Child Care as a Barrier to Perinatal Health Care in Illinois.

PURPOSE: Within a multi-state Collaborative Improvement and Innovation Network addressing the social determinants of health during 2017-2020, the Illinois Department of Public Health led an exploratory project to understand how the availability of child care affects maternal health care utilization. The project assessed whether lack of child care was a barrier to perinatal health care utilization and gathered information on health facility practices, resources, and policies related to child care DESCRIPTION: TWe surveyed (1) birthing hospitals (n = 98), (2) federally qualified health centers (FQHCs) (n = 40), and (3) a convenience sample of postpartum persons (n = 60). ASSESSMENT: Each group reported that child care concerns negatively affect health care utilization (66% of birthing hospitals, 50% of FQHCs, and 32% of postpartum persons). Among postpartum persons, the most common reported reason for missing a visit due to child care issues was "not feeling comfortable leaving my child(ren) in the care of others" (22%). The most common child care resource reported by facilities was "staff watching children" (53% of birthing hospitals, 75% of FQHCs); however, most did not have formal child care policies or dedicated space for children. Fewer than half of FQHCs (43%) discussed child care at the first prenatal visit. CONCLUSION: The project prompted the Illinois Title V program to add a child care-related strategy to their 2021-2025 Action Plan, providing opportunity for further examination of practices and policies that could be implemented to reduce child care barriers to perinatal care. Systematically addressing child care in health care settings may improve health care utilization among birthing/postpartum persons.

Enhancing Role Integrity for Peer Workers.

Although informal peer support has been a central feature of recovery for people with substance use disorder (SUD), more recently there has been a stark increase in formal models of peer support. In the infancy of formalized peer support, researchers warned of potential threats to the integrity of the peer support role. Now, almost two decades into the rapid expansion of peer support, research has yet to evaluate the extent to which peer support is being implemented with fidelity and role integrity. The present study aimed to assess peer workers' perceptions of peer role integrity. Qualitative interviews were conducted with 21 peer workers in Central Kentucky. Results suggest that the role of peers is not well understood by onboarding organizations, and thus, the integrity of peer support is diluted. Findings from this study suggest room for improvement in the training, supervision, and implementation of peer support.

Scales for participant Alliance with Recovery Coach (SPARC): initial development and pilot test.

Recovery coaches are individuals with lived experience with recovery from substance use disorder who typically engender a greater sense of trust than found with other types of healthcare providers. However, there currently are no validated tools that measure the connection between recovery coaches and their participants. The purpose of this study was to describe the initial development of the Scales for Participant Alliance with Recovery Coach (SPARC) to measure recovery coach connection or alliance, including initial psychometric analyses. Measurement development began with five scales of the Client Evaluation of Self Treatment (treatment participation, treatment satisfaction, rapport, peer support, and social support). Adapted items were pre-tested with focus groups (n = 8) to ensure they were meaningful and accurately reflected the domains (Study 1). After modifications, the SPARC has six scales (engagement, satisfaction, rapport, motivation and encouragement, role model and community linkage). The survey was piloted with 100 individuals (Study 2) age 18 or over who had met with a recovery coach within the last six months. Most study participants were male (60%) and white (87%) with less than two years in recovery. After removing two low performing items, the items for five of the domains had acceptable internal consistency. The items for the engagement domain had a slightly lower reliability. Findings suggest that items cover relevant recovery coach roles, are internally consistent within domains, and can be easily administered to individuals engaging in recovery coaching services. Additional research is needed with a larger, more heterogenous sample to further refine items.

Unsupervised Clustering of Missense Variants in HNF1A Using Multidimensional Functional Data Aids Clinical Interpretation.

Exome sequencing in diabetes presents a diagnostic challenge because depending on frequency, functional impact, and genomic and environmental contexts, HNF1A variants can cause maturity-onset diabetes of the young (MODY), increase type 2 diabetes risk, or be benign. A correct diagnosis matters as it informs on treatment, progression, and family risk. We describe a multi-dimensional functional dataset of 73 HNF1A missense variants identified in exomes of 12,940 individuals. Our aim was to develop an analytical framework for stratifying variants along the HNF1A phenotypic continuum to facilitate diagnostic interpretation. HNF1A variant function was determined by four different molecular assays. Structure of the multi-dimensional dataset was explored using principal component analysis, k-means, and hierarchical clustering. Weights for tissue-specific isoform expression and functional domain were integrated. Functionally annotated variant subgroups were used to re-evaluate genetic diagnoses in national MODY diagnostic registries. HNF1A variants demonstrated a range of behaviors across the assays. The structure of the multi-parametric data was shaped primarily by transactivation. Using unsupervised learning methods, we obtained high-resolution functional clusters of the variants that separated known causal MODY variants from benign and type 2 diabetes risk variants and led to reclassification of 4% and 9% of HNF1A variants identified in the UK and Norway MODY diagnostic registries, respectively. Our proof-of-principle analyses facilitated informative stratification of HNF1A variants along the continuum, allowing improved evaluation of clinical significance, management, and precision medicine in diabetes clinics. Transcriptional activity appears a superior readout supporting pursuit of transactivation-centric experimental designs for high-throughput functional screens.

Partnering with recovery community centers to build recovery capital by improving access to reproductive health.

BACKGROUND: People with substance use disorders (SUD), especially opioid use disorder (OUD) have the highest rates of unintended pregnancies (80-95%) and report unmet reproductive health needs. Women of childbearing age have some of the highest death rates from opioids and are notably rising the most rapidly, and when pregnancy does occur overdose is one of the leading causes of maternal mortality. There are numerous gender-based health disparities and social determinants of health shaped by the distribution of power and privilege that influence the risk trajectories of people who can get pregnant or are pregnant with a substance use disorder (SUD). PURPOSE: The purpose of this paper is to describe how reproductive health is essential to recovery and building recovery capital for people who can get pregnant, (1) introduce a pilot implementation science study working with trained peer support coaches to promote reproductive autonomy in the community, and (2) make policy and advocacy recommendations relevant to the new reproductive health landscape in the United States. We will also describe the adaptation and feasibility of the initial pilot study where we partnered with a recovery community center to train peer recovery coaches to provide low barrier resources (contraception, pregnancy tests and prenatal vitamins) and referrals to health care. METHODS: This initiative is the merging of best practices in recovery and community-based global reproductive health, to empower people with SUD who can get pregnant in an implementation science framework. The pilot study will last 3 months in each city and aims to (1) assess and describe the effectiveness of the training of local peer recovery coaches on the link between recovery capital and reproductive health, and (2) assess the feasibility, acceptability, appropriateness, scalability, sustainability, and uptake and reach of low barrier reproductive health resources (pregnancy tests, prenatal vitamins, and emergency contraception). In this paper we are only reporting the initial findings regarding adaptation and feasibility. FINDINGS: Informed by qualitative interviews with stakeholders and participants, the method of contraception was adapted from injectable to emergency to meet the needs and context of the community with SUD. Early outcomes such as uptake and acceptability indicate that this is a feasible model with peer recovery coaches and recovery community centers, with the greatest uptake of emergency contraception and pregnancy tests. CONCLUSION: Considering recent policies limiting access to reproductive health, innovative community-based solutions are needed to engage and empower people who can get pregnant or are pregnant while in active drug use and in recovery. Providing low barrier reproductive health items by people with lived experience with SUD can serve as a valuable harm reduction model and improve recovery capital. CLINICAL RELEVANCE: This is the first study to propose a methodology and context to implement a community-based study merging best practices in recovery with those in reproductive health with the potential to improve recovery capital and maternal/child health trajectories for people with SUD.

Genome-wide associations for birth weight and correlations with adult disease.

Birth weight (BW) has been shown to be influenced by both fetal and maternal factors and in observational studies is reproducibly associated with future risk of adult metabolic diseases including type 2 diabetes (T2D) and cardiovascular disease. These life-course associations have often been attributed to the impact of an adverse early life environment. Here, we performed a multi-ancestry genome-wide association study (GWAS) meta-analysis of BW in 153,781 individuals, identifying 60 loci where fetal genotype was associated with BW (P < 5 × 10-8). Overall, approximately 15% of variance in BW was captured by assays of fetal genetic variation. Using genetic association alone, we found strong inverse genetic correlations between BW and systolic blood pressure (Rg = -0.22, P = 5.5 × 10-13), T2D (Rg = -0.27, P = 1.1 × 10-6) and coronary artery disease (Rg = -0.30, P = 6.5 × 10-9). In addition, using large -cohort datasets, we demonstrated that genetic factors were the major contributor to the negative covariance between BW and future cardiometabolic risk. Pathway analyses indicated that the protein products of genes within BW-associated regions were enriched for diverse processes including insulin signalling, glucose homeostasis, glycogen biosynthesis and chromatin remodelling. There was also enrichment of associations with BW in known imprinted regions (P = 1.9 × 10-4). We demonstrate that life-course associations between early growth phenotypes and adult cardiometabolic disease are in part the result of shared genetic effects and identify some of the pathways through which these causal genetic effects are mediated.

Sensitivity of Pregnancy Field on the COVID-19 Case Report Form Among Pregnancies Completed Through December 31, 2020: Illinois and Tennessee.

PURPOSE: The considerable volume of infections from SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), has made it challenging for health departments to collect complete data for national disease reporting. We sought to examine sensitivity of the COVID-19 case report form (CRF) pregnancy field by comparing CRF data to the gold standard of CRF data linked to birth and fetal death certificates. DESCRIPTION: CRFs for women aged 15-44 years with laboratory-confirmed SARS-CoV-2 infection were linked to birth and fetal death certificates for pregnancies completed during January 1-December 31, 2020 in Illinois and Tennessee. Among linked records, pregnancy was considered confirmed for women with a SARS-CoV-2 specimen collection date on or prior to the delivery date. Sensitivity of the COVID-19 CRF pregnancy field was calculated by dividing the number of confirmed pregnant women with SARS-CoV-2 infection with pregnancy indicated on the CRF by the number of confirmed pregnant women with SARS-CoV-2 infection. ASSESSMENT: Among 4276 (Illinois) and 2070 (Tennessee) CRFs that linked with a birth or fetal death certificate, CRF pregnancy field sensitivity was 45.3% and 42.1%, respectively. In both states, sensitivity varied significantly by maternal race/ethnicity, insurance, trimester of prenatal care entry, month of specimen collection, and trimester of specimen collection. Sensitivity also varied by maternal education in Illinois but not in Tennessee. CONCLUSION: Sensitivity of the COVID-19 CRF pregnancy field varied by state and demographic factors. To more accurately assess outcomes for pregnant women, jurisdictions might consider utilizing additional data sources and linkages to obtain pregnancy status.

Tobacco use and mental health disparities in LGB youth.

OBJECTIVE: In 2019, the Youth Risk Behavioral Survey (YRBS) collected sexual orientation data for the first time in Kentucky. Tobacco use behaviors and mental health status among Lesbian, Gay, and Bisexual (LGB) youth is infrequently documented in southern states such as Kentucky. This study aimed to analyze self-reported tobacco use and mental health in youth by sexual orientation. DESIGN: Cross-sectional survey. SAMPLE: All participants, aged 12-19, of the 2019 Kentucky YRBS that indicated a sexual orientation. MEASUREMENTS: Differences in response distributions for tobacco use and mental health measures were analyzed via chi square by sexual orientation, with additional stratification by sex. RESULTS: A total of n = 1996 respondents were 12.8% LGB-identified and 82.1% heterosexual-identified. No disparities between LGB and heterosexual youth were observed in tobacco-related behaviors for male students, but disparities were persistent for female students (p = .005 for "tried tobacco before age 13"; p = .007 for "current smoking", p = .012 for "ever smoked"). Mental health disparities between LGB and heterosexual youth were significant for males and females (p < .05, all mental health measures). CONCLUSIONS: Findings suggest that tobacco disparities in this most recent data are narrower than in previous years; however, mental health disparities persist between LGB and heterosexual youth in Kentucky.

Care Experiences of Persons With Perinatal Opioid Use: A Qualitative Study.

Opioid use in the perinatal period has escalated rapidly, with potentially devastating outcomes for perinatal persons and infants. Substance use treatment is effective and has the potential to greatly improve clinical outcomes; however, characteristics of care received from providers including nurses have been described as a barrier to treatment. Our purpose was to describe supportive perinatal care experiences of persons with opioid use disorder. A qualitative descriptive study design was used to examine experiences of 11 postpartum persons (ages 22-36 years) in medication-assisted treatment for opioid use disorder at an academic medical center in the southern region of the United States. Participants were interviewed about experiences with perinatal and neonatal care during the child's hospitalization for neonatal abstinence syndrome surveillance and/or treatment. Four themes of supportive care experiences emerged: informing, relating, accepting, and holistic supporting. Participants reported a range of positive and negative perinatal care experiences, with examples and counterexamples provided. This fuller understanding of perceptions and lived experiences of care can inform practice changes and educational/training priorities. Future research is needed to facilitate development of comprehensive care models geared to address perinatal care needs of persons with opioid use disorder.

The interaction of neonatal abstinence syndrome and opioid use disorder treatment availability for women insured by medicaid.

OBJECTIVE: This paper will discuss the process of mapping opioid use disorder (OUD) treatment resources for pregnant women and discuss the intersection between treatment resources and rates of neonatal abstinence syndrome (NAS). DESIGN: A resource manual was developed through a systematic process with stakeholders across Illinois. Resources were mapped by county and overlaid with county rates of NAS, using hospital discharge data. RESULTS: Across Illinois, 89 treatment resources were identified for pregnant women insured by Medicaid. Resources were concentrated in 36% of Illinois' counties. Counties with limited treatment resources generally had high rates of NAS. Sixty-six percent of NAS cases among rural Illinois residents had no OUD treatment resources in their county. Rural counties had less access to medication-assisted treatment (MAT), the standard of care for treatment of OUD, compared with other counties across the state. CONCLUSIONS: Efforts to increase OUD treatment options for pregnant women insured by Medicaid should concentrate on geographic areas with limited access and high need.

Adverse Childhood Experiences Among Children with Neurodevelopmental Delays: Relations to Diagnoses, Behavioral Health, and Clinical Severity.

Limited research has examined adverse childhood experiences (ACEs) among children at risk for neurodevelopmental delays. The purpose of this study was to (1) identify the prevalence of ACEs among children at risk for neurodevelopmental delays; (2) explore differences in rates of ACEs across neurodevelopmental diagnoses; and (3) examine relations between ACEs and indicators of behavioral health functioning (e.g., enuresis, feeding problems, sleeping problems, and functional impairment). Participants were 193 children ages 2 to 11 who received a developmental and behavioral pediatrics evaluation at a subspecialty clinic. Caregivers completed a survey about their child's ACEs, and researchers conducted an electronic health record review. Overall, 47% experienced at least one ACE. ACEs were not related to neurodevelopmental diagnosis or to externalizing symptoms. ACEs were related to difficulty sleeping, lower hyperactivity, and greater functional impairment at home. The relations between early adversity and poor behavioral health functioning may develop over time, creating an excellent window of opportunity for prevention work.

Adverse Childhood Experiences and Obesity Among Young Children with Neurodevelopmental Delays.

OBJECTIVES: Very little research has explored the complex relation between ACEs, poverty, and obesity in young children with neurodevelopmental delays. The purpose of this study was to examine whether ACEs predicted overweight/obesity in young children with neurodevelopmental delays after income was taken into account, and to examine the extent to which poverty moderated the relation between ACEs and overweight/obesity. METHODS: Participants were 180 children between the ages of 2 and 7 who were referred for a developmental and behavioral pediatrics evaluation (mean age 4.5 years old; 76% male) in the northeast United States. Parents completed a survey about their child's ACEs, and an electronic health record review was conducted. RESULTS: ACEs did not directly predict obesity after income was taken into account. However, poverty moderated the relation between ACEs and obesity, such that when children experienced no ACEs, there was no difference in the rates of obesity between children above and below the poverty threshold. Among children who did experience ACEs, children who also lived in poverty had higher rates of obesity than children who did not live in poverty. CONCLUSIONS FOR PRACTICE: Children with neurodevelopmental delays are at greater risk for overweight/obesity if they experience both risk factors of being in poverty and of experiencing ACEs. When conducting screenings, providers should understand that the impact of ACEs may vary by contextual factors such as poverty. More research is needed to identify factors that can mitigate the impact of poverty and ACEs on children's physical health.

Early Indicators of Creatine Transporter Deficiency.

Early identification is a goal for creatine transporter deficiency and will be critical for future treatment. Before their first birthday, one-half of this sample showed both a significant feeding/weight gain issue and delayed sitting or crawling. Combined, these early indicators could have alerted providers to conduct a urine screen.

Primary Care Providers' Attitudes Related to LGBTQ People: A Narrative Literature Review.

The purpose of this article is to review the current literature describing primary care providers' (PCPs) attitudes related to lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) people. LGBTQ individuals experience significant health disparities, and these inequities may be better understood via an ecological systems framework. PCPs' actual or perceived discriminatory attitudes can lead to suboptimal treatment or health outcomes for LGBTQ people. A review of the literature from 2005 through January 2017 was completed using the Cumulative Index for Nursing and Allied Health Literature and PubMed (Medline) databases. The purpose, sample, measure(s), design, findings, strengths, and weaknesses of each study were examined; and findings were synthesized, summarized, and critically appraised. Eight articles were eligible for review. There was significant heterogeneity in the studies' purposes, research questions, LGBTQ population(s) of focus, and findings. Many PCPs' attitudes toward LGBTQ people were positive, but a minority of each studies' participants had negative attitudes toward LGBTQ people. Stigma and health care barriers negatively affect LGBTQ health. Interventions must address LGBTQ health disparities at the individual, mesosytem, exosystem, and macrosystem levels. Research, education, and practice strategies all must be integrated across socioecological levels as components of a population-based approach to eliminate health disparities for LGBTQ persons.

Smoking and Tobacco-Free Policies in Women's Residential Substance Use Disorder Treatment Facilities: A Community-Engaged Approach.

Introduction: The purpose of this study was to (1) describe the role of smoking in the lives of women in residential substance use disorder (SUD) treatment and (2) explore perceptions of the facilitators and barriers to tobacco-free policy among women in residential SUD treatment. Methods: This was a community-engaged study using qualitative descriptive methods. We first recruited women in a residential SUD treatment facility to participate on a community research team. Interviews with staff (N = 10) and focus groups with clients (N = 42) were conducted using guides informed by the community research team. Interviews and focus groups were analyzed using content analysis. Results: There were two themes related to the role of smoking in the women's lives: (1) smoking facilitates socialization and (2) smoking as a coping mechanism. There were three themes related to the benefits of tobacco-free policy: (1) improved health, (2) support for continued abstinence from a previous tobacco-free placement (eg, prison), and (3) less grounds up-keep. Barriers to tobacco-free policy included (1) lack of an alternative coping mechanism to smoking, (2) fear that a tobacco-free policy would drive clients away, and (3) anticipation of implementation challenges. Conclusions: Many women in residential SUD treatment smoke, which they attribute to the fact that smoking is used to facilitate socialization and cope with stress. Future research is needed to develop and test messages to counter the misperception that smoking is an effective method to cope with stress. Ultimately, evidence-based tobacco-free policies are needed to reduce tobacco-related disease among women with SUDs. Implications: To promote smoking cessation among women with substance use disorders through evidence-based tobacco policy, it is necessary to first understand the role of smoking in their lives as well as facilitators and barriers to tobacco-free policy in residential treatment facilities. Participants reported that smoking facilitated socialization and served as a coping mechanism. Tobacco-free policies have many benefits, including improved health, support for continued abstinence from a previous tobacco-free placement (eg, prison), and less grounds up-keep. Barriers include the lack of an alternative coping mechanism, fear that a tobacco-free policy would drive away clients and anticipation of implementation challenges. To reduce the burden of tobacco-related morbidity and mortality among women and their children, it is necessary to catalyze a culture change in behavioral health settings to prioritize the treatment of tobacco alongside treatment of other addictions.

Autism Spectrum Disorder and Transition-Aged Youth.

PURPOSE OF REVIEW: This article discusses common issues surrounding transition to adulthood in youth with autism spectrum disorder (ASD). We review recent evidence on co-occurring medical and mental health conditions and topics of education and employment, sexuality and relationships, independent living, and financial support. RECENT FINDINGS: Transitioning individuals with ASD have increased risk for several medical and behavioral health comorbidities and should be routinely screened for co-occurring conditions. Evidence on interventions for mental health disorders is limited but emerging, particularly with respect to mindfulness training and cognitive behavioral therapy. Many autistic adults or their families express a desire for independent living, participation in education/employment, and intimacy and social relationships, but they often lack skills and/or resources to successfully achieve these outcomes. The time of transition to adulthood for adolescents with ASD is an opportunity for physicians to provide anticipatory guidance and necessary supports around issues of community participation. To allow time for planning, these discussions should occur well before the child reaches adulthood. Clinicians should also routinely screen for and address medical and/or behavioral health comorbidities.

Transcript Expression Data from Human Islets Links Regulatory Signals from Genome-Wide Association Studies for Type 2 Diabetes and Glycemic Traits to Their Downstream Effectors.

The intersection of genome-wide association analyses with physiological and functional data indicates that variants regulating islet gene transcription influence type 2 diabetes (T2D) predisposition and glucose homeostasis. However, the specific genes through which these regulatory variants act remain poorly characterized. We generated expression quantitative trait locus (eQTL) data in 118 human islet samples using RNA-sequencing and high-density genotyping. We identified fourteen loci at which cis-exon-eQTL signals overlapped active islet chromatin signatures and were coincident with established T2D and/or glycemic trait associations. At some, these data provide an experimental link between GWAS signals and biological candidates, such as DGKB and ADCY5. At others, the cis-signals implicate genes with no prior connection to islet biology, including WARS and ZMIZ1. At the ZMIZ1 locus, we show that perturbation of ZMIZ1 expression in human islets and beta-cells influences exocytosis and insulin secretion, highlighting a novel role for ZMIZ1 in the maintenance of glucose homeostasis. Together, these findings provide a significant advance in the mechanistic insights of T2D and glycemic trait association loci.

Discovery and Fine-Mapping of Glycaemic and Obesity-Related Trait Loci Using High-Density Imputation.

Reference panels from the 1000 Genomes (1000G) Project Consortium provide near complete coverage of common and low-frequency genetic variation with minor allele frequency ≥0.5% across European ancestry populations. Within the European Network for Genetic and Genomic Epidemiology (ENGAGE) Consortium, we have undertaken the first large-scale meta-analysis of genome-wide association studies (GWAS), supplemented by 1000G imputation, for four quantitative glycaemic and obesity-related traits, in up to 87,048 individuals of European ancestry. We identified two loci for body mass index (BMI) at genome-wide significance, and two for fasting glucose (FG), none of which has been previously reported in larger meta-analysis efforts to combine GWAS of European ancestry. Through conditional analysis, we also detected multiple distinct signals of association mapping to established loci for waist-hip ratio adjusted for BMI (RSPO3) and FG (GCK and G6PC2). The index variant for one association signal at the G6PC2 locus is a low-frequency coding allele, H177Y, which has recently been demonstrated to have a functional role in glucose regulation. Fine-mapping analyses revealed that the non-coding variants most likely to drive association signals at established and novel loci were enriched for overlap with enhancer elements, which for FG mapped to promoter and transcription factor binding sites in pancreatic islets, in particular. Our study demonstrates that 1000G imputation and genetic fine-mapping of common and low-frequency variant association signals at GWAS loci, integrated with genomic annotation in relevant tissues, can provide insight into the functional and regulatory mechanisms through which their effects on glycaemic and obesity-related traits are mediated.

Pharmacists' role in harm reduction: a survey assessment of Kentucky community pharmacists' willingness to participate in syringe/needle exchange.

BACKGROUND: Pharmacists' role in harm reduction is expanding in many states, yet there are limited data on pharmacists' willingness to participate in harm reduction activities. This study assessed community pharmacists' willingness to participate in one harm reduction initiative: syringe/needle exchange. METHODS: In 2015, all Kentucky pharmacists with active licenses were emailed a survey that examined attitudes towards participation in syringe/needle exchange. Response frequencies were calculated for community pharmacist respondents. Ordinal logistic regression estimated the impact of community pharmacist characteristics and attitudes on willingness to provide clean needles/syringes to people who inject drugs and to dispose of used syringes/needles, where both dependent variables were defined as Likert-type questions on a scale of 1 (not at all willing) to 6 (very willing). RESULTS: Of 4699 practicing Kentucky pharmacists, 1282 pharmacists responded (response rate = 27.3%); the majority (n = 827) were community pharmacists. Community pharmacists were divided on willingness to provide clean needles/syringes, with 39.1% not willing (score 1 or 2 of 6) and 30% very willing (score 5 or 6 of 6). Few were willing to dispose of used needles/syringes, with only 18.7% willing. Community pharmacists who agreed that pharmacists could have significant public health impact by providing access to clean needles expressed 3.56 times more willingness to provide clean needles (95% CI 3.06-4.15), and 2.04 times more willingness to dispose of used needles (95% CI 1.77-2.35). Chain/supermarket pharmacists (n = 485, 58.6% of community pharmacies) were 39% less likely to express willingness to dispose of used needles (95% CI 0.43-0.87) when compared with independent community pharmacists (n = 342, 41.4% of community pharmacies). Independent pharmacists reported different barriers (workflow) than their chain/supermarket pharmacist colleagues (concerns of clientele). CONCLUSIONS: Kentucky community pharmacists were more willing to provide clean needles than to dispose of used needles. Strategies to mitigate barriers to participation in syringe/needle exchange are warranted.

Perceptions and use of electronic cigarettes in pregnancy.

Use of electronic cigarettes (e-cigs) is quickly growing in the United States, despite the unknown health implications and unregulated device contents. Although research is emerging around e-cigs in general, there continues to be a lack of scientific evidence regarding the safety and risks of e-cig use on maternal and fetal health, even though adverse health effects of nicotine on maternal and fetal outcomes are documented. This review summarizes existing perceptions of e-cig use in pregnancy, based on the limited number of publications available, and highlights the necessity of conducting additional research in this field of public health. Authors conducted a literature search of scientific peer-reviewed articles published from January 2006 to October 2016, comprising more than a decade of research. Search keywords include 'tobacco use', 'electronic cigarette(s)' and 'pregnancy'. Fifty-seven publications were identified, narrowed to fifteen by screening title/abstract for potential relevance, with seven articles chosen for final inclusion. Of these seven studies, most participants not only believed e-cigs pose risks to maternal and child health but also perceived e-cigs as a safer and potentially healthier alternative to traditional cigarettes, and may assist with smoking cessation. Further research is needed to determine health implications and provide clinical guidelines for e-cig use in pregnancy.