Unintended pregnancy rates remain a world wide public health concern. Healthy People 2030 has designated unintended pregnancies a key initiative, stating that increasing the use of contraception and decreasing unintended pregnancy is an important public health goal. According to the American Academy of Family Physicians, approximately one-half of the 6.6 million pregnancies each year in the United States are unintended. Family medicine physicians have an ideal position to provide contraception counseling in our communities. Unfortunately when surveyed, although 95% of medicine faculty and residents responded that contraceptive counseling is important, only one-quarter of providers reported providing contraceptive counseling “routinely” (defined as ≥ 80% of the time) to reproductive aged women during prevention-focused visits. Several studies have attempted to understand why primary care physicians are not routinely providing preconception and contraception counseling with multiple factors identified including inadequate knowledge of contraception methods (especially in regards to long-acting reversible contraceptives or LARCs), lack of time, lack of routine sexually history taking, and provider misconception regarding contraception. This study was completed as a quality improvement project among ETSU Health Family Medicine Kingsport residents. The aim of the quality improvement project was to determine if increasing awareness of gaps in contraception counseling and providing contraception counseling education would increase the rates of contraception counseling during yearly visits (well child checks, annual physicals, and annual wellness visits) for women of reproductive age (defined as ages 14-45). Clinic charts were reviewed in a 3 month time period pre and post an educational intervention. The educational intervention included a 1 hour lecture on current contraception methods and recommendations. A survey was also collected pre and post educational intervention to identify self-reported rates of contraception counseling and other perceived barriers to contraception counseling in our clinic. The rates of contraception were determined by either the presence or absence of the billing ICD-10 code Z30.09 (Encounter for contraceptive management). Pre-intervention chart review revealed a documented contraceptive counseling rate of 13% at annual preventative visits. Despite these low rates, 71% of residents surveyed pre-intervention strongly agreed that contraceptive counseling was important at annual exams for women of reproductive age. Post-intervention chart review revealed a contraceptive counseling rate of 31% at annual preventative visits, an 18% increase in contraceptive counseling. The results showed that while residents did not self-identify inadequate knowledge of contraceptive methods as a barrier to providing counseling, raising awareness of the importance of contraception counseling and providing an educational intervention did increase rates of contraception counseling. The major barrier identified by providers was a perceived lack of time. One limitation of this study was measuring contraceptive counseling rates by the use of the billing ICD-10 code of Z30.09. By only using this ICD code, visits that documented sexually activity, current contraceptive use, and/or history of prior hysterectomy but did not properly bill for Z30.09 were not included.

Delta-8-tetrahydrocannabinol (THC), although less potent than THC, can still reduce memory cognition and anxiety. However, Delta-8 can have adverse effects at high doses, like inducing anxiety, confusion, and hallucinations. The brain of Danio rerio (zebrafish) resembles human neuroanatomical and neurochemical pathways and demonstrates robust behavioral phenotypes, making zebrafish an excellent model organism for memory and anxiety. Subjects will be fed 5mg of Delta 8-THC before entering the experimental apparatus. Fish for both memory and anxiety tests will be observed and recorded through Noldus Ethovision Software. For testing memory, five female and five male zebrafish will be individually placed in a three-compartment memory tank. One side of the memory tank will have a star shape, while the other side will have a circle shape. About .83mg of commercial fish flakes will be administered to the fish on the circle side in the first trial, then on the star side in the second trial, and will continue on either side for 20 trials. Correct responses will be scored when the fish are present on the side of the tank used to present the fish flakes. We hypothesize that there will be fewer correct responses for fish fed with Delta-8-THC than the control. For testing anxiety, ten male and female zebrafish will be fed 5mg of Delta 8-THC before entering the diving tank. Typically, zebrafish experiencing anxiety will stay at the bottom of the diving tank, but if they are relaxed, they will be at the top. We hypothesize that fish fed with Delta-8-THC will spend more time at the top of the diving tank than the control.

Family physicians are often tasked with ensuring patients have the durable medical equipment (DME) they need for a given ailment. This includes nebulizers, rolling walkers, crutches, wheelchairs, and hospital beds. Family physicians are expected to be familiar with the DME indications and ordering procedures in order to obtain these items for their patients. For many of our family medicine residents, this is a vast and overwhelming facet of primary care that is often dreaded due to lack of knowledge concerning medical indications and processes of ordering DME. Therefore, our project at ETSU Family Medicine Residency of Bristol aimed to improve our residents comfort with and understanding of the clinic’s protocol surrounding the ordering of DME. We started with an evaluation of our residents’ knowledge and comfort with the indications, ordering protocol, and documentation requirements of durable medical equipment. We then conducted an educational didactic on the information needed to be able to document and order DME in our clinic. Additionally, we provided our physicians with “dot phrase macros” for proper documentation required when ordering DME through insurance. After the presentation, we re-assessed the resident’s knowledge and comfort with understanding and ordering DME in our clinic. We found that overall there was an improvement in the residents’ comfort and understanding of the DME ordering processes as well as an improvement in their knowledge of DME ordering requirements. As a result of these findings, we plan to continue DME education for all future residents at ETSU Family Medicine Residency of Bristol.

Background: According to the Centers for Disease Control and Prevention in 2015, suicide was second leading cause of death for adolescents (age 15-24). Over the past 15 years, the suicide rate has increased 24%. Previous research has connected the importance of physical activity as a protective measure to mental health problems such as depression which is often a preceding cursor of suicide. Previous research has also provided evidence supporting adult connectedness to the adolescent as a protective effector for suicide ideology. Although there is leading independent corroboration for each of these factors as preventative measures for suicide, there is limited research on the effect of both components combined. The aim of this study is to determine the relationship between usual activity, mental state, adult involvement for connectedness and suicide idealization. Hypothesis: Usual activity alone will have a strong correlation with mental state and suicide idealization. Adult involvement for connectedness alone will have a strong correlation with mental state and suicide idealization. Usual activity and adult involvement together will have the strongest correlation with mental state and suicide idealization. Methods: Data was collected at high schools in Appalachian Tennessee and Virginia. Between January and June 2017, the Adolescent Community Health Survey was conducted among random classrooms. Tennessee schools totaled 444 students and Virginia schools totaled 385 students. Information about the study was given to teachers, parents and students before school visits. Parental permission was written and received before survey was administered. A team of researchers administered and monitored the questionnaire in classrooms where students provided individual responses on the health survey. All data was weighted according to logistic regression statistics. Results: As a result of completing the above procedure, it was learned that physical activity is directly related to suicide ideation with adult connectedness as a mediator. It was also learned that mental health is directly related with suicide with physical activity as a mediator. Conclusions: Ultimately, it was demonstrated that physical activity and mental health has the highest significance to suicide ideation. Parent connectedness is only significant as a mediator. This significantly means the focus to prevent suicide ideation is to focus on intervention for mental health and physical activity. Sub focuses should be on adult connectedness and physical activity to monitor warning signs of suicide ideation.

Introduction: Transgender is an identity term used to describe people with diverse gender identities and expressions that differ from their sex assigned at birth. People who identify as transgender have worse health outcomes than the cisgender or non-transgender populations. Limited healthcare access and chronic stress from discrimination all contribute to worsening health outcomes for this population. However, research regarding this population is limited, particularly in the rural southern United States. The purpose of this study was to assess physicians’, nurse practitioners’, and physician assistants’ experience with, attitude towards, and knowledge of transgender healthcare in the Northeast Tennessee region. Methods: Medical providers, including NPs, PAs, DOs and MDs from Family Medicine, Emergency Medicine, Internal Medicine, Pediatrics, and Obstetrics and Gynecology in both academic and community settings were surveyed regarding their attitudes toward, knowledge of, and experiences with gender, sexual orientation, and sexuality as they relate to healthcare. All potential participants were informed that participation was voluntary. Limited demographics were gathered and surveys were collected in a confidential manner. Data were analyzed for statistical significance. Results: Initial analyses showed the majority of providers had not received training in transgender healthcare and perceived they had few to no trans-identified patients. Over half of all respondents felt competent in providing healthcare to trans people and the majority felt comfortable treating this population. Providers indicated it is important to know their patients’ sexual practices, gender identity and sexual orientation; however, the majority of providers do not ask patients their gender identity, sexuality, or desired pronouns. Respondents were unsure whether gender confirmation surgery is covered by insurance and widely accessible. In assessing clinical knowledge of providers, there were a wide variety of responses suggesting varying level of competence amongst providers. Responses were split regarding whether access to healthcare is the same for the transgender population as it is for the general population. Pediatric providers were asked about comfort in prescribing hormones, knowledge of mental health support in the area, referrals and discussing gender identity with patients. These responses fell along a normal distribution, indicating a variety of training, experiences, and opinion regarding trans healthcare for the adolescent population. Conclusions: Overall results from the preliminary data demonstrate a contradiction between ideology and practice. With most participants responding they felt comfortable and competent providing care to the transgender population, yet their responses indicated a lack of training and absence of inclusivity in their health care practices. This suggests that education is needed within the healthcare community on transgender healthcare.

Introduction. Popularity of electronic cigarettes (e-cigarettes) has increased dramatically in recent years, especially among adolescents. The most recent data from the National Institute on Drug Abuse (NIDA) cites that >16% of 12th graders have tried e-cigarettes, and >30% of those individuals will start smoking within 6 months1. E-cigarettes are available in a variety of ‘strengths’ indicating the labeled nicotine concentration in the product. In this project, we sought to investigate the accuracy of nicotine labeling found in some commercially available e-liquids. As such, we developed and validated a liquid chromatography-mass spectrometry (LC-MS) assay to determine the nicotine concentration in these products. Methods. A literature search revealed that the two most commonly used chromatographic approaches for nicotine are hydrophilic interaction liquid chromatography (HILIC) and reversed phase chromatography (RP). Both options were evaluated, and nicotine peak quality and reproducibility were assessed. Mass spectrometric conditions for positive electrospray (+ESI) ionization were optimized, including collision energy and ion accumulation time. The optimized method included a gradient separation using a UCT C18 column (2.1 x 100 mm; 1.8 micron) with acetonitrile as the organic phase and 0.1% formic acid in water as the aqueous phase. Nicotine stock solutions were prepared in 100% ethanol and diluted in acetonitrile to achieve calibration concentrations (5 – 75 micrograms/mL). Deuterium labeled nicotine (d4) was used as the internal standard at a concentration of 10 micrograms/mL. The method was evaluated for precision, reflected by percent relative standard deviation (%RSD) and accuracy, or percent error, at each concentration for three days. The method was applied to the assessment of nicotine concentration in samples of e-liquids labeled as 3 mg/mL nicotine. Results. Reversed phase chromatography outperformed HILIC separation for nicotine under the conditions tested. The final RP-LC-MS/MS method involves direct monitoring of m/z 163.1219 for quantification of nicotine (167.1219 for d4-nicotine). The method exhibits < 15% RSD and < 15% error for all concentrations in the calibration range (< 20% at the lower limit of quantification). The developed method allows for rapid throughput, with a run time of 5 minutes. The lower limit of detection was determined to be 1 microgram/mL. Of the e-liquids evaluated, variations of up to 37% from the labeled amount of 3 mg/mL were detected. Additionally, a product labeled ‘zero nicotine’ contained no detectable nicotine. Conclusions. A fast, accurate, and reproducible LC-MS/MS assay has been developed and validated for the determination of nicotine in e-cigarette liquids. This method was applied to the evaluation of e-liquids, which showed significant variability in nicotine content from the labeled amount. 1 https://www.drugabuse.gov/related-topics/trends-statistics/infographics/teens-e-cigarettes

Introduction Acromegaly is an endocrine disorder characterized by excessive growth hormone production.The most common cause is a benign pituitary adenoma, which can be an isolated tumor or part of a group of concomitant endocrine neoplasms. We present a case of a middle aged woman with sleep apnea and a newly diagnosed acromegaly secondary to a pituitary macroadenoma. Case presentation A 51-year-old woman was seen in the endocrinology clinic for evaluation of hyperparathyroidism and mild hypercalcemia. She had no symptoms related to hypercalcemia. However, she complained of enlargement of her fingers and toes. She also reported galactorrhea and breast engorgement. There was no hyperhidrosis or frontal bossing present and she denied headaches or vision symptoms. Past medical history was significant for obstructive sleep apnea. Insulin like growth factor level was 630 ng/ml (reference 53 - 190 ng/ml), prolactin level was 109 ng/ml (reference 1.9- 25 ng/ml), and Follicular stimulating hormone was 0.4mIU/ml (reference 1.2 - 21.0 mIU/ml). TSH, free T4, ACTH, and cortisol were normal. The labs were consistent with pituitary macroadenoma secreting growth hormone (GH) and prolactin. MRI pituitary showed a 1.9 cm macroadenoma with no evidence of optic nerve compression. Due to the coexisting diagnoses of hyperparathyroidism and pituitary adenoma, CT abdomen was done to evaluate for neuroendocrine tumor and to rule out Multiple Endocrine Neoplasia (MEN) Type 1. She then underwent transsphenoidal resection of the pituitary, with immunostaining reflecting diffuse prolactin and patchy GH expression. Post-surgery IGF, prolactin, thyroid function tests were normal. She was started on hydrocortisone replacement due to abnormal ACTH and cortisol. Her calcium levels normalized, and further genetic testing for MEN was abandoned. Her repeat sleep study also showed resolution of sleep apnea. She did not suffer from further symptoms of acromegaly and was scheduled for periodic surveillance for thyroid axis dysfunction. Discussion Dysregulated growth hormone production seen in acromegaly leads to increased GH and IGF-1 levels. It has many ramifications including debilitating arthritis from osteoarthropathy, glucose intolerance due to insulin resistance, higher propensity for GI neoplasms, and macroglossia with prognathism causing sleep apnea. Average lifespan is decreased by 30% due to cardiovascular and pulmonary dysfunction. Treatment is aimed at decreasing IGF levels and controlling any mass effect or metabolic abnormalities caused by the tumor. Treatment options include invasive procedures for good surgical candidates and medical therapy via somatostatin analogue for patients who are not. Residual or unresectable tumors can be treated with medical therapy or radiation therapy if there is no response to medication.

Eosinophilia is not an uncommon finding on a routine complete blood count (CBC) during a primary care visit. The differential diagnosis is varied including allergic/atopic disease, drug reaction, infection, inflammatory conditions, and malignancy. An 80-year-old male was incidentally found to have leukocytosis on routine labs. White blood cell (WBC) was 27.5 K/ul with eosinophilia 4.3 K/ul (normal range 0-0.6 Kul) and Hemoglobin/Platelet counts were normal. Patient was asymptomatic. Denied history of medication change or allergy. Chest X-Ray (CXR) followed by Computed tomography (CT) showed 5 cm pulmonary mass with mediastinal lymphadenopathy. Patient developed progressively enlarging left neck mass, hoarseness, weight loss and decreased appetite in the next 3 weeks. WBC increased steeply to 65 K/ul with eosinophil count - 18.5 K/ul. CT neck revealed a large heterogeneous mass of the thyroid extending to the trachea, esophagus, and mediastinum. Patient decided not to proceed with further diagnostic workup and management given his age and comorbidities. Eosinophilia can be asymptomatic or present with nonspecific symptoms like cough, fatigue, skin rash or neuropathy. Eosinophilia work up starts with a comprehensive history detailing travel history, exposure to well water/spring water, analysis of past medical history to include asthma, atopy and especially medication history. Physical exam with attention to atopy/eczema and skin rash is vital. Work up may include a CBC, peripheral blood smear, stool test (for ova and parasite), IgE/tryptase levels and evaluation for occult malignancy (CXR is an ideal first step). Further testing with Bone marrow biopsy and CT scans is a consideration if a clear diagnosis is not achieved. Life-threatening complications of untreated hyper-eosinophilia include thromboembolism, endomyocardial fibrosis, cognitive disturbances, and respiratory failure. Incidence of eosinophilia is 1% in malignant tumors. Malignancy encompasses hematological cancers (acute leukemia, chronic myeloid leukemia, systemic mastocytosis, lymphoid neoplasms) and solid tumors (lung, thyroid, breast and gastrointestinal tract cancers). Eosinophilia suggests advanced disease in solid tumors and portends poor prognosis. Paraneoplastic eosinophilia has been reported in thyroid cancer (sclerosing muco-epidermoid) and lung cancer (squamous and adenocarcinoma). Pathophysiology of eosinophilia in solid tumors is related to bone marrow stimulation through cytokines (interleukin-5, granulocyte-macrophage colony-stimulating factor, and interleukin-2). Primary eosinophilia responds to steroids and hydroxyurea. Treating the underlying malignancy is the cornerstone of paraneoplastic eosinophilia management. We present a case of extreme progressive eosinophilia secondary to a malignancy which would be of interest to the primary care clinician.

Hyper eosinophilia with cardiomyopathy as manifestation of Churg Strauss syndrome Hakam Khazrik MD1, Purva Sharma MD1 Division of Hematology/Oncology, Dept of Internal Medicine, East Tennessee State University. Eosinophilia (≥500 eosinophils/micro-L) and hyper eosinophilia (≥1500 eosinophils/micro-L) could be caused by many conditions including allergic, infectious, inflammatory and neoplastic disorders. Patient may present with severe organ involvement require hospitalization and urgent intervention. A 39-year-old female with history of asthma, nasal polyps presented with worsening dyspnea, lower extremity edema, acute left heart failure and non-ST elevation myocardial infarction with significant troponin elevation (31 ng/ml). Cardiac catheterization revealed no stenosis, echocardiogram showed severely reduced ejection fraction 20%. She was managed medically with presumptive diagnosis of viral myocarditis. One month later she represented with similar symptoms associated with mild facial malar rash and worsening peripheral eosinophilia (absolute count 6400cells/micro-L), leukocytosis (WBC 11k/ul norma differential except eosinophilia mild anemia Hg: 10g/dl, normal platelet(304k/ul), normal renal and liver functions, mild elevated tryptase 16. CT chest revealed bilateral hilar lymphadenopathy with no pulmonary infiltrate. Parasite, fungal,, tuberculosis, HIV, hepatitis infections were ruled out. Bone marrow biopsy revealed hypercellular marrow for age, mild increased marrow eosinophilic precursor, normal cytogenetics, FISH studies for MDS, eosinophilia, and BCR-ABL as well as molecular MPN panel were unremarkable. No lymphoproliferative disorder or increased blasts noted. Subcarinal lymph node biopsy with normal lymph node tissue. Extensive rheumatological workup was unremarkable except for elevated rheumatoid factor, ESR, CRP, anti-myeloperoxidase and anti-protease- 3. Eosinophilic granulomatosis with polyangiitis, (EGPA)was diagnosed. Patient started on long taper prednisone with improvement in her symptoms and her eosinophilia. Given severe disease with cardiac involvement she was started on cyclophosphamide to improve her prognosis. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss), is multisystem disorder characterized by chronic rhinosinusitis, asthma and prominent peripheral blood eosinophilia. Asthma is the cardinal feature. Skin and neurological involvement is usually common but cardiac involvement is one of the more serious manifestations of EGPA accounting for approximately one-half of deaths attributable to EGPA. Two sets of diagnostic criteria are commonly used: the American College of Rheumatology (ACR) criteria and the Lanham criteria. Main diseases to consider in the differential diagnosis of EGPA are aspirin-exacerbated respiratory disease, the eosinophilic pneumonias, allergic bronchopulmonary aspergillosis, hyper eosinophilic syndrome, granulomatosis with polyangiitis and microscopic polyangiitis.

The purpose was to evaluate the psychometric properties of a 25-item questionnaire on learning orientation in a nursing educational program. The questionnaire is a standardized instrument used in industry and universities but this is the first time its psychometric properties were assessed in a nursing students. Learning orientation is a vital aspect that includes elements such as: desire to learn, an outreaching toward the goal, and seriousness in using instructional resources provided. Four hundred and seventy-two undergraduate nursing students at the first semester junior level completed the Learning Orientation Questionnaire online. The data were imported into an R language processor (Version 3.3.1) for plotting and statistical analysis. This first step was manual extraction to identify correlations between items and group them into categories using cluster analysis. Six categories were formed: learning interest, ambitious goals, instructor, achievement of goals, and lone survivor. The second step was the automatic extraction of factors with functions in the R language. The items were grouped into four factors rather than six. The automatic extraction combined the factors learning interest and ambitious goals together and removed the lone survivor factor. The lone survivor factor contained one question (q24) with a low eigenvalue of (0.3). This question was deemed both minor and irrelevant to the topic of the questionnaire and therefore is proposed to be removed. The result of the factor and cluster analyses in nursing students was compared to that of a previous study (Martinez, 2005) that used a heterogeneous sample of both high school and university students of many different majors. The differences in the results were substantial. First, Martinez (2005) found three extracted factors in her research in comparison to the current research of four factors. Moreover, the previous study grouped our main two factors into a single factor, which means that the factors for learning interest, ambitious goals, and instructor influence were a single factor in the previous study. The eigenvalues were almost identical to the current research, yet the factors did not correspond. Another major difference between the two studies is that in the previous study’s second factor called “learning independence or autonomy” did not correlate with the description of the factor. The author explains the factor as growing to learn independently by finding the motivation from within. Yet, the questions selected in the factor solemnly incorporate the instructor as a resource of learning. In this study, the factor was placed in a separate category and was labeled “instructor influenced” based on the fact that it heavily relied on the demand of an instructor. The conclusions are: (1) The factors extracted in nursing students in the present study do not correspond closely to those of the sample used by Martinez (2005) and this might be explained by the greater focus on applied practice in nursing education. (2) The current questionnaire could be reduced in size to 8 questions while maintaining strong measurement quality.