The Thuss Lectureship Series at Vanderbilt University.

BACKGROUND: The Thuss lectureship began in 1978 and is carried at both Vanderbilt University Medical Center and Stanford Medical Center. The 2-day event consists of a resident and fellow workshop and dinner with an invited keynote speaker, followed by a didactic session and research presentation the following morning. This lecture honors the career of Dr Charles J. Thuss, Sr, and acts as a memorial for Dr Thuss, Jr, and his son, Carter. Trainee presentations have been catalogued since 2019, and we sought to identify the presentations that resulted in publications. METHODS: Internal records from 2019 to 2022 were referenced to catalogue presenters and project titles. PubMed searches were conducted to identify projects from these presenters with direct links to their presentations at the lectureship series. RESULTS: The event has been held consecutively from 1978 to 2023 with 44 keynote lecturers. Between 2019 and 2023, 17 residents, fellows, and medical students from Vanderbilt University Medical Center or/and the Tennessee Society of Plastic Surgery gave 19 research presentations for the Thuss lectureship at Vanderbilt. Due to the pandemic, no resident or trainee presentations were given in 2020. Nine of 11 project presentations resulted in publications, with presenters being the resultant first author of 6 of these articles. CONCLUSION: The Thuss lectureship at Vanderbilt serves as an academic conduit to share research and build camaraderie among plastic surgeons across Tennessee. Additionally, it fosters a platform for trainees to contribute to the academic literature and see projects from inception to publication.

Two cases of Angiostrongylus vasorum, a cardiopulmonary nematode, in a wild black bear and coyote of Tennessee.

Angiostrongylus vasorum, commonly known as the French heartworm, is a metastrongyloid parasitic nematode that infects wild and domestic canids. In North America, A. vasorum is endemic to the Canadian island of Newfoundland, but has been expanding to new areas including Nova Scotia, Prince Edward Island, and West Virginia (USA). Two cases of A. vasorum are reported from the state of Tennessee. The first case in a black bear (Ursus americanus) and the second case in a coyote (Canis latrans). The black bear was found dead in Sevier County in November of 2022, while the coyote was trapped and euthanized as part of a predator control program in Campbell County in January of 2023. Histology of the lungs revealed both animals had verminous pneumonia. DNA was extracted from the lungs of both, and PCR was performed using NC1 and NC2 primers. Sequencing results of the PCR products from the bear and coyote samples indicated that they were 95% and 96% similar, respectively, to European strains of A. vasorum. This report marks the first time A. vasorum has been reported in Tennessee as well as only the second and third report of autochthonous A. vasorum infection in the United States and the first report in an ursid. These two cases confirm the spread of A. vasorum further into North America. This nematode is highly pathogenic to wild and domestic canids, and thus these cases represent an emerging threat to both and underscore the need for further surveillance for the parasite.

Do local and landscape context affect the attractiveness of flower gardens to bees?

Planting floral resources is a common strategy for increasing the abundance and diversity of beneficial flower-visiting insects in human-modified systems. However, the context of the local area and surrounding landscape may affect the attractiveness of these floral resource provisioning plots. We compared the relative effects of local floral resources and surrounding urban land-use on the abundance of bees on flowering plants in common gardens in eastern Tennessee, USA. We planted four types of common garden plots at each of five different landscapes representing a variety of surrounding land use: 1) Urban Garden, 2) Forage Grassland, 3) Mixed Agriculture, 4) Forest, and 5) Organic Farm. Each common garden plot type had a fixed plant community representing one of three plant families (Asteraceae, Fabaceae, Lamiaceae) or a mix of all three, and all four common gardens were replicated at all the sites. We concurrently sampled bees in the garden plots and in a 50 m radius (local area) around the garden plots. We found that the size of the floral display (i.e. the visual display size of flowers) and diversity of flowers in the local area did not affect bee abundance or species richness in the garden plots. Although there was a significant positive association between developed land use in a 2 km radius and bee abundance in the gardens, the effect was small, and there was no relationship between land use and bee abundance or species richness in the local area. There were significant differences in the composition of the bee community between the local area and garden plots, but the largest determinants of bee community composition and species richness in the gardens were floral display size and variation in the garden plant species in bloom. This finding is promising for anyone wishing to promote pollinator populations by providing more floral resources.

The Unforeseen Costs of Medical Education.

OBJECTIVE: Financial burdens of medical education are a major barrier for many students. The goal of this study is to identify and quantify unforeseen costs associated with being a medical student. METHODS: Medical students at the University of Tennessee Health Science Center were surveyed on unforeseen financial costs. Qualitative data were collected. RESULTS: Students spent significant extra funds in professional development, social spending, living, and technology. CONCLUSION: Schools and students should consider all aspects of life to have a fruitful education and appropriately provide loan funding and financial education for both enough and thoughtful use of financial resources during medical education.

Multisystemic inflammatory disease in Pheasantshell (Unionidae, Actinonaias pectorosa) associated with Yokenella regensburgei infection at sites experiencing seasonal mass mortality events.

Freshwater mussels are integral components of riverine ecosystems, influencing water quality, nutrient cycling, and habitat characteristics. Enigmatic freshwater mussel declines, often characterized by sudden mass mortality events, pose significant challenges to conservation efforts. The Clinch River, a freshwater biodiversity hotspot in Virginia and Tennessee, USA, has experienced several enigmatic mass mortality events since 2016. Studies have reported bacteria associated with moribund Pheasantshell (Actinonaias pectorosa) during mortality events in the Clinch River, specifically Yokenella regensburgei. Despite reports of bacterial infection, little is known about their role as pathogens. Through a multiyear case-control study, combining in-situ experiments, field surveys, histology, bacterial isolation, and high-throughput sequencing, we assessed the role of bacteria in Pheasantshell (Actinonais pectorosa) mortality at three sites in the Clinch River. Between May 2021 and December 2023, we collected 21 wild moribund free-living A. pectorosa and 68 hatchery-reared A. pectorosa maintained in silos at the same sites and investigated differences in pathology and microbiologye between groups. No silo mussels presented clinical signs of disease, or gross or microscopic lesions associated with pathological conditions leading to mortality. Our findings reveal a significant association between Yokenella regensburgei and severe multisystemic and multifocal infiltrative hemocytosis with necrosis, consistent with sepsis. Lesions associated with yokenellosis were of sufficient severity and physiological significance to explain mortality in infected hosts. Although our study does not explain the cause of these infections, it confirms that mussels at our study sites are ultimately dying with an infectious disease and that Y. regensburgei can be pathogenic in free-living mussels. Our results underscore the importance of considering bacterial diseases in wild mussel populations and emphasize the need for further research to elucidate the epidemiology and pathogenicity of Y. regensburgei. Overall, our study highlights the importance of integrated approaches combining pathology, microbiology, and epidemiology in freshwater mussel conservation efforts.

Evaluating the delivery of care by telemedicine for incarcerated people living with HIV: a cohort study.

BACKGROUND: The use of telemedicine has grown significantly since the COVID-19 pandemic and has the potential to improve access to specialized care for otherwise underserved populations. Incarcerated people living with HIV (PLWH) could potentially benefit from expanded access to HIV care through telemedicine. METHODS: All PLWH who were incarcerated within the Tennessee Department of Corrections and received care through the HIV telemedicine clinic at Regional One Hospital between 5/1/2019 through 2/28/2022 were identified from the electronic health records (EHR). Demographics, laboratory data, vaccine history, and treatment outcomes were abstracted from the EHR. Retention in care and viral suppression were defined using Centers for Disease Control and Prevention definitions. RESULTS: Of the 283 incarcerated PLWH receiving care from this telemedicine clinic, 78% remained retained in care and 94% achieved or maintaining viral suppression at 12 months. Many preventative care measures remained unperformed or undocumented, including vaccinations and testing for concurrent sexually transmitted infections. There were 56 patients (20%) found to have chronic hepatitis C in this population, with 71% either cured or still on treatment in this study period. CONCLUSIONS: Retention in care and viral suppression rates were excellent among incarcerated PLWH receiving telemedicine care for their HIV. HIV related primary health care screenings and vaccinations, however, were less consistently documented and represent areas for improvement.

Improving Pain Self-Management Among Rural Older Adults With Cancer.

Importance: Undertreated cancer pain is a major public health concern among older adults in rural communities. Interventions to improve pain management among this vulnerable population are needed. Objective: To test the feasibility, acceptability, and changes in pain outcomes from exposure to an adapted intervention, Cancer Health Empowerment for Living without Pain (CA-HELP), to improve patients' communication about pain to their clinicians. Design, Setting, and Participants: Older adults with cancer (aged ≥65 years) who were residing in a noninstitutional rural setting and receiving outpatient care at a rural-based clinic in Tennessee were enrolled in the study, in which everyone received the intervention, in May 2022. All patients were given assessments at baseline and 1 week after intervention. Mean score differences were analyzed using 1-tailed paired sample t tests (α = .05). Data were analyzed in June 2022. Exposure: The adapted version of CA-HELP included an 18-page patient-facing workbook and a 30-minute telephone coaching call with a registered nurse to coach patients on pain education and communication techniques to discuss pain with their medical team. Main Outcomes and Measures: Feasibility was examined through accrual and completion rates. Acceptability was measured by helpfulness, difficulty, and satisfaction with the intervention. Changes in outcomes were measured using mean score differences from pre-post assessments of pain self-management, self-efficacy for communicating with clinicians about pain, patient-reported pain, and misconceptions about pain. Results: Among the 30 total participants, the mean (SD) age was 73.0 (5.1) years; 17 participants (56.7%) were female, 5 (16.7%) were Black or African American, 30 (100%) were non-Hispanic or non-Latino, 24 (80.0%) were White, 16 (53.3%) had less than a high school education, and 15 (50.0%) reported income less than $21 000 per year. Based on accrual and completion rates of 100%, this intervention was highly feasible. Fidelity rates for delivering intervention components (100%) and communication competence (27 participants [90%]) were also high. Regarding acceptability, all patients rated the intervention as helpful, with the majority (24 participants [80%]) rating it as "very helpful." Most patients rated the intervention as "not at all difficult" (27 participants [90%]), enjoyed participating (21 participants [70%]), and reported being "very satisfied" (25 participants [83.3%]). Pre-post changes in outcomes suggested significant improvements in pain self-management and self-efficacy for communicating with clinicians about pain, as well as significant reductions in patient-reported pain and pain misconceptions. Conclusions and Relevance: In this case-series study of CA-HELP, results suggested the adapted version of CA-HELP was feasible and acceptable and showed changes in pain-related outcome measures among older adults with cancer in a rural setting.

Association of Symptoms and Viral Culture Positivity for SARS-CoV-2-Tennessee, April-July 2020.

BACKGROUND: Understanding how symptoms are associated with SARS-CoV-2 culture positivity is important for isolation and transmission control guidelines. METHODS: Individuals acutely infected with SARS-CoV-2 in Tennessee and their household contacts were recruited into a prospective study. All participants self-collected nasal swabs daily for 14 days and completed symptom diaries from the day of illness onset through day 14 postenrollment. Nasal specimens were tested for SARS-CoV-2 using RT-qPCR. Positive specimens with cycle threshold values < 40 were sent to the Centers for Disease Control and Prevention (CDC) for viral culture. First, we modeled the association between symptoms and the risk of culture positivity using an age-adjusted generalized additive model (GAM) accounting for repeated measurements within participants and a symptom-day spline. Next, we investigated how timing of symptom resolution was associated with the timing of culture resolution. RESULTS: In a GAM restricted to follow-up days after symptoms began, the odds of a specimen being culture positive was significantly increased on days when wheezing, loss of taste or smell, runny nose, nasal congestion, sore throat, fever, or any symptom were reported. For all symptoms except sore throat, it was more common for participants to have culture resolution before symptom resolution than for culture to resolve after or on the same day as symptom resolution. CONCLUSIONS: Overall, symptomatic individuals were more likely to be SARS-CoV-2 viral culture positive. For most symptoms, culture positivity was more likely to end before symptoms resolved. However, a proportion of individuals remained culture positive after symptom resolved, across all symptoms.

Keeping it real: A descriptive analysis of HIV testing history, PrEP awareness, and PrEP use among Black cisgender women in Middle Tennessee, 2018.

INTRODUCTION: HIV disproportionately affects Black/African American women in the United States, particularly in the southern states, including Tennessee. Despite this, limited research and intervention are targeting this population, especially regarding biomedical prevention technologies such as pre-exposure prophylaxis (PrEP). This study aims to describe the HIV testing history of a sample of Black women in middle Tennessee, assess their awareness and potential for adopting modern HIV prevention technologies like PrEP, and explore the dyadic and social factors that influence their HIV prevention awareness and use. THEORY: The Precaution Adoption Process Model (PAPM) is employed to understand how individuals progress through decision-making stages when adopting new health behaviors, especially related to novel interventions. METHODS: For survey development and deployment, this cross-sectional survey study engaged the Nashville Health Disparities Coalition and the Resident Association for the Metropolitan Developmental Housing Association in Nashville. Eligible participants included African American and Black women aged 18 and above. The survey collected demographic information, HIV testing history, reasons for testing or not testing, dyadic HIV risk factors, awareness, and use of rapid HIV testing and PrEP, and social norms related to these prevention technologies. RESULTS AND DISCUSSION: Age significantly influenced HIV testing history, emphasizing the importance of regular screening, especially among older women. Dyadic factors such as concurrency and having a shared male partner were associated with differences in testing behavior. Awareness of both rapid HIV testing and PrEP was limited among participants, highlighting the need for increased education and awareness campaigns specifically highlighting benefits to Black women. Social norms, particularly recommendations from healthcare providers, played a crucial role in influencing women's willingness to adopt these prevention technologies. [Increasing routine HIV testing and awareness of PrEP, especially among women in non-monogamous relationships, is essential in reducing HIV disparities among Black women.] IMPLICATIONS: Healthcare providers play a crucial role in initiating and recommending HIV testing and PrEP among Black women, emphasizing the importance of patient-provider relationships and ongoing conversations about prevention strategies. This study underscores the importance of community-engaged research in addressing HIV disparities and highlights the potential for partnerships between medical centers and community organizations in the fight against HIV.

The Tennessee Heart Health Network effectiveness study: A stepped wedge cluster randomized controlled trial to assess the effectiveness of statewide quality improvement cooperative participation on cardiovascular outcomes.

BACKGROUND: Cardiovascular disease (CVD) is the primary cause of premature morbidity and mortality in the United States and Tennessee ranks among the highest in CVD events. While patient-centered outcomes research (PCOR) evidence-based approaches that reach beyond the traditional doctor-patient visit hold promise to improve CVD care and prevent serious complications, most primary care providers lack time, knowledge, and infrastructure to implement these proven approaches. Statewide primary care quality improvement (QI) collaboratives hold potential to help address primary care needs, however, little is known regarding their effectiveness in improving uptake of PCOR evidence-based population health approaches and improving CVD outcomes. This study describes the design and implementation of a stepped-wedge cluster randomized controlled trial to assess the effectiveness of participation in a statewide quality improvement cooperative (The Tennessee Heart Health Network [TN-HHN]) on cardiovascular outcomes. METHODS/DESIGN: The TN-HHN Effectiveness Study randomized 77 practices to 4 waves (i.e., clusters), with each wave beginning three months after the start of the prior wave and lasting for 18 months. All practice clusters received one of three Network interventions, and outcomes are measured for each three months both in the control phase and the intervention phase. Primary outcomes include Center for Medicare and Medicaid Services measures for aspirin use, blood pressure control, cholesterol control, and smoking cessation (ABCS). CONCLUSIONS: This trial, upon its conclusion, will allow us to assess the effect of participation in a statewide quality improvement cooperative on cardiovascular outcomes as well as key contributors to successful practice transformation.

"Locate the Law" activity: Evaluating student pharmacists' ability to locate and use legal resources.

OBJECTIVE: Pharmacy students must be able to locate and use legal resources to prepare for licensure and be practice-ready. We aimed to assess pharmacy students' ability and confidence in locating and using publicly available legal resources. METHODS: The "Locate the Law" activity was implemented in a pharmacy law course in the fall of 2021, 2022, and 2023 for third-year pharmacy students at 1 college of pharmacy in the Mid-South. The activity consisted of a 108-question (61 law questions) survey that evaluated the students' confidence before and after they were required to locate publicly available legal resources online and answer a set of guided questions about each resource. Descriptive and inferential statistics were conducted to evaluate student responses. The University of Tennessee Institutional Review Board approved this study. RESULTS: A total of 363 students participated in the study (response rate: 77%) over a 3-year period. Most students were female (67%), on average 25 years old, and reported having pharmacy work experience (95%). Before the activity, students reported being slight to somewhat confident in finding a statute (mean [M]: 2.5) or regulation (M: 2.5). Most graded question responses averaged ≥ 90%, and no question scored below a 75% average. After the activity, students' confidence increased significantly increased in finding a statute (M: 4.1) or regulation (M: 4.1). CONCLUSION: The "Locate the Law" activity significantly improved student pharmacists' self-reported confidence in locating publicly available legal resources, and most students correctly answered most activity questions. Pharmacy law educators should consider incorporating training on using legal resources in the pharmacy law course.

A theoretical explanation of naloxone provision among primary care physicians and community pharmacists in Tennessee.

BACKGROUND: Increasing access to naloxone reduces opioid-related morbidity and mortality. Primary care and community pharmacy settings are critical access points, yet limited theoretical research has examined naloxone prescribing and dispensing behaviors. OBJECTIVES: To determine if the theory of planned behavior (TPB) combined with theoretical constructs from communication science explains intentions to co-prescribe and discuss co-dispensing naloxone among primary care physicians and community pharmacists, respectively. METHODS: This cross-sectional study surveyed cohorts of licensed primary care physicians and community pharmacists in Tennessee in 2017. Intentions were measured using profession-specific case vignettes, whereby they were asked given 10 similar patients, how many times (0-10) would they co-prescribe or discuss co-dispensing naloxone. Bivariate and multivariable analyses were used. RESULTS: The analytic sample included 295 physicians (response rate = 15.6 %) and 423 pharmacists (response rate = 19.4 %). Approximately 65 % of physicians reported never intending to co-prescribe naloxone (0 out of 10 patients), while 47 % of pharmacists reported never intending to discuss co-dispensing. All TPB constructs-attitudes (AOR = 1.32, CI = 1.16-1.50), subjective norms (AOR = 1.17, CI = 1.06-1.30), and perceived behavioral control (AOR 1.16, CI = 1.02-1.33)-were associated with an increased likelihood of pharmacists always (versus never) discussing co-dispensing. Similarly, two TPB constructs-attitudes (AOR = 1.41, CI = 1.19-1.68) and subjective norms (AOR = 1.22, CI = 1.08-1.39)-were associated with an increased likelihood of physicians always co-prescribing. Among physicians only, one communication construct-self-perceived communication competence (AOR = 1.19, CI = 1.01-1.41)-was associated with an increased likelihood of always co-prescribing. CONCLUSION: Findings support the value of theory, particularly TPB, in explaining primary care physician intentions to co-prescribe and community pharmacist intentions to discuss co-dispensing naloxone.

Factors Influencing Vision Health and Eye Care among Older Adults in Northeast Tennessee.

OBJECTIVES: The purpose of this study was to examine the factors associated with vision impairment (VI), age-related eye disease (ARED), and frequency of eye examinations among older adults. METHODS: A cross-sectional study (N = 166) was designed to identify barriers in vision and eye care services among adults 50 years and older in four counties in Appalachian Tennessee. Surveys were administered in March 2023. Simple and multiple logistic regression analyses were used to determine the risk factors of VI and ARED and the frequency of eye examinations. RESULTS: In two out of the three regression models, predictors such as traveling >10 mi to an eye care provider, barriers to eye care, and a lack of exposure to eye health information emerged as significant factors. Individuals who traveled >10 mi to an eye care provider were more than twice as likely than individuals who traveled shorter distances to have VI and not maintain routine eye care (adjusted odds ratio [AOR] 2.69, 95% confidence interval [CI] 1.08-6.75; AOR 2.82, 95% CI 1.05-7.55, respectively). Reporting barriers to eye care doubled the odds of ARED (AOR 2.33, 95% CI 1.02-5.34) and substantially increased the odds of reporting a 3-year or longer interval since the last eye examination (AOR 7.45, 95% CI 1.85-29.96) compared with having no barriers to eye care. Moreover, limited exposure to eye health information tripled the odds of VI (AOR 3.26, 95% CI 1.15-9.24) and not maintaining routine eye care (AOR 3.07, 95% CI 0.97-9.70) compared with more exposure to eye health information. Other predictors also were uncovered in the analysis. CONCLUSIONS: This study contributes to the scarce literature on risk factors associated with vision health among older adults in Appalachia.

Persistent spatial clustering and predictors of pediatric La Crosse virus neuroinvasive disease risk in eastern Tennessee and western North Carolina, 2003-2020.

The combined region of eastern Tennessee and western North Carolina has a persistently high risk of pediatric La Crosse virus neuroinvasive disease (LACV-ND). To guide public health intervention in this region, the objectives of this retrospective ecological study were to investigate the geographic clustering and predictors of pediatric LACV-ND risk at the ZIP code tabulation area (ZCTA) level. Data on pediatric cases of LACV-ND reported between 2003 and 2020 were obtained from Tennessee Department of Health and North Carolina Department of Health and Human Services. Purely spatial and space-time scan statistics were used to identify ZCTA-level clusters of confirmed and probable pediatric LACV-ND cases from 2003-2020, and a combination of global and local (i.e., geographically weighted) negative binomial regression models were used to investigate potential predictors of disease risk from 2015-2020. The cluster investigation revealed spatially persistent high-risk and low-risk clusters of LACV-ND, with most cases consistently reported from a few high-risk clusters throughout the entire study period. Temperature and precipitation had positive but antagonistic associations with disease risk from 2015-2020, but the strength of those relationships varied substantially across the study area. Because LACV-ND risk clustering in this region is focally persistent, retroactive case surveillance can be used to guide the implementation of targeted public health intervention to reduce the disease burden in high-risk areas. Additional research on the role of climate in LACV transmission is warranted to support the development of predictive transmission models to guide proactive public health interventions.

Inflammatory markers and body mass index amoung hispanic children.

BACKGROUND AND OBJECTIVES: Body mass index (BMI) is inversely proportional with adiponectin levels among adults, while insulin, C-reactive protein (CRP), interleukin 6 (IL-6), resistin and tumor necrosis factor-alpha (TNF-α) have been linked with elevated BMI. The role and relation of these biomarkers with BMI among a Hispanic pediatric population are less known. Thus, the objective of this study was to examine the association of inflammatory markers with the odds of overweight/obesity while controlling for several sociodemographic factors among a Hispanic youth population in Northeast Tennessee. METHODS: Height, weight, demographic information, and blood samples were collected from 107 Hispanic children aged 2 to 10 years recruited at a large community health center in 2015-2016 in Northeast Tennessee. Data for this research were accessed and analyzed in 2022. Multivariable logistic regression was conducted to assess the relations between adiponectin, insulin, resistin, CRP, TNF-α, and IL-6, and overweight/obesity vs. having a healthy (normal) weight. RESULTS: Adiponectin levels were significantly lower among overweight/obese Hispanic children (p = 0.0144) compared to healthy weight children. The odds of overweight/obesity decreased by 4% for every one-unit increase in serum adiponectin. Insulin levels were significantly higher among overweight/obese Hispanic children compared to healthy weight children (p = 0.0048). The odds of overweight/obesity increased by 7% for every one-unit increase in serum insulin. Resistin, IL-6, TNF-α, and CRP were not significantly associated with overweight/obesity in this population. CONCLUSION: Adiponectin behaves similarly in Hispanic youth as it does in other pediatric populations, possibly making it a valuable marker when examining metabolic health status in this population.

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.

Comparing Chest Tube Thoracostomy in East Tennessee Trauma Centers: A Prospective Study Highlighting Differences in Urban vs Rural Locations.

Chest tube thoracostomy (CTT) is essential for lung expansion, but protocol discrepancies exist across trauma centers. This prospective study compared CTT protocols between an urban (center 1) and rural (center 2) level 1 trauma center in East Tennessee from June to August 2023. 66 trauma patients required CTT (51 from center 1 and 15 from center 2). Diagnostic practices and post-pull chest X-rays (CXR) differed significantly. Center 1 favored CXR for diagnosis (P = 0.012), while center 2 relied more on clinical presentation (P = 0.012). Post-pull CXR was less common at center 2 (P = 0.012). Center 2 had lower Glasgow Coma Scale scores (P = 0.028), shorter tube duration (P = 0.044), and more needle thoracostomy use (P = 0.393). These findings underscore the need for regional protocols considering pre-arrival factors, hospital practices, and injury patterns. Protocol adjustments aim to improve adherence and patient outcomes, with ongoing data collection exploring factors influencing protocol evolution.

Seroprevalence of Leprosy in Nine-Banded Armadillos (Dasypus novemcinctus) from Tennessee, USA, 2021-22.

The nine-banded armadillo (Dasypus novemcinctus) is currently considered an invasive species in parts of its range in the USA, and this range continues to expand to the north and east. Nine-banded armadillos are one of a handful of mammals known to contract leprosy (also known as Hansen's disease); range expansion thus leads to public health concerns about whether this might increase human exposure to infected animals. We collected blood samples from 61 road-killed armadillos over two summers (2021 and 2022) in Tennessee, a US state near the northern extreme of the species' current range, and screened them for exposure to Mycobacterium leprae, the causative agent of leprosy. All animals were seronegative, providing no evidence that range expansion is increasing the distribution of leprosy in the US.