Rural Appalachian Women Will Suffer Disproportionately if Attempts to Further Restrict Emergency Contraception are Successful.

The removal of federal abortion protection has incited fear that restrictions on contraception may be next. Many states now imposing abortion restrictions and bans are in the South and Appalachian Regions of the U.S., where rates of unplanned pregnancy and poor health outcomes are already disproportionately high. Numerous studies have documented variable access to levonorgestrel EC (LNG EC) in community pharmacies, with particularly low rates of access at independent pharmacies that are more likely to be located in rural communities than chain pharmacies. Since the overturn of Roe v. Wade, some large chain pharmacies and online retailers are restricting the purchase of LNG EC, limiting its availability. Some legislators and activists are calling for a ban on EC based on a misunderstanding about its mechanism of action, equating it with abortion. At a time when access to the full range of contraceptive options is more critical than ever, already limited access to LNG EC is worsening. Extensive data on LNG EC availability in 509 pharmacies and 400 health clinics across West Virginia, contextualized with socioeconomic demographics, illustrate existing disparities in LNG EC access.

Direct Oral Anticoagulants: Probability of Recurrent Venous Thromboembolism and Bleeding Risk in an Obese Population.

BACKGROUND: Direct-acting oral anticoagulants (DOACs) have become the preferred drugs for managing venous thromboembolism (VTE). Despite their advantages over vitamin K antagonists such as warfarin, their use in obese patients remains controversial with many providers reluctant to switch patients managed on warfarin. Outcome research that opts to increase provider confidence when prescribing DOACs for patients with obesity will be invaluable. OBJECTIVE: This investigation evaluated whether patients with a body mass index (BMI) 35 kg/m2 or greater who were prescribed a DOAC had a higher risk for a recurrent VTE or bleed event relative to warfarin. METHODS: The study was conducted in West Virginia which has the highest rate of obesity in the United States. RESULTS: Of the total study population (1633), 2.3% (37) had a recurrent thrombotic event, 5.5% (89) had a major bleed event, and 10.7% (174) had some type of bleeding event. No individual patient characteristic was associated with recurrent thrombosis-including BMI. Older age, antiplatelet use, and taking a medication with a theoretical risk of increasing the effect of DOACs were associated with any and major bleeding events. The use of warfarin was associated with major bleeding events more frequently versus a DOAC. Body mass index was not a predictor for recurrent VTE or any bleed or major bleed events. CONCLUSIONS: These findings support the conclusion that DOACs are an appropriate and effective drug class for the management of VTE in patients with obesity.

Risk factors for metabolic syndrome in self-identified and questioning sexual minority women.

OBJECTIVE: Studies have shown sexual minority women (SMW) have a higher incidence of obesity, but the risk of metabolic syndrome (MetS) in SMW is unclear. We examined the association between sexual orientation and MetS and its components. METHODS: Data were extracted from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2016 examining women aged 20 to 59 years. Participants were divided into three categories: heterosexual, self-identified SMW, and questioning SMW. Logistic regression was used to analyze the association between sexual orientation and MetS. RESULTS: Of 12,755 women, 708 (5.6%) were self-identified SMW, and 365 (2.9%) were questioning SMW. The incidence of MetS was not significantly different across the groups. Logistic regression demonstrated that self-identified SMW had significantly higher odds of large waist circumference (odds ratio [OR] 1.39; 95% CI: 1.14-1.71) and obesity (OR 1.53; 95% CI: 1.24-1.90), while questioning SMW had significantly higher odds of low levels of high-density lipoprotein (OR 1.5; 95% CI: 1.13-1.98) compared with heterosexual women. CONCLUSIONS: Self-identified and questioning SMW did not have an increased incidence of MetS compared with heterosexual women, but they had higher odds of large waist circumference and low high-density lipoprotein, respectively. Further studies are needed to identify the gaps in social determinants of health in SMW.

The Impact of Tele-Education on Family Medicine Clerkship Students' Learning Outcomes.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic necessitated rapid changes to medical education for student and patient protection. A dearth of published US studies examine resulting clinical education outcomes due to pandemic-induced curricula changes. We describe adaptations made to a family medicine clerkship to move it from traditional in-person delivery to virtual only, and then from virtual to hybrid; and compare educational outcomes of students across delivery types. METHODS: We stratified 386 medical students in their third year completing their 8-week family medicine clerkship by type of content delivery, including in person, virtual only, and hybrid instruction. We examined the impact of these changes on three clerkship learning outcomes: the midblock assessment score, the National Board of Medical Examiners (NBME) exam score, and the final numeric score (FNS). RESULTS: In our sample, 164 (42.5%) received content in person, 36 (9.3%) received virtual only, and 186 (48.2%) received hybrid content. Students receiving virtual only (M=76.4, SD=9.1) had significantly higher midblock assessment scores (F=8.06, df=2, P=.0004) than students receiving hybrid (M=71.7, SD=8.8) and in-person training (M=74.5, SD=7.2). No significant differences existed in students' NBME exam scores or FNSs across delivery types. CONCLUSIONS: Students receiving virtual-only or hybrid content performed at least as well on three clerkship-related educational outcomes as their pre-COVID peers participating in person. Further research is needed to understand how changes to medical education affected student learning and skill development.

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

BACKGROUND: To ensure access to effective levonorgestrel (LNG) emergency contraception (EC), pharmacies must keep medication in stock or available for quick delivery, and pharmacists must be knowledgeable about sales restrictions and the therapeutic window for EC. We conducted a mystery caller study to assess LNG EC availability and information accuracy provided by staff in West Virginia community pharmacies. METHODS: A female research team member posed as a 16-year-old caller to ask pharmacy staff questions about whether LNG EC was in stock, the requirements for purchase, and when it should be taken for effectiveness. Data were analyzed with SPSS using the Pearson's χ2 test to determine if there was a relationship between pharmacy type and response accuracy to our questions about point-of-sale requirements and timing for effectiveness for LNG EC. RESULTS: Of the 506 pharmacies in the sample, 275 (54.3%) were chain pharmacies and 231 (45.7%) were independent. Overall, chain pharmacies provided significantly more accurate answers than independent pharmacies on all point-of-sale requirements. Regarding timing for effectiveness, 49.2% of all pharmacies provided an accurate response (62.9% for chain pharmacies vs. 32.9% for independent pharmacies). CONCLUSIONS: Overall, availability and accuracy regarding LNG EC were poor in West Virginia pharmacies. Pharmacists, particularly those at independent pharmacies serving rural communities, are in a critical and powerful position to influence community health by providing accurate and timely information and access to all contraceptive options, including LNG EC.

Seronegative immunity to SARS-CoV-2: a case study.

BACKGROUND: COVID-19 presents with a variable clinical course from asymptomatic to severe respiratory distress with nearly 25% mortality in mechanically-ventilated patients. As such, there is uncertainty regarding how host factors modulate the disease course. CASE PRESENTATION: This report examines these factors in two geriatric patients with multiple comorbid conditions who were residents of the long-term care facility in West Virginia that was the epicenter of COVID-19 in the state. Each patient had substantial, unprotected exposure to SARS-CoV-2 with subsequent negative PCR and antibody testing. CONCLUSIONS: These cases could represent an important step in understanding host factors that modulate the disease course and susceptibility of patients exposed to SARS-CoV-2, and illustrate the need for further research into host resistance relating to this pandemic.

The impact of caller characteristics on levonorgestrel emergency contraception access in West Virginia community pharmacies.

OBJECTIVE: Access to levonorgestrel (LNG) emergency contraception (EC) has increased since the FDA removed age restrictions on over-the-counter (OTC) LNG EC in 2013, but availability is highly variable and numerous barriers to access remain. The purpose of this study was to assess availability and accessibility of LNG EC at community pharmacies in West Virginia (WV). METHODS: A mystery caller cross-sectional study was conducted to assess availability and accessibility of LNG EC. Inquiries were made by identified 'research' staff and by staff presenting as a 16 y/o. RESULTS: Nearly half of community pharmacies reported having LNG EC in stock. Pharmacy staff were significantly more likely to tell research callers LNG EC was in stock (53%) and more likely to report willingness to order it (50%) than 'teen' callers (45% and 34%, respectively). There was no significant difference between caller types on the five barriers assessed. CONCLUSION: Lack of availability may contribute to teen and unintended pregnancies.

Hepatic Fibrosis and Steatosis in Metabolic Syndrome.

Background: Metabolic syndrome (MetS) is a group of factors associated with increased risks of cardiovascular disease and overall mortality. Nonalcoholic fatty liver disease (NAFLD) is a common disorder that has been shown to cause hepatic steatosis and fibrosis. The relationship between NAFLD and MetS appears to be bidirectional, but very few studies have examined the role of MetS in hepatic steatosis and fibrosis. The present study investigated the relationships between MetS and its components and the severity of hepatic fibrosis and steatosis, and fibrosis independent of steatosis. Methods: The study was a cross-sectional population-based survey of 4,678 National Health and Nutrition Examination Survey participants from 2017 to 2018 in the United States. Hepatic fibrosis and steatosis were measured using liver elastography. The MetS components were assessed using demographic, examination, laboratory, and self-reported data. Results: Using survey-weighted population estimates, 26% of the population had steatosis, 7.5% had fibrosis, and 3.3% had fibrosis without steatosis. The adjusted odds ratio for any level of steatosis was 4.12 times higher (95% confidence interval [CI], 3.16-5.37) and any level of fibrosis was 3.34 times higher (95% CI, 2.26-4.94) among participants with MetS than those without. The adjusted odds ratio for fibrosis without steatosis is 2.67 times higher (95% CI, 1.47-4.87) among participants with MetS than those without. Conclusion: The presence of MetS significantly increases the risk of hepatic fibrosis and steatosis, providing evidence for MetS to be considered an additional independent risk factor for hepatic fibrosis together with other known etiologies.

The [underutilized] power of independent pharmacies to promote public health in rural communities: A call to action.

Independent community pharmacies are in a unique and powerful position to promote public and individual health in their communities. Independent pharmacies are particularly important in rural communities where there are few chain pharmacies and accessible health clinics. West Virginia received national attention recently when they opted out of the Federal Pharmacy Program collaborating with CVS and Walgreens and developed their own plan for COVID-19 vaccine distribution and administration, heavily relying on independent pharmacies and the infrastructure they already have in local communities. However, in other areas of public health with urgent, unmet need, such as pregnancy prevention, there is considerable room for independent pharmacies to improve. The pandemic has allowed independent pharmacies to shine during the vaccination effort and has demonstrated what can be accomplished when policymakers, providers, and pharmacists work together for the benefit of community health. Expanding such collaboration to include contraceptive provision and counseling in a timely, nonjudgmental manner could play a pivotal role in preventing unintended and unwanted pregnancies.

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

PURPOSE: Long term care facility (LTCF) residents are at high risk for severe COVID-19 symptoms, but those in rural and resource-limited areas, such as West Virginia (WV) and the larger Appalachian region, may experience delays in obtaining higher levels of medical care due to isolated geography and limited transportation. The study examined the outcomes between residents from 1 LCTF in WV who were moved to a hospital as compared to those remaining in the facility. METHODS: This cohort study compares mortality outcomes among severely symptomatic residents desiring hospitalization and those electing to stay at the facility receiving palliative opioids with supplemental oxygen. FINDINGS: Forty residents tested positive for COVID-19 with 11 developing severe respiratory symptoms. Eight residents elected to receive care at the LTCF while 3 desired hospitalization. Mortality was assessed at 4 time points and was not statistically different between those who were hospitalized versus those who received palliative opioids at the LTCF. Although not significant, the difference in mortality between those hospitalized (66.7%) and those receiving opioids at the LTCF (12.5%) in the acute phase trended toward significance (P = .072). Overall mortality at the 6-month time point among all residents who developed severe respiratory symptoms at this LTCF was 54.5%. CONCLUSIONS: LTCF residents choosing different levels of therapeutic intervention for severe COVID-19 symptoms had no mortality difference. Palliative opioids may be an effective treatment for LTCF residents with severe COVID-19 and also a bridge to care in rural areas with limited resources until more advanced treatments can be accessed.

Responding to a COVID-19 Outbreak at a Long-Term Care Facility.

This article describes an outbreak of COVID-19 in a long-term care facility (LTCF) in West Virginia that was the epicenter of the state's pandemic. Beginning with the index case, we describe the sequential order of procedures undertaken by the facility including testing, infection control, treatment, and communication with facility residents, staff, and family members. We also describe the lessons learned during the process and provide recommendations for handling an outbreak at other LTCFs.

Improving Chronic Obstructive Pulmonary Disease (COPD) Symptoms Using a Team-Based Approach.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States (US), with West Virginia bearing a disproportionate disease burden. Complex COPD cases can be difficult to manage during a standard primary care provider (PCP) visit, and pharmacological treatment regimens should be individually tailored to each patient. METHODS: To address these needs, the West Virginia University Department of Family Medicine created an interdisciplinary COPD specialty clinic that uses a team-based approach to treat patients with COPD. In order to evaluate the effectiveness of the specialty clinic, we conducted a retrospective chart review to examine the impact of the clinic on patient hospitalizations, emergency department visits, and urgent care visits six months and one year before and after initiating care at the clinic. We also examined the impact of the clinic on patients' self-reported nicotine dependency, COPD symptoms, and tobacco use behavior. Patients referred to the clinic and having at least one visit from February 2015 to February 2019 were included in this study (n = 149). RESULTS: Patients treated at the COPD specialty clinic had significantly fewer hospital admissions and ED visits six months after and one year after initiating care at the clinic as compared to six months before and one year before, respectively. Patients at this clinic also reported smoking significantly fewer cigarettes per day with significantly fewer self-identifying as smokers and experiencing significantly reduced COPD symptoms. CONCLUSION: An interdisciplinary, team-based approach was effective for improving the health of COPD patients in an Appalachian academic primary care practice.

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

OBJECTIVES: Emergency contraception (EC) is the only noninvasive form of contraception available after risk exposure and is an important tool for preventing unintended pregnancy resulting from unprotected sex, sexual assault, or contraceptive failure. The U.S. Food and Drug Administration (FDA) removed age restrictions on levonorgestrel EC and made it available over-the-counter to everyone in 2013. Despite improved availability and accessibility since the change in FDA regulations, community pharmacies have not uniformly embraced the policy. West Virginia is a rural state with high rates of poverty and teen pregnancy. DESIGN: The investigators called community pharmacies in West Virginia to assess the availability and accessibility of levonorgestrel EC in addition to the pharmacy staff's knowledge of effectiveness for this cross-sectional study. SETTING AND PARTICIPANTS: The study sample consisted of 509 community pharmacies throughout the state. OUTCOME MEASURES: A structured script was employed to conduct phone calls to community pharmacies with items assessing availability, accessibility, and knowledge of effectiveness. RESULTS: At the time of the phone calls, levonorgestrel EC was reported to be available in 48.9% of the community pharmacies in West Virginia. Chain pharmacies were more likely to report EC as being in stock (0.76) than independent pharmacies (0.15.). Other measures of accessibility also favored chain pharmacies versus independent pharmacies. The overall accessibility of EC at West Virginia community pharmacies was derived from a binary composite variable of "completely accessible" or "not completely accessible" by combining 5 predetermined items. Overall, EC was completely accessible to callers in 0.27 of all pharmacies with significant differences by pharmacy type (0.47 of chain pharmacies as compared with 0.03 of independent pharmacies). CONCLUSION: Accessible EC could reduce unintended pregnancy and help break the state's generational cycle of poverty and poor educational, social, and health outcomes. Pharmacists will be instrumental in expanding access to EC.

Human Immunodeficiency Virus in Adolescents: Risk, Prevention, Screening, and Treatment.

Adolescents and young adults are at high risk for human immunodeficiency virus (HIV) infection. Several risk factors that strongly contribute to HIV infection risk are described, including physical, cognitive, social, and economic factors. Strategies for screening and prevention of HIV infection, including universal screening, behavioral counseling, and preexposure prophylaxis, are reviewed, and the initial treatment approach to a diagnosis of HIV in adolescents is outlined.

Video Intervention to Increase Perceived Self-Efficacy for Condom Use in a Randomized Controlled Trial of Female Adolescents.

STUDY OBJECTIVE: To assess the effects of the Seventeen Days interactive video on young women's perceived self-efficacy for using condoms 6 months after being offered the intervention, relative to a control. DESIGN: Multisite randomized controlled trial. SETTING: Twenty participating health clinics and county health departments in Ohio, Pennsylvania, and West Virginia. PARTICIPANTS: Sexually active female adolescents ages 14 to 19 years. INTERVENTIONS: Seventeen Days (treatment intervention; sex education) vs Driving Skills for Life (control intervention; driving education). MAIN OUTCOME MEASURES: Perceived self-efficacy for condom use. RESULTS: Participants in the Seventeen Days group reported higher perceived condom acquisition self-efficacy after 6 months than those in the driving group. This finding held after controlling for baseline self-efficacy scores and other covariates. CONCLUSION: The Seventeen Days program shows promise to improve perceived self-efficacy to acquire condoms among sexually active female adolescents-an important precursor to behavior change.

Talking to Parents About Adolescent Sexuality.

This article is intended as a resource for pediatric providers to help them guide parents in increasing the quantity and quality of their communication about sexuality. The article provides an overview of the best practices associated with parent-adolescent communication about major topics related to sexuality (eg, masturbation, contraception, romantic relationships). In additionally, the article includes concrete suggestions for parents to improve their communication with teens as well as resources for further guidance.