The differential proteomic response to ischemic stroke in appalachian subjects treated with mechanical thrombectomy.

INTRODUCTION: The Appalachia region of North America is known to have significant health disparities, specifically, worse risk factors and outcomes for stroke. Appalachians are more likely to have comorbidities related to stroke, such as diabetes, obesity, and tobacco use, and are often less likely to have stroke interventions, such as mechanical thrombectomy (MT), for emergent large vessel occlusion (ELVO). As our Comprehensive Stroke Center directly serves stroke subjects from both Appalachian and non-Appalachian areas, inflammatory proteomic biomarkers were identified associated with stroke outcomes specific to subjects residing in Appalachia. METHODS: There were 81 subjects that met inclusion criteria for this study. These subjects underwent MT for ELVO, and carotid arterial blood samples acquired at time of intervention were sent for proteomic analysis. Samples were processed in accordance with the Blood And Clot Thrombectomy Registry And Collaboration (BACTRAC; clinicaltrials.gov; NCT03153683). Statistical analyses were utilized to examine whether relationships between protein expression and outcomes differed by Appalachian status for functional (NIH Stroke Scale; NIHSS and Modified Rankin Score; mRS), and cognitive outcomes (Montreal Cognitive Assessment; MoCA). RESULTS: No significant differences were found in demographic data or co-morbidities when comparing Appalachian to non-Appalachian subjects. However, time from stroke onset to treatment (last known normal) was significantly longer and edema volume significantly higher in patients from Appalachia. Further, when comparing Appalachian to non-Appalachian subjects, there were significant unadjusted differences in the NIHSS functional outcome. A comprehensive analysis of 184 proteins from Olink proteomic (92 Cardiometabolic and 92 Inflammation panels) showed that the association between protein expression outcomes significantly differed by Appalachian status for seven proteins for the NIHSS, two proteins for the MoCA, and three for the mRS. CONCLUSION: Our study utilizes an ELVO tissue bank and registry to investigate the intracranial/intravascular proteomic environment occurring at the time of thrombectomy. We found that patients presenting from Appalachian areas have different levels of proteomic expression at the time of MT when compared to patients presenting from non-Appalachian areas. These proteins differentially relate to stroke outcome and could be used as prognostic biomarkers, or as targets for novel therapies. The identification of a disparate proteomic response in Appalachian patients provides initial insight to the biological basis for health disparity. Nevertheless, further investigations through community-based studies are imperative to elucidate the underlying causes of this differential response.

Thin seams and small mines are associated with higher exposures to respirable crystalline silica in US underground coal mines.

OBJECTIVES: Previous radiologic and histopathologic studies suggest respirable crystalline silica (RCS) overexposure has been driving the resurgence of pneumoconiosis among contemporary US coal miners, with a higher prevalence of severe disease in Central Appalachia. We sought to better understand RCS exposure among US underground coal miners. METHODS: We analysed RCS levels, as measured by respirable quartz, from coal mine dust compliance data from 1982 to 2021. RESULTS: We analysed 322 919 respirable quartz samples from 5064 US underground coal mines. Mean mine-level respirable quartz percentage and mass concentrations were consistently higher for Central Appalachian mines than the rest of the USA. Mean mine-level respirable quartz mass concentrations decreased significantly over time, from 0.116 mg/m3 in 1982 to as low as 0.017 mg/m3 for Central Appalachian mines, and from 0.089 mg/m3 in 1983 to 0.015 mg/m3 in 2020 for the rest of the USA. Smaller mine size, location in Central Appalachia, lack of mine safety committee and thinner coal seams were predictive of higher respirable quartz mass concentrations. CONCLUSIONS: These data substantially support the association between RCS overexposure and the resurgence of coal workers' pneumoconiosis in the USA, particularly in smaller mines in Central Appalachia.

Risk Factors for Pediatric Facial Trauma in an Appalachian Region: An Epidemiological Review at a Single Institution.

BACKGROUND: Rural and low-income pediatric populations are at higher risk for trauma. Craniomaxillofacial (CMF) trauma in this population has not been studied. PURPOSE: This study's purpose was to determine if rural populations or low-income populations are at higher risk for pediatric CMF trauma than urban or high-income populations, respectively, and to determine differences in mechanism of injury (MOI). STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study of CMF trauma patients younger than 17 years-old, living in the region served by one institution in Tennessee, and requiring oral and maxillofacial surgery consultation between January 2011 and December 2022 was performed. Exclusion criteria were incomplete medical records. PREDICTOR VARIABLE: The primary predictor variable was geographic residence of the patient grouped into two categories: rural or urban defined by the state of Tennessee. Secondary variables were postal code (PC) average median household income (MHI) and PC population density. MAIN OUTCOME VARIABLE(S): The main outcome variable was pediatric CMF injury rate per 100,000 people. MOI is a secondary outcome variable. COVARIATE(S): Covariates included sex, age, and race. ANALYSES: Frequencies and percentages, Fisher's exact test, and Poisson regression models were utilized. Statistical significance was assumed at P-value <.05. RESULTS: Rural or urban county designation was not associated with differing trauma rates (incident risk ratio (IRR) = 0.91; 95% confidence interval (CI) 0.78 to 1.05; P = .18) by itself. One standard deviation increase in MHI decreased CMF trauma rates in rural designation counties by 24% (IRR: 0.76, 95% CI: 0.66, 0.88) and 6% in urban designation counties (IRR: 0.94, 95% CI: 0.87, 1.02). Lower rates of CMF trauma were associated with residence in higher income PCs (IRR = 0.91; 95% (CI) 0.86 to 0.97; P = .004), and higher population density (IRR = 0.87; 95% CI 0.79 to 0.94; P < .001). Dog bites and falls were more common in infancy and early childhood. Interpersonal violence was more common in older patients. CONCLUSIONS AND RELEVANCE: Patients in PCs with lower population density or incomes were at highest risk for CMF injuries. MOI differences by age were similar to findings in other studies. Tennessee's urban/rural county designation has complex interactions with MHI and pediatric CMF trauma rates.

Geographic Differences in Preconception Health Indicators Among Ohio Women Who Delivered Live Births, 2019-2021.

To determine whether geographic differences in preconception health indicators exist among Ohio women with live births, we analyzed 9 indicators from the 2019-2021 Ohio Pregnancy Assessment Survey (N = 14,377) by county type. Appalachian women reported lower rates of folic acid intake and higher rates of depression than women in other counties. Appalachian and rural non-Appalachian women most often reported cigarette use. Suburban women reported lower rates of diabetes, hypertension, and unwanted pregnancy than women in other counties. Preconception health differences by residence location suggest a need to customize prevention efforts by region to improve health outcomes, particularly in regions with persistent health disparities.

Rural Appalachian Adolescent Alcohol Misuse and the Triple Threat for Marginalization.

Rural Appalachian adolescents are disproportionately affected by alcohol misuse, depression, and mortality rates. Disparities in Appalachia influence national health indicators and the social determinants of health, which may lead to marginalization and vulnerability to poorer health outcomes. Geographic and social isolation often results in missed opportunities for preventative and mental health care. There are an estimated 35% fewer mental health providers in rural areas to deal with these issues. This article examines the influence of marginalization on rural Appalachian adolescents. A case example was used to describe rural Appalachian adolescent alcohol misuse within the context of the Triple Threat for Marginalization, utilizing conversation within a natural setting. Marginalization contributes to alcohol misuse and adverse health outcomes. Nurses must advocate for marginalized rural adolescent patients to decrease alcohol misuse, depression, and mortality rates in this vulnerable population.

Examining Smoking Prevalence Disparities in Virginia Counties by Rurality, Appalachian Status, and Social Vulnerability, 2011-2019.

Objectives. To estimate county-level cigarette smoking prevalence in Virginia and examine cigarette use disparities by rurality, Appalachian status, and county-level social vulnerability. Methods. We used 2011-2019 Virginia Behavioral Risk Factor Surveillance System proprietary data with geographical information to estimate county-level cigarette smoking prevalence using small area estimation. We used the Centers for Disease Control and Prevention's social vulnerability index to quantify social vulnerability. We used the 2-sample statistical t test to determine the differences in cigarette smoking prevalence and social vulnerability between counties by rurality and Appalachian status. Results. The absolute difference in smoking prevalence was 6.16 percentage points higher in rural versus urban counties and 7.52 percentage points higher in Appalachian versus non-Appalachian counties in Virginia (P < .001). Adjusting for county characteristics, a higher social vulnerability index is associated with increased cigarette use. Rural Appalachian counties had 7.41% higher cigarette use rates than did urban non-Appalachian areas. Tobacco agriculture and a shortage of health care providers were significantly associated with higher cigarette use prevalence. Conclusions. Rural Appalachia and socially vulnerable counties in Virginia have alarmingly high rates of cigarette use. Implementation of targeted intervention strategies could reduce cigarette use, ultimately reducing tobacco-related health disparities. (Am J Public Health. 2023;113(7):811-814. https://doi.org/10.2105/AJPH.2023.307298).

Impact of the Affordable Care Act on Providing Equitable Healthcare Access for IBD in the Kentucky Appalachian Region.

BACKGROUND: Medicaid expansion improved insurance coverage for patients with chronic conditions and low income. The effect of Medicaid expansion on patients with IBD from high-poverty communities is unknown. OBJECTIVE: This study aimed to evaluate the impact of Medicaid expansion in Kentucky on care for patients with IBD from the Eastern Kentucky Appalachian community, a historically impoverished area. DESIGN: This study was a retrospective, descriptive, and ecological study. SETTINGS: This study was conducted in Kentucky using the Hospital Inpatient Discharge and Outpatient Services Database. PATIENTS: All encounters for IBD care for 2009-2020 for patients from the Eastern Kentucky Appalachian region were included. MAIN OUTCOME MEASURES: The primary outcomes measured were proportions of inpatient and emergency encounters, total hospital charge, and hospital length of stay. RESULTS: Eight hundred twenty-five preexpansion and 5726 postexpansion encounters were identified. Postexpansion demonstrated decreases in the uninsured (9.2%-1.0%; p < 0.001), inpatient encounters (42.7%-8.1%; p < 0.001), emergency admissions (36.7%-12.3%; p < 0.001), admissions from the emergency department (8.0%-0.2%; p < 0.001), median total hospital charge ($7080-$3260; p < 0.001), and median total hospital length of stay (4-3 days; p < 0.001). Similarly, postexpansion demonstrated increases in Medicaid coverage (18.8%-27.7%; p < 0.001), outpatient encounters (57.3%-91.9%; p < 0.001), elective admissions (46.9%-76.2%; p < 0.001), admissions from the clinic (78.4%-90.2%; p < 0.001), and discharges to home (43.8%-88.2%; p < 0.001). LIMITATIONS: This study is subject to the limitations inherent in being retrospective and using a partially de-identified database. CONCLUSION: This study is the first to demonstrate the changes in trends in care after Medicaid expansion for patients with IBD in the Commonwealth of Kentucky, especially Appalachian Kentucky, showing significantly increased outpatient care utilization, reduced emergency department encounters, and decreased length of stays. IMPACTO DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO EN LA PROVISIN DE ACCESO EQUITATIVO A LA ATENCIN MDICA PARA LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LA REGIN DE LOS APALACHES DE KENTUCKY: ANTECEDENTES: La expansión de Medicaid mejoró la cobertura de seguro para pacientes con enfermedades crónicas y bajos ingresos. Se desconoce el efecto de la expansión de Medicaid en pacientes con enfermedad inflamatoria intestinal de comunidades de alta pobreza.OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la expansión de Medicaid en Kentucky en la atención de pacientes con enfermedad inflamatoria intestinal de la comunidad de los Apalaches del este de Kentucky, un área históricamente empobrecida.DISEÑO: Este estudio fue un estudio retrospectivo, descriptivo, ecológico.ESCENARIO: Este estudio se realizó en Kentucky utilizando la base de datos de servicios ambulatorios y de alta hospitalaria en pacientes hospitalizados.PACIENTES: Se incluyeron todos los encuentros para la atención de la enfermedad inflamatoria intestinal de 2009-2020 para pacientes de la región de los Apalaches del este de Kentucky.MEDIDAS DE RESULTADO PRINCIPALES: Los resultados primarios medidos fueron proporciones de encuentros de pacientes hospitalizados y de emergencia, cargo hospitalario total y duración de la estancia hospitalaria.RESULTADOS: Se identificaron 825 encuentros previos a la expansión y 5726 posteriores a la expansión. La posexpansión demostró disminuciones en los no asegurados (9.2% a 1.0%, p < 0.001), encuentros de pacientes hospitalizados (42.7% a 8.1%, p < 0.001), admisiones de emergencia (36.7% a 12.3%, p < 0,001), admisiones desde el servicio de urgencias (8.0% a 0.2%, p < 0.001), la mediana de los gastos hospitalarios totales ($7080 a $3260, p < 0.001) y la mediana de la estancia hospitalaria total (4 a 3 días, p < 0.001). De manera similar, la cobertura de Medicaid (18.8% a 27.7%, p < 0.001), consultas ambulatorias (57.3% a 91.9%, p < 0.001), admisiones electivas (46.9% a 76.2%, p < 0.001), admisiones desde la clínica (78.4% al 90.2%, p < 0.001), y las altas domiciliarias (43.8% al 88.2%, p < 0.001) aumentaron después de la expansión.LIMITACIONES: Este estudio está sujeto a las limitaciones inherentes de ser retrospectivo y utilizar una base de datos parcialmente desidentificada.CONCLUSIONES: Este estudio es el primero en demostrar los cambios en las tendencias en la atención después de la expansión de Medicaid para pacientes con enfermedad inflamatoria intestinal en el Estado de Kentucky, especialmente en los Apalaches de Kentucky, mostrando un aumento significativo en la utilización de la atención ambulatoria, visitas reducidas al departamento de emergencias y menor duración de la estancia hospitalaria. (Traducción-Dr. Jorge Silva Velazco ).

Adult asthma associated with roadway density and housing in rural Appalachia: the Mountain Air Project (MAP).

BACKGROUND: Appalachian Kentucky is a rural area with a high prevalence of asthma among adults. The relative contribution of environmental exposures in the etiology of adult asthma in these populations has been understudied. OBJECTIVE: This manuscript describes the aims, study design, methods, and characteristics of participants for the Mountain Air Project (MAP), and focuses on associations between small area environmental exposures, including roadways and mining operations, and lifetime and current asthma in adults. METHODS: A cohort of residents, aged 21 and older, in two Kentucky counties, was enrolled in a community-based, cross-sectional study. Stratified cluster sampling was used to select small geographic areas denoted as 14-digit USGS hydrologic units (HUCs). Households were enumerated within selected HUCs. Community health workers collected in-person interviews. The proximity of nearby active and inactive coal mining operations, density of oil and gas operations, and density of roadways were characterized for all HUCs. Poisson regression analyses were used to estimate adjusted prevalence ratios. RESULTS: From 1,459 eligible households contacted, 1,190 individuals were recruited, and 972 persons completed the interviews. The prevalence of lifetime asthma was 22.8%; current asthma was 16.3%. Adjusting for covariates, roadway density was positively associated with current asthma in the second (aPR = 1.61; 95% CI 1.04-2.48) and third tertiles (aPR = 2.00; 95% CI 1.32-3.03). Increased risk of current asthma was associated with residence in public, multi-unit housing (aPR = 2.01; 95% CI 1.27-3.18) compared to a residence in a single-family home. There were no notable associations between proximity to coal mining and oil and gas operations and asthma prevalence. CONCLUSIONS: This study suggests that residents in rural areas with higher roadway density and those residing in public housing units may be at increased risk for current asthma after accounting for other known risk factors. Confirming the role of traffic-related particulates in producing high asthma risk among adults in this study contributes to the understanding of the multiple environmental exposures that influence respiratory health in the Appalachia region.

Development and Evaluation of Patient Navigation Training for Rural and Appalachian Populations.

The Appalachian region of the USA includes 423 counties in 13 states positioned along the spine of the Appalachian Mountains stretching from New York to Mississippi. Approximately 42% of Appalachia is rural, and while the economy of Appalachia has diversified over the past two decades from reliance on agriculture and coal mining, 176 (41.6%) of the 423 counties are classified as economically distressed or at-risk. Patient navigation (PN) has been shown to be effective as an approach to address multiple barriers and enhance access to healthcare services, and yet there are no known PN programs focusing on the Appalachian population. This project was designed to develop, implement, and evaluate a curriculum and training program for PN for cancer prevention and control in Appalachia. The training program was developed through formative evaluation and offered daylong workshops that provided instruction in 60-90-min modules. Workshop topics included an introduction to PN, Appalachian culture, community needs assessment, communication, financial navigation, and navigation for screening and diagnostic follow-up for breast, cervical, and colorectal cancers. A total of 20 workshops were conducted with 334 attendees. The workshops were evaluated using a mixed-method approach using pre- and posttests and participant evaluations. The overall mean posttest scores increased by 4% from pretest (p < 0.05). Evaluation also showed that attendees valued the focus on Appalachian culture and judged the content relevant and useful. Attendees also expressed interest in additional opportunities for similar workshops that expanded upon current topics and allowed for exploration of Appalachian health-related issues.

Using Culturally Focused Storytelling to Empower Appalachian Kentucky Youth to Understand and Address Cancer Disparities in Their Communities.

Kentucky has the highest cancer incidence and mortality rates in the nation with the Appalachian region of the state being most affected. These rates are driven by health behaviors and inequities in social determinants of health. Herein, Appalachian Kentucky students with the University of Kentucky's Appalachian Career Training in Oncology (ACTION) program were engaged in a storytelling exercise by writing culturally framed essays. Students discussed their personal experiences with cancer and their thoughts on the causes of and potential solutions to Appalachian Kentucky's cancer disparities. Content analysis was used to identify common themes, subthemes, and subtopics in the essays regarding cancer types, causes of cancer in Appalachia, and solutions to the high cancer rates. Common cancer types experienced by the students included breast, lung, and prostate. The most frequently identified themes that drive cancer rates in Appalachian Kentucky were identified as geography, environmental factors, tobacco use, education, poverty, prevention, and mistrust. Common proposed solutions to decrease cancer rates were to increase education and awareness, screening, and tobacco cessation. Overall, through storytelling, youth gained a better understanding of cancer in their communities and envisioned culturally tailored, community-based intervention strategies that can aid in reducing the cancer burden in Appalachian Kentucky.

Impact of a Cancer Education Curriculum on Appalachian Kentucky Middle and High School Students.

Appalachian Kentucky is disproportionately affected by elevated cancer incidence and mortality rates. This disparity is driven by inequities in health behaviors and social determinants of health including decreased education attainment levels that cause lower health literacy. To increase cancer literacy in the region, a three-part cancer education curriculum was designed for Appalachian Kentucky middle and high school students. This study was designed to evaluate the effect the curriculum had on students' cancer literacy. The curriculum lessons were disseminated to Appalachian Kentucky middle and high school teachers who engaged 223 students with the material. For each lesson, students filled out a 10-question pretest and an identical 10-question posttest. The average and median percent of correct responses from the pre- to posttests were analyzed. The average percentage of correct responses significantly increased from 40% to 70%, 52% to 69%, and 33% to 53% on lessons 1, 2, and 3, respectively. A significant increase in the average percentage of correct responses on each individual question was also observed. The results demonstrate that the three-part cancer education curriculum intervention can significantly increase Appalachian Kentucky middle and high school students' cancer literacy. Increased cancer knowledge has the potential to encourage behavioral modifications that could reduce cancer incidence and mortality rates over time. Future work will include further improving the content relative to the target age/grade level and implementing the material with a broader group of teachers and students.

Comparison of Nonprofit Hospital Community Benefit Substance Abuse Identification and Practice Implementation in Appalachian and Non-Appalachian Counties.

CONTEXT: As substance use continues to be a public health crisis nationally, it disproportionately affects the Appalachian region. OBJECTIVES: Our research seeks to explore whether there is a greater substance use burden in Appalachia and whether that burden is being prioritized in local hospital systems' community health needs assessments (CHNAs) and implementation strategies (ISs). SETTING: The setting for this study is the 13 states that are represented within the Appalachian region. PARTICIPANTS: This study examines CHNAs and ISs of a stratified random sample (n = 140) representing 20% of the hospital population within the identified states (those with counties within the Appalachian region). Each sampled hospital is labeled as Appalachian or non-Appalachian based on its county designation. MAIN OUTCOME MEASURES: Our main outcome measures were the percentage of hospitals listing substance abuse in their CHNAs, with comparisons between Appalachian and non-Appalachian subgroups, and percent addressing substance use in their ISs in Appalachia and non-Appalachia. DESIGN: Community health needs assessments and ISs produced between the years 2018 and 2021 were gathered for each hospital within the sample; each document was then coded for the inclusion of substance use. Chi-square tests and logistic regression were employed to conduct the analysis and draw conclusions. RESULTS: Although all non-Appalachian Counties that had substance use listed as a need within a CHNA correspondingly addressed that need in their ISs, only 75% of Appalachian counties that listed substance use a need went on to prioritize substance use in an IS. In addition, logistic regression indicated no significant link between overdose rates and addressing substance use. CONCLUSIONS: These findings further support other literature that suggests that lack of resources is limiting Appalachian health care organizations' ability to address substance use issues.

An Exploratory Examination of Social Media Use and Risky Sexual Practices: A Profile of Women in Rural Appalachia Who Use Drugs.

HIV/HCV risk behavior among women who use drugs is often exacerbated within high risk networks. The use of social media platforms such as Facebook to identify sex partners within these high-risk networks has not been examined among rural Appalachian women who use drugs. This paper provides an exploratory examination of Facebook use to identify sex partners among rural Appalachian women who use drugs, as well as associated risky sexual practices. Rural Appalachian women were randomly selected from two rural jails, consented, screened for eligibility (including drug use), and interviewed prior to jail release. Findings indicated that using Facebook to meet sex partners was associated with exchanging sex for drugs or money and having a male casual partner during the same time frame. These study findings suggest that the use of social media for high-risk sexual practices may provide a valuable platform for intervention delivery, particularly in resource-deprived areas where formal prevention and treatment services are limited.

Dusty trades and associated rheumatoid arthritis in a population-based study in the coal mining counties of Appalachia.

OBJECTIVES: We previously showed increased coal mining-associated risk of rheumatoid arthritis (RA). Using additional survey data, we sought to delineate this risk further. METHODS: We used data from two cross-sectional, random-digit-dial, population-based surveys (males;≥50 years) in selected counties in the Appalachian region of the inland, mid-Atlantic USA with elevated pneumoconiosis mortality. Surveys ascertained age, smoking, coal mining and non-coal silica exposure jobs. In a subset, we surveyed ergonomic exposures, scored by intensity. We queried diagnosis of RA, corticosteroid use, and, in a subset, use of disease modifying antirheumatic drugs (DMARDs). Multivariable logistic regression modelled RA risk (defined by glucocorticoid or DMARDs use) associated with coal mining employment, other silica exposure, smoking status, and age and ergonomic exposures. RESULTS: We analysed data for 2981 survey respondents (mean age 66.6 years; 15% current, 44% ex-smokers). The prevalence of glucocorticoid-treated and DMARD-treated RA was 11% and 4%, respectively. Glucocorticoid-treated RA was associated with coal mining (OR 3.5; 95% CI 2.5 to 4.9) and non-coal mining silica exposure (OR 3.2; 95% CI 2.4 to 4.4). For DMARD-treated RA, the odds associated with coal mining and other silica remained elevated: OR 2.3 (95% CI 1.18, 4.5) and OR 2.7 (95% CI 1.51, 5.0), respectively. In the same model, the highest intensity ergonomic exposure also was associated with increased odds of RA (OR 4.3; 95% CI 1.96 to 9.6). CONCLUSIONS: We observed a strong association between coal mining and other silica-exposing dusty trades and RA. Clinicians and insurers should consider occupational histories in the aetiology of RA.

Elucidating the Relationship Between Maternal Diabetes and Neonatal Abstinence Syndrome: A 2017-2018 Project WATCH Study in Rural Appalachia.

BACKGROUND: Previous research indicated that diabetes during pregnancy results in a more permeable placenta. Based on this data, we hypothesized that women with maternal diabetes were more likely to have infants who developed neonatal abstinence syndrome (NAS). PURPOSE: The purpose of the study was to examine the association between maternal diabetes and NAS in a cohort of women reporting substance use during pregnancy. METHODS: This study used data from a population-based cohort of all newborns born in 2017 and 2018 (N = 36,974) in the state of West Virginia and restricted the analysis to those infants with intrauterine substance exposure (14%, n = 5188). Multiple logistic regression was performed to analyze the adjusted relationship between maternal diabetes and NAS while controlling for maternal and infant covariates. RESULTS: Just over 28% of women with diabetes had an infant who developed NAS, whereas 34.8% of women without diabetes had an infant who developed NAS. The adjusted odds ratio of infants developing NAS born to women with diabetes was 0.70 (95% confidence interval: 0.51, 0.94) compared with those born to mothers without diabetes after controlling for covariates. Contrary to our hypothesis, the study suggests that maternal diabetes during pregnancy is associated with a decreased risk of an infant developing NAS. IMPLICATIONS FOR PRACTICE: Future research generating from this hypothesis may lead to potential implications for practice for infants born to mothers with substance use during pregnancy and diabetes. IMPLICATIONS FOR RESEARCH: More research should be conducted to investigate the relationship between glucose metabolism and NAS.

Comparison between Rural and Urban Appalachian Children in Hospice Care.

OBJECTIVE: The goal of this study was to compare rural and urban pediatric hospice patients in Appalachia. METHODS: Using a retrospective, nonexperimental design, we sought to compare characteristics of Appalachian rural and urban children younger than 21 years enrolled in the Medicaid hospice benefit. Descriptive statistics were calculated on the demographic, hospice, and clinical characteristics of children from Appalachia. Comparisons were calculated using Pearson χ2 for proportions and the Student t test for means. RESULTS: Less than half of the 1788 Appalachian children admitted to hospice care resided in rural areas (40%). Compared with children in urban areas of Appalachia, rural children were significantly younger (8 years vs 9.5 years) and more often had a complex chronic condition (56.0% vs 35.1%) and comorbidities (38.5% vs 17.0%) with technology dependence (32.6% vs 17.0%). Children in rural Appalachian were commonly from communities in the southern region of Appalachia (27.9% vs <10.0%), with median household incomes <$50,000/year (96.7% vs 22.4%). Significant differences were present in clinical care between rural and urban Appalachian children. Rural children had longer lengths of stay in hospice care (38 days vs 11 days) and were less likely to use the emergency department during hospice admission (19.0% vs 43.0%). These children more often visited their primary care provider (49.9% vs 31.3%) and sought care for symptoms from nonhospice providers (18.1% vs 10.0%) while admitted to hospice. CONCLUSIONS: Our results suggest that children admitted to hospice care in rural versus urban Appalachia have distinct characteristics. Rural children are admitted to hospice care with significant medical complexities and reside in areas of poverty. Hospice care for rural children suggests a continuity of care with longer hospice stays and fewer transitions to the emergency department; however, the potential for care fragmentation is present, with frequent visits to primary care and nonhospice providers for symptom management. Understanding the unique characteristics of children in Appalachia may be essential for advancing knowledge and care for these children at the end of life. Future research examining geographic variation in hospice care in Appalachia is warranted.

Using an Implementation Research Framework to Identify Facilitators and Barriers to Physical Activity and Weight Loss in Appalachia.

OBJECTIVES: West Virginia (WV) is the only state entirely located in Appalachia, a large, mostly rural area in the eastern United States. WV has the highest adult obesity rate in the United States, as well as one of the highest physical inactivity rates. Obesity has been found to be significantly higher in rural counties than in urban counties, and many rural communities do not have the resources to address this growing health concern. It is well documented that healthy eating and becoming more physically active can be successful in reducing weight and managing obesity-related illness. Despite this overwhelming evidence, obesity rates in WV continue to climb. The purpose of this study was to understand the factors associated with obesity in WV and identify what influences the behavior of people in regard to weight loss and exercise. METHODS: Four focus groups were conducted across the state of WV, transcribed, and thematically analyzed to examine the facilitators and barriers associated with healthy behaviors. The Consolidated Framework for Implementation Research (CFIR) was used as an approach to classify characteristics and plan implementation strategies integrating five domains. The CFIR has been used to identify potential barriers and facilitators to interventions and can be used before or during an intervention. In addition, the CFIR has been used as a framework to guide analysis and provide a means to organize intervention stakeholders' perceptions of barriers and facilitators to successful interventions. RESULTS: Participants identified barriers and facilitators across all 5 major domains of the CFIR-intervention characteristics, outer setting (eg, cultural norms, infrastructure), inner setting (eg, access to knowledge), characteristics of individuals, and the implementation process-and 16 subdomains. Participants discussed how socioeconomic, cultural, and environmental factors influenced diet and exercise. Cost, family culture, and limited access to resources (eg, healthy foods, community-based fitness programs, health care) were common themes expressed by participants. CONCLUSIONS: The results of this study identify how individuals living in rural Appalachian view lifestyle changes and what influences their ability to pursue physical activity and healthy eating. Future programs to encourage healthy lifestyles in Appalachia need to consider the characteristics of the given community to achieve the goal of a tailored lifestyle intervention program that is feasible and effective. In addition, the findings suggest that the CFIR can be used to implement and refine intervention strategies that can be used in the real world.

Hepatitis C and HIV Screening, Testing, and Risk Perceptions among South-Central Appalachian County Health Department Staff.

OBJECTIVES: Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are significant public health concerns, especially given the risks for disease interactions. Rates of HCV and HIV are increasing, especially in rural areas. Local health departments (LHDs) play an important role in rural health care, offering screening, testing, and treatment for HCV and HIV. Gaps persist in LHD resources for meeting these demands, especially in Appalachia and the US South. METHODS: To explore HCV/HIV screening, testing, and treatment approaches and perspectives in south-central Appalachian North Carolina, structured telephone questionnaires were administered to communicable disease nurses and other health department staff directly involved in screening and testing. Mixed-methods data analyses were conducted and triangulated with stakeholders. RESULTS: Eighteen participants representing 19 counties completed the questionnaire, achieving a saturation sample. Participants reported barriers to screening and testing, including housing insecurity, lack of transportation and insurance, unemployment, and the isolation of living in a rural area. Divergence in perceptions of barriers between public health regions emerged, as did perceptions of who is at risk and use of stigmatizing language about people at risk for HCV/HIV. CONCLUSIONS: This study highlights the impact of LHD behaviors and perceptions on screening and testing, and offers recommendations to improve HCV/HIV screening and testing accessibility in south-central Appalachia, a high-risk region.

Exploring Patterns of the Use of Electronic Nicotine Delivery Systems among Adolescents in High-Risk Appalachian (U.S.A) Communities.

Background: Electronic nicotine delivery systems (ENDS) use among adolescents in the United States (U.S.) has surpassed conventional tobacco products (CTPs), including cigarettes. Increasingly, ENDS are used concurrently with CTPs and substances such as cannabis. However, few studies involve Central Appalachia, a region with historically high rates of tobacco and other substance use. Objective:  To examine prevalence of concurrent use of ENDS and cannabis among school-going adolescents in Appalachian Tennessee and delineate associations between ENDS use and substance-related risk behavior (cannabis use), social relations (peer use), and school-related risk behavior (academic performance). Methods: Data were obtained from a survey conducted with youth aged 13-17 years in 2018 in a county in Appalachian Tennessee (n = 280). A multivariable logistic regression model was fit to evaluate associations between ENDS and cannabis use, and other factors. Results: Overall, lifetime ENDS and cannabis prevalence estimates were 31.1% and 18.6%, respectively. Lifetime ENDS users had increased odds of also being lifetime cannabis users [OR = 9.22, 95% confidence interval (CI): 3.44-24.75]. Lifetime ENDS users had increased odds of reporting ENDS use among peers [OR = 12.11; 95% CI: 5.40-27.12] and lower academic performance (OR associated with mostly C or D vs. A grades was 4.28, 95% CI: 1.68-10.90). Conclusion: This study found an association between ENDS and cannabis use among adolescents in Appalachian Tennessee exists. Additionally, peer use and academic performance were associated with ENDS use. The findings have implications for public health intervention planning to address not only ENDS but also substance use among Appalachian youth.

Prevalence of Opioid Use and Intimate Partner Violence among Pregnant Women in South-Central Appalachia, USA.

Background: Recent research indicates that pregnant women in rural communities are at increased risk of experiencing IPV and comorbid illicit opioid use compared to urban-residing pregnant women. Few studies of the interactions among rurality, substance use, and victimization in pregnant women exist. The current study sought to examine the relationship between IPV and opioid use and the interaction effects of rurality in Appalachian pregnant women. Methods: A convenience sample of pregnant women who were enrolled in a smoking cessation research study was used for this analysis. Participants included 488 pregnant women from five prenatal clinics in South-Central Appalachia. Data were from self-reported assessments and semi-structured interviews on substance use and IPV conducted from first trimester of pregnancy through eight months postpartum. Results: Four hundred and ten participants reported experiencing any form of IPV in the past year. Logistic regression results indicated that physical IPV was associated with opioid use, but sexual and psychological IPV were not. The moderation model indicated direct effects between IPV and opioid use, but were not moderated by rurality. Conclusion: This study suggests a need to further understand the relationship between substance use, IPV, and rurality in pregnant women. The specific subtopic of opioid use by pregnant women living in rural communities, and its relationship to IPV victimization and adverse fetal and maternal health outcomes, continues to be an understudied, but critically important area. Limitations and future directions pertaining to IPV screenings and interventions for pregnant women are discussed.