil and gas production. We measured PFAS concentrations in 45 private wells and 8 surface water sources in the oil and gas-producing Doddridge, Marshall, Ritchie, Tyler, and Wetzel Counties of northern West Virginia and investigated relationships between potential PFAS sources and drinking water receptors. All surface water samples and 60% of the water wells sampled contained quantifiable levels of at least one targeted PFAS compound, and four wells (8%) had concentrations above the proposed maximum contaminant level (MCL) for perfluorooctanoic acid (PFOA). Individual concentrations of PFOA and perfluorobutanesulfonic acid exceeded those measured in finished public water supplies. Total targeted PFAS concentrations ranged from nondetect to 36.8 ng/L, with surface water concentrations averaging 4-fold greater than groundwater. Semiquantitative, nontargeted analysis showed concentrations of emergent PFAS that were potentially higher than targeted PFAS. Results from a multivariate latent variable hierarchical Bayesian model were combined with insights from analyses of groundwater chemistry, topographic characteristics, and proximity to potential PFAS point sources to elucidate predictors of PFAS concentrations in private wells. Model results reveal (i) an increased vulnerability to contamination in upland recharge zones, (ii) geochemical controls on PFAS transport likely driven by adsorption, and (iii) possible influence from nearby point sources.

Prevalence and Spatial Distribution of Gastroschisis in an Industrial Watershed

The relationship between the congenital defect of gastroschisis and environmental toxins is poorly understood. We examined gastroschisis incidence, risk factors, and spatial association in a geographic region with known environmental pollution and hazardous waste sites. An observational study of fetal and neonatal gastroschisis diagnosed from 1/1/2006 to 12/31/2020 was conducted in a southern West Virginia (WV) tertiary care hospital. Emerging hot spot analysis and Ripley's K-Function examined the spatial relationship between gastroschisis cases and Environmental Protection Agency (EPA) Federal Registry Sites (FRS). A total of 63 gastroschisis cases provided a prevalence rate of 14.6 per 10000 live births. Gastroschisis was associated with younger maternal age, decreased pre-pregnancy BMI, and increased maternal tobacco use. Relative to FRS sites, spatial clusters were identified with emerging hot spot analysis. Observed Ripley K was higher at all measured bands. Results suggest a potential geographic association between gastroschisis cases and EPA-designated hazardous waste sites.

Impact of a Permitless Concealed Firearm Carry Law in West Virginia, 1999-2015 and 2016-2020

We used firearm mortality and sales data to assess the impact of HB 4145, a May 2016 law that legalized concealed firearm carry without a permit in West Virginia. Firearm mortality was significantly higher (29%) in the years after the enactment of the law; handgun mortality was also higher (48% increase), whereas long gun deaths and firearm sales were unaffected. This may suggest that HB 4145 increased rates of firearm-related mortality in West Virginia without affecting firearm sales in the state. (Am J Public Health. 2023;113(11):1163-1166. https://doi.org/10.2105/AJPH.2023.307382).

Evaluation of self-measured blood pressure monitoring in a southern rural West Virginia health system

INTRODUCTION

At the time of the 2021 Behavioral Risk Factor Surveillance System survey, an estimated 32.3% of adults in the US and nearly half (43.4%, 776 000) of adults in West Virginia (WV) had hypertension. Further, the Interactive Atlas of Heart Disease and Stroke estimates an increase in the percentage of adults with hypertension in the US from 32.3% to 47.0%, with hypertension rates in WV rising as high as 58.7%, indicating a significant public health concern in the community. Hypertension increases the risk of several negative health outcomes, including heart disease and stroke, and leads to increased economic and chronic disease burden. Although certain unmodifiable factors (sex, age, race, ethnicity, and family history) increase the risk of developing hypertension, a healthy lifestyle - including a nutritious diet, maintaining a healthy weight, avoiding nicotine products, and participating in regular moderate physical activity - can decrease the risk of developing hypertension. Self-measured blood pressure (SMBP) monitoring, or home BP monitoring, when integrated with a provider's clinical management approach, is linked to improvements in BP management and control. This study represents a mid-point assessment of a remote SMBP monitoring program implemented by Cabin Creek Health Systems (CCHS), a federally qualified health center, and its impact on BP control.

METHODS

CCHS implemented SMBP programming in March 2020 as one element of a developing comprehensive program aimed at reducing uncontrolled hypertension, and therefore chronic disease burden, in its service area and patient population. The project, funded by the Health Resources and Services Administration, continued to February 2023. This report represents a mid-point analysis and was based on the retrospective analysis of de-identified data collected for 234 patients to June 2022, who were assessed for changes in BP between the date of enrollment and the most recently available BP measurement. Patients were enrolled in the SMBP program if they exhibited current or previous indicators of uncontrolled hypertension (systolic ≥140 mmHg and/or diastolic ≥90 mmHg), at the discretion of their provider, and were equipped with an iBloodPressure cellular connected home BP monitoring system, manufactured by Smart Meter. Their BP readings were documented in the integration software TimeDoc Health and electronic health record athenahealth.

RESULTS

At the time of enrollment, 201 (86.0%) patients had uncontrolled hypertension, with 116 (49.6%) patients having both uncontrolled systolic (≥140 mmHg) and diastolic (≥90 mmHg) values. At follow-up, the number of patients with uncontrolled hypertension decreased from 201 to 98 (41.9%), with only 36 (15.4%) patients having both uncontrolled systolic and diastolic values. Additionally, 26 (11.1%) patients were in hypertensive crisis at the time of enrollment, and no patients remained in crisis at the time of follow-up. The number of patients with BP values in the controlled range (systolic <140 mmHg and diastolic <90 mmHg) increased from 33 (14.1%) at enrollment to 136 (58.1%) at follow-up. Overall, there was a 44.0% increase in the number of patients with BP values in the controlled range at follow-up, and a concomitant 44.1% decrease in the number of patients in the uncontrolled range. These observations were consistent across multiple demographic indicators, including clinic location, three-digit zip code, and patient sex.

CONCLUSION

Systematic implementation of remote BP monitoring, when integrated into clinician workflows, was associated with a substantial reduction in the number of patients with uncontrolled hypertension in this rural federally qualified health center. Further, CCHS was successful in implementing a remote SMBP monitoring program in a community challenged with transportation insecurity, and poor cellular and broadband access, of which lessons learned are applicable to other health systems interested in pursuing comparable efforts.

Levonorgestrel Emergency Contraception Information Accuracy From West Virginia Community Pharmacies: A Mystery Caller Approach

BACKGROUND

To ensure access to effective levonorgestrel (LNG) emergency contraception (EC), pharmacies must keep medication in stock or available for quick delivery, and pharmacists must be knowledgeable about sales restrictions and the therapeutic window for EC. We conducted a mystery caller study to assess LNG EC availability and information accuracy provided by staff in West Virginia community pharmacies.

METHODS

A female research team member posed as a 16-year-old caller to ask pharmacy staff questions about whether LNG EC was in stock, the requirements for purchase, and when it should be taken for effectiveness. Data were analyzed with SPSS using the Pearson's χ2 test to determine if there was a relationship between pharmacy type and response accuracy to our questions about point-of-sale requirements and timing for effectiveness for LNG EC.

RESULTS

Of the 506 pharmacies in the sample, 275 (54.3%) were chain pharmacies and 231 (45.7%) were independent. Overall, chain pharmacies provided significantly more accurate answers than independent pharmacies on all point-of-sale requirements. Regarding timing for effectiveness, 49.2% of all pharmacies provided an accurate response (62.9% for chain pharmacies vs. 32.9% for independent pharmacies).

CONCLUSIONS

Overall, availability and accuracy regarding LNG EC were poor in West Virginia pharmacies. Pharmacists, particularly those at independent pharmacies serving rural communities, are in a critical and powerful position to influence community health by providing accurate and timely information and access to all contraceptive options, including LNG EC.

'The High Five Club': Social Relations and Perspectives on HIV-Related Stigma During an HIV Outbreak in West Virginia

In the United States, HIV outbreaks are occurring in areas most affected by the opioid epidemic, including West Virginia (WV). Cultural Theory contends that multiple cultures co-exist within societies distinguished by their differing intensities of rules or norms of behavior ('grid') or degree of group allegiance/individual autonomy ('group'). Accordingly, we would expect that perceptions about HIV, including stigma, correspond with individuals' grid/group attributes. To explore this, we conducted qualitative interviews with people who inject drugs (PWID) recruited from a WV syringe service program. This paper focuses on our unexpected findings on stigma during a coinciding HIV outbreak. PWID living homeless identified as belonging to a 'street family'. Its members were mutually distrustful and constrained by poverty and drug dependence but despite their conflicts, reported openness between each other about HIV + status. Interviewees living with HIV perceived little enacted stigma from peers since the local outbreak. Contrasting stigmatizing attitudes were attributed to the town's mainstream society. The 'High Five' (Hi-V) Club, expressing defiance towards stigmatizing behavior outside the street family, epitomized the tensions between a desire for solidary and mutual support and a fatalistic tendency towards division and distrust. Fatalism may hinder cooperation, solidarity and HIV prevention but may explain perceived reductions in stigma.

A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia

BACKGROUND

The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia.

METHODS

From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data.

RESULTS

Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff.

CONCLUSIONS

Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.

Provider Mistrust and Telemedicine Abortion Care Preferences Among Patients in Ohio, West Virginia, and Kentucky

Objectives: The convenience and privacy provided by telemedicine medication abortion may make this service preferable to patients who mistrust their abortion provider. We assessed associations between mistrust in the abortion provider and preferences for telemedicine abortion. Study Design: From April 2020 to April 2021, we surveyed patients seeking abortion in Ohio, West Virginia, and Kentucky. Using unconditional logistic regression models, we examined unadjusted and adjusted associations between mistrust in the abortion provider and preferences for telemedicine abortion among all participants, and among only participants undergoing medication abortion. Results: Of 1,218 patients who met inclusion criteria, 546 used medication abortion services. Just more than half (56%) of all participants and many (64%) of medication abortion participants preferred telemedicine services. Only 6% of medication abortion participants received telemedicine medication dispensing services. Only 1.4% of all participants and 1% of medication abortion participants mistrusted the abortion provider. Participants who mistrusted the abortion provider were somewhat more likely to prefer telemedicine abortion (unadjusted odds ratio [OR]: 2.5, 95% CI: 0.8-7.9; adjusted OR: 2.9, 95% CI: 0.9-9), and medication abortion participants who mistrusted the abortion provider were also somewhat more likely to prefer telemedicine abortion (unadjusted OR: 3.5, 95% CI: 0.4-28.9; adjusted OR: 5.0, 95% CI: 0.6-43), although these associations were not statistically significant. Conclusions: In three abortion-restrictive states, most patients expressed preferences for telemedicine abortion, but few accessed them. Provider mistrust was rare, but those experiencing mistrust trended toward preferring telemedicine services. Telemedicine may improve access to abortion services for patients experiencing medical mistrust.

Sap flow velocities of Acer saccharum and Quercus velutina during drought: Insights and implications from a throughfall exclusion experiment in West Virginia, USA

Forest species composition mediates evapotranspiration and the amount of water available to human-use downstream. In the last century, the heavily forested Appalachian region has been undergoing forest mesophication which is the progressive replacement of xeric species (e.g. black oak (Quercus velutina)) by mesic species (e.g. sugar maple (Acer saccharum)). Given differences between xeric and mesic species in water use efficiency and rainfall interception losses, investigating the consequences of these species shifts on water cycles is critical to improving predictions of ecosystem responses to climate change. To meet this need, we quantified the degree to which the sap velocities of two dominant broadleaved species (sugar maple and black oak) in West Virginia, responded to ambient and experimentally altered soil moisture conditions using a throughfall exclusion experiment. We then used these data to explore how predictions of future climate under two emissions scenarios could affect forest evapotranspiration rates. Overall, we found that the maples had higher sap velocity rates than the oaks. Sap velocity in maples showed a stronger sensitivity to vapor pressure deficit (VPD), particularly at high levels of VPD, than sap velocity in oaks. Experimentally induced reductions in shallow soil moisture did not have a relevant impact on sap velocity. In response to future climate scenarios of increased vapor pressure deficits in the Central Appalachian Mountains, our results highlight the different degrees to which two important tree species will increase transpiration, and potentially reduce the water available to the heavily populated areas downstream.

Patterns in benthic macroinvertebrate assemblages in an active region of unconventional shale-gas development in the western Appalachian Plateau of West Virginia, USA

We sampled headwater streams to characterize impacts of unconventional shale gas development (SGD) on aquatic ecosystems. The study area was relatively un-impacted by confounding activities. Intensity of SGD over the study decreased then increased again but not to levels seen the first year. Shale gas development was associated with increased, but non-impaired, water pH and specific conductance during the latter part of the study. Metrics summarizing macroinvertebrate assemblages were better on average in un-impacted reaches. A genus-level multimetric index of biotic integrity was statistically lower downstream of impacts compared to upstream, but only in the year when SGD activity was most intense. Multivariate analyses indicated that assemblages diverged in similarity downstream compared to upstream of impacts in the first and last years of the study when SGD activity was elevated. Assemblage divergence was related to variation in water quality. Indicator species analysis linked a few key taxa to un-impacted conditions in the first year of the study; tolerant taxa were indicators for impacted conditions later in the study. Our study links SGD to weak negative changes in water quality and benthic macroinvertebrates, which may have negative consequences to food quality for wildlife that rely on aquatic prey within forested systems.

Using Health Information Technology to Create Pathways for Hepatitis C Treatment and Cure in West Virginia

This case study describes use of health information technology for enhanced team-based care and care coordination between primary care providers and infectious disease specialists for curing and eventually eliminating hepatitis C in West Virginia. This program, the West Virginia Hepatitis Academic Mentoring Partnership, aims to improve outcomes of West Virginians with chronic hepatitis C infection by training and supporting primary care providers to screen, diagnose, evaluate, treat, cure, and follow patients in the community rather than referring them to distant specialists with long wait times. This initiative supports health equity by increasing access to quality care in severely under-resourced rural areas. Primary care providers engage with hepatitis C experts in a web-based training and mentoring process, combined with informatics training in use of a customized Research Electronic Data Capture (REDCAP) platform for secure data tracking and bidirectional communication. This use of an informatics platform available to all partners supports shared decision-making between primary care providers and specialists, fostering a primary care learning network for improved hepatitis C care in West Virginia.

COVID-19 and the Drug Overdose Crisis: Uncovering the Deadliest Months in the United States, January‒July 2020

Objectives. To determine the magnitude of increases in monthly drug-related overdose mortality during the COVID-19 pandemic in the United States. Methods. We leveraged provisional records from the Centers for Disease Control and Prevention provided as rolling 12-month sums, which are helpful for smoothing, yet may mask pandemic-related spikes in overdose mortality. We cross-referenced these rolling aggregates with previous monthly data to estimate monthly drug-related overdose mortality for January through July 2020. We quantified historical errors stemming from reporting delays and estimated empirically derived 95% prediction intervals (PIs). Results. We found that 9192 (95% PI = 8988, 9397) people died from drug overdose in May 2020-making it the deadliest month on record-representing a 57.7% (95% PI = 54.2%, 61.2%) increase over May 2019. Most states saw large-magnitude increases, with the highest in West Virginia, Kentucky, and Tennessee. We observed low concordance between rolling 12-month aggregates and monthly pandemic-related shocks. Conclusions. Unprecedented increases in overdose mortality occurred during the pandemic, highlighting the value of presenting monthly values alongside smoothed aggregates for detecting shocks. Public Health Implications. Drastic exacerbations of the US overdose crisis warrant renewed investments in overdose surveillance and prevention during the pandemic response and postpandemic recovery efforts.

Pathologic Fibrinolysis is More Common in a Rural Trauma Setting

INTRODUCTION

Fibrinolysis (lysis) has been extensively studied in trauma patients. Many studies on the distribution of lysis phenotype have been conducted in setting with short prehospital time. This study aimed to evaluate the distribution of lysis phenotypes in a population with prolonged prehospital times in a rural environment.

METHODS

A retrospective study was performed at an American College of Surgeons-verified level 1 trauma center, serving a large rural population. Full trauma team activations from January 1, 2017 to August 31, 2018 were evaluated, and all patients with an ISS>15 analyzed. Thromboelastography was routinely performed on all participants on arrival. Lysis phenotypes were classified based on LY30 results: shutdown (≤.8%), physiologic (.9-2.9%), and hyper (>2.9%).

RESULTS

259 patients were evaluated, 134 (52%) presented direct from the scene. For scene patients, lysis distribution was 24% physiologic, 49% shutdown, and 27% hyper. Transferred patients demonstrated a reduction in physiologic lysis to 14% (P = .03), shutdown present in 66%, and hyper in 20%. Empiric prehospital tranexamic acid was given to 18 patients, physiologic lysis was present in 6%, shutdown 72%, and hyper 22%; this increase was not statistically significant (P = .5).

CONCLUSION

Fibrinolysis phenotypes are not consistent across all trauma populations. This study showed rural trauma patients had a significantly increased rate of pathologic lysis. This was consistent for scene and transfer patients who received care at another facility prior to arrival for definitive care. Future studies to evaluate the factors influencing these differences are warranted.

Palliative Opioids May Be a Bridge to Care for Rural Long-Term Care Facility Residents with Severe COVID-19 Symptoms

Purpose

Long term care facility (LTCF) residents are at high risk for severe COVID-19 symptoms, but those in rural and resource-limited areas, such as West Virginia (WV) and the larger Appalachian region, may experience delays in obtaining higher levels of medical care due to isolated geography and limited transportation. The study examined the outcomes between residents from 1 LCTF in WV who were moved to a hospital as compared to those remaining in the facility.

Methods

This cohort study compares mortality outcomes among severely symptomatic residents desiring hospitalization and those electing to stay at the facility receiving palliative opioids with supplemental oxygen.

Findings

Forty residents tested positive for COVID-19 with 11 developing severe respiratory symptoms. Eight residents elected to receive care at the LTCF while 3 desired hospitalization. Mortality was assessed at 4 time points and was not statistically different between those who were hospitalized versus those who received palliative opioids at the LTCF. Although not significant, the difference in mortality between those hospitalized (66.7%) and those receiving opioids at the LTCF (12.5%) in the acute phase trended toward significance (P = .072). Overall mortality at the 6-month time point among all residents who developed severe respiratory symptoms at this LTCF was 54.5%.

Conclusions

LTCF residents choosing different levels of therapeutic intervention for severe COVID-19 symptoms had no mortality difference. Palliative opioids may be an effective treatment for LTCF residents with severe COVID-19 and also a bridge to care in rural areas with limited resources until more advanced treatments can be accessed.

Land use intensification destabilizes stream microbial biodiversity and decreases metabolic efficiency

Urbanization and agricultural intensification can transform landscapes. Changes in land-use can lead to increases in storm runoff and nutrient loadings which can impair the health and function of stream ecosystems. Microorganisms are an integral component of stream ecosystems. Due to the sensitivity of microorganisms to perturbations, changes in hydrology and water chemistry may alter microbial activity and structure. These shifts in microbial community dynamics may alter stream metabolism and water quality, potentially impacting higher trophic levels. Here we examine the effects of land-use and associated changes in water chemistry on sediment microbial communities by studying the West Run Watershed (WRW) a mixed-land-use system in West Virginia, USA. Streams were sampled throughout the growing season at six sites within the WRW spanning different levels of land use intensification. The proportion of land impacted by agricultural and urban development was positively correlated with temporal variation in stream sediment microbial community composition (adj R² = 0.65), suggesting development can destabilize microbial communities. Moreover, streams in developed watersheds had an increased metabolic quotient (20-50% higher), this indicates that microorganisms have greater respiration per unit biomass and signifies reduced metabolic efficiency. Further, our results suggest that land use associated changes in water chemistry alter microbial function both directly and indirectly via changes in microbial community composition and biomass. Taken together our results suggest that highly developed watersheds with elevated conductivity, metal ion concentration, and pH impose stress on microbial communities resulting in reduced microbial efficiency and elevated respiration.

Informatics-Supported Diabetes Prevention Programming in West Virginia

Addressing diabetes, prediabetes, and related health conditions such as high blood pressure, high cholesterol, obesity, and physical inactivity are critical public health priorities for the United States, particularly West Virginia. Preventing chronic conditions through early identification of risk and intervention to reduce risk is essential. Primary care and community-based programs need a more connected informatics system by which they work in tandem to identify, refer, treat, and track target populations. This case study in quality improvement examines the effectiveness of national diabetes prevention programming in West Virginia via the West Virginia Health Connection initiative, which was designed to provide such an informatics structure. Cohort analysis reveals an average weight loss of 13.6 pounds-or 6.3 percent total body weight loss-per person. These changes represent decreased risk of diabetes incidence and increased healthcare savings. Lessons learned are applicable to other areas aiming to build and sustain a data-informed health analytics network.

Universal Well-Being Assessment Associated With Increased Resident Utilization of Mental Health Resources and Decrease in Professionalism Breaches

BACKGROUND

A previous study showed that residents felt a universal well-being visit to a Faculty Staff Assistance Program (FSAP) would increase self-initiated visits. It is unknown whether such program is associated with more self-initiated visits, improved professionalism, or positive well-being measures.

OBJECTIVE

We measured internal medicine (IM) resident-initiated visits before and after the universal well-being FSAP intervention to assess for increased utilization of FSAP services and effect on professionalism and well-being measures.

METHODS

Universally scheduled, resident-initiated, program-mandated FSAP visits for IM residents at West Virginia University were counted for years 2014-2019. Professionalism reports of all residents and IM residents were tallied. A Mann-Kendall trend test was used to estimate slope of trends. Burnout and compassion satisfaction (CS) scores were assessed from 2017-2020.

RESULTS

Residents opted-out of 8 of 239 (3.3%) universally scheduled FSAP visits. Resident-initiated visits significantly increased from 0 in 2014-2015 to 23 in 2018-2019 (slope = 6.5; P = .027; 95% CI [1.0, 8.0]). Program-mandated visits significantly decreased from 12 in 2014-2015 to 3 in 2018-2019 (slope = -2.4; P = .027; 95% CI [-3.0, -1.0]). IM-attributed professionalism reports significantly decreased from 17 of 62 (31%) in 2014 to 1 of 62 (1.6%) in 2019 (slope = -5.7%; P = .024; 95% CI [-11.6%, -0.6%]). Burnout scores remained in the low range (≤ 22) and CS scores in the average-high range (38.7-42) from 2017-2020.

CONCLUSIONS

A universal well-being FSAP program increased resident utilization of mental health resources and was associated with fewer professionalism breaches.

Serological Responses of Raccoons and Striped Skunks to Ontario Rabies Vaccine Bait in West Virginia during 2012-2016

Since the 1990s, oral rabies vaccination (ORV) has been used successfully to halt the westward spread of the raccoon rabies virus (RV) variant from the eastern continental USA. Elimination of raccoon RV from the eastern USA has proven challenging across targeted raccoon (Procyon lotor) and striped skunk (Mephitis mephitis) populations impacted by raccoon RV. Field trial evaluations of the Ontario Rabies Vaccine Bait (ONRAB) were initiated to expand ORV products available to meet the rabies management goal of raccoon RV elimination. This study describes the continuation of a 2011 trial in West Virginia. Our objective was to evaluate raccoon and skunk response to ORV occurring in West Virginia for an additional two years (2012–2013) at 75 baits/km² followed by three years (2014–2016) of evaluation at 300 baits/km². We measured the change in rabies virus-neutralizing antibody (RVNA) seroprevalence in targeted wildlife populations by comparing levels pre- and post-ORV during each year of study. The increase in bait density from 75/km² to 300/km² corresponded to an increase in average post-ORV seroprevalence for raccoon and skunk populations. Raccoon population RVNA levels increased from 53% (300/565, 95% CI: 50–57%) to 82.0% (596/727, 95% CI: 79–85%) during this study, and skunk population RVNA levels increased from 11% (8/72, 95% CI: 6–20%) to 39% (51/130, 95% CI: 31–48%). The RVNA seroprevalence pre-ORV demonstrated an increasing trend across study years for both bait densities and species, indicating that multiple years of ORV may be necessary to achieve and maintain RVNA seroprevalence in target wildlife populations for the control and elimination of raccoon RV in the eastern USA.

How COVID-19 Changed Advance Care Planning: Insights From the West Virginia Center for End-of-Life Care

CONTEXT

Coronavirus disease 2019 (COVID-19) led to increased attention nationally on advance care planning.

OBJECTIVES

To describe the impact COVID-19 had on advance care planning based on changes in the calls to the West Virginia Center for End-of-Life Care (center) and in the volume and types of documents requested from and submitted to the center and its e-Directive Registry (registry).

METHODS

A retrospective and observational analysis between January 1, 2020 and June 30, 2020 of calls to the center; advance directives downloaded from the center's Web site as well as mailed to the public and medical orders mailed to health care professionals on request to the center; and advance directives and medical orders submitted to the registry.

RESULTS

The nature of calls changed to COVID-19-related topics, including confirmation of forms on the registry, urgent desire to initiate advance care planning, temporary rescindment of treatment-limiting forms, and questions on how to honor patients' wishes in advance directives and medical orders in light of their COVID-19 status. Also in the first six months of 2020, the center distributed more advance directives than it had during the same months in the last five years and more medical orders than it had in the preceding four years when there were no revisions to the medical order forms required by changes to the state law.

CONCLUSION

COVID-19 resulted in a new sense of urgency regarding advance care planning by West Virginians with increased attention to document their wishes and ensure that they were in the registry.

Adequacy of sample size for estimating a value from field observational data

In 2011, the U.S. EPA Office of Research and Development released a field-based method for deriving aquatic life benchmarks for conductivity. Since its release, it has been verified, validated, and corroborated by the authors, reviewers, and independent researchers. However, the method and published results have been recently challenged as being artifacts of small sample sizes, prompting this re-evaluation. This paper supplements prior causal analyses by weighing evidence that specifically addresses the hypothesis that the benchmark is a statistical artifact. Four types of evidence are presented: (1) Permutation analyses show that the data sets are able to reliably estimate the extirpation of 5% of genera. (2) Analyses show that 25 occurrences of a genus are sufficient to estimate extirpation. (3) Coherent ecological explanations show that the claimed influence of sample size is actually a result of community ecology. (4) A review of relevant independent studies supports the benchmark. The permutation test is a useful test of the adequacy of field data sets. Furthermore, this weight-of-evidence approach and the individual types of evidence can be a model for analysis of other field-based benchmark values.

Google Trends as a resource for bariatric education: what do patients want to know?

BACKGROUND

Bariatric surgery (BaS) is the safest, most effective, and most durable therapy for obesity but is performed in less than 1% of the affected United States (US) population. It is challenging to determine from traditional surveys if this phenomenon is the result of poor access to care or lack of interest among Internet users.

OBJECTIVES

The aim of this study was to use Google Trends (GT) as a tool to analyze the US general population interest in BaS.

SETTING

Academic Hospital, United States.

METHODS

GT was used to access data searched for the term bariatric surgery. The gathered information included data from 2008 through 2018 in English within the US. Search frequency, time intervals, locations, frequent topics of interest, and related searches were analyzed. GT reports search frequency on means, and a value of 100 represented peak popularity.

RESULTS

The number of Google searches related to the term bariatric surgery has gradually increased over time, from a mean of 67% in 2008 to a 94% interest in 2017. Regarding interest by subregion in 2017, the state of Michigan lead the frequency of searches, followed by Indiana, Delaware, West Virginia, and Tennessee. Top searched terms by frequency were the following: patient eligibility for BaS, what is BaS, what are the complications of BaS, financial costs of BaS, and what insurance companies cover BaS. It appears that traditional Web sites only address a few.

CONCLUSIONS

GT complements the understanding of interest in BaS. Using these trends can improve an Internet user's education, and tailor specific official Web sites for the public's general interest.

Duplication of the inferior vena cava: evidence of a novel type IV

Anatomical variations of the inferior vena cava, including the double inferior vena cava or isolated left inferior vena cava, are uncommon and of great clinical importance. Inferior vena cava variations signify predisposition to deep vein thrombosis and may complicate retroperitoneal surgeries including abdominal aortic surgery. Failure to recognize such variations may predispose a patient to life- threatening complications. This prospective anatomical study assessed 129 cadavers for variations of the inferior vena cava. One of the 129 cadavers (0.78%) possessed a double inferior vena cava and none (0%) possessed an isolated left inferior vena cava. The left-sided inferior vena cava was of a larger diameter than that of the right-sided inferior vena cava - opposite of what would be seen in a Type III duplication. Therefore, this observation expands the three-type classification system to include a Type IV duplication.

Predicting Nonalcoholic Fatty Liver Disease through a Panel of Plasma Biomarkers and MicroRNAs in Female West Virginia Population

(1) Background: Nonalcoholic fatty liver disease (NAFLD) is primarily characterized by the presence of fatty liver, hepatic inflammation and fibrogenesis eventually leading to nonalcoholic steatohepatitis (NASH) or cirrhosis. Obesity and diabetes are common risk factors associated with the development and progression of NAFLD, with one of the highest prevalence of these diseased conditions in the West Virginia population. Currently, the diagnosis of NAFLD is limited to radiologic studies and biopsies, which are not cost-effective and highly invasive. Hence, this study aimed to develop a panel and assess the progressive levels of circulatory biomarkers and miRNA expression in patients at risk for progression to NASH to allow early intervention strategies. (2) Methods: In total, 62 female patients were enrolled and blood samples were collected after 8–10 h of fasting. Computed tomography was performed on abdomen/pelvis following IV contrast administration. The patients were divided into the following groups: Healthy subjects with normal BMI and normal fasting blood glucose (Control, n = 20), Obese with high BMI and normal fasting blood glucose (Obese, n = 20) and Obese with high fasting blood glucose (Obese + DM, n = 22). Based on findings from CT, another subset was created from Obese + DM group with patients who showed signs of fatty liver infiltration (Obese + DM(FI), n = 10). ELISA was performed for measurement of plasma biomarkers and RT-PCR was performed for circulating miRNA expression. (3) Results: Our results show significantly increased levels of plasma IL-6, Leptin and FABP-1, while significantly decreased level of adiponectin in Obese, Obese + DM and Obese + DM(FI) group, as compared to healthy controls. The level of CK-18 was significantly increased in Obese + DM(FI) group as compared to control. Subsequently, the expression of miR-122, miR-34a, miR-375, miR-16 and miR-21 was significantly increased in Obese + DM and Obese + DM(FI) group as compared to healthy control. Our results also show distinct correlation of IL-6, FABP-1 and adiponectin levels with the expression of miRNAs in relation to the extent of NAFLD progression. (4) Conclusion: Our results support the clinical application of these biomarkers and miRNAs in monitoring the progression of NAFLD, suggesting a more advanced diagnostic potential of this panel than conventional methods. This panel may provide an appropriate method for early prognosis and management of NAFLD and subsequent adverse hepatic pathophysiology, potentially reducing the disease burden on the West Virginia population.

Examining Rural Food-Insecure Families' Perceptions of the Supplemental Nutrition Assistance Program: A Qualitative Study

The Supplemental Nutrition Assistance Program (SNAP) is a critical program that helps reduce the risk of food insecurity, yet little is known about how SNAP addresses the needs of rural, food-insecure residents in the United States (U.S.). This study examines how rural, food-insecure residents perceive SNAP. Semi-structured interviews were conducted with 153 individuals living in six diverse rural regions of Arkansas, Montana, North Carolina, Oregon, Texas, and West Virginia. SNAP was described as a crucial stop-gap program, keeping families from experiencing persistent food insecurity, making food dollars stretch when the family budget is tight, and helping them purchase healthier foods. For many rural residents interviewed, SNAP was viewed in a largely positive light. In efforts to continue improving SNAP, particularly in light of its relevance during and post-coronavirus (COVID-19) pandemic, policymakers must be aware of rural families' perceptions of SNAP. Specific improvements may include increased transparency regarding funding formulas, budgeting and nutrition education for recipients, effective training to improve customer service, connections among social service agencies within a community, and increased availability of automation to streamline application processes.

Creating a Human Gross Anatomy Laboratory: The Experience at a Primarily Undergraduate Institution

This paper details the creation of a human gross anatomy laboratory from a defunct chemistry laboratory at West Liberty University, a small primarily undergraduate institution in West Virginia. The article highlights important considerations with regard to the development of a human gross anatomy laboratory including access to human gifts; assessment of the space for size, security, and privacy; assessment of the utilities; acquisition of a dissection table; ventilation; aesthetics in functional design; expenses; and sustainability. The report also identifies favorable conditions and potential pitfalls regarding the creation of a human gross anatomy laboratory. This paper demonstrates that a human gross anatomy laboratory can be created quickly and at little expense.

Harder to get than you think: Levonorgestrel emergency contraception access in West Virginia community pharmacies

OBJECTIVES

Emergency contraception (EC) is the only noninvasive form of contraception available after risk exposure and is an important tool for preventing unintended pregnancy resulting from unprotected sex, sexual assault, or contraceptive failure. The U.S. Food and Drug Administration (FDA) removed age restrictions on levonorgestrel EC and made it available over-the-counter to everyone in 2013. Despite improved availability and accessibility since the change in FDA regulations, community pharmacies have not uniformly embraced the policy. West Virginia is a rural state with high rates of poverty and teen pregnancy.

DESIGN

The investigators called community pharmacies in West Virginia to assess the availability and accessibility of levonorgestrel EC in addition to the pharmacy staff's knowledge of effectiveness for this cross-sectional study.

SETTING AND PARTICIPANTS

The study sample consisted of 509 community pharmacies throughout the state.

OUTCOME MEASURES

A structured script was employed to conduct phone calls to community pharmacies with items assessing availability, accessibility, and knowledge of effectiveness.

RESULTS

At the time of the phone calls, levonorgestrel EC was reported to be available in 48.9% of the community pharmacies in West Virginia. Chain pharmacies were more likely to report EC as being in stock (0.76) than independent pharmacies (0.15.). Other measures of accessibility also favored chain pharmacies versus independent pharmacies. The overall accessibility of EC at West Virginia community pharmacies was derived from a binary composite variable of "completely accessible" or "not completely accessible" by combining 5 predetermined items. Overall, EC was completely accessible to callers in 0.27 of all pharmacies with significant differences by pharmacy type (0.47 of chain pharmacies as compared with 0.03 of independent pharmacies).

CONCLUSION

Accessible EC could reduce unintended pregnancy and help break the state's generational cycle of poverty and poor educational, social, and health outcomes. Pharmacists will be instrumental in expanding access to EC.

The effects of tissue fixation on sequencing and transcript abundance of nucleic acids from microdissected liver samples of smallmouth bass (Micropterus dolomieu)

There is an increasing emphasis on effects-based monitoring to document responses associated with exposure to complex mixtures of chemicals, climate change, pathogens, parasites and other environmental stressors in fish populations. For decades aquatic monitoring programs have included the collection of tissues preserved for microscopic pathology. Consequently, formalin-fixed, paraffin-embedded (FFPE) tissue can be an important reservoir of nucleic acids as technologies emerge that utilize molecular endpoints. Despite the cross-linking effects of formalin, its impact on nucleic acid quality and concentration, amplification, and sequencing are not well described. While fresh-frozen tissue is optimal for working with nucleic acids, FFPE samples have been shown to be conducive for molecular studies. Laser capture microdissection (LCM) is one technology which allows for collection of specific regions or cell populations from fresh or preserved specimens with pathological alterations, pathogens, or parasites. In this study, smallmouth bass (Micropterus dolomieu) liver was preserved in three different fixatives, including 10% neutral buffered formalin (NBF), Z-Fix® (ZF), and PAXgene® (PG) for four time periods (24 hr, 48 hr, seven days, and 14 days). Controls consisted of pieces of liver preserved in RNALater® or 95% ethanol. Smallmouth bass were chosen as they are an economically important sportfish and have been utilized as indicators of exposure to endocrine disruptors and other environmental stressors. Small liver sections were cut out with laser microdissection and DNA and RNA were purified and analyzed for nucleic acid concentration and quality. Sanger sequencing and the NanoString nCounter® technology were used to assess the suitability of these samples in downstream molecular techniques. The results revealed that of the formalin fixatives, NBF samples fixed for 24 and 48 hr were superior to ZF samples for both Sanger sequencing and the Nanostring nCounter®. The non-formalin PAXgene® samples were equally successful and they showed greater stability in nucleic acid quality and concentration over longer fixation times. This study demonstrated that small quantities of preserved tissue from smallmouth bass can be utilized in downstream molecular techniques; however, future studies will need to optimize the methods presented here for different tissue types, fish species, and pathological conditions.

Assessment of dissolved organic carbon and iron effects on water color between a forest and pasture-dominated fine-scale catchment in a Central Appalachian region, West Virginia

Dissolved organic carbon (DOC) and iron (Fe) have been observed to be the important contributors to surface water brownification. Additionally, the DOC quality influences water color by forming Fe-DOC complexes that provide additive effects and is influenced by dominant land use type within watersheds. However, the influence of quantity and quality of DOC on Fe and water color is poorly understood in headwater streams. The aim of this study was to investigate the effects of DOC and Fe on water color in forest (FC) and pasture (GFC) fine-scale watersheds to remove the confounding effects of climate and soil parent material. Significant differences of DOC, Fe, and water absorbance at 420 nm (a₄₂₀) between FC and GFC were found (p < 0.05). A dominant contribution to water color was from DOC (95.5 - 63.7%) with a decreasing trend when Fe increased from 0.011 to 0.258 mg L^-1. There were no significant interactions between FC and GFC and Fe on either a₄₂₀/DOC (p = 0.06) or specific ultraviolet absorbance at 254 nm (SUVA₂₅₄) (p = 0.30). Increasing values of a₄₂₀/DOC and SUVA₂₅₄ were significantly associated with increasing Fe concentration (p < 0.01). Significant interactions were found between FC and GFC and Fe on spectral slope ratio (S ratio) (p < 0.01). The response rate of S ratio with increasing Fe per unit was 0.235 for GFC while it was - 11.043 for FC. These differences indicate that land use may change the quality of DOC, influence Fe-DOC interactions, and thus affect water color. Linking the effects of soil Fe and DOC and headwater Fe and DOC may help identify optimal management practice to mitigate surface water brownification.

(My Microbiome) Would Walk 10,000 miles: Maintenance and Turnover of Microbial Communities in Introduced Dung Beetles

Host-associated microbes facilitate diverse biotic and abiotic interactions between hosts and their environments. Experimental alterations of host-associated microbial communities frequently decrease host fitness, yet much less is known about if and how host-microbiome interactions are altered by natural perturbations, such as introduction events. Here, we begin to assess this question in Onthophagus dung beetles, a species-rich and geographically widely distributed genus whose members rely on vertically transmitted microbiota to support normal development. Specifically, we investigated to what extent microbiome community membership shifts during host introduction events and the relative significance of ancestral associations and novel environmental conditions in the structuring of microbial communities of introduced host species. Our results demonstrate that both evolutionary history and local environmental forces structure the microbial communities of these animals, but that their relative importance is shaped by the specific circumstances that characterize individual introduction events. Furthermore, we identify microbial taxa such as Dysgonomonas that may constitute members of the core Onthophagus microbiome regardless of host population or species, but also Wolbachia which associates with Onthophagus beetles in a species or even population-specific manner. We discuss the implications of our results for our understanding of the evolutionary ecology of symbiosis in dung beetles and beyond.

Wellness and resilience for college and beyond: protocol for a quasi-experimental pilot study investigating a dialectical behaviour therapy skill-infused college course

INTRODUCTION

College students' mental health problems and suicidal behaviour are serious, persistent and prevalent public health issues. With the need for mental health support greatly exceeding the availability of on-campus treatment, a recent trend on college campuses is to offer courses designed to teach students strategies for developing mental health or resilience. While these courses are exceptionally popular among students, a paucity of research investigates the health outcomes associated with participation. The purpose of this study is to investigate the acceptability, appropriateness, feasibility and preliminary effectiveness of a college course grounded in skills from dialectical behaviour therapy (DBT) titled, 'Wellness and Resilience for College and Beyond'.

METHODS AND ANALYSIS

During the spring and fall 2020 semesters, the course will be offered on five campuses in Southwestern Pennsylvania and West Virginia. The course consists of 15 weekly 2.5-hour lessons, weekly homework assignments and a final examination with content drawn from DBT, acceptance and commitment therapy and positive psychology. Undergraduate students aged 18-24 will self-select into the course and control subjects receiving 'university as usual' will be recruited to serve as a comparison group. Students who receive the course will complete measures of course acceptability, appropriateness and feasibility. All study participants will complete measures of adaptive coping skills use, emotion dysregulation and suicidality.

ETHICS AND DISSEMINATION

All of the study procedures were approved as an exempt protocol for evaluation of educational curricula by the University of Pittsburgh Human Research Protections Office (HRPO); the study was approved as a research study by the institutional review board (IRB) of the fifth study site. The University of Pittsburgh HRPO served as the IRB of record for all except one study site, which required standard IRB review. Data from this study will be disseminated via conference presentations, peer-reviewed publications and via our online stakeholder learning collaborative.

TRIAL REGISTRATION NUMBER

NCT04338256.

Evidence of Air Dispersion: HFPO-DA and PFOA in Ohio and West Virginia Surface Water and Soil near a Fluoropolymer Production Facility

Perfluorooctanoic acid (PFOA) was used as a fluoropolymer manufacturing aid at a fluoropolymer production facility in Parkersburg, WV from 1951 to 2013. The manufacturer introduced a replacement surfactant hexafluoropropylene oxide dimer acid (HFPO-DA) that has been in use at this site since 2013. Historical releases of PFOA and related epidemiological work in this area has been primarily focused on communities downstream. To provide an update on the ongoing impacts from this plant, 94 surface water samples and 13 soil samples were collected mainly upstream and downwind of this facility. PFOA was detected in every surface water sample with concentrations exceeding 1000 ng/L at 13 sample sites within an 8 km radius of the plant. HFPO-DA was also found to be widespread with the highest levels (>100 ng/L) found in surface water up to 6.4 km north of the plant. One sample site, 28 km north of the plant, had PFOA at 143 ng/L and HFPO-DA at 42 ng/L. Sites adjacent to landfills containing fluorochemical waste had PFOA concentrations ranging up to >1000 ng/L. These data indicate that downwind atmospheric transport of both compounds has occurred and that the boundaries of the impact zone have yet to be fully delineated.

Dental Care Needs of Male versus Female Children Visiting a School-based Mobile Dental Facility in West Virginia

Purpose: Many school-aged children have not received dental care in West Virginia, despite mandated statewide requirements of a dental evaluation and dental treatment before entering school, and the provision of Medicaid/CHIP insurance coverage for children from families below the federal poverty level. An innovative mobile oral health program to educate children, provide preventive care, and bring technology to public schools was developed for West Virginia children in a need shortage area. It was unknown if the unmet dental needs challenge was greater for male or female children residing in that area. The purpose of this study was to determine whether there was a difference by sex in the number of attendees and the incidence of dental caries for children who visited a school-based mobile dental facility.Methods: School-aged children who had not had a dental examination within the previous year were offered school-based examinations/assessments, preventive care, and oral health education via a mobile oral health program following parental/guardian consent. Data were collected concerning the number of current carious teeth in need of restoration. Descriptive statistics and chi square analyses were conducted to analyze the data.Results: There were 429 students evaluated at the school-based mobile dental facility. Half (50.3%) were male. Referrals for additional necessary oral/medical care were made for 214 (50.1%) children; 45.9% of males and 53.3% of females (p= 0.287) had dental caries.Conclusion: Results from this study indicate that sex was not a statistically significant factor in school-based mobile dental facility attendance nor in current dental caries incidence among school-aged children in an underserved area of West Virginia.

Geochemical and isotope analysis of produced water from the Utica/Point Pleasant Shale, Appalachian Basin

While development of the Utica/Point Pleasant Shale (UPP) is extensive in Ohio (U.S.) and increasing in Pennsylvania and West Virginia, few studies report the chemistry of produced waters from UPP wells. These data have important implications for developing best management practices for handling and waste disposal, or identifying the fluid in the event of accidental spill events. Here, we evaluated the elemental and isotope chemistry of UPP produced waters from 26 wells throughout Ohio, Pennsylvania, and West Virginia to determine any unique fluid chemistries that could be used for forensic studies. Compared to the Marcellus, UPP produced waters contain higher activities of total radium (²²⁶Ra + ²²⁸Ra) and higher ²²⁸Ra/²²⁶Ra ratios. As with the Marcellus Shale, elemental ratios (Sr/Ca) and isotope ratios (⁸⁷Sr/⁸⁶Sr) can distinguish UPP produced waters from many conventional oil and gas formations. Sr/Ca and ⁸⁷Sr/⁸⁶Sr ratios can fingerprint small fractions (∼0.1%) of UPP produced water in freshwater. However, because Marcellus and UPP produced waters display similar major elemental chemistry (i.e., Na, Ca, and Cl) and overlapping ratios of Sr/Ca and ⁸⁷Sr/⁸⁶Sr, ²²⁸Ra/²²⁶Ra ratios may be the best tracer to distinguish these waters.

Attractiveness of Pheromone Components With and Without the Synergist, Methyl (2E,4E,6Z)-2,4,6-Decatrienoate, to Brown Marmorated Stink Bug (Hemiptera: Pentatomidae)

The brown marmorated stink bug, Halyomorpha halys (Stål) (Hemiptera: Pentatomidae) is attracted to its male-produced aggregation pheromone, a ~3.5:1 mixture of (3S,6S,7R,10S)- and (3R,6S,7R,10S)-10,11-epoxy-1-bisabolen-3-ol (SSRS and RSRS respectively), and also to the pheromone of its Asian sympatric species Plautia stali Scott (Hemiptera: Pentatomidae), methyl (2E,4E,6Z)-2,4,6-decatrienoate (MDT). A stereoisomeric mixture of (7R) 10,11-epoxy-1-bisabolen-3-ols (= mixed murgantiols) is used together in commercialized products with MDT because the latter is a synergist for H. halys attraction to mixed murgantiols. However, the optimal ratio for MDT combination with mixed murgantiols, and the sensitivity of bug captures to variation in ratio of the two pheromone components, have not been tested to date. Using black pyramid traps at two sites (in Maryland and West Virginia, United States), different ratios of mixed murgantiols to MDT were tested over two entire seasons. Also, captures using various ratios of the two active pheromone stereoisomers were undertaken in month-long trials with and without MDT. Results showed that H. halys adult and nymphal captures were relatively insensitive to the ratio of synthetic pheromone (mixed murgantiols) to MDT, as long as each was present in the trap. Captures of adults and nymphs were responsive to the lure loading of the SSRS isomer, but relatively insensitive to levels of the minor component, RSRS. The relative insensitivity of H. halys to these attractant ratios gives flexibility to development of more cost-efficient synthesis and trapping as well as other semiochemical-based management tactics.

The shale gas production and economic growth in local economies across the US

Recently, several seminal works have been drawing attention to the revolution of shale gas production technology of the USA, the impact of shale gas on energy sectors, as well as the influences of shale gas on macroeconomic variables of employment, economic growth, etc. Nevertheless, one may claim that two gaps appear in literature. The first gap is the absence of an econometric study estimating the effect of shale oil/gas on national economies. The more considerable second gap is the absence of econometric analyses revealing the impulses of shale gas on local economies. Therefore, this paper observes the possible causalities between the shale gas and local gross domestic product (GDP) employing quarterly data covering the period 2007-2016 for 12 states in the US. After performing the tests of cross-sectional dependence, heterogeneity, stationarity, and cointegration, the paper conducts the panel Granger causality analyses. The empirical findings depict that (i) there is available unidirectional relationship from local shale gas production to local GDP in Colorado, Ohio, and West Virginia; (ii) there occurs an impulse from GDP to local shale gas production for Louisiana, North Dakota, and Oklahoma; (iii) a bidirectional causality coexists between local shale gas production and GDP in Arkansas, California, and Texas; and (iv) there exists no association between local GDP and local shale gas extraction in Montana, New Mexico, and Wyoming.

Adolescents' Evaluations of Political Leaders: The Case of President Donald Trump

The current study explored youths' views of President Donald Trump using quantitative ratings and open-ended responses from a diverse sample of 1,432 U.S. adolescents from three geographic regions. Adolescent demographic characteristics (i.e., gender, race, geographic location) were systematically associated with their views about Trump. Open-ended responses demonstrated substantial variability in youths' rationales for approving or disapproving of the president. Adolescents' attitudes were informed by knowledge of the president's leadership attributes, political views and policies, and their own experiences. Findings indicate that adolescents draw upon and synthesize a broad range of information when formulating their political views and coordinate this knowledge with their own opinions and experiences when evaluating political figures.

School Climate as an Intervention to Reduce Academic Failure and Educate the Whole Child: A Longitudinal Study

BACKGROUND

Preventing student academic failure is crucial to student health and life success. Previous studies suggest a positive school climate may reduce students' risk for academic failure and contribute to academic success. The purpose of this study was to determine the longitudinal associations between school climate and academic grades in a group of middle school students who transition into high school.

METHODS

Parallel latent growth curve modeling was used to examine changes among study variables longitudinally using a sample of 2604 in 6th, 7th, and 8th-grade students across 16 regional schools located in 3 counties in West Virginia.

RESULTS

Students with higher perceptions of a positive school climate exhibited sustained or improved academic achievement over time (β = 0.22 to 0.30, p < .01). Higher positive perceptions of school climate appear to sustain students who earn As/Bs (β = 0.20 to 0.27, p < .01) and strengthen students who earn Cs/Ds/Fs (β = -0.16 to -0.46, p < .05).

CONCLUSIONS

Positive student perceptions of school climate may sustain high academic performance while strengthening students who earn Cs/Ds/Fs. School climate may be useful as an intervention to support school-based health promotion to reduce the achievement gap in the United States.