An exploration of barriers to access to healthcare in Hancock County, Tennessee: A qualitative study.

OBJECTIVE: Explore barriers to healthcare access in Hancock County, Tennessee using a conceptual framework for access to healthcare. METHODS: We collected data from 30 participants in Hancock County during 1 week in April 2023 using a combination of network and purposive sampling. We analyzed the data using thematic analysis and the conceptual framework of healthcare access. RESULTS: All dimensions of the conceptual framework of healthcare access presented barriers to healthcare access for participants of the study. A lack of acceptability of local healthcare among participants manifested in a perceived lack of availability of healthcare. This resulted in participants travelling or considering it necessary to travel long distances for care, even in a life-threatening emergency, despite the local availability of a hospital with an emergency department. CONCLUSIONS: A lack of acceptability can create healthcare access barriers similar to a lack of availability of healthcare facilities. PATIENT OR PUBLIC CONTRIBUTION: The research team met several times with the leader of a local community organization to discuss this research in Hancock County. These conversations helped to inform the study design and provided necessary background to conduct in-depth interviews. Members of the community organization helped identify individuals to interview and provide access to Remote Area Medical clinic patients. The research team discussed the final themes with the primary community collaborator.

Our hands are tied: abortion bans and hesitant medicine.

Trained for decades to analyze risks, benefits, unique body compositions, and complex medical scenarios, healthcare providers are now faced with one of medicine's most trying obstacles: how to practice medicine when new abortion bans contradict best practice standards. Drawn from qualitative interviews with medical providers in Tennessee, USA conducted between October 2022 and December 2022, this study shows how medical providers often must make medical decisions based on legal risks as opposed to standards of care. This is particularly significant as malpractice insurance does not cover criminal charges. In states with abortion bans, often hastily implemented and subject to changes by lawmakers, medical providers are now practicing a new kind of defensive medicine in an effort to protect themselves from legal threats. We call this hesitant medicine, where providers often experience a tension between their own legal protection and the well-being of their patients, making them hesitant to provide necessary abortion care. This has serious, far-reaching consequences. We focus on three distinct arenas impacted by this new form of defensive medicine, specifically: providers' decision-making around patient care, impacts on patient relationships, and finally, what we call the ultimate defense, leaving states with abortion bans to move to states with fewer legal risks. We conclude with commentary on potential ways to reduce the negative impacts of these trends.

Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration.

BACKGROUND: Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration. METHODS: We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process. RESULTS: We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal. CONCLUSIONS: The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.

Estimating the Undetected Burden of Respiratory Syncytial Virus Hospitalizations in Adults Through Capture-Recapture Methods.

INTRODUCTION: Traditional surveillance systems may underestimate the burden caused by respiratory syncytial virus (RSV). Capture-recapture methods provide alternatives for estimating the number of RSV-related hospitalizations in a population. METHODS: Capture-recapture methods were used to estimate the number of RSV-related hospitalizations in adults in Middle Tennessee from two independent hospitalization surveillance systems during consecutive respiratory seasons from 2016-2017 to 2019-2020. Data from the Hospitalized Adult Influenza Vaccine Effectiveness Network (HAIVEN) and the Emerging Infections Program (EIP) were used. Annual RSV hospitalization rates were calculated using the capture-recapture estimates weighted by hospitals' market share divided by the corresponding census population. RESULTS: Using capture-recapture methods, the estimated overall adult hospitalization rates varied from 8.3 (95% CI: 5.9-15.4) RSV-related hospitalizations per 10,000 persons during the 2016-2017 season to 28.4 (95% CI: 18.2-59.0) hospitalizations per 10,000 persons in the 2019-2020 season. The proportion of hospitalizations that HAIVEN determined ranged from 8.7% to 36.7% of the total capture-recapture estimated hospitalization, whereas EIP detected 23.5% to 52.7% of the total capture-recapture estimated hospitalizations. CONCLUSION: Capture-recapture estimates showed that individual traditional surveillance systems underestimated the hospitalization burden in adults. Using capture-recapture allows for a more comprehensive estimate of RSV hospitalizations.

The Impact on Environmental Health from Cemetery Waste in Middle Tennessee.

The burial of caskets with arsenic-treated wood and formaldehyde-based embalming fluids can harm the environment and health. Arsenic (As) can leach into water, affecting aquatic life and the food chain. Formaldehyde can contaminate groundwater, risking drinking water and causing health problems. The purpose of this study was to investigate the prevalence of As and formaldehyde in cemetery plots of different ages. For this, we evaluated whether there is a potential for formaldehyde and As from cemetery caskets to contaminate waterways, which could impact livestock and allow transmission to individuals. There were six soil samples (n = 6), collected at 2 m depth, close to the buried caskets, as well as two (n = 2) groundwater samples (soil + groundwater) collected from a cemetery in Middle Tennessee. The soil was analyzed by an environmental lab using EPA 8315A for formaldehyde and EPA 3050B for As. All samples were below the limit of detection (

Novel Integration of a Health Equity Immersion Curriculum in Medical Training.

Health disparities education is an integral and required part of medical professional training, and yet existing curricula often fail to effectively denaturalize injustice or empower learners to advocate for change. We discuss a novel collaborative intervention that weds the health humanities to the field of health equity. We draw from the health humanities an intentional focus retraining provider imaginations by centering patient narratives; from the field of health equity, we draw the linkage between stigmatized social identities and health disparities. We describe a longitudinal health equity curriculum for the Hospice and Palliative Medicine fellowship in Memphis, Tennessee, to give trainees exposure to the concept of structural violence and how it affects clinical care. The curriculum was developed in partnership with humanities and social sciences faculty who staff a Health Equity academic program at a small liberal arts college in Memphis. This curriculum has been implemented for the past four years in support of 22 hospice and palliative medicine fellows. Group debriefs and a mixed methods survey have revealed widespread and lasting impact towards understanding health equity concepts, enhanced communication and treatment of patients, and empowerment to address the broader needs and policies affecting patients and the communities in which they live. Ultimately, we model an educational initiative that integrates equity across the full scope of healthcare practice and equips learners with skills for sustaining compassionate practices, focusing on equity-oriented, person-centered care across the full scope of healthcare practice.

Perceived Barriers and Strategies to Increasing the BSN-Prepared Nursing Workforce.

ABSTRACT: Care provided by Bachelor of Science in Nursing (BSN)-prepared Registered Nurses (RNs) has been shown to lead to more positive patient outcomes compared to care provided by non-BSN-prepared RNs. A Fall 2021 study explored barriers of requiring a BSN degree of staff nurses from the perspective of hospital and long-term care facility nurse leaders in Tennessee (N = 89), strategies to increase the number of nurses with BSNs, and association between leadership goals and the number of BSN-prepared nurses in the facilities. Seven barriers to requiring the BSN and nine strategies to increase BSNs were identified. Significant association was found between having plans to increase the number of BSN nurses and the percentage of nurses in the facility with BSN degrees.

Individual and Neighborhood Level Predictors of Children's Exposure to Residential Greenspace.

Inequities in urban greenspace have been identified, though patterns by race and socioeconomic status vary across US settings. We estimated the magnitude of the relationship between a broad mixture of neighborhood-level factors and residential greenspace using weighted quantile sum (WQS) regression, and compared predictive models of greenspace using only neighborhood-level, only individual-level, or multi-level predictors. Greenspace measures included the Normalized Difference Vegetation Index (NDVI), tree canopy, and proximity of the nearest park, for residential locations in Shelby County, Tennessee of children in the CANDLE cohort. Neighborhood measures include socioeconomic and education resources, as well as racial composition and racial residential segregation. In this sample of 1012 mother-child dyads, neighborhood factors were associated with higher NDVI and tree canopy (0.021 unit higher NDVI [95% CI: 0.014, 0.028] per quintile increase in WQS index); homeownership rate, proximity of and enrollment at early childhood education centers, and racial composition, were highly weighted in the WQS index. In models constrained in the opposite direction (0.028 unit lower NDVI [95% CI: - 0.036, - 0.020]), high school graduation rate and teacher experience were highly weighted. In prediction models, adding individual-level predictors to the suite of neighborhood characteristics did not meaningfully improve prediction accuracy for greenspace measures. Our findings highlight disparities in greenspace for families by neighborhood socioeconomic and early education factors, and by race, suggesting several neighborhood indicators for consideration both as potential confounders in studies of greenspace and pediatric health as well as in the development of policies and programs to improve equity in greenspace access.

Predictors of seasonal influenza and COVID-19 vaccination coverage among adults in Tennessee during the COVID-19 pandemic.

Background: The COVID-19 pandemic has convoluted hesitancy toward vaccines, including the seasonal influenza (flu) vaccine. Because of COVID-19, the flu season has become more complicated; therefore, it is important to understand all the factors influencing the uptake of these vaccines to inform intervention targets. This article assesses factors related to the uptake of influenza and COVID-19 vaccines among adults in Tennessee. Methods: A cross-sectional, secondary data analysis of 1,400 adults was conducted in Tennessee. The adult sample came from two data sources: Data source 1 completed a baseline survey from January to March 2022, and data source 2 was completed from May to August 2022. Data on vaccine attitudes, facilitators and barriers, and communication needs were collected via random digit dial by Scientific Telephone Samples (STS). Two multivariable logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to predict sociodemographic and overall vaccine-related factors associated with receipt or non-receipt (referent) of COVID-19 and influenza vaccines. Results: Approximately 78% of the adult sample had received the COVID-19 vaccination. A significant positive association for COVID-19 vaccine uptake was seen among those who were older (aged 50-65) (aOR = 1.9; 95% CI: 1.2-3.2), Black (aOR = 2.0; 95% CI:1.3-2.8), and had a college education and higher (aOR = 2.3; 95% CI: 1.5-3.6). However, there was a significant negative association for persons reporting they were extremely religious (aOR = 0.5; 95% CI:0.3-0.9). Over 56% of the adult sample had received the influenza vaccination this season. Those who had a higher annual household income ($80,000+) (aOR = 1.9; 95% CI: 1.3-2.6) and had health insurance (aOR = 2.6; 95% CI: 1.4-4.8) had a significant positive association with influenza vaccine receipt. However, those who were employed part-time or were unemployed had a significant negative association for influenza vaccine receipt (aOR = 0.7; 95% CI: 0.5-0.9). Both COVID-19 and influenza vaccine receipt had strongly significant positive trends with increasing belief in effectiveness and trust (p < 0.0001) and strongly significant negative trends with higher levels of overall vaccine hesitancy (p < 0.0001). Conclusion: Strategies to increase COVID-19 and influenza vaccination should be age-specific, focus on increasing geographical and financial access, and offer tailored messages to address concerns about these vaccines.

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

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

State-level variation in distribution of oxycodone and opioid-related deaths from 2000 to 2021: an ecological study of ARCOS and CDC WONDER data in the USA.

OBJECTIVES: This study aims to characterise oxycodone's distribution and opioid-related overdoses in the USA by state from 2000 to 2021. DESIGN: This is an observational study. SETTING: More than 80 000 Americans died of an opioid overdose in 2021 as the USA continues to struggle with an opioid crisis. Prescription opioids play a substantial role, introducing patients to opioids and providing a supply of drugs that can be redirected to those seeking to misuse them. METHODS: The Drug Enforcement Administration annual summary reports from the Automation of Reports and Consolidated Orders System provided weights of oxycodone distributed per state by business type (pharmacies, hospitals and practitioners). Weights were converted to morphine milligram equivalents (MME) per capita and normalised for population. The Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research provided mortality data for heroin, other opioids, methadone, other synthetic narcotics and other/unspecified narcotics. RESULTS: There was a sharp 280.13% increase in total MME/person of oxycodone from 2000 to 2010, followed by a slower 54.34% decrease from 2010 to 2021. Florida (2007-2011), Delaware (2003-2020) and Tennessee (2012-2021) displayed consistent and substantial elevations in combined MME/person compared with other states. In the peak year (2010), there was a 15-fold difference between the highest and lowest states. MME/person from only pharmacies, which constituted >94% of the total, showed similar results. Hospitals in Alaska (2000-2001, 2008, 2010-2021), Colorado (2008-2021) and DC (2000-2011) distributed substantially more MME/person over many years compared with other states. Florida stood out in practitioner-distributed oxycodone, with an elevation of almost 15-fold the average state from 2006 to 2010. Opioid-related deaths increased +806% from 2000 to 2021, largely driven by heroin, other opioids and other synthetic narcotics. CONCLUSIONS: Oxycodone distribution across the USA showed marked differences between states and business types over time. Investigation of opioid policies in states of interest may provide insight for future actions to mitigate opioid misuse.

New records of three parasitoids, Pteroptrix chinensis, Aphytis hispanicus, and Marlattiella prima (Hymenoptera: Aphelinidae) associated with an exotic scale, Lopholeucaspis japonica (Hemiptera: Diaspididae) in Tennessee.

A survey for parasitoids of Lopholeucaspis japonica Cockerell (Hemiptera: Diaspididae), an exotic scale of woody ornamentals, resulted in the discovery of 3 species of aphelinid parasitoid wasps, Pteroptrix chinensis (Howard), Aphytis hispanicus (Mercet), and Marlattiella prima Howard. This serves as the first report of these parasitoids reared from a host in the state of Tennessee, USA. Despite routine pesticide applications in the surveyed nursery and directed treatments of the infested plants to control the scale outbreak, the percentage of parasitized scale in privet and euonymus shrubs averaged 7.0% and 7.9%, respectively. These parasitoids may be useful in the natural or managed control of this pest in the United States, but additional research is needed to understand how these parasitoids contribute to the control of L. japonica in the landscape and how nursery production practices can be modified to promote parasitoid populations.

Implications of Measles Inclusion by Commercial Syndromic Polymerase Chain Reaction Panels - United States, May 2022-April 2023.

Syndromic polymerase chain reaction (PCR) panels are used to test for pathogens that can cause rash illnesses, including measles. Rash illnesses have infectious and noninfectious causes, and approximately 5% of persons experience a rash 7-10 days after receipt of a measles, mumps, and rubella (MMR) vaccine. MMR vaccine includes live attenuated measles virus, which is detectable by PCR tests. No evidence exists of person-to-person transmission of measles vaccine virus, and illness does not typically result among immunocompetent persons. During September 2022-January 2023, the Tennessee Department of Health received two reports of measles detected by syndromic PCR panels. Both reports involved children (aged 1 and 6 years) without known risk factors for measles, who were evaluated for rash that occurred 11-13 days after routine MMR vaccination. After public health responses in Tennessee determined that both PCR panels had detected measles vaccine virus, six state health departments collaborated to assess the frequency and characteristics of persons receiving a positive measles PCR panel test result in the United States. Information was retrospectively collected from a commercial laboratory testing for measles in syndromic multiplex PCR panels. During May 2022-April 2023, among 1,548 syndromic PCR panels, 17 (1.1%) returned positive test results for measles virus. Among 14 persons who received a positive test result and for whom vaccination and case investigation information were available, all had received MMR vaccine a median of 12 days before specimen collection, and none had known risk factors for acquiring measles. All positive PCR results were attributed to detection of measles vaccine virus. Increased awareness among health care providers about potential measles detection by PCR after vaccination is needed. Any detection of measles virus by syndromic PCR testing should be immediately reported to public health agencies, which can use measles vaccination history and assessment of risk factors to determine the appropriate public health response. If a person recently received MMR vaccine and has no risk factors for acquiring measles, additional public health response is likely unnecessary.

Associations of residential green space with internalizing and externalizing behavior in early childhood.

BACKGROUND: Green space exposures may promote child mental health and well-being across multiple domains and stages of development. The aim of this study was to investigate associations between residential green space exposures and child mental and behavioral health at age 4-6 years. METHODS: Children's internalizing and externalizing behaviors in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood (CANDLE) cohort in Shelby County, Tennessee, were parent-reported on the Child Behavior Checklist (CBCL). We examined three exposures-residential surrounding greenness calculated as the Normalized Difference Vegetation Index (NDVI), tree cover, and park proximity-averaged across the residential history for the year prior to outcome assessment. Linear regression models were adjusted for individual, household, and neighborhood-level confounders across multiple domains. Effect modification by neighborhood socioeconomic conditions was explored using multiplicative interaction terms. RESULTS: Children were on average 4.2 years (range 3.8-6.0) at outcome assessment. Among CANDLE mothers, 65% self-identified as Black, 29% as White, and 6% as another or multiple races; 41% had at least a college degree. Higher residential surrounding greenness was associated with lower internalizing behavior scores (-0.66 per 0.1 unit higher NDVI; 95% CI: -1.26, -0.07) in fully-adjusted models. The association between tree cover and internalizing behavior was in the hypothesized direction but confidence intervals included the null (-0.29 per 10% higher tree cover; 95% CI: -0.62, 0.04). No associations were observed between park proximity and internalizing behavior. We did not find any associations with externalizing behaviors or the attention problems subscale. Estimates were larger in neighborhoods with lower socioeconomic opportunity, but interaction terms were not statistically significant. CONCLUSIONS: Our findings add to the accumulating evidence of the importance of residential green space for the prevention of internalizing problems among young children. This research suggests the prioritization of urban green spaces as a resource for child mental health.

An adaptive metaheuristic optimization approach for Tennessee Eastman process for an industrial fault tolerant control system.

The Tennessee Eastman Process (TEP) is widely recognized as a standard reference for assessing the effectiveness of fault detection and false alarm tracking methods in intricate industrial operations. This paper presents a novel methodology that employs the Adaptive Crow Search Algorithm (ACSA) to improve fault identification capabilities and mitigate the occurrence of false alarms in the TEP. The ACSA is an optimization approach that draws inspiration from the observed behavior of crows in their natural environment. This algorithm possesses the capability to adapt its search behavior in response to the changing dynamics of the optimization process. The primary objective of our research is to devise a monitoring strategy that is adaptable in nature, with the aim of efficiently identifying faults within the TEP while simultaneously minimizing the occurrence of false alarms. The ACSA is applied in order to enhance the optimization of monitoring variables, alarm thresholds, and decision criteria selection and configuration. When compared to traditional static approaches, the ACSA-based monitoring strategy is better at finding faults and reducing false alarms because it adapts well to changes in process dynamics and disturbances. In order to assess the efficacy of our suggested methodology, we have conducted comprehensive simulations on the TEP dataset. The findings suggest that the monitoring strategy based on ACSA demonstrates superior fault identification rates while concurrently mitigating the frequency of false alarms. In addition, the flexibility of ACSA allows it to efficiently manage process variations, disturbances, and uncertainties, thereby enhancing its robustness and reliability in practical scenarios. To validate the effectiveness of our proposed approach, extensive simulations were conducted on the TEP dataset. The results indicate that the ACSA-based monitoring strategy achieves higher fault detection rates while simultaneously reducing the occurrence of false alarms. Moreover, the adaptability of ACSA enables it to effectively handle process variations, disturbances, and uncertainties, making it robust and reliable for real-world applications. The contributions of this research extend beyond the TEP, as the adaptive monitoring strategy utilizing ACSA can be applied to other complex industrial processes. The findings of this study provide valuable insights into the development of advanced fault detection and false alarm monitoring techniques, offering significant benefits in terms of process safety, reliability, and operational efficiency.

TennCare Disenrollment Led To Increased Eviction Filings And Evictions In Tennessee Relative To Other Southern States.

Previous research suggests that enrolling in Medicaid reduces evictions by improving health and providing financial protection. However, previous studies have not examined whether the loss of Medicaid affects eviction outcomes. We analyzed eviction filings and completed evictions after a large, mandatory Medicaid disenrollment in Tennessee in 2005. We conducted a difference-in-differences analysis using data from the Eviction Lab at Princeton University and found that relative to other southern states, the TennCare disenrollment led to a 27.6 percent greater increase in the average annual number of eviction filings at the county level during the period 2005-09 and a 24.5 percent greater increase in the average annual number of completed evictions at the county level during that same period. Our findings have implications for the housing stability of Medicaid recipients today, many of whom are being disenrolled because of the unwinding of the Medicaid continuous enrollment provision that is occurring across the country. To protect housing stability for people disenrolled from Medicaid, policy makers may wish to consider new initiatives aimed at preventing an increase in eviction.

The effect of smaller classes on infection-related school absence: evidence from the Project STAR randomized controlled trial.

BACKGROUND: In an effort to reduce viral transmission, many schools reduced class sizes during the recent pandemic. Yet the effect of class size on transmission is unknown. METHODS: We used data from Project STAR, a randomized controlled trial in which 10,816 Tennessee elementary students were assigned at random to smaller classes (13 to 17 students) or larger classes (22 to 26 students) in 1985-89. We merged Project STAR schools with data on local deaths from pneumonia and influenza in the 122 Cities Mortality Report System. Using mixed effects linear, Poisson, and negative binomial regression, we estimated the main effect of smaller classes on absence. We used an interaction to test whether the effect of small classes on absence was larger when and where community pneumonia and influenza prevalence was high. RESULTS: Small classes reduced absence by 0.43 days/year (95% CI -0.06 to -0.80, p < 0.05), but small classes had no significant interaction with community pneumonia and influenza mortality (95% CI -0.27 to + 0.30, p > 0.90), indicating that the reduction in absence due to small classes was not larger when community disease prevalence was high. CONCLUSION: Small classes reduced absence, but the reduction was not larger when disease prevalence was high, so the reduction in absence was not necessarily achieved by reducing infection. Small classes, by themselves, may not suffice to reduce the spread of respiratory viruses.

The Effect of Mandatory Fitness Requirements on Cardiovascular Events: A State-by-State Analysis Using a National Database.

BACKGROUND: Cardiovascular events are known to be the leading cause of death among on-duty firefighters. Implementing fitness standards may help reduce the incidence of cardiovascular deaths; however, standards vary between firefighter type and states. We aimed to investigate the rate of cardiovascular events among firefighters across states. METHODS: Using publicly available data from the United States Fire Administration, we explored the rates of cardiovascular deaths between firefighter type (e.g., career, volunteer, and wildland) and state. Specifically, we examined rates of cardiovascular deaths between California and Tennessee, which have fitness standards for all firefighters, and New York, which does not have fitness standards for volunteer firefighters. We used descriptive statistics and trend analysis to examine the data. FINDINGS: Most cardiovascular events occur among volunteer firefighters (60.6%, n = 877). Volunteer firefighters had 7.5 (95% CI = [4.8, 11.7], p < .001) greater odds of cardiovascular events compared to wildland firefighters, who had the lowest incidence of cardiovascular events (1.7%, n = 24). New York reported the most cardiovascular events (n = 161), primarily among volunteer firefighters (73.9%, n = 119). After the passage of legislation mandating fitness standards in California, a downtrend in the number of volunteer firefighter fatalities is observed. However, a null effect was observed in Tennessee after the passage of similar fitness standards as in California. CONCLUSIONS/APPLICATIONS TO PRACTICE: Volunteer firefighters are significantly more likely to die of a cardiovascular event than career and wildland firefighters, both of which have stricter fitness standards. However, the effect of legislation mandating stricter fitness standards among volunteers did not produce a clear benefit for preventing fatalities. Nurses need to promote cardiovascular health among volunteer firefighters.

Overnight heat in sleep spaces of housed and unhoused residents: results and recommendations from a Knoxville, Tennessee, case study.

Nighttime heat is an important factor in heat-health outcomes, though nighttime heat exposure and its impacts are poorly understood. We assessed overnight heat in indoor (n = 12) and outdoor (n = 3) living spaces in Knoxville, Tennessee, using iButton Hygrochrons in August 2021. Indoor sleep spaces, all of which were air conditioned, reported a variety of overnight conditions. Indoor sleep spaces were both warmer and cooler than outdoor temperatures overnight, and some participants noted having physical health effects of overnight heat in their homes. Downtown outdoor sleep spaces, including a park and encampment, exhibited an urban heat island signal, staying warmer than other outdoor areas. Future research should focus on the intensity and length of the overnight recovery period for individuals and how that affects heat-health outcomes, especially after being exposed to daytime heat. Specifically, do homes reach a cool enough temperature for recovery, and do outdoor sleeping spaces offer a long enough and cool enough period for recovery? We provide some recommendations for such future studies, including (1) focus on purposeful sampling, (2) use deliberate sensor placement for representative results, (3) prepare for participant drop-off due to non-compliance and technological problems, and (4) strategically gather demographic information.

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

BACKGROUND: Diphenhydramine (DPH), known as the brand name Benadryl, is an over-the-counter medication associated with accidental ingestion leading to nonfatal overdoses. Additionally, DPH has been used in tandem with illicit substances leading to fatal drug overdoses. OBJECTIVE: In response to DPH being seized with illicit drugs as an adulterant, as well as its growing intentional misuse, we sought to explore its recent involvement in fatal and nonfatal drug overdoses in the state of Tennessee. METHODS: We conducted a statewide cross-sectional study to determine the characteristics of DPH-involved fatal and nonfatal overdoses in Tennessee during 2019-2022 using data from the State Unintentional Drug Overdose Reporting System, the Electronic Surveillance System for the Early Notification of Community-based Epidemics, and the National Forensic Laboratory Information System Public Data Query System. Frequencies were generated to compare demographic characteristics, circumstances, and toxicology between fatal and nonfatal DPH-involved overdoses. RESULTS: We identified 143 suspected nonfatal DPH and 409 fatal DPH-involved overdoses in Tennessee from 2019 to 2022. Nonfatal overdoses remained consistent while fatal overdoses peaked in 2021. Most nonfatal overdoses were under 18 (63.4%), while most fatal overdoses were between 18 and 64 years of age (95.7%). For fatal overdoses, fentanyl was the most prevalent substance on toxicology followed by prescription opioids. CONCLUSION: Nonfatal overdoses remained consistent while fatal overdoses peaked in 2021 in Tennessee. Use of DPH among other illicit substances lends to evidence suggesting its use as an adulterant. Monitoring of DPH-involved fatal and nonfatal overdoses is critical to inform harm reduction initiatives.