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Background: According to the U.S. Centers for Disease Control and Prevention, approximately 10.2 % of fatal overdoses in 2022 were among people experiencing homelessness or housing instability. In the United States, the majority of all drug overdoses now involve stimulants., Methods: We linked stimulant-involved fatal overdose records occurring between 2017 and 2021 from Kentucky's Drug Overdose Fatality Surveillance System to the electronic health records (EHR) of the state's largest safety-net hospital network. We used State Unintentional Drug Overdose Reporting System (SUDORS) definitions of homelessness or housing instability to establish baseline estimates before linking decedents to medical records. After linkage, we augmented SUDORS data with structured administrative billing codes, semi-structured address data, and unstructured clinical notes identifying homelessness from the EHR., Results: There were 313 individuals with stimulant-involved fatal overdoses linked to at least one medical encounter in the EHR (2017-2021). Thirty-three individuals (10.5 %) were identified as having unstable housing according to SUDORS. After linkage, 130 individuals (41.5 %) had evidence of housing instability. For this period, these 313 individuals represent 8.0 % of stimulant-involved overdoses in KY or 38.5 % of stimulant-involved overdoses from residents of the primary and secondary catchment area of our healthcare network., Conclusions: The single-site increase in observed housing instability in stimulant-involved fatal overdoses suggests that increased data linkage between state medicolegal death investigation system and EHRs would significantly improve the public health surveillance of overdoses., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024. Published by Elsevier B.V.)

Occupational motor vehicle (OMV) crashes are a leading cause of occupation-related injury and fatality in the United States. Statewide crash databases provide a good source for identifying crashes involving large commercial vehicles but are less optimal for identifying OMV crashes involving light or medium vehicles. This has led to an underestimation of OMV crash counts across states and an incomplete picture of the magnitude of the problem. The goal of this study was to develop and pilot a systematic process for identifying OMV crashes in light and medium vehicles using both state crash and health-related surveillance databases. A two-fold process was developed that included: 1) a machine learning approach for mining crash narratives and 2) a deterministic data linkage effort with crash state data and workers compensation (WC) claims records and emergency medical service (EMS) data, independently. Overall, the combined process identified 5,302 OMV crashes in light and medium vehicles within one year's worth of crash data. Findings suggest the inclusion of multi-method approaches and multiple data sources can be implemented and used to improve OMV crash surveillance in the United States., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Importance: The HEALing Communities Study (HCS) evaluated the effectiveness of the Communities That HEAL (CTH) intervention in preventing fatal overdoses amidst the US opioid epidemic., Objective: To evaluate the impact of the CTH intervention on total drug overdose deaths and overdose deaths involving combinations of opioids with psychostimulants or benzodiazepines., Design, Setting, and Participants: This randomized clinical trial was a parallel-arm, multisite, community-randomized, open, and waitlisted controlled comparison trial of communities in 4 US states between 2020 and 2023. Eligible communities were those reporting high opioid overdose fatality rates in Kentucky, Massachusetts, New York, and Ohio. Covariate constrained randomization stratified by state allocated communities to the intervention or control group. Trial groups were balanced by urban or rural classification, 2016-2017 fatal opioid overdose rate, and community population. Data analysis was completed by December 2023., Intervention: Increased overdose education and naloxone distribution, treatment with medications for opioid use disorder, safer opioid prescribing practices, and communication campaigns to mitigate stigma and drive demand for evidence-based interventions., Main Outcomes and Measures: The primary outcome was the number of drug overdose deaths among adults (aged 18 years or older), with secondary outcomes of overdose deaths involving specific opioid-involved drug combinations from death certificates. Rates of overdose deaths per 100 000 adult community residents in intervention and control communities from July 2021 to June 2022 were compared with analyses performed in 2023., Results: In 67 participating communities (34 in the intervention group, 33 in the control group) and including 8 211 506 participants (4 251 903 female [51.8%]; 1 273 394 Black [15.5%], 603 983 Hispanic [7.4%], 5 979 602 White [72.8%], 354 527 other [4.3%]), the average rate of overdose deaths involving all substances was 57.6 per 100 000 population in the intervention group and 61.2 per 100 000 population in the control group. This was not a statistically significant difference (adjusted rate ratio [aRR], 0.92; 95% CI, 0.78-1.07; P = .26). There was a statistically significant 37% reduction (aRR, 0.63; 95% CI, 0.44-0.91; P = .02) in death rates involving an opioid and psychostimulants (other than cocaine), and nonsignificant reductions in overdose deaths for an opioid with cocaine (6%) and an opioid with benzodiazepine (1%)., Conclusion and Relevance: In this clinical trial of the CTH intervention, death rates involving an opioid and noncocaine psychostimulant were reduced; total deaths did not differ statistically. Community-focused data-driven interventions that scale up evidence-based practices with communications campaigns may effectively reduce some opioid-involved polysubstance overdose deaths., Trial Registration: ClinicalTrials.gov Identifier: NCT04111939.

Purpose: Cancer registries offer an avenue to identify cancer clusters across large populations and efficiently examine potential environmental harms affecting cancer. The role of known metal carcinogens (i.e., cadmium, arsenic, nickel, chromium(VI)) in breast and colorectal carcinogenesis is largely unknown. Historically marginalized communities are disproportionately exposed to metals, which could explain cancer disparities. We examined area-based metal exposures and odds of residing in breast and colorectal cancer hotspots utilizing state tumor registry data and described the characteristics of those living in heavy metal-associated cancer hotspots., Methods: Breast and colorectal cancer hotspots were mapped across Kentucky, and area-based ambient metal exposure to cadmium, arsenic, nickel, and chromium(VI) were extracted from the 2014 National Air Toxics Assessment for Kentucky census tracts. Among colorectal cancer (n = 56,598) and female breast cancer (n = 77,637) diagnoses in Kentucky, we used logistic regression models to estimate Odds Ratios (ORs) and 95% Confidence Intervals to examine the association between ambient metal concentrations and odds of residing in cancer hotspots, independent of individual-level and neighborhood risk factors., Results: Higher ambient metal exposures were associated with higher odds of residing in breast and colorectal cancer hotspots. Populations in breast and colorectal cancer hotspots were disproportionately Black and had markers of lower socioeconomic status. Furthermore, adjusting for age, race, tobacco and neighborhood factors did not significantly change cancer hotspot ORs for ambient metal exposures analyzed., Conclusion: Ambient metal exposures contribute to higher cancer rates in certain geographic areas that are largely composed of marginalized populations. Individual-level assessments of metal exposures and cancer disparities are needed., (© 2024. The Author(s).)

Objectives: Food insecurity (FI) may be associated with worsened neonatal abstinence syndrome severity in infants born to individuals with substance use disorder. This study evaluates FI and housing insecurity (HI) influence on maternal and neonatal outcomes., Methods: This was a cohort study of patients receiving obstetric care through a multispecialty program in Kentucky from 2015 to 2023. Inclusion criteria were: (1) program participants over age 18 consenting to observational research, (2) delivering at University of Kentucky, and (3) not withdrawing from research at any time. Initially, a subset of patients for whom FI and HI concerns were heightened were screened. In 2019, FI and HI screening became standard of care at the clinic. Housing was assessed on enrollment. A validated 2-question Hunger Vital Sign FI screen was utilized for a subset of patients. Maternal and neonatal outcomes, including adverse delivery outcomes, maternal comorbidities, and birth complications, were observed. Fisher's exact and 2 sample t tests were performed., Results: Of 494 participants, 188 (38%) identified at risk for HI. At enrollment, 221 (45%) individuals reported owning their primary residence, 85 (17%) were in group residential treatment, 34 (6.9%) had no housing, and 134 (27%) lived at another's residence. Disposition of a child to a relative or not the patient's own care was greater with HI, 51% versus 47%. Of 155 respondents, 96 (62%) reported FI, associated with increased neonatal intensive care unit (NICU) admission, 86% versus 74%. Using the validated tool, Abuse Assessment Screen, abuse was significantly greater with FI, 76% versus 58%. Edinburgh Postpartum Depression Scales >12 indicating depression were more common with FI, 63% versus 32%, P  < .05. Anxiety scores were also higher with FI, P  < .05. Patients with FI were more likely to experience abuse., Conclusions: FI and HI were health-related needs associated with increased anxiety, depression, infant NICU admission, and loss of child custody., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: This exploratory study described facilitators and barriers to reducing tobacco disparities in 2 small rural communities and identified ways to reduce tobacco use., Methods: This was a descriptive design using qualitative methods. We created a resource database for 2 rural Kentucky counties, using a Culture of Health Framework. We recruited 16 organizational stakeholders serving low-socioeconomic populations and conducted focus groups and key informant interviews. We also completed key informant interviews with 7 tobacco users. Lastly, we tailored Community Action Plans for each county based on the data and then solicited feedback from the key stakeholders., Findings: The 2 counties were similar in population size, but County A had fewer resources than County B, and the stakeholders expressed differences toward tobacco use and quitting. County A stakeholders talked most about the protobacco culture and that tobacco users accept the risks of smoking outweighing the benefits of quitting; they also expressed concerns about youth use and the influences of family, society, and industry. County B stakeholders described ambivalence about the health effects of use and quitting. County A's Action Plan identified an opportunity to build Community Health Worker-delivered tobacco treatment into a new school-based health center. County B's Action Plan focused on reaching tobacco users by providing incentives for participation and tailoring messages to different audiences., Conclusions: Tobacco control resources and stakeholder perspectives vary in small rural communities, implying a need for tailored approaches. Tobacco users in rural areas are a critical population to target with cessation resources., (© 2024 National Rural Health Association.)

Introduction: Long-acting injectable buprenorphine (LAI-bup) formulations have advantages over transmucosal buprenorphine (TM-bup), but barriers may limit their utilization. Several policies shifted during the COVID-19 pandemic to promote buprenorphine access. The federal government expanded telemedicine treatment for opioid use disorder and Kentucky (KY) Medicaid lifted prior authorization requirements (PAs) for LAI-bup (i.e., Sublocade®). This retrospective cohort study evaluated changes in LAI-bup access, utilization, and retention before and after these policy changes in KY., Methods: Individual-level TM-bup and LAI-bup dispensing record data from KY's prescription drug monitoring program examined LAI-bup utilization and retention, without a >30-day gap in coverage, for patients starting a new episode of LAI-bup treatment. Two key time periods were examined: pre-policy changes (Apr 1, 2019 - Dec 31, 2019) and post-policy changes (Apr 1, 2020 - Dec 31, 2020). Data on PA requests among Medicaid managed care organizations and availability of LAI-bup Risk Evaluation and Mitigation Strategy (REMS)-certified pharmacies were also obtained. A multivariable Cox proportional hazard regression model analysis compared pre- versus post-policy period treatment discontinuation., Results: The number of patients initiating LAI-bup increased from 211 to 481 over the two periods. By the end of the post-policy period, 24.3 % of eligible patients were retained on LAI-bup, versus 12.5 % in the pre-policy change period. The adjusted hazard ratio, comparing discontinuation during the post- versus pre-policy change periods, was 0.70 (95 % confidence interval: 0.55-0.89). There were also more REMS-certified pharmacies and providers in the post-policy change period., Conclusions: LAI-bup access, utilization, and retention increased after several policy changes., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Sharon Walsh reports financial support was provided by National Institutes of Health and the Substance Abuse and Mental Health Services Administration. Lindsey Hammerslag reports administrative support and data access were provided by Kentucky Cabinet for Health and Family Services (KASPER Data Access). Michelle Lofwall reports a relationship with Berkshire Biomedical that includes: consulting or advisory. Michelle Lofwall reports a relationship with Braeburn Pharmaceuticals Inc. that includes: consulting or advisory. Michelle Lofwall reports a relationship with Journey Colab that includes: consulting or advisory. Sharon Walsh reports a relationship with Braeburn Pharmaceuticals Inc. that includes: consulting or advisory. Sharon Walsh reports a relationship with Astra Zeneca that includes: consulting or advisory. Sharon Walsh reports a relationship with Cerevel Therapeutics Inc. that includes:. Sharon Walsh reports a relationship with Opiant Pharmaceuticals Inc. that includes: consulting or advisory. Sharon Walsh reports a relationship with Pocket Naloxone that includes: consulting or advisory. Sharon Walsh reports a relationship with Titan Pharmaceuticals that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Opioid-related overdose mortality disproportionally affects Black adults in Kentucky, particularly overdoses associated with prescription opioid misuse (POM). Black adults also face other consequences of POM, such as disparate health and legal outcomes. While several factors effect POM, such as generational factors and gender, these risk factors are understudied among Black adults with a history of POM. Current literature primarily focuses on White individuals who use opioids., Method: The present study qualitatively examined reasons for POM, prescription opioids misused, how prescription opioids are obtained, and initiation of POM among Black adults using thematic analysis. Participants included a sample (n = 39) of Black adults from a southern state, stratified by gender and age across four cohorts: born (1) 1995-2001, (2) 1980-1994, (3) 1970-1979, and (4) 1955-1969., Results: Results revealed similarities and differences in these themes across age cohorts and gender., Conclusions: Implications for findings include the importance of culturally responsive interventions that utilize dual diagnosis treatment and idiographic approaches due to heterogeneous experiences with POM among Black adults., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Prior studies have shown that individuals and their peers often have similar substance use behaviors, but the mechanisms driving these similarities - particularly in rural settings, are not well understood. The primary objectives of this analysis are to (1) identify factors that contribute to relationship turnover and maintenance within a rural network of persons who use drugs (PWUD), (2) determine whether assimilation and/or homophily shape participants use of injection drugs, heroin, and stimulants (methamphetamine and cocaine), and (3) assess the extent that these mechanisms influence networks ties and/or behaviors and whether these effects vary across time., Methods: Sociometric network data were collected from a cohort of PWUD in rural Eastern Kentucky at baseline (2008-2010) and at four follow-up visits conducted approximately semiannually. Stochastic actor-oriented models (SAOMS) were used to model network structure and participant behaviors as jointly dependent variables and to identify characteristics associated with the maintenance, dissolution, and formation of network ties and changes in drug use behaviors., Results: Findings suggest (1) greater network stability over time for reciprocal and transitive relationships, (2) both homophily and assimilation played a greater role in shaping injection drug use (IDU) initiation and cessation than they did in shaping heroin and stimulant use, and (3) the importance of these mechanisms appeared consistent over time., Conclusion: Given the stability of particular network structures and evidence of both homophily and assimilation with respect to drug-use behaviors, interventions that leverage social networks could be used to motivate health-promoting behaviors., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Although prison facilities are not fully isolated from the communities in which they are located, most of the population is confined and requires high levels of health vigilance and protection. This study aimed to examine the dynamic relationship between facility-level wastewater viral concentrations and the probability of at least one positive COVID-19 case within the facility. The study period was from January 11, 2021 to May 8, 2023. Wastewater samples were collected and analyzed for SARS-CoV-2 (N1) and pepper mild mottle virus (PMMoV) three times weekly across 14 prison facilities in Kentucky (USA). Positive clinical case reports were also provided. A hierarchical Bayesian facility-level temporal model with a latent lagged process was developed. We modeled facility-specific SARS-CoV-2 (N1) normalized by the PMMoV wastewater concentration ratio threshold associated with at least one COVID-19 clinical case at an 80 % probability. The threshold differed among facilities. Across the 14 facilities, our model demonstrates a mean capture rate of 94.95 % via the N1/PMMoV ratio threshold with p ts ≥0.5. However, as the p ts threshold was set higher, such as at ≥0.9, the mean capture rate of the model was reduced to 60 %. This robust performance underscores the effectiveness of the model for accurately detecting the presence of positive COVID-19 cases among incarcerated people. The findings of this study provide a facility-specific threshold model for public health response based on frequent wastewater surveillance., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background and Objectives: Few studies have examined trends and disparities in long-term outcome after stroke in a representative US population. We used a population-based stroke study in the Greater Cincinnati Northern Kentucky region to examine trends and racial disparities in poststroke 5-year mortality., Methods: All patients with acute ischemic strokes (AISs) and intracerebral hemorrhages (ICHs) among residents ≥20 years old were ascertained using ICD codes and physician-adjudicated using a consistent case definition during 5 periods: July 1993-June 1994 and calendar years 1999, 2005, 2010, and 2015. Race was obtained from the medical record; only those identified as White or Black were included. Premorbid functional status was assessed using the modified Rankin Scale, with a score of 0-1 being considered "good." Mortality was assessed with the National Death Index. Trends and racial disparities for each subtype were analyzed with logistic regression., Results: We identified 8,428 AIS cases (19.3% Black, 56.3% female, median age 72) and 1,501 ICH cases (23.5% Black, 54.8% female, median age 72). Among patients with AIS, 5-year mortality improved after adjustment for age, race, and sex (53% in 1993/94 to 48.3% in 2015, overall effect of study year p = 0.009). The absolute decline in 5-year mortality in patients with AIS was larger than what would be expected in the general population (5.1% vs 2.8%). Black individuals were at a higher risk of death after AIS (odds ratio [OR] 1.23, 95% CI 1.08-1.39) even after adjustment for age and sex, and this effect was consistent across study years. When premorbid functional status and comorbidities were included in the model, the primary effect of Black race was attenuated but race interacted with sex and premorbid functional status. Among male patients with a good baseline functional status, Black race remained associated with 5-year mortality (OR 1.4, 95% CI 1.1-1.7, p = 0.002). There were no changes in 5-year mortality after ICH over time (64.4% in 1993/94 to 69.2% in 2015, overall effect of study year p = 0.32)., Discussion: Long-term survival improved after AIS but not after ICH. Black individuals, particularly Black male patients with good premorbid function, have a higher mortality after AIS, and this disparity did not change over time.

Background: Despite the increase in firearm injury observed across the country, significant gaps remain relevant to our understanding of how firearm exposure translates to injury. Using acoustic gunshot detection and a collaborative hospital and law enforcement firearm injury database, we sought to identify the relationship between firearm discharge and injury over time., Study Design: From 2018 to 2021, instances of firearm discharge captured via acoustic detection in 6 square miles of Louisville, KY, were merged with data from the collaborative firearm injury database. Key outcomes included the total number of rounds fired, injury and fatality rates per round, and the percentage of rounds discharged from automatic weapons and high-capacity magazines., Results: During the study period, 54,397 rounds of ammunition were discharged resulting in 914 injuries, 435 hospital admissions, 2,442 hospital days, 155 emergent operations, and 180 fatalities. For each round of ammunition fired, the risk of injury and fatality was 1.7% and 0.3%, respectively. The total number of rounds fired per month nearly tripled (614 vs 1,623, p < 0.001) leading to increased injury (15 vs 37, p < 0.001) and fatality (3 vs 7, p < 0.001). The percentage of rounds fired from automatic weapons (0 vs 6.8%, p < 0.001) and high-capacity magazines (7.6 vs 28.9%, p < 0.001) increased over time., Conclusions: The increased burden of firearm injury is related to an overall increase in firearm exposure as measured by the total number of rounds discharged. High-capacity magazines and automatic weaponry are being used with increasing frequency in urban America., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Wild turkeys (Meleagris gallopavo) are an important game species throughout the geographic range. Populations throughout multiple regions of the US have been declining, including in Kentucky, US, raising concerns among managers and resource users. To better understand the overall population health, we performed postmortem examinations and targeted pathogen, mineral, and toxicant testing on 36 adult male, apparently healthy, wild turkeys that were hunter harvested in western Kentucky during April 2018. We found that birds were in fair to good nutritional condition with no significant gross or microscopic lesions. Ticks (Amblyomma spp.) and lice (three species) were present on 94 and 31% of birds, respectively. We commonly detected intestinal nematodes and cestodes and found coccidian oocysts in 39% and capillarid eggs in 6% of birds. The prevalences of lymphoproliferative disease virus and reticuloendotheliosis virus were 39 and 11%, respectively. Spleen samples tested with PCR were positive for Borrelia burgdorferi, Haemoproteus sp., and Leucocytozoon sp. in 11, 83, and 3%, respectively. Based on a subjective histologic assessment of testis tissues, most birds had widespread and abundant sperm present. Mineral analysis and broad toxicant screening on liver samples from 32 turkeys were unremarkable. Further work is needed to assess potential population risk factors and to determine individual- and population-level impacts of pathogens on adults and poults., (© Wildlife Disease Association 2024.)

We estimated the population-level incidence of human papillomavirus (HPV)-positive oropharyngeal, cervical, and anal cancers by smoking status. We combined HPV DNA genotyping data from the Centers for Disease Control and Prevention's Cancer Registry Sentinel Surveillance System with data from the Kentucky Cancer Registry and Behavioral Risk Factor Surveillance System across smoking status. During 2004-2005 and 2014-2015 in Kentucky, most cases of oropharyngeal (63.3%), anal (59.7%), and cervical (54.9%) cancer were among individuals who ever smoked. The population-level incidence rate was higher among individuals who ever smoked than among those who never smoked for HPV-positive oropharyngeal (7.8 vs 2.1; adjusted incidence rate ratio = 2.6), cervical (13.7 vs 6.8; adjusted incidence rate ratio = 2.0), and anal (3.9 vs 1.6; adjusted incidence rate ratio = 2.5) cancers. These findings indicate that smoking is associated with increased risk of HPV-positive oropharyngeal, cervical, and anal cancers, and the population-level burden of these cancers is higher among individuals who ever smoked., (Published by Oxford University Press 2024.)

Background: In 2019, over 459,000 persons in the United States survived sexual assault, and 21%-26% sought medical treatment. Ideally, trained medical professionals who understand the unique physical and mental health needs of this patient population, such as forensic nurses, would provide care. Yet, the care that forensic nurses and other healthcare providers can offer to sexual violence/abuse survivors is hindered by the lack of understanding of the demographics of those who seek care. With the delineation of highly affected demographic groups, barriers to care can be addressed., Purpose: This study compared rates, demographic characteristics, acuity, and codes for sexual violence/abuse encounters experienced by those patients residing in rural versus urban counties of Kentucky (KY). This included encounters before and after SARS-CoV-2., Methods: Deidentified claims data were extracted for patient encounters billed with the International Classification of Diseases, 10th Revision, Clinical Modification for sexual violence/abuse seen at a university healthcare center serving the Northeastern, Southeastern, and Central regions of KY from October 2015 to February 2021. Analysis comprised descriptive statistics, independent samples t tests, and chi-square tests of association., Results: Significant demographic differences were identified between the two groups. The mean age of those residing in rural areas was significantly younger than those living in urban areas. Similarly, the percentage of male survivors was significantly higher in the rural population. The racial composition also differed, with higher percentages of survivors being Black and Hispanic in the urban population, relative to rural dwellers., Conclusion: Findings suggest that rural youth (especially boys aged 10 years and younger) and urban minorities are at a higher risk for sexual violence/abuse in KY when compared with their counterparts (i.e., urban youth and rural minorities)., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 International Association of Forensic Nurses.)

Background and Objectives: Poverty is associated with greater stroke incidence. The relationship between poverty and stroke recurrence is less clear., Methods: In this population-based study, incident strokes within the Greater Cincinnati/Northern Kentucky region were ascertained during the 2015 study period and followed up for recurrence until December 31, 2018. The primary exposure was neighborhood socioeconomic status (nSES), defined by the percentage of households below the federal poverty line in each census tract in 4 categories (≤5%, >5%-10%, >10%-25%, >25%). Poisson regression models provided recurrence rate estimates per 100,000 residents using population data from the 2015 5-year American Community Survey, adjusting for age, sex, and race. In a secondary analysis, Cox models allowed for the inclusion of vascular risk factors in the assessment of recurrence risk by nSES among those with incident stroke., Results: Of 2,125 patients with incident stroke, 245 had a recurrent stroke during the study period. Poorer nSES was associated with increased stroke recurrence, with rates of 12.5, 17.5, 25.4, and 29.9 per 100,000 in census tracts with ≤5%, >5%-10%, >10%-25%, and >25% below the poverty line, respectively ( p < 0.01). The relative risk (95% CI) for recurrent stroke among Black vs White individuals was 2.54 (1.91-3.37) before adjusting for nSES, and 2.00 (1.47-2.74) after adjusting for nSES, a 35.1% decrease. In the secondary analysis, poorer nSES (HR 1.74, 95% CI 1.10-2.76 for lowest vs highest category) and Black race (HR 1.31, 95% CI 1.01-1.70) were both independently associated with recurrence risk, though neither retained significance after full adjustment. Age, diabetes, and left ventricular hypertrophy were associated with increased recurrence risk in fully adjusted models., Discussion: Residents of poorer neighborhoods had a dose-dependent increase in stroke recurrence risk, and neighborhood poverty accounted for approximately one-third of the excess risk among Black individuals. These results highlight the importance of poverty, race, and the intersection of the 2 as potent drivers of stroke recurrence.

The rise in opioid misuse coincides with increased sexually transmitted infection (STI) and HIV incidence. Transactional sex is an under-researched phenomenon among Black Americans who misuse opioids, and may increase their risk of STI or HIV transmission. Given the disproportionate impact of the opioid epidemic on Black Americans and the risks associated with opioid misuse, the current study aims to investigate sociostructural factors, history of violence, and sexual risk factors associated with transactional sex among Black men and women. A sample of n = 375 Black adult Kentuckians reporting opioid misuse completed a survey including transactional sex, sociostructural, violence history, and sexual risk measures. Results of chi-squares and independent samples t -tests revealed that compared to men who did not report engaging in transactional sex, men who engaged in transactional sex were less educated, reported being sexually assaulted or having an unwanted sexual experience in their lifetime, and were more likely to use opioids or cocaine before or during sex in the last year. Women who engaged in transactional sex had a history of violence, more structural barriers, higher psychological distress, and engaged in more sexual risk behaviors compared to women who did not engage in transactional sex. Implications for future research and interventions with this population are discussed., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The COVID-19 pandemic has had drastic effects on K-12 teachers. Researchers partnered with a teacher advisory board to identify factors associated with K-12 teachers' consideration of leaving teaching during Fall 2020., Methods: A web-based survey focused on teachers' working experiences was emailed to school union membership listservs in Indiana, Kentucky, and Ohio. A logistic regression model was developed to identify working conditions associated with teachers considering leaving the profession., Results: Among 5873 K-12 teachers, 27% (n = 1319) were considering leaving the profession either because of COVID-19 (10%), for other reasons (6%) or were undecided (11%). Teachers who were midcareer, having taught 6-10 years, who perceived less supervisor support, whose job duties had changed significantly, who were dissatisfied with the COVID-19 related decision-making, who reported poor or fair mental health, and who were mostly or extremely afraid that a household member would get COVID-19 had higher odds of considering leaving teaching or being undecided about future career plans., Implications for School Health Policy, Practice and Equity: Understanding factors influencing teachers' career decisions will help school leaders improve teacher retention amid challenging circumstances., Conclusion: In this study in 3 midwestern US states, limited supervisor support, significant job duty change, dissatisfaction with COVID-19-related decision-making, poor or fair mental health, and fear that a household member would get COVID-19 were associated with teachers' consideration of leaving the profession or being undecided about future career plans., (© 2024, American School Health Association.)

Background: Hypertension is a stroke risk factor with known disparities in prevalence and management between Black and White patients. We sought to identify if racial differences in presenting blood pressure (BP) during acute ischemic stroke exist., Methods and Results: Adults with acute ischemic stroke presenting to an emergency department within 24 hours of last known normal during study epochs 2005, 2010, and 2015 within the Greater Cincinnati/Northern Kentucky Stroke Study were included. Demographics, histories, arrival BP, National Institutes of Health Stroke Scale score, and time from last known normal were collected. Multivariable linear regression was used to determine differences in mean BP between Black and White patients, adjusting for age, sex, National Institutes of Health Stroke Scale score, history of hypertension, hyperlipidemia, smoking, stroke, body mass index, and study epoch. Of 4048 patients, 853 Black and 3195 White patients were included. In adjusted analysis, Black patients had higher presenting systolic BP (161 mm Hg [95% CI, 159-164] versus 158 mm Hg [95% CI, 157-159], P <0.01), diastolic BP (86 mm Hg [95% CI, 85-88] versus 83 mm Hg [95% CI, 82-84], P <0.01), and mean arterial pressure (111 mm Hg [95% CI, 110-113] versus 108 mm Hg [95% CI, 107-109], P <0.01) compared with White patients. In adjusted subanalysis of patients <4.5 hours from last known normal, diastolic BP (88 mm Hg [95% CI, 86-90] versus 83 mm Hg [95% CI, 82-84], P <0.01) and mean arterial pressure (112 mm Hg [95% CI, 110-114] versus 108 mm Hg [95% CI, 107-109], P <0.01) were also higher in Black patients., Conclusions: This population-based study suggests differences in presenting BP between Black and White patients during acute ischemic stroke. Further study is needed to determine whether these differences influence clinical decision-making, outcome, or clinical trial eligibility.

Objectives: This study compared incidence rates, stage at presentation, and cause-specific mortality of nodular and superficial spreading melanoma along the rural-urban continuum in Kentucky. We compared resulting patterns in our data with sample demographic and other potential factors, including population by county and primary care provider rate., Methods: Retrospective patient data were extracted from the Surveillance, Epidemiology, and End Results database from 2010 through 2017. These data were supplemented by environmental, demographic, and socioeconomic data derived from publicly accessible databases. Correlation and χ 2 analyses were used to test for significant differences in outcome variables by US Department of Agriculture Rural-Urban Continuum Code (RUCC) categories and other potential predictor variables., Results: Incidence rates by Kentucky county were not associated with RUCC or population; likewise, there was no relationship between stage at presentation and RUCC category. There was, however, a highly significant association between cause-specific mortality and RUCC; patients from rural areas were significantly more likely to die from melanoma than those in urban areas. This overall difference was due to differences in mortality for superficial spreading melanoma., Conclusions: Our results suggest that a disparity in patients' ability or tendency to access primary care and/or specialist providers postdiagnosis may be critical factors in determining the ultimate outcome of a melanoma diagnosis. Further studies should explore the availability of dermatologists and/or treatment options for melanoma in rural areas. Our data also provide additional support for inclusion of melanoma subtype in the American Joint Committee on Cancer guidelines.

Objective: Buprenorphine is a medication for opioid use disorder that reduces mortality. This study aims to investigate the less well-understood relationship between the dose in the early stages of treatment and the subsequent risk of death., Methods: We used Kentucky prescription monitoring data to identify adult Kentucky residents initiating transmucosal buprenorphine medication for opioid use disorder (January 2017 to November 2019). Average daily buprenorphine dose for days covered in the first 30 days of treatment was categorized as ≤8 mg, >8 to ≤16 mg, and >16 mg. Patients were followed for 365 days after the first 30 days of buprenorphine treatment. Endpoints were opioid-involved overdose death and death from other causes. Causes and dates of death were obtained using Kentucky death certificate records. Associations were evaluated using multivariable Fine and Gray models adjusting for patient baseline characteristics., Results: In the cohort of 49,857 patients, there were 227 opioid-involved overdose deaths and 459 deaths from other causes. Compared with ≤8 mg, the adjusted subdistribution hazard ratio (aSHR) of opioid-involved overdose death decreased by 55% (aSHR, 0.45; 95% confidence interval [CI], 0.34-0.60) and 64% (aSHR, 0.36; 95% CI, 0.25-0.52) for patients receiving doses of >8 to ≤16 mg and >16 mg, respectively. The incidence of death from other causes was lower in patients receiving >8 to ≤16 mg (aSHR, 0.78; 95% CI, 0.62-0.98) and >16 mg (aSHR, 0.62; 95% CI, 0.47-0.80) versus ≤8 mg dose., Conclusions: Higher first 30-day buprenorphine doses were associated with reduced opioid-involved overdose death and death from other causes, supporting benefit of higher dosing in reducing mortality., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Purpose: Populations with high cancer risk that are targeted for screening, education, and vaccination have been shown to increase rates of screening, which ultimately may improve timing of diagnosis and overall outcome for certain cancers. Spatial scan analysis provides a visual representation of areas with higher rates of disease. Limited research has used this methodology to assess HPV-associated cancers. Using, spatial scan statistics, our goal was to identify regions within Kentucky having significantly higher rates of HPV-associated tumors. These regions can be targeted for public health efforts in the form of education, vaccination, screening, and physician recruitment., Methods: The Kentucky Cancer Registry data from 1995 to 2016 and spatial scan statistics were used to identify county-level clusters with high-incidence of HPV-associated cancers after adjustment for age and sex. Anatomic sites included in this analysis were oropharynx, cervix, anus, penis, and vulva., Results: There was one high-rate cluster of oropharyngeal cancer, which was observed in the Louisville metropolitan region (Relative Risk [RR] = 1.24, p < 0.001). One high-rate cluster of anal and penile cancer incidence in men was identified that partially overlapped with the oropharyngeal cluster. There were five clusters of higher cervical, vulvar, and anal cancer incidence in females, one of which overlapped with the oropharyngeal cluster., Conclusion: Overlapping clusters of HPV-associated cancers were identified at the county-level and included both urban and rural counties of Kentucky. Findings can assist in the design of public health interventions to increase screenings, promote vaccination, and recruit physicians in these regions to improve prevention, diagnosis, and early treatment of HPV-associated cancers., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Hospitalizations are more resource intensive and expensive than outpatient care. Therefore, type 2 diabetes-related preventable hospitalization are a major topic of research efficiency in the healthcare system., Objectives: Analyze county level variation in type 2 diabetes-related preventable hospitalization rates in Kentucky before the Medicaid expansion (2010-2013) and after the Medicaid expansion (2014-2017)., Design: Geographic mapping and cluster analysis., Setting: Data for a state of the United States of America., Methods: We used the KID data to generate geographic mapping for type 2 diabetes-related preventable hospitalizations to visualize rates. We included all Kentucky discharges of age 18 years and older with the ICD9/10 principal diagnosis code for type 2 diabetes. Then, we conducted cluster analysis techniques to compare county-level variation in type 2 diabetes-related preventable hospitalization rates across Kentucky counties pre- and post-Medicaid expansion., Main Outcome and Measures: County type 2 diabetes-related preventable hospitalization pre- and post-Medicaid expansion., Results: From 2010-2017, type 2 diabetes-related preventable hospitalization discharge rates reduced significantly in the period of the post-Medicaid expansion ( P =.001). The spatial statistics analysis revealed a significant spatial clustering of counties with similar rates of type 2 diabetes-related preventable hospitalization in the south, east, and southeastern Kentucky pre- and post-Medicaid expansion (positive z-score and positive Moran's Index value ( P >.05). Also, there was a significant clustering of counties with low type 2 diabetes-related preventable hospitalization rates in the north, west, and central regions of the state pre-Medicaid expansion and post-Medicaid expansion (positive z-score and positive Moran's Index value ( P >.05)., Conclusion: Kentucky counties in the southeast have experienced a significant clustering of highly avoidable hospitalization rates during both periods. Focusing on the vulnerable counties and the economic inequality in Kentucky could lead to efforts to lowering future type 2 diabetes-related preventable hospitalization rates., Limitations: We used de-identified data which does not provide insights into the frequency of hospitalizations per patient. An individual patient may be hospitalized several times and counted as several individuals., Competing Interests: CONFLICT OF INTEREST: None.

Persons living in long-term care facilities (LTCFs) were disproportionately affected by COVID-19. We used wastewater surveillance to detect SARS-CoV-2 infection in this setting by collecting and testing 24-hour composite wastewater samples 2-4 times weekly at 6 LTCFs in Kentucky, USA, during March 2021-February 2022. The LTCFs routinely tested staff and symptomatic and exposed residents for SARS-CoV-2 using rapid antigen tests. Of 780 wastewater samples analyzed, 22% (n = 173) had detectable SARS-CoV-2 RNA. The LTCFs reported 161 positive (of 16,905) SARS-CoV-2 clinical tests. The wastewater SARS-CoV-2 signal showed variable correlation with clinical test data; we observed the strongest correlations in the LTCFs with the most positive clinical tests (n = 45 and n = 58). Wastewater surveillance was 48% sensitive and 80% specific in identifying SARS-CoV-2 infections found on clinical testing, which was limited by frequency, coverage, and rapid antigen test performance.

The present study investigated the impact of real-time weather (air temperature, relative humidity, precipitation, wind speed, and solar radiation) on crash injury severity. Recent crash data (January 2016 to April 2021) on Interstate-75 in the state of Kentucky were merged with real-time weather information (retrieved from Kentucky Mesonet stations) at the 1-hour level. The severity index "SI" (i.e., the ratio of percent severe crashes to percent exposure of a specific weather state during the crash period) was introduced to evaluate the impact of different real-time weather states on fatal and severe injury crashes. Furthermore, the standard mixed logit (MXL), correlated mixed logit (CMXL), and correlated mixed logit with heterogeneity in means (CMXLHM) models were fitted and compared to identify the risk factors contributing to crash injury severity while accounting for unobserved heterogeneity. The results showed that the CMXLHM model was statistically superior to the CMXL and MXL models based on various goodness-of-fit measures (e.g., Akaike information criterion "AIC" and McFadden pseudo R-squared). Results from the SI analysis and CMXLHM model showed that real-time weather-related factors (e.g., air temperature ≥ 70 0 F and relative humidity ≥ 90 %) were significantly associated with higher severe injury likelihood. Further, driving under the influence (DUI), young drivers, and vehicle travel speed were associated with greater injury severities. On the other hand, presence of horizontal curve, passenger cars, and hourly traffic volume were associated with lower injury severity likelihood. The study outcomes can help in incident management by suggesting specific real-time weather-related states to feed to dynamic message signs (DMS) to enhance travelers' safety along the interstates., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Rural residence has been associated with a lower incidence of inflammatory bowel disease (IBD) but higher health care utilization and worse outcomes. Socioeconomic status is intrinsically tied to both IBD incidence and outcomes. Inflammatory bowel disease outcomes have not been investigated in Appalachia: a rural, economically distressed region rife with risk factors for both increased incidence and unfavorable outcomes., Methods: Hospital inpatient discharge and outpatient services databases were utilized to assess outcomes in patients diagnosed with either Crohn's disease (CD) or ulcerative colitis (UC) in Kentucky. Encounters were classified by patient residence in Appalachian or non-Appalachian counties. Data were reported as crude and age-adjusted rates of visits per 100,000 population per year collected in 2016 to 2019. National inpatient discharge data from 2019, stratified by rural and urban classification codes, were utilized to compare Kentucky to national trends., Results: Crude and age-adjusted rates of inpatient, emergency department and outpatient encounters were higher in the Appalachian cohort for all 4 years observed. Appalachian inpatient encounters are more frequently associated with a surgical procedure (Appalachian, 676, 24.7% vs non-Appalachian, 1408, 22.2%; P = .0091). In 2019, the Kentucky Appalachian cohort had significantly higher crude and age-adjusted rates of inpatient discharges for all IBD diagnoses compared with national rural and nonrural populations (crude 55.2; 95% CI, 50.9-59.5; age-adjusted 56.7; 95% CI, 52.1-61.3)., Conclusions: There is disproportionately higher IBD health care utilization in Appalachian Kentucky compared with all cohorts, including the national rural population. There is a need for aggressive investigation into root causes of these disparate outcomes and identification of barriers to appropriate IBD care., (© The Author(s) 2023. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Little is known whether engagement in sexual behaviors associated with potential HIV risks differs by subgroups of men who have sex with men (MSM), who are distinct regarding patterns of use of online tools for partner-seeking. Using latent class analysis, we revealed four classes of app-using MSM (n = 181, 18-34 y.o., 82.4% identified as White and non-Hispanic) residing in Central Kentucky: the Grindr/Tinder class; the Poly App Use class of MSM-oriented apps; the General Social Media class, and the Bumble class. Unadjusted penalized logistic regressions showed associations of the Poly App Use class with increased numbers of receptive anal sex partners and reporting condomless receptive anal sex. Adjusting for other covariates, poly app users versus others were more likely to be older (25-34 vs. 18-24, AOR = 3.81, 95%CI = 1.70-9.03), to report past six-month illicit drug use (AOR = 2.93, 95%CI = 1.25-7.43) and to have ever used pre-exposure prophylaxis (AOR = 2.79, 95%CI = 1.10-7.12). Poly app users had behavior profiles associated with an elevated HIV risk and also reported HIV-related protective behaviors likely indicating increased risk awareness among this class. Our findings warrant differentiation of behavior profiles by patterns of app use and suggest not to generalize sexual behaviors associated with potential HIV risks to all app-using MSM., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Objectives: Understanding the current status of and temporal trends of stroke epidemiology by age, race, and stroke subtype is critical to evaluate past prevention efforts and to plan future interventions to eliminate existing inequities. We investigated trends in stroke incidence and case fatality over a 22-year time period., Methods: In this population-based stroke surveillance study, all cases of stroke in acute care hospitals within a 5-county population of southern Ohio/northern Kentucky in adults aged ≥20 years were ascertained during a full year every 5 years from 1993 to 2015. Temporal trends in stroke epidemiology were evaluated by age, race (Black or White), and subtype (ischemic stroke [IS], intracranial hemorrhage [ICH], or subarachnoid hemorrhage [SAH]). Stroke incidence rates per 100,000 individuals from 1993 to 2015 were calculated using US Census data and age-standardized, race-standardized, and sex-standardized as appropriate. Thirty-day case fatality rates were also reported., Results: Incidence rates for stroke of any type and IS decreased in the combined population and among White individuals (any type, per 100,000, 215 [95% CI 204-226] in 1993/4 to 170 [95% CI 161-179] in 2015, p = 0.015). Among Black individuals, incidence rates for stroke of any type decreased over the study period (per 100,000, 349 [95% CI 311-386] in 1993/4 to 311 [95% CI 282-340] in 2015, p = 0.015). Incidence of ICH was stable over time in the combined population and in race-specific subgroups, and SAH decreased in the combined groups and in White adults. Incidence rates among Black adults were higher than those of White adults in all time periods, and Black:White risk ratios were highest in adults in young and middle age groups. Case fatality rates were similar by race and by time period with the exception of SAH in which 30-day case fatality rates decreased in the combined population and White adults over time., Discussion: Stroke incidence is decreasing over time in both Black and White adults, an encouraging trend in the burden of cerebrovascular disease in the US population. Unfortunately, however, Black:White disparities have not decreased over a 22-year period, especially among younger and middle-aged adults, suggesting the need for more effective interventions to eliminate inequities by race.

Introduction: Pediatric and young adult brain tumors (PYBT) account for a large share of cancer-related morbidity and mortality among children in the United States, but their etiology is not well understood. Previous research suggests the Appalachian region of Kentucky has high rates of PYBT. This study explored PYBT incidence over 25 years in Kentucky to identify geographic and temporal trends and generate hypotheses for future research., Methods: The Kentucky Cancer Registry contributed data on all PYBT diagnosed among those aged 0-29 during years 1995-2019. Age- and sex-adjusted spatio-temporal scan statistics-one for each type of PYBT, and one for all types-comprised the primary analysis. These results were mapped along with environmental and occupational data., Results: Findings indicated that north-central Kentucky and the Appalachian region experienced higher rates of some PYBT. High rates of astrocytomas were clustered in a north-south strip of central Kentucky toward the end of the study period, while high rates of other specified types of intracranial and intraspinal neoplasms were significantly clustered in eastern Kentucky. The area where these clusters overlapped, in north-central Kentucky, had significantly higher rates of PYBT generally., Discussion: This study demonstrates north-central Kentucky and the Appalachian region experienced higher PYBT risk than the rest of the state. These regions are home to some of Kentucky's signature industries, which should be examined in further research. Future population-based and individual-level studies of genetic factors are needed to explore how the occupations of parents, as well as prenatal and childhood exposures to pesticides and air pollutants, impact PYBT incidence., Competing Interests: Declaration of Competing Interest The authors declare no competing interests., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Fatal overdoses involving fentanyl/fentanyl analogs (F/FA) have increased in the US, raising questions about naloxone doses for F/FA overdose reversal. Emergency medical services (EMS) data provide an opportunity to examine naloxone administration changes as fentanyl increases in the illicit opioid supply., Methods: Administered naloxone intranasal-equivalent total dose (INTD) in milligrams (mg) was calculated for Kentucky EMS suspected opioid overdose (SOO) encounters (n=33,846), 2018-2021, and patterns of administration were examined. County-level F/FA availability was measured as 1) proportion of fatal drug overdoses involving F/FA, and 2) F/FA police seizures. Linear mixed models estimated changes in INTD in relation to local F/FA availability accounting for patient characteristics., Results: From 2018-2021, SOOs increased by 44% (6853 to 9888) with an average INTD increase from 4.5mg to 4.7mg, with more than 99% of encounters resulting in successful reversal each year. For SOO encounters examined by outcome at the scene (i.e., non-fatal fatal vs fatal), average INTD for non-fatal were 4.6mg compared to 5.9mg for fatal overdoses. Mixed modeling found no significant relationship between INTD and the two measures for local F/FA availability., Conclusion: As F/FA-involved overdose risk increased, we observed a modest increase in INTD administered in SOO EMS encounters - just slightly higher than the 4mg standard dose. The lack of significant relationship between F/FA and naloxone dose suggests that naloxone utilization in SOO with EMS involvement remains effective for overdose reversal, and that EMS naloxone dosing patterns have not changed substantially., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023. Published by Elsevier B.V.)

Background: People who inject drugs (PWID) experience high rates of violence, especially in early childhood, increasing their likelihood of engaging in risky substance use behavior in adulthood. Additionally, complex trauma has been reported among PWID due to witnessing and experiencing an overdose, further highlighting the need to examine the role of multiple experiences of trauma on their vulnerability to substance misuse., Methods: Our study of 350 PWID from rural Kentucky examined differences in polysubstance use between participants who experienced violence earlier (≤15 years old) versus later (≥16 years old) in their childhood., Results: Findings highlighted a direct association between experiences of early childhood violence and polysubstance use in adulthood. Additionally, our sample of PWID who experienced violence early in their childhood reported higher rates of severe substance use disorder and mental health distress., Conclusions: Tailored approaches that incorporate trauma-informed care may help to address the disproportionate rates of substance use and related adverse effects among PWID.

Background:   Previous non-fatal overdose may increase risk of overdose fatality for women reentering the community following incarceration, but pre-incarceration overdose experiences are understudied. This study describes the prevalence and correlates of non-fatal overdose prior to jail among women with opioid use disorder (OUD). Methods:  Women ( N  = 700) were randomly selected from eight Kentucky jails, screened for OUD, and interviewed as part of the NIDA-funded Kentucky Justice Community Opioid Innovation Network (JCOIN) trial. Descriptive statistics were used to examine women's prior overdose experiences, while bivariate analyses and logistic regression were used to identify correlates of overdose in the 90 days prior to jail. Results:  Analyses found that 55.4% of women had overdosed in their lifetime, and 21.4% overdosed in the 90 days prior to jail. Of those who overdosed in the 90 days prior to jail, heroin (80.7%) was the most-commonly used drug prior to overdose, 35.2% received emergency, medically-attended services post-overdose, and 92.4% were administered naloxone - primarily by acquaintances. Overdosing in the 90 days prior to jail was positively correlated with identifying as a sexual minority, being from an urban community, childhood victimization, as well as recent heroin, fentanyl, and injection drug use. Conclusions:  Findings indicate that prior overdose is common among jailed women with OUD, and although naloxone was often administered, few women received medically-attended services post-overdose. Results highlight the importance of distributing naloxone to community members and women reentering the community from jail, and suggest additional research is needed to understand factors inhibiting medical care following an overdose.

Objective: Timely data on drug overdose deaths can help identify community needs, evaluate the effectiveness of interventions, and allocate resources. We identified variations in death investigation and reporting systems within and between states that affect the timeliness and accuracy of death certificate information., Methods: The HEALing Communities Study (HCS) is a community-engaged, data-driven approach to combating the opioid crisis in 67 communities in 4 states: Kentucky, Massachusetts, New York, and Ohio. HCS conducted a survey of coroners and medical examiners to understand variability in drug overdose death data. We compared survey results in Massachusetts, New York, and Ohio with national data to investigate the completeness of provisional death counts by type of death investigation system., Results: Communities in each HCS state had different ways of collecting and reporting mortality data. Completion of death certificates for drug overdoses ranged from <2 weeks in 23% (7 of 31) of those surveyed to more than 3 months in 10% (3 of 31) of those surveyed. Variabilities in the timeliness of reporting drug overdose deaths were not associated with type of coroner or medical examiner office in each state, urban versus rural setting, or specificity of drug information on the death certificate., Conclusion: Having specific drug information on the death certificate may increase death certificate quality, comparability, and accuracy. We recommend the following: (1) all coroners and medical examiners should be trained on conducting death investigations, interpreting toxicology reports, and completing death certificates; (2) 1 office in each state should oversee all coroners and medical examiners to increase data consistency; and (3) communities should identify and address barriers to timely death certification., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Epidemiological nowcasting traditionally relies on count surveillance data. The availability and quality of such count data may vary over time, limiting representation of true infections. Wastewater data correlates with traditional surveillance data and may provide additional value for nowcasting disease trends., Methods: We obtained SARS-CoV-2 case, death, wastewater, and serosurvey data for Jefferson County, Kentucky (USA), between August 2020 and March 2021, and parameterized an existing nowcasting model using combinations of these data. We assessed the predictive performance and variability at the sewershed level and compared the effects of adding or replacing wastewater data to case and death reports., Findings: Adding wastewater data minimally improved the predictive performance of nowcasts compared to a model fitted to case and death data (Weighted Interval Score (WIS) 0.208 versus 0.223), and reduced the predictive performance compared to a model fitted to deaths data (WIS 0.517 versus 0.500). Adding wastewater data to deaths data improved the nowcasts agreement to estimates from models using cases and deaths data. These findings were consistent across individual sewersheds as well as for models fit to the aggregated total data of 5 sewersheds. Retrospective reconstructions of epidemiological dynamics created using different combinations of data were in general agreement (coverage >75%)., Interpretation: These findings show wastewater data may be valuable for infectious disease nowcasting when clinical surveillance data are absent, such as early in a pandemic or in low-resource settings where systematic collection of epidemiologic data is difficult., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Fayette Klaassen reports financial support was provided by Centers for Disease Control and Prevention. Fayette Klaassen reports financial support was provided by Council of State and Territorial Epidemiologists. Nicolas Menzies reports financial support was provided by Centers for Disease Control and Prevention. Nicolas Menzies reports financial support was provided by Council of State and Territorial Epidemiologists. Ted Cohen reports financial support was provided by Council of State and Territorial Epidemiologists. Rochelle H Holm reports financial support was provided by Centers for Disease Control and Prevention. Ted Smith reports financial support was provided by Centers for Disease Control and Prevention. Aruni Bhatnagar reports financial support was provided by Centers for Disease Control and Prevention. Rochelle H Holm reports financial support was provided by Louisville-Jefferson County Metro Government. Ted Smith reports financial support was provided by Louisville-Jefferson County Metro Government. Aruni Bhatnagar reports financial support was provided by Louisville-Jefferson County Metro Government. Rochelle Holm reports financial support was provided by James Graham Brown Foundation. Ted Smith reports financial support was provided by James Graham Brown Foundation. Aruni Bhatnagar reports financial support was provided by James Graham Brown Foundation. Rochelle H Holm reports financial support was provided by Owsley Brown II Family Foundation. Ted Smith reports financial support was provided by Owsley Brown II Family Foundation. Aruni Bhatnagar reports financial support was provided by Owsley Brown II Family Foundation. Rochelle H Holm reports financial support was provided by Welch Family. Ted Smith reports financial support was provided by Welch Family. Aruni Bhatnagar reports financial support was provided by Welch Family. Rochelle H Holm reports financial support was provided by Jewish Heritage Fund. Ted Smith reports financial support was provided by Jewish Heritage Fund. Aruni Bhatnagar reports financial support was provided by Jewish Heritage Fund. Rochelle H Holm reports financial support was provided by University of Louisville Center for Predictive Medicine for Biodefense and Emerging Infectious Diseases. Ted Smith reports financial support was provided by University of Louisville Center for Predictive Medicine for Biodefense and Emerging Infectious Diseases. Aruni Bhatnagar reports financial support was provided by University of Louisville Center for Predictive Medicine for Biodefense and Emerging Infectious Diseases., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

We sought to deliver a geotargeted digital health advertising intervention. We assessed risk of community infection through an integrated public health and wastewater rubric and delivered advertisements between November 2021 and April 2022 in Louisville, Kentucky. The average daily click-through rates for the campaigns were 0.19%, 0.15%, and 0.13%. Results show potential for digital public health interventions that are geographically anchored to subcity sewersheds and community interest and willingness to engage with targeted wastewater-themed public health messaging. ( Am J Public Health. 2024;114(1):34-37. https://doi.org/10.2105/AJPH.2023.307439).

Purpose: Cancer is the second leading cause of death in the United States, and the disease burden is elevated in Appalachian Kentucky, due in part to health behaviors and inequities in social determinants of health. This study's goal was to evaluate Appalachian Kentucky's cancer burden compared to non-Appalachian Kentucky, and Kentucky compared to the United States (excluding Kentucky)., Methods: The following data were analyzed: annual all-cause and all-site cancer mortality rates from 1968 to 2018; 5-year all-site and site-specific cancer incidence and mortality rates from 2014 to 2018; aggregated screening and risk factor data from 2016 to 2018 for the United States (excluding Kentucky), Kentucky, non-Appalachian Kentucky, and Appalachian Kentucky; and human papilloma virus vaccination prevalence by sex from 2018 for the United States and Kentucky., Findings: Since 1968, the United States has experienced a large decrease in all-cause and cancer mortality, but the reduction in Kentucky has been smaller and slower, driven by even smaller and slower reductions within Appalachian Kentucky. Appalachian Kentucky has higher overall cancer incidence and mortality rates and higher rates for several site-specific cancers compared to non-Appalachian Kentucky. Contributing factors include screening rate disparities and increased rates of obesity and smoking., Conclusions: Appalachian Kentucky has experienced persistent cancer disparities, including elevated all-cause and cancer mortality rates for 50+ years, widening the gap between this region and the rest of the country. In addition to addressing social determinants of health, increased efforts aimed at improving health behaviors and increased access to health care resources could help reduce this disparity., (© 2023 National Rural Health Association.)

Appalachian Kentucky is disproportionately affected by elevated cancer incidence and mortality rates. This disparity is driven by inequities in health behaviors and social determinants of health including decreased education attainment levels that cause lower health literacy. To increase cancer literacy in the region, a three-part cancer education curriculum was designed for Appalachian Kentucky middle and high school students. This study was designed to evaluate the effect the curriculum had on students' cancer literacy. The curriculum lessons were disseminated to Appalachian Kentucky middle and high school teachers who engaged 223 students with the material. For each lesson, students filled out a 10-question pretest and an identical 10-question posttest. The average and median percent of correct responses from the pre- to posttests were analyzed. The average percentage of correct responses significantly increased from 40% to 70%, 52% to 69%, and 33% to 53% on lessons 1, 2, and 3, respectively. A significant increase in the average percentage of correct responses on each individual question was also observed. The results demonstrate that the three-part cancer education curriculum intervention can significantly increase Appalachian Kentucky middle and high school students' cancer literacy. Increased cancer knowledge has the potential to encourage behavioral modifications that could reduce cancer incidence and mortality rates over time. Future work will include further improving the content relative to the target age/grade level and implementing the material with a broader group of teachers and students., (© 2023. The Author(s) under exclusive licence to American Association for Cancer Education.)

Background: Outreach campaigns have sought to reduce the burden of stroke by improving knowledge of stroke risk factors (RF) and warning signs (WS). We describe trends in stroke knowledge from 1995 to 2021., Methods: From 1995 to 2021, 6 separate surveys were conducted in the Greater Cincinnati Northern Kentucky Region. Temporal trends in RF/WS knowledge were analyzed using logistic regression adjusting for Race, sex, age, and education., Results: In 1995, 28.6% of participants (537/1880) could name ≥2 WS, compared with 50.6% (983/1944) in 2021 (trend P <0.0001 after adjustment). In 1995, 44.5% of participants (836/1880) knew ≥2 RF, compared with 56.7% (1103/1944) in 2021 (trend P <0.0001 after adjustment). Although still improved compared with 1995, fewer participants could identify ≥2 RF in 2021 (1103/1944, 56.7%) when compared with 2011 (1287/2036, 63.2%, pairwise P <0.05). This decline in RF knowledge was disproportionately larger in women (odds ratio of 0.67 for knowledge in 2021 compared with 2011 in females, P =0.047 for the interaction between sex and study year)., Conclusions: Although stroke knowledge has overall improved since 1995, there is evidence for lost gains since 2011, particularly in women. Stroke outreach campaigns need ongoing evaluation., Competing Interests: Disclosures Dr Kissela reports service on the Board of Directors for the American Academy of Neurology. The other authors report no conflicts.

Purpose: All-terrain vehicles (ATVs) pose a significant risk for morbidity and mortality amongst children. We hypothesize that current vague legislation regarding helmet use impacts injury patterns and outcomes in pediatric ATV accidents., Methods: The institutional trauma registry was queried for pediatric patients involved in ATV accidents from 2006 to 2019. Patient demographics and helmet wearing status were identified in addition to patient outcomes, such as injury pattern, injury severity score, mortality, length of stay, and discharge disposition. These elements were analyzed for statistical significance., Results: 720 patients presented during the study period, which were predominantly male (71%, n = 511) and less than 16 years old (76%, n = 543). Most patients were not wearing a helmet (82%, n = 589) at time of injury. Notably, there were 7 fatalities. A lack of helmet use is positively associated with head injury (42% vs 23%, P < .01), intracranial hemorrhage (15% vs 7%, P = .03), and associated with lower Glasgow Coma Scale (13.9 vs 14.4, P < .01). Children 16 years and older were least likely to wear a helmet and most likely to incur injuries. Patients over 16 years had longer lengths of stay, higher mortality, and higher need for rehabilitation., Conclusion: Not wearing a helmet is directly correlated with injury severity and concerning rates of head injury. Children 16 years and older are at greatest risk for injury, but younger children are still at risk. Stricter state laws regarding helmet use are necessary to reduce pediatric ATV-related injury burden., Level of Evidence: level III retrospective comparative study., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: To investigate the incidence and prevalence rates of coronary artery disease (CAD) in women with and without rheumatoid arthritis (RA). Methods: Data was collected from the Kentucky Women's Health Registry (2007, 2008, 2009 and 2010) with 3982, 6730, 6898 and 7944, respectively. Results: Women with RA and reported CAD were over 45 years. 10% of women with RA reported CAD, while 4% of women without RA reported CAD. The incidence of CAD in women with RA were 10, 5.2 and 3.4% while the incidence of CAD in women without RA were 2.2, 2.2 and 1.4% in 2007-2010, 2008-2010 and 2009-2010, respectively. Conclusion: The incidence and prevalence of CAD was greater in women with RA compared with women without RA.

Introduction: During early stages of COVID-19 in the United States, government representatives in Kentucky, Ohio, and West Virginia restricted or threatened to restrict abortion care under elective surgery bans. We examined how abortion utilization changed in these states., Methodology: We examined COVID-19 abortion-related state policies implemented in March and April 2020 using publicly available sources. We analyzed data on abortions by method and gestation and experiences of facility staff, using a survey of 14 facilities. We assessed abortions that took place in February-June 2020 and February-June 2021., Results: In February-June 2020 the monthly average abortion count was 1916; 863 (45%) were medication abortions and 229 (12%) were ≥14 weeks gestation. Of 1959 abortions performed across all three states in April 2020, 1319 (67%) were medication abortions and 231 (12%) were ≥14 weeks gestation. The shift toward medication abortion that took place in April 2020 was not observed in April 2021. Although the total abortion count in the three-state region remained steady, West Virginia had the greatest decline in total abortions, Ohio experienced a shift from instrumentation to medication abortions, and Kentucky saw little change. Staff reported increased stress from concerns over health and safety and increased scrutiny by the state and anti-abortion protesters., Discussion: Although abortion provision continued in this region, policy changes restricting abortion in Ohio and West Virginia resulted in a decrease in first trimester instrumentation abortions, an overall shift toward medication abortion care, and an increase in stress among facility staff during the early phase of COVID-19., (© 2023 The Authors. Perspectives on Sexual and Reproductive Health published by Wiley Periodicals LLC on behalf of University of Ottawa.)

Background: The shift from prescription to illicit drugs involved in drug poisoning deaths raises questions about the current utility of prescription drug monitoring program (PDMP) data to inform drug poisoning (overdose) prevention efforts. In this study, we describe relations between specific drugs involved in Kentucky drug poisoning deaths and antecedent controlled substance (CS) dispensing., Methods: The study used linked death certificates and PDMP data for 2,248 Kentucky resident drug poisoning deaths in 2021. Death certificate literal text analysis identified drugs mentioned with involvement (DMI) in drug poisoning deaths. We characterized the concordance between each DMI and the CS dispensing history for this drug at varying timepoints since 2008., Results: Overall, 25.5% of all decedents had dispensed CS in the month before fatal drug poisoning. Over 80% of decedents were dispensed opioid(s) since 2008; the percentage was similar regardless of opioid involvement in the poisoning death. One-third of decedents had dispensed buprenorphine for treatment of opioid use disorder since 2008, but only 6.1% had dispensed buprenorphine in the month preceding death. Fentanyl/fentanyl analogs were DMI in 1,568 (69.8%) deaths, yet only 3% had received a fentanyl prescription since 2008. The highest concordance in the month preceding death was observed for clonazepam (43.6%)., Conclusion: Overall, concordance between CS dispensing history and the drugs involved in poisoning deaths was low, suggesting a need to reevaluate the complex relationships between prescription medication exposure and overdose death and to expand harm reduction interventions both within and outside the healthcare system to reduce drug poisoning mortality., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Purpose: Effectiveness of COVID-19 mRNA vaccines is influenced by SARS-CoV-2 variant and history of prior infection. Data regarding protection against SARS-CoV-2 infection among adolescents, accounting for prior infection and time since vaccination, are limited., Methods: SARS-CoV-2 testing and immunization data from the Kentucky Electronic Disease Surveillance System and the Kentucky Immunization Registry, August-September 2021 (Delta predominance) and January 2022 (Omicron Predominance) among adolescents aged 12-17 years, were used to assess association of SARS-CoV-2 infection with mRNA vaccination and prior SARS-CoV-2 infection. Estimated protection was derived from prevalence ratios ([1-PR] × 100%)., Results: During Delta predominance, 89,736 tested adolescents were evaluated. Completion of primary series (second dose of mRNA vaccine ≥ 14 days prior to testing) and history of prior infection (> 90 days prior to testing) were both protective against SARS-CoV-2 infection (primary series: 81%, 95% confidence interval [CI] 79.7-82.3; prior infection: 66%, 95% CI 62.0-69.6). Prior infection plus primary series provided the greatest protection (92.3%, 95% CI 88.0-95.1). During Omicron predominance, 67,331 tested adolescents were evaluated. Primary series alone provided no benefit against SARS-CoV-2 infection after 90 days; prior infection was protective for up to one year (24.2%, 95% CI 17.2-30.7). Prior infection plus booster vaccination provided the greatest protection against infection (82.4%, 95% CI 62.1-91.8)., Discussion: Strength and duration of protection against infection provided by COVID-19 vaccination and prior SARS-CoV-2 infection differed by variant. Vaccination provided additional benefit to the protection offered by prior infection alone. Remaining up to date with vaccination is recommended for all adolescents regardless of infection history., (Published by Elsevier Inc.)

Background: At the beginning of the opioid overdose epidemic, overdose mortality rates were higher in urban than in rural areas. We examined the association between residence in an urban or rural county and subsequent opioid overdose mortality in Kentucky, a state highly impacted by the opioid epidemic, and whether this was modified by the COVID-19 pandemic., Methods: We captured hospitalizations in Kentucky from 2016 to 2020, involving an opioid using ICD-10-CM codes T40.0-T40.4 and T40.6. Patient's county was classified as urban or rural based on the NCHS Urban-Rural Classification Scheme. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of opioid overdose mortality, adjusted for demographics, hospitalization severity, and zip code SES. We assessed effect modification by the COVID-19 pandemic., Results: Overall, patients living in urban counties had 46% higher odds of opioid overdose death than patients residing in rural counties (adjusted OR=1.46; 95% CI=1.22, 1.74). Before the pandemic, patients in urban counties had 63% increased odds of opioid overdose death (adjusted OR=1.63; 95% CI=1.34, 1.97); however, during the COVID-19 pandemic, patients in urban and rural counties became more similar in regard to opioid overdose mortality (adjusted OR=0.72; 95% CI=0.45, 1.16; p-value for interaction =0.02)., Conclusion: Before the pandemic, living in urban counties was associated with higher opioid overdose mortality among Kentucky hospitalizations; however, during the COVID-19 pandemic, opioid overdose mortality in rural areas increased, approaching rates in urban areas. COVID-19 posed social, economic, and healthcare challenges that may be contributing to worsening mortality trends affecting both urban and rural patients., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Peiper reports research grants from Gilead Sciences and Norton Healthcare Foundation unrelated to the submitted publication. Dr. Peiper reports salary and stock options from Meru Health, a mental health provider unrelated to the submitted publication., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Medicaid expansion improved insurance coverage for patients with chronic conditions and low income. The effect of Medicaid expansion on patients with IBD from high-poverty communities is unknown., Objective: This study aimed to evaluate the impact of Medicaid expansion in Kentucky on care for patients with IBD from the Eastern Kentucky Appalachian community, a historically impoverished area., Design: This study was a retrospective, descriptive, and ecological study., Settings: This study was conducted in Kentucky using the Hospital Inpatient Discharge and Outpatient Services Database., Patients: All encounters for IBD care for 2009-2020 for patients from the Eastern Kentucky Appalachian region were included., Main Outcome Measures: The primary outcomes measured were proportions of inpatient and emergency encounters, total hospital charge, and hospital length of stay., Results: Eight hundred twenty-five preexpansion and 5726 postexpansion encounters were identified. Postexpansion demonstrated decreases in the uninsured (9.2%-1.0%; p < 0.001), inpatient encounters (42.7%-8.1%; p < 0.001), emergency admissions (36.7%-12.3%; p < 0.001), admissions from the emergency department (8.0%-0.2%; p < 0.001), median total hospital charge ($7080-$3260; p < 0.001), and median total hospital length of stay (4-3 days; p < 0.001). Similarly, postexpansion demonstrated increases in Medicaid coverage (18.8%-27.7%; p < 0.001), outpatient encounters (57.3%-91.9%; p < 0.001), elective admissions (46.9%-76.2%; p < 0.001), admissions from the clinic (78.4%-90.2%; p < 0.001), and discharges to home (43.8%-88.2%; p < 0.001)., Limitations: This study is subject to the limitations inherent in being retrospective and using a partially de-identified database., Conclusion: This study is the first to demonstrate the changes in trends in care after Medicaid expansion for patients with IBD in the Commonwealth of Kentucky, especially Appalachian Kentucky, showing significantly increased outpatient care utilization, reduced emergency department encounters, and decreased length of stays., Impacto De La Ley Del Cuidado De Salud a Bajo Precio En La Provisin De Acceso Equitativo a La Atencin Mdica Para La Enfermedad Inflamatoria Intestinal En La Regin De Los Apalaches De Kentucky: ANTECEDENTES: La expansión de Medicaid mejoró la cobertura de seguro para pacientes con enfermedades crónicas y bajos ingresos. Se desconoce el efecto de la expansión de Medicaid en pacientes con enfermedad inflamatoria intestinal de comunidades de alta pobreza.OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la expansión de Medicaid en Kentucky en la atención de pacientes con enfermedad inflamatoria intestinal de la comunidad de los Apalaches del este de Kentucky, un área históricamente empobrecida.DISEÑO: Este estudio fue un estudio retrospectivo, descriptivo, ecológico.ESCENARIO: Este estudio se realizó en Kentucky utilizando la base de datos de servicios ambulatorios y de alta hospitalaria en pacientes hospitalizados.PACIENTES: Se incluyeron todos los encuentros para la atención de la enfermedad inflamatoria intestinal de 2009-2020 para pacientes de la región de los Apalaches del este de Kentucky.MEDIDAS DE RESULTADO PRINCIPALES: Los resultados primarios medidos fueron proporciones de encuentros de pacientes hospitalizados y de emergencia, cargo hospitalario total y duración de la estancia hospitalaria.RESULTADOS: Se identificaron 825 encuentros previos a la expansión y 5726 posteriores a la expansión. La posexpansión demostró disminuciones en los no asegurados (9.2% a 1.0%, p < 0.001), encuentros de pacientes hospitalizados (42.7% a 8.1%, p < 0.001), admisiones de emergencia (36.7% a 12.3%, p < 0,001), admisiones desde el servicio de urgencias (8.0% a 0.2%, p < 0.001), la mediana de los gastos hospitalarios totales ($7080 a $3260, p < 0.001) y la mediana de la estancia hospitalaria total (4 a 3 días, p < 0.001). De manera similar, la cobertura de Medicaid (18.8% a 27.7%, p < 0.001), consultas ambulatorias (57.3% a 91.9%, p < 0.001), admisiones electivas (46.9% a 76.2%, p < 0.001), admisiones desde la clínica (78.4% al 90.2%, p < 0.001), y las altas domiciliarias (43.8% al 88.2%, p < 0.001) aumentaron después de la expansión.LIMITACIONES: Este estudio está sujeto a las limitaciones inherentes de ser retrospectivo y utilizar una base de datos parcialmente desidentificada.CONCLUSIONES: Este estudio es el primero en demostrar los cambios en las tendencias en la atención después de la expansión de Medicaid para pacientes con enfermedad inflamatoria intestinal en el Estado de Kentucky, especialmente en los Apalaches de Kentucky, mostrando un aumento significativo en la utilización de la atención ambulatoria, visitas reducidas al departamento de emergencias y menor duración de la estancia hospitalaria. (Traducción-Dr. Jorge Silva Velazco )., (Copyright © The ASCRS 2023.)

Young Black men who have sex with men (MSM) living with HIV evidence the lowest rates of linkage to care and viral suppression of all US MSM. Kentucky, identified by the US Department of Health and Human Services as a "hot spot" state with elevated HIV incidence compared to the rest of the country, exhibits similar racialized outcomes. Structural, interpersonal, and individual drivers of engagement along the HIV care continuum among people living with HIV have been identified, primarily through quantitative designs. However, the mechanisms by which these factors shape HIV care engagement, and the ways they may combine or reinforce each other, as well as from the lived experience of young Black MSM living with HIV, have been studied to a lesser extent. In this study, a purposive sample of n = 29 HIV-positive young Black MSM (age M = 25 years old; 38% retained in care) residing in Kentucky participated in in-depth interviews. Factors that were most influential on engagement varied along the continuum, with health insurance status and knowledge of HIV being relatively more influential to diagnosis, and housing stability, psychological processes, and interpersonal relationships being more influential on retention. For some participants, barriers to care at multiple levels had a mutually influencing and intensifying impact on care engagement. Additional efforts to center the voices of young Black MSM living with HIV will help illuminate acceptable and sustainable interventions for increasing their care engagement and narrowing persistent racial disparities in HIV morbidity and mortality., (© 2022. W. Montague Cobb-NMA Health Institute.)

Low educational attainment and high cancer incidence and mortality rates have long been a challenge in Appalachian Kentucky. Prior studies have reported disparities in cancer incidence and mortality between Appalachian and non-Appalachian populations, but the influence of education on this disparity has not been extensively studied. Herein, all cancers and two cancer sites with available screenings (colorectal and lung) were joined with education indicators (educational attainment and literacy) and one geographic indicator across all 120 Kentucky counties. This dataset was used to build choropleth maps and perform simple linear and spatial regression to assess statistical significance and to measure the strength of the linear relationship between county-level education and cancer-related outcomes in Appalachian and non-Appalachian Kentucky. Among all cancer sites, age-adjusted cancer incidence and mortality was higher in Appalachian versus non-Appalachian Kentucky. The percentage of the population not completing high school was positively correlated with increased colorectal and lung cancer incidence and mortality in Appalachia. Similarly, counties with a higher percentage of the population lacking basic literacy had the strongest correlation with colorectal and lung cancer incidence and mortality, which were concentrated in Appalachian Kentucky. Our findings suggest a need for implementing interventions that increase educational attainment and enhance basic literacy as a means of improving cancer outcomes in Appalachia.

Introduction: The opioid overdose epidemic continues to impact a large swath of the population in the US. Medications for opioid use disorders (MOUD) are an effective resource to combat the epidemic; however, there is limited research on MOUD treatment access that accounts for both supply of and demand for services. We aimed to examine access to buprenorphine prescribers in the HEALing Communities Study (HCS) Wave 2 communities in Massachusetts, Ohio, and Kentucky during 2021, and the association between buprenorphine access and opioid-related incidents, specifically fatal overdoses and opioid-related responses by emergency medical services (EMS)., Methods: We calculated Enhanced 2-Step Floating Catchment Area (E2SFCA) accessibility indices for each state, as well as Wave 2 communities in each state, based on the location of providers (buprenorphine-waivered clinicians from the US Drug Enforcement Agency Active Registrants database), population-weighted centroids at the census block group level, and catchment areas defined by the state or community's average commute time. In advance of intervention initiation, we quantified the opioid-related risk environment of communities. We assessed gaps in services by using bivariate Local Moran's I analysis, incorporating accessibility indices and opioid-related incident data., Results: Massachusetts Wave 2 HCS communities had the highest rates of buprenorphine prescribers per 1000 patients (median: 165.8) compared to Kentucky (38.8) and Ohio (40.1). While urban centers in all three states had higher E2SFCA index scores compared to rural communities, we observed that suburban communities often had limited access. Through bivariate Local Moran's I analysis, we identified numerous locations with low buprenorphine access surrounded by high opioid-related incidents, particularly in communities that surrounded Boston, Massachusetts; Columbus, Ohio; and Louisville, Kentucky., Conclusion: Rural communities demonstrated a great need for additional access to buprenorphine prescribers. However, policymakers should also direct attention toward suburban communities that have experienced significant increases in opioid-related incidents., Competing Interests: Declaration of competing interest No conflict declared., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Early-onset hypertensive disorders of pregnancy (eHDP) are associated with more severe maternal and infant outcomes than later-onset disease. However, little has been done to evaluate population-level trends. Therefore, in this paper, we seek to address this understudied area by describing the geospatial and temporal patterns of county-level incidence of eHDP and assessing county-level demographics that may be associated with an increased incidence of eHDP., Methods: Employing Kentucky certificates of live and stillbirth from 2008-2017, this ecological study detected county-level clusters of early-onset hypertensive disorders of pregnancy using SaTScan, calculated average annual percent change (AAPC) with a join point analysis, and identified county-level covariates (% of births to women ≥ 35 years of age, % with BMI ≥ 30 kg/m 2 , % currently smoking, % married, and % experienced eHDP) with a fixed-effects negative binomial regression model for longitudinal data with an autoregressive (AR) correlation structure offset with the natural log of the number of births in each county and year., Results: County-level incidence of eHDP had a non-statistically significant increase of almost 3% (AAPC: 2.84, 95% CI: -4.26, 10.46), while maternal smoking decreased by almost 6% over the study period (AAPC:-5.8%, 95%CI: -7.5, -4.1), Risk factors for eHDP such as pre-pregnancy BMI ≥ 30 and proportion of births to women ≥ 35 years of age increased by 2.3% and 3.4% respectively (BMI AAPC:2.3, 95% CI: 0.94, 3.7; ≥ 35 years AAPC:3.4, 95% CI: 0.66, 6.3). After adjusting for race, county-level proportions of college attainment, and maternal smoking throughout pregnancy, counties with the highest proportion of births to women with BMI ≥ 30 kg/m 2 reported an eHDP incidence 20% higher than counties with a lower proportion of births to mothers with a BMI ≥ 30 kg/m 2 and a 20% increase in eHDP incidence (aRR = 1.20, 95% CI: 1.00, 1.44). We also observed that counties with the highest proportion vs. the lowest of mothers ≥ 35 years old (> 6.1%) had a 26% higher incidence of eHDP (RR = 1.26, 95%CI: 1.04, 1.50) compared to counties with the lowest incidence (< 2.5%). We further identified two county-level clusters of elevated eHDP rates. We also observed that counties with the highest vs. lowest proportion of mothers ≥ 34 years old (> 6.1% vs. < 2.5%) had a 26% increase in the incidence of eHDP (RR = 1.26, 95% CI: 1.04, 1.50). We further identified two county-level clusters of elevated incidence of eHDP., Conclusions: This study identified two county-level clusters of eHDP, county-level covariates associated with eHDP, and that while increasing, the average rate of increase for eHDP was not statistically significant. This study also identified the reduction in maternal smoking over the study period and the concerning increase in rates of elevated pre-pregnancy BMI among mothers. Further work to explore the population-level trends in this understudied pregnancy complication is needed to identify community factors that may contribute to disease and inform prevention strategies., (© 2023. The Author(s).)