Restless legs syndrome in an appalachian primary care population: prevalence, demographic and lifestyle correlates, and burden

BACKGROUND

Restless legs syndrome (RLS) is a common and distressing sensorimotor disorder of unknown etiology. While the epidemiology of RLS has been examined in several North American and European studies, research on RLS and RLS burden in poor, rural populations, including those residing in Appalachia, remains sparse. In this study, we investigated RLS prevalence in an Appalachian primary care population and examined the association of RLS to demographic factors, lifestyle characteristics, sleep quality, and mood disorders.

METHODS

Participants of this anonymous survey study were community-dwelling adults aged ≥ 18 years visiting one of 4 West Virginia primary care clinics. Data gathered included detailed information on sleep patterns, demographic characteristics, lifestyle factors, and health/medical history; the survey also included questions specific to RLS diagnosis and severity. Response rates were excellent, with 68% of eligible adults contacted returning completed surveys (N = 1,424/2,087). Pregnant women (N = 65) and those with missing data on key variables (N = 142) were excluded from the analyses.

RESULTS

Of the 1,217 participants included in the final analytic sample, 19.6% (18.2% with symptoms at least once/month) met the 4 IRLSSG diagnostic criteria in the absence of positional discomfort or leg cramps; 14.5% reported RLS symptoms at least once/week and 10.1% indicated symptoms ≥ 3×/week. Excluding respondents with diabetes, kidney disease, or anemia reduced these rates only slightly. Those with RLS were more likely to be older, female, lower income, unemployed, disabled, non-Hispanic white, and less likely to be college educated than those without RLS. Mood and sleep impairment were significantly elevated in those with RLS; after adjustment for demographic and lifestyle characteristics, health history, and other factors, those with RLS remained significantly more likely to indicate a history of depression (adjusted odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.4, 2.6) and anxiety (OR = 1.6, CI 1.1, 2.2), to report sleep impairment both 4 (OR = 2.4, CI 1.6, 3.7) and 7 days/week (OR = 1.8, CI 1.3, 2.4), and a mean sleep duration < 5 h/night (OR = 1.7, CI 1.2, 2.3). These associations increased in both strength and magnitude with increasing symptom frequency (p's for trend ≤ 0.01).

CONCLUSIONS

Findings of this preliminary anonymous survey study suggest that RLS prevalence is high in this Appalachian primary care population and that RLS is associated with significant burden in terms of both mood and sleep impairment.

Effects of exurban development and temperature on bird species in the southern Appalachians

Land-use dynamics and climatic gradients have large effects on many terrestrial systems. Exurban development, one of the fastest growing forms of land use in the United States, may affect wildlife through habitat fragmentation and building presence may alter habitat quality. We studied the effects of residential development and temperature gradients on bird species occurrence at 140 study sites in the southern Appalachian Mountains (North Carolina, U.S.A.) that varied with respect to building density and elevation. We used occupancy models to determine 36 bird species' associations with building density, forest canopy cover, average daily mean temperature, and an interaction between building density and mean temperature. Responses varied with habitat requirement, breeding range, and migration distance. Building density and mean temperature were both included in the top occupancy models for 19 of 36 species and a building density by temperature interaction was included in models for 8 bird species. As exurban development expands in the southern Appalachians, interior forest species and Neotropical migrants are likely to decline, but shrubland or edge species are not likely to benefit. Overall, effects of building density were greater than those of forest canopy cover. Exurban development had a greater effect on birds at high elevations due to a greater abundance of sensitive forest-interior species and Neotropical migrants. A warming climate may exacerbate these negative effects.

Acceptability of HPV vaccine for males and preferences for future education programs among Appalachian residents

Appalachia is a geographic region with several disparities related to human papillomavirus (HPV) infection, yet little is known about acceptability of HPV vaccine for males among Appalachian residents. HPV vaccine acceptability and preferences for future HPV vaccine education programs were examined among residents of Appalachian Ohio. Focus groups and in-depth interviews were conducted with Appalachian Ohio residents between July and October 2011. Participants (n = 102 from 24 focus groups and 5 in-depth interviews) included four key stakeholder groups: health care providers, community leaders, parents with adolescent sons, and young adult men ages 18 to 26 years. Support for vaccinating males against HPV was high among participants, despite low awareness and knowledge about HPV vaccine for males. Participants reported three categories of potential barriers to vaccinating males against HPV: concerns about vaccine safety and side effects, access to care and vaccination logistics, and gender and cultural issues. Participants reported that HPV vaccine was viewed as being only for females in their communities and that receiving the vaccine may be emasculating or embarrassing to males. Participants suggested that future HPV vaccine education programs mainly target parents, include basic information about HPV-related diseases and HPV vaccine (e.g., number of doses, cost), and present the vaccine as having the potential to prevent cancer (as opposed to preventing genital warts). Acceptability of HPV vaccine for males was high among residents of Appalachian Ohio. Future HPV vaccine education programs in Appalachia should address common potential barriers to vaccination and help destigmatize vaccination among males.

Description of healthcare needs at an episodic clinic in rural southwest Virginia

INTRODUCTION

The objective of this study was to describe the population served at an episodic clinic in Southwest Virginia to better understand patient needs at a yearly episodic Remote Area Medical (RAM) clinic that provides free healthcare services.

METHODS

The dataset was compiled retrospectively from 2834 medical records from RAM patients between 1 July 2006 and 31 July 2008. Information was de-identified and manually recorded from paper records. The data were analyzed using descriptive statistics and compared to pre-existing estimates from the region.

FINDINGS

The number and type of services rendered at the RAM clinic each year varied greatly, and was dependent on the availability of staff and supplies. Diabetes, hypertension, and other prevalent diseases were reported, and an overwhelming majority (74%) of patients were overweight or obese. In 2008, 62% of patients were uninsured, 44% had no primary care physician, and a majority of patients were diagnosed with hypertension or poorly managed diabetes.

CONCLUSIONS

Chronic diseases including obesity, hypertension, diabetes, and arthritis plague the Appalachian region. However, better knowledge of the medically underserved in this region can help address the patient's needs through RAM clinics and other accessible health clinics by increasing patient and physician awareness of available services, decreasing patient waiting time, and improving medical recordkeeping.

Down deep in the holler: chasing seeds and stories in southern Appalachia

This essay, which is the third in the series "Recollections, Reflections, and Revelations: Ethnobiologists and their First Time in the Field", is a personal reflection by the researcher on his experience and involvement in kinship and friendship networks while conducting agrobiodiversity research in southern Appalachia, USA. Vignettes are given from moving moments spent with Native spiritual leaders, backcountry mountain people, and local co-collaborators in the research process. The author demonstrates how lasting field friendships have helped lead to groundbreaking ethnoecological research.

Appalachian women's perspectives on breast and cervical cancer screening

INTRODUCTION

Although breast and cervical cancer screening rates have been increasing over the three past decades, many Appalachian women in the USA do not receive screening, leading to disproportionate mortality rates. The aims of this study were to: (1) better understand barriers to and facilitators of breast and cervical cancer screening among Appalachian women; and (2) identify strategies to increase cancer screening.

METHODS

Eight focus groups and 19 key informant interviews were conducted with 79 participants. Tape-recorded session were transcribed and content analyzed.

RESULTS

Findings consistent with screening determinants research include: inadequate personal and community resources, attitudinal and knowledge barriers, and competing demands. Less commonly described factors include family cancer history, personal health habits, and the multiple influences of healthcare providers.

CONCLUSIONS

Interpreting findings in terms of consumer information processing theory, healthcare providers and supports play a key role in educating and influencing the screening uptake among Appalachian Kentucky women. These findings have the potential to inform innovative and culturally consonant intervention approaches capable of increasing screening and decreasing mortality rates.

Frenolicins C-G, pyranonaphthoquinones from Streptomyces sp. RM-4-15

Appalachian active coal fire sites were selected for the isolation of bacterial strains belonging to the class actinobacteria. A comparison of high-resolution electrospray ionization mass spectrometry (HRESIMS) and ultraviolet (UV) absorption profiles from isolate extracts to natural product databases suggested Streptomyces sp. RM-4-15 to produce unique metabolites. Four new pyranonaphthoquinones, frenolicins C-F (1-4), along with three known analogues, frenolicin (6), frenolicin B (7), and UCF76-A (8), were isolated from the fermentation of this strain. An additional new analogue, frenolicin G (5), along with two known compounds, deoxyfrenolicin (9) and UCF 13 (10), were isolated from the fermentation supplied with 18 mg/L of scandium chloride, the first example, to the best of our knowledge, wherein scandium chloride supplementation led to the confirmed production of new bacterial secondary metabolites. Structures 1-5 were elucidated on the basis of spectral analysis and chemical modification. While frenolicins are best known for their anticoccidial activity, the current study revealed compounds 6-9 to exhibit moderate cytotoxicity against the human lung carcinoma cell line (A549) and thereby extends the anticancer SAR for this privileged scaffold.

Appalachian women and heart health: current prevention strategies and future directions

BACKGROUND

Heart disease claims the lives of 25% of women in the United States. Only about half of women recognize it as the number one cause of adult female mortality, indicating a gap in the public's knowledge base. In West Virginia, women often face barriers such as social isolation, lack of healthy lifestyle options and fewer physician visits.

METHODS

Literature review focused on successful efforts to remedy barriers in Appalachian women with strategies such as community outreach, group, and individual education.

RESULTS

Primary care doctors can get involved by providing personalized information on heart health risk and utilizing appointments as opportunities for preventative heart health treatment.

CONCLUSIONS

Future initiatives should highlight the need for brief, accurate risk assessments and continued encouragement to decrease cardiac risk factors. An ongoing West Virginia Rural Scholars project is aimed at achieving those two aforementioned goals: increasing awareness and reducing risk factors for women's heart health.

Adaptation of an evidence-based intervention for Appalachian women: new STEPS (Strength Through Education, Physical fitness and Support) for breast health

Appalachia is characterized by a high prevalence of individual-level risks for breast cancer, including physical inactivity and postmenopausal obesity. The availability of local, evidence-based programs to improve physical fitness is limited. We adapted an evidence-based intervention, StrongWomen, to improve physical fitness and increase breast cancer knowledge among women 40 years and older in Appalachian Pennsylvania. Utilizing a multi-site, community-based design, we tested the adapted 12-week, supervised program-New STEPS (Strength Through Education, Physical fitness and Support)-among 139 women. The completion rate was 67.6 %. Pre/post scores improved for each of six fitness assessments (P<0.01). We found differences in overall fitness by study site (P<0.001), but no differences by age (P=0.13) or by previous breast cancer diagnosis (P=0.73). New STEPS is an adapted, evidence-based program that can improve physical fitness and breast cancer awareness among women in Appalachian Pennsylvania. New STEPS may help fill a void in local fitness programs for Appalachian women at risk for breast cancer or breast cancer recurrence.

Future species composition will affect forest water use after loss of eastern hemlock from southern Appalachian forests

Infestation of eastern hemlock (Tsuga canadensis (L.) Carr.) with hemlock woolly adelgid (HWA, Adelges tsugae) has caused widespread mortality of this key canopy species throughout much of the southern Appalachian Mountains in the past decade. Because eastern hemlock is heavily concentrated in riparian habitats, maintains a dense canopy, and has an evergreen leaf habit, its loss is expected to have a major impact on forest processes, including transpiration (E(t)). Our goal was to estimate changes in stand-level E(t) since HWA infestation, and predict future effects of forest regeneration on forest E(t) in declining eastern hemlock stands where hemlock represented 50-60% of forest basal area. We used a combination of community surveys, sap flux measurements, and empirical models relating sap flux-scaled leaf-level transpiration (E(L)) to climate to estimate the change in E(t) after hemlock mortality and forecast how forest E(t) will change in the future in response to eastern hemlock loss. From 2004 to 2011, eastern hemlock mortality reduced annual forest E(t) by 22% and reduced winter E(t) by 74%. As hemlock mortality increased, growth of deciduous tree species--especially sweet birch (Betula lenta L.), red maple (Acer rubrum L.), yellow poplar (Liriodendron tulipifera L.), and the evergreen understory shrub rosebay rhododendron (Rhododendron maximum L.)--also increased, and these species will probably dominate post-hemlock riparian forests. All of these species have higher daytime E(L) rates than hemlock, and replacement of hemlock with species that have less conservative transpiration rates will result in rapid recovery of annual stand E(t). Further, we predict that annual stand E(t) will eventually surpass E(t) levels observed before hemlock was infested with HWA. This long-term increase in forest E(t) may eventually reduce stream discharge, especially during the growing season. However, the dominance of deciduous species in the canopy will result in a permanent reduction in winter E(t) and possible increase in winter stream discharge. The effects of hemlock die-off and replacement with deciduous species will have a significant impact on the hydrologic flux of forest transpiration, especially in winter. These results highlight the impact that invasive species can have on landscape-level ecosystem fluxes.

Predictors of alcohol use among rural drug users after disclosure of hepatitis C virus status

OBJECTIVE

Alcohol consumption dramatically increases the risk of liver damage among those with hepatitis C virus (HCV) infection, yet the impact of HCV status disclosure and standard informational counseling on alcohol use among rural drug users remains poorly understood.

METHOD

In this prospective study, 503 rural Appalachian drug users were recruited using respondent-driven sampling. Participants were tested for HCV antibodies, and data on sociodemographic characteristics, lifetime and past-30-day drug and alcohol use, and psychiatric disorders were collected by interviewer-administered questionnaires. A total of 470 participants returned after 6 months for follow-up; however,4 of those had no history of alcohol use, thus leaving a final sample size of 466. Multivariate negative binomial regression was used to determine the effect of disclosure of HCV status and posttest counseling on alcohol consumption at follow-up.

RESULTS

Despite an overall decrease in drinking frequency in the cohort, those who were HCV-positive were drinking at a frequency similar to their HCV-negative counterparts at follow-up, despite posttest counseling informing them of the risks of alcohol use with an HCV diagnosis (adjusted incidence rate ratio = 1.07, 95% CI [0.72, 1.61]). Significant predictors of increased days of alcohol use after 6 months included baseline alcohol use, baseline marijuana use, and meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for antisocial personality disorder. Those using OxyContin at baseline had significantly fewer days of alcohol use at follow-up.

CONCLUSIONS

HCV status disclosure and standard informational counseling alone do not curtail drinking among HCV-positive drug users in the rural setting. Targeted interventions with regard to alcohol use are warranted in order to mitigate the damage of the HCV epidemic.

Ecosystem function in Appalachian headwater streams during an active invasion by the hemlock woolly adelgid

Forested ecosystems in the southeastern United States are currently undergoing an invasion by the hemlock woolly adelgid (HWA). Previous studies in this area have shown changes to forest structure, decreases in canopy cover, increases in organic matter, and changes to nutrient cycling on the forest floor and soil. Here, we were interested in how the effects of canopy loss and nutrient leakage from terrestrial areas would translate into functional changes in streams draining affected watersheds. We addressed these questions in HWA-infested watersheds at the Coweeta Hydrologic Laboratory in North Carolina. Specifically, we measured stream metabolism (gross primary production and ecosystem respiration) and nitrogen uptake from 2008 to 2011 in five streams across the Coweeta basin. Over the course of our study, we found no change to in-stream nutrient concentrations. While canopy cover decreased annually in these watersheds, this change in light penetration did not translate to higher rates of in-stream primary production during the summer months of our study. We found a trend towards greater heterotrophy within our watersheds, where in-stream respiration accounted for a much larger component of net ecosystem production than GPP. Additionally, increases in rhododendron cover may counteract changes in light and nutrient availability that occurred with hemlock loss. The variability in our metabolic and uptake parameters suggests an actively-infested ecosystem in transition between steady states.

Adherence to a Mediterranean diet in a rural Appalachian food desert

INTRODUCTION

Rural Appalachian food deserts have disproportionately high cardiovascular disease (CVD) rates. The Mediterranean diet, consisting of plant-based dishes prepared with unsaturated fatty acids, contributes to decreased risk of CVD. Several factors can affect dietary choices in rural food deserts. The purpose of this exploratory study was to identify predisposing, reinforcing and enabling factors that affect eating a Mediterranean diet in a rural Appalachian food desert with disproportionately high rates of cardiovascular disease. The PRECEDE-PROCEED model was used as an assessment framework in this study.

METHODS

Volunteers (n=43) were recruited from four churches in a rural Appalachian county to participate in this mixed methods convergent parallel design study. During each of four sessions with 8-12 participants each, a Mediterranean-style meal was prepared by a local caterer and included plant-based dishes prepared with unsaturated fatty acids. The nature of a Mediterranean diet was explained to participants using an illustrated pamphlet. Nominal group process was used to determine predisposing, reinforcing and enabling factors that would affect adherence to a Mediterranean diet. Multivariate ANOVA and t-tests, using SPSS 18, were performed to determine factors associated with potential future adoption and adherence to a Mediterranean diet among a sample of rural residents and assess whether the factors varied based on age, gender and socioeconomic status. All p values of ≤0.05 were considered significant.

RESULTS

Factors affecting future adherence to a Mediterranean diet included difficulty changing personal habits, limited access to healthy foods, cost, difficulty of preparation, limited knowledge of the health benefits of foods, family attitudes toward food and difficulty determining how to incorporate healthy foods into meals. Younger participants and those with lower incomes were more likely to identify food cost as a barrier to adherence compared to those who were older with higher incomes. Participants with lower educational levels were more likely to report family members would be hesitant to try a Mediterranean diet. Women were more likely than men to report an understanding of the health impact of certain foods as motivation to adopt and adhere to a Mediterranean diet.

CONCLUSION

Multiple factors were reported as influencing dietary habits in this sample of rural Appalachian residents. Several of the factors reported are amenable to behavioral interventions. Although Appalachia has more residents per square kilometer than the rest of the country, the population density is not uniform across the region. Because many Appalachians live in sparsely populated counties, rurality plays a significant role in factors that affect dietary choice. Interventions that address barriers related to limited knowledge of nutrition, ease of preparation and changing personal habits as well as promote locally available foods, while considering issues specific to a rural population, may lead to sustained dietary changes.

Predictors of initial uptake of human papillomavirus vaccine uptake among rural Appalachian young women

Women in Appalachian Kentucky experience a high burden of cervical cancer and have low rates of human papillomavirus (HPV) vaccination. The purpose of this study was to identify normative influences predicting initial HPV vaccine uptake among a sample of young women in southeastern Kentucky. Women (N = 495), ages 18 through 26 years, were recruited from clinics and community colleges. After completing a questionnaire, women received a free voucher for HPV vaccination. Whether women redeemed the voucher for Dose 1 served as the primary outcome variable. Hierarchical logistic regression was used to estimate the influence of healthcare providers, friends, mothers, and fathers on vaccine uptake. One-quarter of the total sample (25.9%) received Dose 1. Uptake was higher in the clinic sample (45.1%) than in the college sample (6.9%). On multivariate analysis, women indicating that their healthcare provider suggested the vaccine, that their friends would "definitely" want them to be vaccinated, and that their fathers would "definitely" want them to receive the vaccine all were 1.6 times more likely to receive Dose 1. Interaction effects occurred between recruitment site (clinic vs. community college) and all three of the normative influences retaining multivariate significance, indicating that the associations only applied to the clinic sample. HPV vaccine interventions may benefit from highlighting paternal endorsement, healthcare provider recommendation, and peer support.

Perceptions of healthful eating and influences on the food choices of Appalachian youth

OBJECTIVE

Patterns of overweight and obesity have an unequal geographic distribution, and there are elevated rates in Appalachia. Perceptions of Appalachian youth toward healthful eating and influences on food choice were examined as part of formative research to address these disparities.

METHODS

Eleven focus groups, averaging 6 youth (n = 68) and moderated by experienced local residents, were conducted with participants aged 8-17. Session transcripts were coded for thematic analysis, using measures to enhance rigor and transferability.

RESULTS

Participants discussed numerous internal and external factors affecting dietary choices. They expressed confidence in their own nutritional knowledge, and they stressed the importance of taste preferences, cost, convenience, social influences, and advertising on diet.

CONCLUSIONS AND IMPLICATIONS

Appalachian youth awareness of the multiple influences on diet may create opportunities for multifaceted, ecologically based interventions. In particular, participants stressed the importance of social influences on diet and on successful nutrition programming.

The conceptualization and communication of risk among rural appalachian adolescents

This study uses a meta-theoretical perspective for examining risk perceptions and behavior in the rural Appalachian cultural context, an area that remains largely unexplored. The authors conducted in-depth interviews with 113 rural adolescents to describe how youth conceptualize risk and how risk is communicated in the rural environment. Analyses revealed adolescents viewed behavior as risky when they had personal or vicarious experiences resulting in a loss of control or physical harm. Elements of the rural Appalachian culture including activities, familism, and community ties can prevent and promote adolescent risk taking in various forms. This study demonstrates the conceptualization of risk and messages about risk are culturally situated and communicatively devised and enacted. The implications of these findings for adolescent risk prevention programs are discussed.

Treatment adherence in a lay health adviser intervention to treat tobacco dependence

Lay health advisers (LHAs) are increasingly used to deliver tobacco dependence treatment, especially with low-socioeconomic status (SES) populations. More information is needed about treatment adherence to help interpret mixed evidence of LHA intervention effectiveness. This study examined adherence to behavioral counseling and nicotine patches in an LHA intervention with 147 Ohio Appalachian female daily smokers. Participants were randomly selected from clinics and randomized to the intervention condition of a randomized controlled trial. Overall, 75.5% of participants received all seven planned LHA visits, 29.3% used patches for >7 weeks and approximately half received high average ratings on participant responsiveness. Depressive symptoms and low nicotine dependence were associated with lower patch adherence while high poverty-to-income ratio was associated with high responsiveness. Compared with those with fewer visits, participants who received all visits were more likely to be abstinent (22.5 versus 2.8%, P=0.026) or have attempted quitting (85.0 versus 47.4%, P=0.009) at 3 months. High participant responsiveness was associated with 12-month abstinence. LHA interventions should focus on improving adherence to nicotine patches and managing depression because it is an independent risk factor for low adherence.

Relationship of land use and elevated ionic strength in Appalachian watersheds

Coal mining activities have been implicated as sources that increase stream specific conductance in Central Appalachia. The present study characterized potential sources of elevated ionic strength for small subwatersheds within the Coal, Upper Kanawha, Gauley, and New Rivers in West Virginia. From a large monitoring data set developed by the West Virginia Department of Environmental Protection, 162 < 20-km(2)-watersheds were identified that had detailed land cover information in southwestern West Virginia with at least one water chemistry sample. Scatter plots of specific conductance were generated for nine land cover classifications: open water, agriculture, forest, residential, barren, total mining, valley fill, abandoned mine lands, and mining excluding valley fill and abandoned mine lands. Conductivity was negatively correlated with the percentage of forest area and positively associated with other land uses. In a multiple regression, the percentage of area in valley fill was the strongest contributor to increased ionic strength, followed by percentage of area in urban (residential/buildings) land use and other mining land use. Based on the 10th quantile regression, 300 µS/cm was exceeded at 3.3% of area in valley fill. In most catchments, HCO 3(-) and SO 4(2-) concentrations were greater than Cl(-) concentration. These findings confirm coal mining activities as the primary source of high conductivity waters. Such activities might be redressed with the goal of protecting sources of dilute freshwater in the region.

Assessing causation of the extirpation of stream macroinvertebrates by a mixture of ions

Increased ionic concentrations are associated with the impairment of benthic invertebrate assemblages. However, the causal nature of that relationship must be demonstrated so that it can be used to derive a benchmark for conductivity. The available evidence is organized in terms of six characteristics of causation: co-occurrence, preceding causation, interaction, alteration, sufficiency, and time order. The inferential approach is to weight the lines of evidence using a consistent scoring system, weigh the evidence for each causal characteristic, and then assess the body of evidence. Through this assessment, the authors found that a mixture containing the ions Ca(+), Mg(+), HCO 3(-), and SO 4(-), as measured by conductivity, is a common cause of extirpation of aquatic macroinvertebrates in Appalachia where surface coal mining is prevalent. The mixture of ions is implicated as the cause rather than any individual constituent of the mixture. The authors also expect that ionic concentrations sufficient to cause extirpations would occur with a similar salt mixture containing predominately HCO 3(-), SO 4(2-), Ca(2+), and Mg(2+) in other regions with naturally low conductivity. This case demonstrates the utility of the method for determining whether relationships identified in the field are causal.

Ethanol injection of ornamental trees facilitates testing insecticide efficacy against ambrosia beetles (Coleoptera: Curculionidae: Scolytinae)

Exotic ambrosia beetles are damaging pests in ornamental tree nurseries in North America. The species Xylosandrus crassiusculus (Motshulsky) and Xylosandrus germanus (Blandford) are especially problematic. Management of these pests relies on preventive treatments of insecticides. However, field tests of recommended materials on nursery trees have been limited because of unreliable attacks by ambrosia beetles on experimental trees. Ethanol-injection of trees was used to induce colonization by ambrosia beetles to evaluate insecticides and botanical formulations for preventing attacks by ambrosia beetles. Experiments were conducted in Ohio, Tennessee, and Virginia. Experimental trees injected with ethanol had more attacks by ambrosia beetles than uninjected control trees in all but one experiment. Xylosandrus crassiusculus and X. germanus colonized trees injected with ethanol. In most experiments, attack rates declined 8 d after ethanol-injection. Ethanol-injection induced sufficient pressure from ambrosia beetles to evaluate the efficacy of insecticides for preventing attacks. Trunk sprays of permethrin suppressed cumulative total attacks by ambrosia beetles in most tests. Trunk sprays of the botanical formulations Armorex and Veggie Pharm suppressed cumulative total attacks in Ohio. Armorex, Armorex + Permethrin, and Veggie Pharm + Permethrin suppressed attacks in Tennessee. The bifenthrin product Onyx suppressed establishment of X. germanus in one Ohio experiment, and cumulative total ambrosia beetle attacks in Virginia. Substrate drenches and trunk sprays of neonicotinoids, or trunk sprays of anthranilic diamides or tolfenpyrad were not effective. Ethanol-injection is effective for inducing attacks and ensuring pressure by ambrosia beetles for testing insecticide efficacy on ornamental trees.

A method for assessing the potential for confounding applied to ionic strength in central Appalachian streams

Causal relationships derived from field data are potentially confounded by variables that are correlated with both the cause and its effect. The present study presents a method for assessing the potential for confounding and applies it to the relationship between ionic strength and impairment of benthic invertebrate assemblages in central Appalachian streams. The method weighs all available evidence for and against confounding by each potential confounder. It identifies 10 types of evidence for confounding, presents a qualitative scoring system, and provides rules for applying the scores. Twelve potential confounders were evaluated: habitat, organic enrichment, nutrients, deposited sediments, pH, selenium, temperature, lack of headwaters, catchment area, settling ponds, dissolved oxygen, and metals. One potential confounder, low pH, was found to be biologically significant and eliminated by removing sites with pH < 6. Other potential confounders were eliminated based on the weight of evidence. This method was found to be useful and defensible. It could be applied to other environmental assessments that use field data to develop causal relationships, including contaminated site remediation or management of natural resources.

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.

Compositional stability and diversity of vascular plant communities following logging disturbance in Appalachian forests

Human-caused changes in disturbance regimes and introductions of nonnative species have the potential to result in widespread, directional changes in forest community structure. The degree that plant community composition persists or changes following disturbances depends on the balance between local extirpation and colonization by new species, including nonnatives. In this study, we examined species losses and gains, and entry of native vs. exotic species to determine how oak forests in the Appalachian Mountains might shift in species composition following a gradient of pulse disturbances (timber harvesting). We asked (1) how compositional stability of the plant community (resistance and resilience) was influenced by disturbance intensity, (2) whether community responses were driven by extirpation or colonization of species, and (3) how disturbance intensity influenced total and functional group diversity, including the nonnative proportion of the flora through time. We collected data at three spatial scales and three times, including just before, one year post-disturbance, and 10 years post-disturbance. Resistance was estimated using community distance measures between pre- and one year post-disturbance, and resilience using community distance between pre- and 10-year post-disturbance conditions. The number of colonizing and extirpated species between sampling times was analyzed for all species combined and for six functional groups. Resistance and resilience decreased with increasing timber-harvesting disturbance; compositional stability was lower in the most disturbed plots, which was driven by colonization, but not extirpation, of species. Colonization of species also led to increases in diversity after disturbance that was typically maintained after 10 years following disturbance. Most of the community-level responses were driven by post-disturbance colonization of native forbs and graminoids. The nonnative proportion of plant species tended to increase following disturbance, especially at large spatial scales in the most disturbed treatments, but tended to decrease through time following disturbance due to canopy development. The results of this study are consistent with the theory that resources released by disturbance have strong influences on species colonization and community composition. The effects of management activities tested in this study, which span a gradient of timber-harvesting disturbance, shift species composition largely via an increase in species colonization and diversity.

The effects of mountaintop mines and valley fills on the physicochemical quality of stream ecosystems in the central Appalachians: a review

This review assesses the state of the science on the effects of mountaintop mines and valley fills (MTM-VF) on the physicochemical characteristics of streams in the central Appalachian coalfields of West Virginia, Kentucky, Virginia and Tennessee, USA. We focus on the impacts of mountaintop removal coal mining, which involves removing all - or some portion - of the top of a mountain or ridge to expose and mine one or more coal seams. Excess overburden is disposed in constructed fills in small valleys adjacent to the mining site. MTM-VF leachate persistently increases the downstream concentrations of major ions. Conductivity is a coarse measure of these ions, which are dominated by a distinct mixture of SO(4)(2-), HCO(3)(-), Ca(2+) and Mg(2+), that reflects their source, the oxidation of pyrite to form acid followed by neutralization of the acidity by carbonate minerals within the valley fills. This results in neutral to alkaline pHs, a range at which many metals are relatively insoluble. Other compounds within coal or overburden are solubilized and occur at elevated albeit lower concentrations, including K(+), Na(+), Cl(-), Se and Mn. In terms of physical characteristics, the valley fills act like headwater aquifers, baseflows increase in streams below valley fills and water temperatures exhibit reduced seasonal variation. Peak discharges may be increased in response to intense precipitation events, because of compaction of base surfaces of the MTM-VF areas, but newer approaches to reclamation reduce this compaction and may ameliorate these peak flows. Although the sedimentation pond is intended to capture fine particles that wash downstream from the valley fill, some studies found increased fine sediments in streams downstream from valley fills. However, a proportion of these fines may be eroded from stream banks rather than the valley fills. This is probably a result of the alterations in stream flows.

Ohio Appalachian residents' views on smoke-free laws and cigarette warning labels

INTRODUCTION

Smoke-free laws and the addition of graphic warning labels to cigarette packages represent public health policies that can potentially reduce smoking and smoking-related disease. The attitudes and beliefs relating to these policies were examined among residents of Ohio Appalachia, a mostly rural region with high smoking prevalence among its residents.

METHODS

Focus groups were conducted with participants from Ohio Appalachia during the summer of 2007. Groups included healthcare providers (n=37), community leaders (n=31), parents (n=19), and young adult women aged 18-26 years (n=27).

RESULTS

Most participants were female (94%), non-Hispanic White (94%), and married (65%). Participants believed that most non-smokers supported Ohio's enforced statewide comprehensive smoke-free law that began in 2007, while some smokers opposed the law due to a perceived infringement of their rights. They also reported that most residents and local businesses were abiding by and enforcing the law. Participants supported the addition of graphic warning labels to cigarette packages in the USA. They believed that such warning labels could help deter adolescents and adult non-smokers from smoking initiation, particularly if the negative aesthetic effects of smoking were emphasized. However, they felt the labels would be less effective among current smokers and older individuals living in their communities.

CONCLUSIONS

Participants generally held positive views about both the smoke-free law and the addition of graphic warning labels to cigarette packages in the USA. These tobacco-related public health policies are promising strategies for potentially reducing smoking and its associated diseases among residents living in Appalachia. Additional research is needed to further examine support for these policies among more diverse Appalachian populations.

Disparities in underserved white populations: the case of cancer-related disparities in Appalachia

There are meaningful cancer-related disparities in the Appalachian region of the U.S. To address these disparities, the Appalachia Community Cancer Network (ACCN), a collaboration of investigators and community partners in five states (Kentucky, Ohio, Pennsylvania, Virginia, and West Virginia), is involved in increasing cancer education and awareness, conducting community-based participatory research (CBPR), and creating mentorship and training opportunities. The primary objective of this paper is to describe cancer-related disparities in the Appalachian region of the U.S. as an example of the disparities experienced by underserved, predominantly white, rural populations, and to describe ACCN activities designed to intervene regarding these disparities. An ACCN overview/history and the diverse activities of ACCN-participating states are presented in an effort to suggest potential useful strategies for working to reduce health-related disparities in underserved white populations. Strengths that have emerged from the ACCN approach (e.g., innovative collaborations, long-standing established networks) and remaining challenges (e.g., difficulties with continually changing communities, scarce resources) are described. Important recommendations that have emerged from the ACCN are also presented, including the value of allowing communities to lead CBPR efforts. Characteristics of the community-based work of the ACCN provide a framework for reducing health-related disparities in Appalachia and in other underserved white and rural populations.