"They either leave you or they get involved in it": Familial factors influencing drug use amongst Appalachian people.

West Virginia, the only state entirely in Appalachia, is considered the epicenter of the opioid crisis. Children raised in families affected by opioid use disorder can develop their own substance use disorder later in life. The continuing opioid crisis coupled with social and health disparities suggest families in West Virginia are vulnerable to generational cycles of substance misuse. This qualitative study uses content analysis to present emergent themes discerned from participant interviews on the opioid epidemic and impacts of a restrictive opioid prescribing law in West Virginia. Participants in this study described how using opioids has impacted their lives, their family, and community. They recognized drug use was embedded along familial groups and influenced by significant others such as partners or peers. Parents described how children were a strong motivator for recovery and how they felt remorse for exposing their children to their drug use. This study highlights the importance of community engagement, parental support, and early identification of vulnerable young people to lessen the intergenerational continuance of substance use.

Twitter and Communicating Stigma about Medications to Treat Obesity.

In North America, stigma remains a significant barrier to treating obesity. Many candidates for medical weight management do not seek treatment, possibly related to anticipated and internalized stigma and weight bias. Pharmacologic treatment of obesity remains highly stigmatized, despite advances in drug development and medical weight management programs. People contemplating medical weight management are likely to see information about "diet pills" on social media sites, such as Twitter. However, Twitter has been found to contain false and stigmatizing information. This study examines a sample of 2170 Tweets to better understand the content through the lens of obesity stigma. Tweets were collected over a seven-day period containing general terms such as "diet pills," "weight loss pills," or "fat burner" using the Twitter advanced search option. The analysis revealed that almost 50% of Tweets containing "diet pills" contained stigmatizing language. The most common elements of stigma communication were taking personal blame for obesity and the perils associated with taking medications for weight loss. Further analysis revealed sub-themes such as profiting from social pressures to lose weight, distrust of physicians and the practice of obesity medicine, lack of efficacy of medications, and the use of social media to disseminate stigma. Most Tweets were from personal accounts followed by direct sales of weight loss supplements. The findings have potential implications for medically supervised weight management programs and may drive the need for more evidence-based social media messaging around obesity related healthcare.

"You didn't have a choice, but to be on your train. The train was moving": West Virginia pharmacists' perspectives on opioid dispensing during the evolution of the opioid crisis.

BACKGROUND: West Virginia (WV) has been at the forefront of the opioid crisis in the United States, with the highest rate of opioid overdose mortality involving prescription opioids in the country. To curb the crisis, the state government implemented a restrictive opioid prescribing law in March 2018, Senate Bill 273 (SB273), to decrease opioid prescribing. However, sweeping changes in opioid policy can have downstream effects on stakeholders such as pharmacists. This study is part of a sequential mixed methods investigation of the impact of SB273 in WV in which we interviewed various stakeholders-including pharmacists-about the impact of the law. OBJECTIVES: This paper aims to explore how pharmacy practice during the opioid crisis impacted the need for restrictive legislation and how SB273 impacted subsequent pharmacy practice in WV. METHODS: Semi-structured interviews were conducted with 10 pharmacists who were practicing in counties that had been designated as high-prescribing counties based upon county-level prescribing/dispensing data from state records. Analysis of the interviews was informed by the methodological orientation of content analysis to identify emerging themes. RESULTS: Participants described confronting questionable opioid prescriptions, treatment costs, and insurance coverage driving opioids as a first-line choice for pain management, as well as the influence of corporate policies and the immense responsibility of being the "last line of defense" in the opioid crisis. A central impediment to the care of patients was the inability of the pharmacists to effectively communicate their concerns to prescribers, making improved prescriber-dispenser communication an essential next step in minimizing opioid care gaps. CONCLUSION: This is one of few qualitative studies that have explored pharmacists' experiences, perceptions, and role in the opioid crisis leading up to and during the enactment of a restrictive opioid prescribing law. In light of the difficulties they faced, a restrictive opioid prescribing law was viewed positively by pharmacists.

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.

Exploring Resident Physician Wellness at an Allopathic Medical School in West Virginia: A Qualitative Study.

Introduction: Social support is key to wellness, especially during times of stress and uncertainty. The working climate, including the multidisciplinary medical community provides opportunities for both positive and negative wellness experiences. The purpose of this study is to explore residents' concepts of wellness and the influence of programs, faculty, peers, and nursing and ancillary staff. Methods: An email with a link to the REDCap survey was sent to each resident (n=450) in the school of medicine at West Virginia University asking them to give examples of ways their wellness has been supported (or not) by faculty members, their program, co-residents, and nursing and ancillary staff. The residents returned 51 completed surveys (11% response rate). Seven residents participated in a face to face interview. A content analysis using Hale's adaptation of resident wellness (based upon Maslow's Hierarchy of Needs) as the theoretical framework was conducted on the data. Results: Positive wellness elements frequently focused on time, supportive actions, and social connection. Negative examples impacting wellness included feeling disrespected, not being included in decision making, conflicts, and feeling unappreciated. Suggestions from the residents often described low cost interventions such as being" included" and feeling part of the team. Conclusion: The participants described how all members of the healthcare team can support resident wellness in a variety of domains. Peers, support staff in the hospital environment, faculty supervisors, and the program overall can contribute to the basic physiologic needs, safety, belonging, esteem, and self-actualization of resident learners through social support.

Prone Position Ventilation in Neurologically Ill Patients: A Systematic Review and Proposed Protocol.

OBJECTIVES: Prone positioning has been shown to be a beneficial adjunctive supportive measure for patients who develop acute respiratory distress syndrome. Studies have excluded patients with reduced intracranial compliance, whereby patients with concomitant neurologic diagnoses and acute respiratory distress syndrome have no defined treatment algorithm or recommendations for management. In this study, we aim to determine the safety and feasibility of prone positioning in the neurologically ill patients. DESIGN AND SETTING: A systematic review of the literature, performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses 2009 guidelines, yielded 10 articles for analysis. Using consensus from these articles, in combination with review of multi-institutional proning protocols for patients with nonneurologic conditions, a proning protocol for patients with intracranial pathology and concomitant acute respiratory distress syndrome was developed. MEASUREMENTS AND MAIN RESULTS: Among 10 studies included in the final analysis, we found that prone positioning is safe and feasible in the neurologically ill patients with acute respiratory distress syndrome. Increased intracranial pressure and compromised cerebral perfusion pressure may occur with prone positioning. We propose a prone positioning protocol for the neurologically ill patients who require frequent neurologic examinations and intracranial monitoring. CONCLUSIONS: Although elevations in intracranial pressure and reductions in cerebral perfusion pressure do occur during proning, they may not occur to a degree that would warrant exclusion of prone ventilation as a treatment modality for patients with acute respiratory distress syndrome and concomitant neurologic diagnoses. In cases where intracranial pressure, cerebral perfusion pressure, and brain tissue oxygenation can be monitored, prone position ventilation should be considered a safe and viable therapy.

Identifying community physical activity and health resources for treatment of back pain by utilizing members of a physical activity network.

BACKGROUND: Back pain is one of the leading causes of health care expenditure in the US and is linked to an increased body mass index. Many evidence-based modalities for the prevention and treatment of back pain closely mirror recommendations for weight loss and include physical activity and health maintenance activities (PAHM). The primary aim of this study was to ascertain community assets, and perceptions of the use of PAHM in the treatment of back pain by West Virginia Physical Activity Network (WVPAN) members. METHODS: Participants for the study were recruited from the West Virginia Physical Activity Network. This grassroots organization is filled with volunteers from various sectors who were recruited from various workshops, conferences, or coalition meetings over a period of several years. This network was purposely selected as the study population because of the statewide reach and their familiarity with resources in their local communities. A brief survey instrument was designed to gather their scaled perceptions about various treatment modalities related to back pain, and to gather their local knowledge related to specific providers in their communities. In addition, participants were given a free text box to list any local assets or resources for the nine treatments listed, and county of residence, and the nature of their connection to the physical activity network. Descriptive analyses were used to describe overall patterns of survey data. The qualitative data were compiled manually by the research team to show themes of specific treatments mentioned across different parts of the state. RESULTS: Participants overwhelmingly supported physical therapy, flexibility training, yoga, and core strengthening as treatments for back pain. The majority of respondents were "undecided" about other treatments such as cognitive behavioral therapies and acupuncture. CONCLUSIONS: The implementation of PAHM interventions in communities could help treat patients with back pain, and may reduce reliance on the pharmacological treatment for back pain. The current study's data support the potential of such approaches in many West Virginia counties. Also, local resources, and context can be gleaned from community leader surveys utilizing previously developed infrastructure for PAHM promotion.

Using the "Patient Generated Index" in Spine Surgery in an Appalachian Population.

In most health care fields, outcomes are becoming increasingly scrutinized and may play a role in "pay for performance;" therefore, selecting the most appropriate outcomes measures for the populations being studied or treated has evolved into a key aspect of outcomes monitoring. One way to assess patient goals is to administer a "patient generated index" (PGI). The philosophical underpinning of the PGI is that the person living the life is the best judge of the quality of that life. The PGI has been utilized in low back pain, as well as in adult spinal deformity surgery, however, it has not been previously utilized in an Appalachian population. The PGI was administered by means of self-report to 80 new patients with back pain who presented for assessment in the neurosurgery clinic. Participants completed an acceptability survey and written comments as well as compliance were analyzed. Findings indicate that the PGI in its earliest form did not meet acceptable levels for use in this Appalachian subspecialist clinic setting. This study contributes to the growing body of knowledge on patient reported outcomes and more specifically, the importance of utilizing patient generated responses to map improvements in quality of life for patients over time.

Mobile Health (mHealth) Use or Non-Use by Residents of West Virginia.

OBJECTIVE: To compare mobile health (mHealth) usage by residents of West Virginia with national estimates. METHODS: Pew Research Center data from its Internet and American Life Project were accessed for secondary data analysis. These data, available to the public, are a probability sample of Internet use in the United States, differences in use based on selected variables (eg, education, household income), and how usage affects the lives of Americans. Using SAS software, diagnostics were performed on the data, revealing that the variables of interest were prepared and represented without any need for information. Data were used as is, with categorical and continuous characteristics and stipulations being provided in accompanying documents from the Pew Research Center. RESULTS: The national sample consisted of 509 men and 557 women with an average age of 51.02 years (standard deviation 17.04). The 30 West Virginia residents included 19 women and 11 men (mean for age 48.10, standard deviation 15.30). When controlling for socioeconomic and demographics factors, the odds of a West Virginia resident using an mHealth device were 82% less than the rest of the country, a statistically significant association. Women in West Virginia were 52% more likely to access mHealth information than men, and an increase in age corresponded with increased mHealth usage. CONCLUSIONS: The lack of mHealth use by residents in West Virginia represents an opportunity for clinicians and scientists. The high rates of preventable diseases in the region could be more effectively managed with greater use of these technologies.

Osteopathia striata with cranial sclerosis (OSCS): review of the literature and case report demonstrating challenges of spinal fusion after trauma.

Osteopathia striata with cranial sclerosis (OSCS) is a rare but well-described pathology characterized by abnormalities in bone deposition in the axial and cranial skeleton as well as other abnormalities and associated deficits. These skeletal abnormalities can lead to significant intra-operative challenges for the surgeon and influence outcomes for the patient. In this report, we present a case of a patient with OSCS who was involved in a traumatic motor vehicle crash and underwent posterior cervico-thoracic fusion for a T4 chance fracture. Bony abnormalities in the cervico-thoracic spine presented a significant operative challenge due to alterations in bony anatomy and bone architecture. This case serves as an example of the challenges that the spine surgeon faces when dealing with OSCS, and highlights the differences between OSCS and commoner skeletal hyperplasias such as osteopetrosis.

Treatment of holocord spinal epidural abscess via alternating side unilateral approach for bilateral laminectomy.

To date, this is the first reported case of the surgical management of a holocord epidural abscess done through level-skipping laminectomies. It is also the first reported case of these laminectomies being performed via an alternating side unilateral approach for this condition. A 51-year-old patient presenting with progressive lower extremity weakness secondary to a spinal epidural abscess extending from C4 to S1. A minimally disruptive method of relieving the spinal cord compression via evacuation of the abscess was employed successfully. This report demonstrates the efficacy of level skipping laminectomies via a unilateral approach for holocord epidural abscesses (extending 20 vertebral levels). Performing the laminectomies via a unilateral approach as well as alternating the side of the approach minimized iatrogenic instability risk. Both strategies were designed to minimize incision size, tissue disruption, and the amount of muscular weakness/imbalance postoperatively.

Radiation-Induced Supratentorial Primitive Neuroectodermal Tumor after Treatment for Non-Hodgkin's Lymphoma.

Secondary, radiation-induced, supratentorial primitive neuroectodermal tumors (PNETs) are extremely rare entities which may present in survivors of childhood cancers after central nervous system radiation. These lesions have been described after a number of pediatric cancers and demonstrate unique treatment problems and an accelerated clinical course compared to primary PNETs. We present a case of a sixteen year old male with a history of non-Hodgkin's lymphoma who presented with a radiation-induced PNET, and describe our treatment for this lesion. These secondary, radiation-induced tumors increase in significance as the survival of childhood malignancy increases in West Virginia.

Intraoperative neuronavigation for transoral surgical approach: use of frameless stereotaxy with 3D rotational C-arm for image acquisition.

The transoral route is a standard surgical approach to the anterior craniovertebral junction, where neuronavigation is difficult secondary to the mobility of the cervical spine in relation to the cranium. We describe the use of neuronavigation combined with intraoperative 3D C-arm to direct our approach and resection of two lesions of the craniovertebral junction. Neuronavigation was employed in planning of incision, bony resection, and assessment of lesion resection. Both patients underwent transoral approach without complication using this method. Frameless stereotaxy with BrainLab VectorVision and 3D C-arm is an effective method of neuronavigated approach to the anterior craniocervical junction, which may contribute to the safety of this approach.

Wilder Penfield - bioethicist.

Bioethics is a new discipline which developed as modern medical and scientific breakthroughs surpassed the ability of traditional medical ethics to contend with unique ethical dilemmas. It evolved into an interdisciplinary discourse regarding the ethical and societal implications of medicine and the biomedical sciences. Wilder Penfield (1891-1976), celebrated neurosurgeon and neuroscientist, is rarely thought of as a "bioethicist," and his mention in texts on the history of bioethics is little more than a footnote. However, he appears to have contributed to the field of bioethics in a number of ways: through his solutions to the ethical problems posed by the unique form of surgery he developed; through his recognition of the limitations of traditional medical ethics; through his involvement of the public and other disciplines in ethical discussions; and through the impact that his work still has today in the area of bioethics termed "neuroethics."

Back Pain in the Era of Opioid Restriction and Implications for Neurosurgeons Based on Qualitative Findings From a Rural State.

Historically, back pain has been an inciting complaint for the initiation of opioids. Aggressive marketing of opioids to treat back pain coupled with the initiation of pain being treated as "the fifth vital sign" contributed to the emerging opioid crisis in the USA. West Virginia (WV) has long been considered the epicenter of the crisis. In 2018, the WV legislature passed a bill that placed prescribing limits on opioids. Our group set out to investigate the impacts of opioid prescribing restrictions through a sequential, mixed methods study evaluating prescription trends and stakeholder experiences. These stakeholder experiences generated emergent themes regarding the evolution of the opioid crisis up to and beyond the implementation of the bill, which is of relevance to neurosurgeons and back pain treatment. This study explores those findings for a neurosurgical audience. This study consisted of open-ended, semi-structured interviews with a purposive sample of 50 physicians, pharmacists, and patients in WV. Interviews were recorded and transcribed verbatim. Content analysis was utilized as the methodological orientation. Five theoretical domains relevant to the treatment of back pain emerged, describing the prevalence of opioid use, barriers to access care, the importance of opioids for function in resource-poor rural areas, disconnected and siloed care, and patient views on the impacts of pain care gaps and solutions. Spinal pain care in rural WV is complex due to identified challenges. Care siloing factors in suboptimal spinal pain care. Future work should define, implement, and assess the real-world effectiveness of treatment paradigms for the full spectrum of surgical and non-surgical back pain complaints. Neurosurgeons should be present in this arena.

Using Medical Cannabis for Chronic Pain: A Social-Ecological Framework.

Early studies suggest medical cannabis (MC) has the potential to benefit people who suffer from chronic pain by offering a less addictive alternative to opioids; however, most investigators agree more research is indicated. Today, in 2023, cannabis remains a Schedule I drug and is an illegal substance in the United States under the Controlled Substances Act of 1970. Despite this designation, as of February 2022, 37 states, three territories, and the District of Columbia allowed using cannabis products to treat certain painful medical conditions. The contradictory status of federal and state legislation regarding cannabis use has resulted in delays and restrictions on relevant research. As a result, an inadequate foundation of knowledge exists needed to inform policy, program, and practice decisions concerning MC to treat pain. Implementing and controlling access to MC is influenced by overlapping individual, interpersonal, community, and organizational influences that all fall under the umbrella of federal and state policies. Increasingly, the legalization and expanded access to MC necessitates the integration of evidence, policy, and social-ecological reality. To adequately delineate these complex factors to anticipate and plan future interventions at multiple levels, we propose a social-ecological framework (SEF) for using MC to treat pain. This SEF assumes the transactional relationship between the individual and the environment and that no single factor can predict behavior or health outcomes. Our framework illustrates five dynamic levels of analysis that interact between dimensions. Key elements and intersections are discussed at the intrapersonal, interpersonal, institutional, community, and policy levels.

A qualitative study of chronic pain and opioid use: The impact of restrictive prescribing.

OBJECTIVES: To explore the continuum of pain and addiction for patients with chronic pain (CP) who used opioids during a time of restrictive opioid prescribing in West Virginia. DESIGN: This qualitative descriptive study used a content analysis of semistructured interviews. Themes were identified through a reflective, iterative coding process. Consolidated criteria for reporting qualitative research guidelines were followed. SETTING: West Virginia. PARTICIPANTS: Twenty people who used opioids to treat a CP condition, 10 pharmacists, 10 primary care providers, and 10 specialists. INTERVENTION: Semistructured interviews. MAIN OUTCOME MEASURE: To better understand the impact of restrictive prescribing measures on people who used opioids for CP. RESULTS: Patients initiated opioids for acute, painful conditions and described how long-term use led to physical dependence and, for some, opioid use disorder. Restrictive opioid prescribing laws led to care interruptions and decreased access and availability of prescribed opioid pain medication, driving some patients to seek illicit drugs. Economic considerations influenced drug use as the price of purchasing prescription opioids on the street went up, making heroin a cheaper alternative. Patients who transitioned to buprenorphine/naloxone as a treatment for pain or opioid use disorder viewed it as a positive change and a "life saver." CONCLUSIONS: Opioid use for CP is complex and multifaceted. The continuum of pain and opioid use disorder can begin with a prescription for acute pain and continue for the treatment of CP. Patients described how continued opioid use was not to "get high" but for pain control to improve their quality of life, continue to work, and be productive. For those who experience physical dependence on opioids, access to treatment is vital to recovery and pain management. KEY MESSAGE: Without individualized managed care, people confronted with a sudden interruption in prescription opioids may turn to illicit drugs to mitigate symptoms of opioid withdrawal and physical dependence.

Stigmatizing Language Expressed Towards Individuals With Current or Previous OUD Who Have Pain and Cancer: A Qualitative Study.

CONTEXT: Stigma is known to impact the care of patients with opioid use disorder (OUD). OBJECTIVES: This qualitative study seeks to understand how stigma is expressed in the medical chart by healthcare workers towards patients with cancer pain and OUD treated at an academic medical center. METHODS: This descriptive qualitative study utilized a thematic analysis approach to analyze the medical charts of 25 hospitalized patients with current or previous opioid use disorder and cancer with respect to their pain care in forty pain-related hospital admissions to a tertiary academic center from 2015 to 2020. The codebook utilized a well-characterized stigma framework and emerging themes were identified through an iterative, comparative method. COREQ guidelines were followed. RESULTS: Evidence of stigma marking was present in the medical chart aligning with several intersecting stigmas. Drivers such as blame and stereotypes impeded pain care, while facilitators such as legal or policy influences and non-care advocates could be either positive or negative determinants to pain care. Care by known providers within the healthcare environment was largely a facilitator of improved pain care. CONCLUSIONS: Healthcare provider stigma must be addressed as its effects are both quantitatively and qualitatively affecting patient care; in particular access to pain treatment. Continuity of care by known care providers may improve pain care for patients with cancer and OUD who are acutely hospitalized.

Traumatic brain injury in college students and the influence of alcohol consumption: A retrospective review from a rural state.

Objectives: There is a strong association between alcohol consumption and traumatic brain injury (TBI). Students are known to consume alcohol at a high rate. Despite the connection between alcohol and TBI, this is one of few studies to examine the connection between students, alcohol, and TBI. The objective of this study was to explore the relationship between students, alcohol, and TBI. Materials and Methods: A retrospective chart review utilizing the institutional trauma data back was performed for patients 18-26 years of age, admitted to the emergency department with a diagnosis of a TBI and positive blood alcohol. Patient diagnosis, injury mechanism, alcohol level on admission, urine drug screen, mortality, injury severity score, and discharge disposition were recorded. The data were analyzed using Wilcoxon rank-sum tests and Chi-square tests to identify differences between students and non-student groups. Results: Six hundred and thirty-six charts were reviewed for patients aged 18-26 with a positive blood alcohol level and TBI. The sample included 186 students, 209 non-students, and 241 uncertain of status. The student group had significantly higher levels of alcohol than the non-student group (P < 0.0001). P < 0.0001 showed that overall alcohol levels for males are significantly higher than levels of alcohol for females in the student group. Conclusion: Alcohol consumption contributes to significant injuries such as TBI in college students. Male students had a higher prevalence of TBI, and higher alcohol levels than female students. These results can be used to inform and better target harm reduction and alcohol awareness programs.