Emulating natural disturbances for declining late-successional species: a case study of the consequences for cerulean warblers (Setophaga cerulea)

Forest cover in the eastern United States has increased over the past century and while some late-successional species have benefited from this process as expected, others have experienced population declines. These declines may be in part related to contemporary reductions in small-scale forest interior disturbances such as fire, windthrow, and treefalls. To mitigate the negative impacts of disturbance alteration and suppression on some late-successional species, strategies that emulate natural disturbance regimes are often advocated, but large-scale evaluations of these practices are rare. Here, we assessed the consequences of experimental disturbance (using partial timber harvest) on a severely declining late-successional species, the cerulean warbler (Setophaga cerulea), across the core of its breeding range in the Appalachian Mountains. We measured numerical (density), physiological (body condition), and demographic (age structure and reproduction) responses to three levels of disturbance and explored the potential impacts of disturbance on source-sink dynamics. Breeding densities of warblers increased one to four years after all canopy disturbances (vs. controls) and males occupying territories on treatment plots were in better condition than those on control plots. However, these beneficial effects of disturbance did not correspond to improvements in reproduction; nest success was lower on all treatment plots than on control plots in the southern region and marginally lower on light disturbance plots in the northern region. Our data suggest that only habitats in the southern region acted as sources, and interior disturbances in this region have the potential to create ecological traps at a local scale, but sources when viewed at broader scales. Thus, cerulean warblers would likely benefit from management that strikes a landscape-level balance between emulating natural disturbances in order to attract individuals into areas where current structure is inappropriate, and limiting anthropogenic disturbance in forests that already possess appropriate structural attributes in order to maintain maximum productivity.

Perceptions of need, service use, and barriers to service access among female methamphetamine users in rural Appalachia

Active substance users have been characterized as ambivalent about accessing treatment services. Few studies have addressed the social context and related barriers that individuals experience in addressing substance abuse problems. These barriers appear to be heightened for female methamphetamine users living in rural areas of Appalachia. The purpose of this study is to document the willingness of active female methamphetamine users to access substance abuse treatment services, their ability to access substance abuse treatment services, and the barriers they experienced in accessing substance abuse treatment services. Findings from a sample of 153 rural female methamphetamine users revealed the majority of respondents met the criteria for substance dependence (99.3%), believed they had a drug problem (84.9%), believed they needed treatment services (62.9%), and wanted to go to treatment "now" (51.4%). However, only one fourth (26.8%) had accessed treatment, and many had experienced barriers in attempting to enter treatment services.

Students delivering health care to a vulnerable Appalachian population through interprofessional service-learning

Interprofessional student service-learning experiences are integrated into the preventive care of older adult residents of public housing in Appalachia. Receiving a Health Resources and Services Administration grant provided the College of Nursing at East Tennessee State University the opportunity to expand interprofessional clinical experiences for students by partnering with the College of Pharmacy, the College of Clinical & Rehabilitative Health Sciences, and the local public housing authority. Select faculty from each college met and developed a plan to form student teams from all three colleges to conduct in-home comprehensive medical and nutrition assessments and medication chart reviews of high-risk older adults. Following the in-home visit, students and faculty discuss the assessment findings at planned interprofessional meetings. Students present their findings from each discipline's perspective and collaboratively set health priorities and develop intervention strategies and an inclusive follow-up plan. Excerpts from students' reflective narratives discussing the impact of the interprofessional service-learning experiences are shared.

Surface water quality is improving due to declining atmospheric N deposition

We evaluated long-term surface water nitrate and atmospheric nitrogen (N) deposition trends for a group of nine predominantly forested Appalachian Mountain watersheds during a recent multidecadal period (1986-2009) in which regional NOx emissions have been progressively reduced. Statistical analysis showed unexpected linear declines in both annual surface water nitrate-N concentrations (mean =46.4%) and yields (mean =47.7%) among the watersheds corresponding to comparable declines in annual wet N deposition (mean =34.4%) resulting from U.S. NOx emission control programs during the same time period. Nitrate-N concentration trends were robust across a large geographical region and appeared insensitive to watershed size across several orders of magnitude-suggesting that the improvements in water quality are probably propagated to surface and estuarine waters downstream. Surface waters are thus responding to declining atmospheric N deposition in much the same way they responded to declining sulfur deposition-although only one watershed showed a 1:1 relationship. Application of a kinetic N saturation model indicated that all nine forested watersheds are exhibiting signs of N saturation as evidenced by a limited, but variable, efficiency of demand for N. Further reductions in N deposition would be expected to produce additional reductions in streamwater N loads.

Oral cancer screening and dental care use among women from Ohio Appalachia

INTRODUCTION

Residents of Appalachia may benefit from oral cancer screening given the region's higher oral and pharyngeal cancer mortality rates. The current study examined the oral cancer screening behaviors and recent dental care (since dentists perform most screening examinations) of women from Ohio Appalachia.

METHODS

Women from Ohio Appalachia were surveyed for the Community Awareness Resources Education (CARE) study, which was completed in 2006. A secondary aim of the CARE baseline survey was to examine oral cancer screening and dental care use among women from this region. Outcomes included whether women (n=477; cooperation rate = 71%) had ever had an oral cancer screening examination and when their most recent dental visit had occurred. Various demographic characteristics, health behaviors and psychosocial factors were examined as potential correlates. Analyses used multivariate logistic regression.

RESULTS

Most women identified tobacco-related products as risk factors for oral cancer, but 43% of women did not know an early sign of oral cancer. Only 15% of women reported ever having had an oral cancer screening examination, with approximately 80% of these women indicating that a dentist had performed their most recent examination. Women were less likely to have reported a previous examination if they were from urban areas (OR=0.33, 95% CI: 0.13-0.85) or perceived a lower locus of health control (OR=0.94, 95% CI: 0.89-0.98). Women were more likely to have reported a previous examination if they had had a dental visit within the last year (OR=2.24, 95% CI: 1.03-4.88). Only 65% of women, however, indicated a dental visit within the last year. Women were more likely to have reported a recent dental visit if they were of a high socioeconomic status (OR=2.83, 95% CI: 1.58-5.06), had private health insurance (OR=2.20, 95% CI: 1.21-3.97) or had consumed alcohol in the last month (OR=2.03, 95% CI: 1.20-3.42).

CONCLUSION

Oral cancer screening was not common among women from Ohio Appalachia, with many missed opportunities having occurred at dental visits. Education programs targeting dentists and other healthcare providers (given dental providers are lacking in some areas of Ohio Appalachia) about opportunistic oral cancer screening may help to improve screening in Appalachia. These programs should include information about populations at high risk for oral cancer (eg smokers) and how screening may be especially beneficial for them. Future research is needed to examine the acceptability of such education programs to healthcare providers in the Appalachian region and to explore why screening was less common among women living in urban areas of Ohio Appalachia.

Perceived risk of cervical cancer in Appalachian women

OBJECTIVE

To examine perceptions of cervical cancer risk in elevated-risk Appalachians.

METHODS

Appalachian women (n=571) completed interviews examining self-regulation model factors relevant to perceived risk of cervical cancer.

RESULTS

Women with good/very good knowledge of cervical cancer, greater worry, and history of sexually transmitted infection had higher odds of rating their perceived risk as somewhat/much higher than did other women. Former smokers, compared to never smokers, had lower risk perceptions.

CONCLUSIONS

Self-regulation model factors are important to understanding perceptions of cervical cancer risk in underserved women. The relationship of smoking and worry to perceived risk may be a target for intervention.

Main challenges facing the pharmaceutical sector in Buchanan County, Virginia: a pilot study

INTRODUCTION

Little is known about the challenges facing the pharmaceutical sector in rural counties in the USA. The aim of this pilot study is to determine the main challenges facing the pharmaceutical sector and suggestions for improving the sector in Buchanan County, a poor and marginalized county in Central Appalachia, Virginia.

METHODS

This cross-sectional study used the drop-by survey based on the first step of the modified Delphi Interview Technique. A convenience sample of healthcare professionals in Buchanan County were asked to complete a self-administered survey instrument between May and August 2011.

RESULTS

A total of 16 healthcare professionals including six pharmacists completed the survey. The respondents had worked for an average of 13.4 (SD=10.7) years in the County (range: 1-33 years). The main challenges facing the pharmaceutical sector were drug abuse (n=11), doctor shopping by patients (n=9), early refills (n=7) and drug shortage (n=6). Respondents suggested increased patient education by pharmacists (n=6) and better coordination and communication between pharmacy and doctor (n=6) to improve the pharmaceutical sector in the County.

CONCLUSIONS

Drug abuse, doctor shopping, early refills and drug shortage are the main challenges facing the pharmaceutical sector in Buchanan County. Concerted efforts are required to solve these problems. More research is required to confirm these findings.

A dynamic model using monitoring data and watershed characteristics to project fish tissue mercury concentrations in stream systems

A complex interplay of factors determines the degree of bioaccumulation of Hg in fish in any particular basin. Although certain watershed characteristics have been associated with higher or lower bioaccumulation rates, the relationships between these characteristics are poorly understood. To add to this understanding, a dynamic model was built to examine these relationships in stream systems. The model follows Hg from the water column, through microbial conversion and subsequent concentration, through the food web to piscivorous fish. The model was calibrated to 7 basins in Kentucky and further evaluated by comparing output to 7 sites in, or proximal to, the Ohio River Valley, an underrepresented region in the bioaccumulation literature. Water quality and basin characteristics were inputs into the model, with tissue concentrations of Hg of generic trophic level 3, 3.5, and 4 fish the output. Regulatory and monitoring data were used to calibrate and evaluate the model. Mean average prediction error for Kentucky sites was 26%, whereas mean error for evaluation sites was 51%. Variability within natural systems can be substantial and was quantified for fish tissue by analysis of the US Geological Survey National Fish Database. This analysis pointed to the need for more systematic sampling of fish tissue. Analysis of model output indicated that parameters that had the greatest impact on bioaccumulation influenced the system at several points. These parameters included forested and wetlands coverage and nutrient levels. Factors that were less sensitive modified the system at only 1 point and included the unfiltered total Hg input and the portion of the basin that is developed.

Factors influencing adherence to mammography screening guidelines in Appalachian women participating in a mobile mammography program

The objectives of this study were to evaluate the characteristics (demographic, access to care, health-related behavioral, self and family medical history, psychosocial) of women age 40 years and above who participated in a mobile mammography screening program conducted throughout West Virginia (WV) to determine the factors influencing their self-reported adherence to mammography screening guidelines. Data were analyzed using the Andersen Behavioral Model of Healthcare Utilization framework to determine the factors associated with adherence to mammography screening guidelines in these women. Of the 686 women included in the analysis, 46.2% reported having had a mammogram in the past 2 years. Bivariate analyses showed predisposing factors such as older age and unemployed status, visit to a obstetrician/gynecologist (OB/GYN) in the past year (an enabling factor) and need-related factors such as having a family history of breast cancer (BC), having had breast problems in the past, having had breast biopsy in the past, having had a Pap test in past 2 years, and having had all the screenings for cholesterol, blood glucose, bone mineral density and high blood pressure in past 2 years to be significant predictors of self-reported adherence to mammography guidelines. In the final model, being above 50 years (OR=2.132), being morbidly obese (OR=2.358), having BC-related events and low knowledge about mammography were significant predictors of self-reported adherence. Breast cancer related events seem to be associated with mammography screening adherence in this rural Appalachian population. Increasing adherence to mammography screening may require targeted, community-based educational interventions that precede and complement visits by the mobile mammography unit.

Hygiene self-care of older adults in West Virginia: effects of gender

PURPOSE

This study investigated whether oral hygiene self-care behavior differs between genders in older adults in Appalachia, a geographic area with significant oral health concerns. Identify ing the practices of older adults may provide valuable information for designing interventions and improving overall oral health outcomes.

METHODS

As part of a larger, on-going study on cognition and oral health in later life in Appalachia, a sample of dentate, older adults without dementia aged 70 and above (n=245, 86 men and 159 women) received an oral assessment by either a dentist or dental hygienist. Psychometricians assessed cognition using a standardized battery of neuropsychological tests. They also administered the General Oral Health Assessment Index and conducted structured interviews concerning diet, oral hygiene practices, oral health, social support, income and years of education Results: Over 80% of women (n=128) and 52.3% of men (n=45) reported brushing their teeth twice daily. Multivariate logistic regression analysis was conducted, controlling for socioeconomic status, social support (i.e., frequency of contacting friends and relatives), general oral health assessment items, number of decayed, missing and filled surfaces, plaque index and having regular dental visits. The results showed that women reported more frequent tooth brushing than their male counterparts (OR=4.04, 95% CI:1.93,8.42).

CONCLUSION

Older women in West Virginia had significantly better oral hygiene practices than older men, particularly regarding tooth brushing. Interventions are needed to improve older men's dental hygiene behaviors to improve overall oral health outcomes.

How many mountains can we mine? Assessing the regional degradation of Central Appalachian rivers by surface coal mining

Surface coal mining is the dominant form of land cover change in Central Appalachia, yet the extent to which surface coal mine runoff is polluting regional rivers is currently unknown. We mapped surface mining from 1976 to 2005 for a 19,581 km(2) area of southern West Virginia and linked these maps with water quality and biological data for 223 streams. The extent of surface mining within catchments is highly correlated with the ionic strength and sulfate concentrations of receiving streams. Generalized additive models were used to estimate the amount of watershed mining, stream ionic strength, or sulfate concentrations beyond which biological impairment (based on state biocriteria) is likely. We find this threshold is reached once surface coal mines occupy >5.4% of their contributing watershed area, ionic strength exceeds 308 μS cm(-1), or sulfate concentrations exceed 50 mg L(-1). Significant losses of many intolerant macroinvertebrate taxa occur when as little as 2.2% of contributing catchments are mined. As of 2005, 5% of the land area of southern WV was converted to surface mines, 6% of regional streams were buried in valley fills, and 22% of the regional stream network length drained watersheds with >5.4% of their surface area converted to mines.

Anthropogenic influences on macro-level mammal occupancy in the Appalachian Trail corridor

Anthropogenic effects on wildlife are typically assessed at the local level, but it is often difficult to extrapolate to larger spatial extents. Macro-level occupancy studies are one way to assess impacts of multiple disturbance factors that might vary over different geographic extents. Here we assess anthropogenic effects on occupancy and distribution for several mammal species within the Appalachian Trail (AT), a forest corridor that extends across a broad section of the eastern United States. Utilizing camera traps and a large volunteer network of citizen scientists, we were able to sample 447 sites along a 1024 km section of the AT to assess the effects of available habitat, hunting, recreation, and roads on eight mammal species. Occupancy modeling revealed the importance of available forest to all species except opossums (Didelphis virginiana) and coyotes (Canis latrans). Hunting on adjoining lands was the second strongest predictor of occupancy for three mammal species, negatively influencing black bears (Ursus americanus) and bobcats (Lynx rufus), while positively influencing raccoons (Procyon lotor). Modeling also indicated an avoidance of high trail use areas by bears and proclivity towards high use areas by red fox (Vulpes vulpes). Roads had the lowest predictive power on species occupancy within the corridor and were only significant for deer. The occupancy models stress the importance of compounding direct and indirect anthropogenic influences operating at the regional level. Scientists and managers should consider these human impacts and their potential combined influence on wildlife persistence when assessing optimal habitat or considering management actions.

Unmet dental and orthodontic need of children with special healthcare needs in West Virginia

INTRODUCTION

Of children aged 0-17 years in the USA, an estimated 11 203 616 (15.1%; 95% CI: 14.8, 15.3) are Children with Special Health Care Needs (CSHCN). The state of West Virginia, the heart of Appalachia, has a land mass which is 97.65% rural with previously identified high overall dental need and oral health disparities. It is home to an estimated 70 609 CSHCN, or 18.5% (95% CI: 17.0, 19.9) of the state's children in 2009-2010. The purpose of this study was to determine the parent/guardian's perceived unmet dental care need of CSHCN in West Virginia.

METHODS

Data from the National Survey of Children with Special Health Care Needs was used to determine prevalence. A telephone survey of 59 941 parents/guardians of CSHCN (1149 from West Virginia) for the dental interview was conducted in 2009-2010.

RESULTS

Nationwide, 26.7% (25.9, 27.5) of parents/guardians reported their CSHCN had dental care or orthodontia needs other than preventive care. In West Virginia, the perceived dental care or orthodontia needs other than preventive dental care need was 26.5% (22.2, 30.0). Unmet national dental care need other than preventive dental care was 5.4% (5.0, 5.9) and in West Virginia 5.0% (2.4, 7.5).

CONCLUSIONS

CSHCN have significant unmet dental needs. Parents/guardians in West Virginia reported similar unmet need compared with national reporting. Policies to address the health care of CSHCN should include dental needs. The clinical implications are that CSHCN have a variety of needs, including orthodontia. The benefits of orthodontic referrals should be considered in treatment planning options for CSHCN.

Chicken manure biochar as liming and nutrient source for acid Appalachian soil

Acid weathered soils often require lime and fertilizer application to overcome nutrient deficiencies and metal toxicity to increase soil productivity. Slow-pyrolysis chicken manure biochars, produced at 350 and 700°C with and without subsequent steam activation, were evaluated in an incubation study as soil amendments for a representative acid and highly weathered soil from Appalachia. Biochars were mixed at 5, 10, 20, and 40 g kg into a Gilpin soil (fine-loamy, mixed, active, mesic Typic Hapludult) and incubated in a climate-controlled chamber for 8 wk, along with a nonamended control and soil amended with agronomic dolomitic lime (AgLime). At the end of the incubation, soil pH, nutrient availability (by Mehlich-3 and ammonium bicarbonate diethylene triamine pentaacetic acid [AB-DTPA] extractions), and soil leachate composition were evaluated. Biochar effect on soil pH was process- and rate-dependent. Biochar increased soil pH from 4.8 to 6.6 at the high application rate (40 g kg), but was less effective than AgLime. Biochar produced at 350°C without activation had the least effect on soil pH. Biochar increased soil Mehlich-3 extractable micro- and macronutrients. On the basis of unit element applied, increase in pyrolysis temperature and biochar activation decreased availability of K, P, and S compared to nonactivated biochar produced at 350°C. Activated biochars reduced AB-DTPA extractable Al and Cd more than AgLime. Biochar did not increase NO in leachate, but increased dissolved organic carbon, total N and P, PO, SO, and K at high application rate (40 g kg). Risks of elevated levels of dissolved P may limit chicken manure biochar application rate. Applied at low rates, these biochars provide added nutritional value with low adverse impact on leachate composition.

An increase in HPV-related knowledge and vaccination intent among parental and non-parental caregivers of adolescent girls, age 9-17 years, in Appalachian Pennsylvania

A theory and community-based educational intervention was designed to increase HPV-related knowledge and intent to vaccinate adolescent girls, against human papillomavirus (HPV) in Appalachia, a region with high cervical cancer incidence and mortality. An HPV educational session was conducted with immediate pre-/post-test questionnaires and 1-month follow-up telephone interview. McNemar tests and paired t tests evaluated change in individual knowledge variables and change in overall knowledge and intent to vaccinate against HPV, respectively. Of 117 attendees, 38 (32.5%) were parents of vaccine-eligible daughters and 79 (67.5%) non-parental caregivers. HPV-related knowledge increased for all participants (p < 0.0001) and among parents (p < 0.0001). Intent to vaccinate daughters within 1 month increased among parents (p = 0.002). Of nine (23.7%) parents who completed the follow-up interview, 100% reported the intervention as helpful and 44.4% reported that they started vaccination. Our education intervention was associated with increased HPV-related knowledge and intent to vaccinate girls in Appalachia against HPV.

Early trends in landcover change and forest fragmentation due to shale-gas development in Pennsylvania: a potential outcome for the Northcentral Appalachians

Worldwide shale-gas development has the potential to cause substantial landscape disturbance. The northeastern U.S., specifically the Allegheny Plateau in Pennsylvania, West Virginia, Ohio, and Kentucky, is experiencing rapid exploration. Using Pennsylvania as a proxy for regional development across the Plateau, we examine land cover change due to shale-gas exploration, with emphasis on forest fragmentation. Pennsylvania's shale-gas development is greatest on private land, and is dominated by pads with 1-2 wells; less than 10 % of pads have five wells or more. Approximately 45-62 % of pads occur on agricultural land and 38-54 % in forest land (many in core forest on private land). Development of permits granted as of June 3, 2011, would convert at least 644-1072 ha of agricultural land and 536-894 ha of forest land. Agricultural land conversion suggests that drilling is somewhat competing with food production. Accounting for existing pads and development of all permits would result in at least 649 km of new road, which, along with pipelines, would fragment forest cover. The Susquehanna River basin (feeding the Chesapeake Bay), is most developed, with 885 pads (26 % in core forest); permit data suggests the basin will experience continued heavy development. The intensity of core forest disturbance, where many headwater streams occur, suggests that such streams should become a focus of aquatic monitoring. Given the intense development on private lands, we believe a regional strategy is needed to help guide infrastructure development, so that habitat loss, farmland conversion, and the risk to waterways are better managed.

Risk factors for smoking in rural women

BACKGROUND

This study examined the association between social, demographic, and psychologic factors and smoking status among Appalachian Ohio women. A secondary aim examined whether specific factors could be identified and segmented for future tailored treatment of tobacco dependence.

METHODS

A cross-sectional survey (n=570) obtained information about social, demographic, and psychologic factors and smoking. Logistic regression described associations between these characteristics and smoking status. Chi-square automatic interaction detection (CHAID) analyses identified subgroups at risk for smoking.

RESULTS

Fifty-two percent never smoked, with 20.5% and 27.5% categorized as former and current smokers, respectively. Women with low adult socioeconomic position (SEP) were more likely to smoke (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.74-5.34) compared to high SEP women. Other factors associated with current smoking included age 31-50 (OR 2.30, 95% CI 1.22-4.33), age 18-30 (OR 3.29, 95% CI 1.72-5.34), Center for Epidemiologic Studies Depression scale (CES-D) score≥16 (OR 1.99, 95% CI 1.31-3.05), and first pregnancy at age<20 (OR 1.74, 95% CI 1.14-2.66). The prevalence of smoking was 50% among those with four or more risk factors compared to 10% for those reporting no risk factors. CHAID analyses identified low adult SEP and depressive symptoms as the combination of risk factors most strongly associated with smoking; 49.3% of women in this subgroup currently smoked.

CONCLUSIONS

Low SEP in adulthood, maternal circumstances, and depressive symptoms are associated with current smoking. Tailored cessation interventions that address these risk factors should be developed and further evaluated in an attempt to reduce disparities in smoking prevalence among this vulnerable group of women.

Young women's perspectives on cervical cancer prevention in Appalachian Kentucky

Human papillomavirus (HPV) vaccination coupled with routine Papanicolaou (Pap) tests can prevent pervasive HPV infections causing cervical cancer. However, both HPV vaccination rates and Pap testing rates in Appalachian Kentucky are lower among all age groups than the rest of the United States. We recruited 19 young women residing in Appalachian Kentucky from university-based and rural clinical settings for group and individual interviews. After considering an integrated behavioral framework, we illustrate these women's perspectives by detailing five themes, including (a) experiential beliefs pose barriers to performing behaviors, (b) three vaccine doses complicate vaccination intention, (c) women have misunderstandings about HPV and the HPV vaccination function, (d) normative influences cue action (and inaction), and (e) specific environmental and contextual barriers exist to performing cervical cancer prevention behaviors in Appalachian Kentucky. These findings related to cervical cancer prevention in Appalachian Kentucky have implications for health-message design and clinical practice.

Which U.S. medical schools are providing the most physicians for the Appalachian region of the United States?

PURPOSE

To identify the U.S. medical schools with the most graduates practicing in rural, urban, and economically distressed areas of Appalachia.

METHOD

Using June 2009 American Medical Association Physician Masterfile data, the authors identified physicians who graduated from medical school during 1991-2005 and were practicing in the 420 counties of the United States' Appalachian region. They then determined the U.S. medical schools with the most 2001-2005 graduates practicing in primary care (PC) or non-PC specialties in urban or rural areas and the most 1991-2005 graduates practicing in economically distressed/at-risk counties.

RESULTS

Ten U.S. medical schools, led by the West Virginia School of Osteopathic Medicine, produced 50.5% (197/390) of 2001-2005 graduates practicing PC in rural areas of Appalachia; 10 schools, led by the University of Alabama School of Medicine, produced 44.1% (366/829) of graduates practicing PC in urban areas. During 2001-2005, 10 schools, led by the West Virginia University School of Medicine, graduated 42.1% (128/304) of non-PC physicians practicing in rural counties; 11 schools, led by the University of Alabama School of Medicine, graduated 38.5% (323/840) of non-PC physicians practicing in urban areas. All schools on the top 10 lists are located within states with Appalachian counties. University of Kentucky College of Medicine had the most 1991-2005 graduates practicing in economically distressed or at-risk counties.

CONCLUSIONS

Physicians practicing in Appalachia are largely graduates of medical schools in or near the region. New schools being developed in the region may help reduce its continuing physician shortages.

Delivering free healthcare to rural Central Appalachia population: the case of the Health Wagon

Central Appalachia residents present unique healthcare challenges. This vulnerable population faces poor health status and low access to health care. 'The Health Wagon' was established to innovatively enhance access to health care for the poor and marginalized rural population of Central Appalachia. This article describes the operations of the Health Wagon, a full mobile medical clinic, in delivering free health care to those in rural Southwest Virginia in Central Appalachia. The Health Wagon provides a wide range of comprehensive healthcare services, such as acute and chronic disease management, laboratory and diagnostic services, medication assistance, dental and eye care and specialty clinics for marginalized, poor and disenfranchised patients living in the mountains of that region. In 2009, a total of 157 clinics were provided and 2900 patients were seen (3165 patient encounters) in addition to 268 telemedicine specialty consultations at no cost to the patients. The work of the Health Wagon has broken down a financial barrier to healthcare access and offers unique and profound opportunities to improve health and expand health care in rural Central Appalachia.

Regionalization of soil base cation weathering for evaluating stream water acidification in the Appalachian Mountains, USA

Estimation of base cation supply from mineral weathering (BC(w)) is useful for watershed research and management. Existing regional approaches for estimating BC(w) require generalized assumptions and availability of stream chemistry data. We developed an approach for estimating BC(w) using regionally specific empirical relationships. The dynamic model MAGIC was used to calibrate BC(w) in 92 watersheds distributed across three ecoregions. Empirical relationships between MAGIC-simulated BC(w) and watershed characteristics were developed to provide the basis for regionalization of BC(w) throughout the entire study region. BC(w) estimates extracted from MAGIC calibrations compared reasonably well with BC(w) estimated by regression based on landscape characteristics. Approximately one-third of the study region was predicted to exhibit BC(w) rates less than 100 meq/m(2)/yr. Estimates were especially low for some locations within national park and wilderness areas. The regional BC(w) results are discussed in the context of critical loads (CLs) of acidic deposition for aquatic ecosystem protection.

Moyamoya in a non-Asian patient: a case report and review of the literature

Moyamoya disease (MMD) has historically been diagnosed in the Japanese population. However, newer studies have demonstrated worldwide distribution. Of note, patients of Appalachian descent with no known Asian ancestry have presented with MMD. We are presenting a case of MMD in an Appalachian, non-Asian patient who presented to the neurosurgical service with a severe headache of four days duration. The patient was found to have multiple hemorrhagic infarcts on CT and was admitted to the ICU. Cerebral angiography findings confirmed the diagnosis of MMD. Our case provides information regarding signs and symptoms, diagnostic neuroimaging findings, and treatment modalities for MMD.

Imidacloprid movement in soils and impacts on soil microarthropods in southern Appalachian eastern hemlock stands

Imidacloprid is a systemic insecticide effective in controlling the exotic pest (hemlock woolly adelgid) in eastern hemlock () trees. Concerns over imidacloprid impacts on nontarget species have limited its application in southern Appalachian ecosystems. We quantified the movement and adsorption of imidacloprid in forest soils after soil injection in two sites at Coweeta Hydrologic Laboratory in western North Carolina. Soils differed in profile depth, total carbon and nitrogen content, and effective cation exchange capacity. We injected imidacloprid 5 cm into mineral soil, 1.5 m from infested trees, using a Kioritz soil injector. We tracked the horizontal and vertical movement of imidacloprid by collecting soil solution and soil samples at 1 m, 2 m, and at the drip line from each tree periodically for 1 yr. Soil solution was collected 20 cm below the surface and just above the saprolite, and acetonitrile-extractable imidacloprid was determined through the profile. Soil solution and extractable imidacloprid concentrations were determined by high-performance liquid chromatography. Soil solution and extractable imidacloprid concentrations were greater in the site with greater soil organic matter. Imidacloprid moved vertically and horizontally in both sites; concentrations generally declined downward in the soil profile, but preferential flow paths allowed rapid vertical movement. Horizontal movement was limited, and imidacloprid did not move to the tree drip line. We found a negative relationship between adsorbed imidacloprid concentrations and soil microarthropod populations largely in the low-organic-matter site; however, population counts were similar to other studies at Coweeta.

Perceptions of smoking cessation programs in rural Appalachia

OBJECTIVES

To identify perspectives on smoking cessation programs in Appalachian Kentucky, a region with particularly high smoking rates and poor health outcomes.

METHODS

Insufficient existing research led us to conduct 12 focus groups (smokers and nonsmokers) and 23 key informant interviews.

RESULTS

Several findings previously not described in this high-risk population include (1) transition from pro-tobacco culture toward advocacy for tobacco cessation approaches, (2) region-specific challenges to program access, and (3) strong and diverse social influences on cessation.

CONCLUSIONS

To capitalize on changes from resistance to support for smoking cessation, leaders should incorporate culturally appropriate programs and characteristics identified here.