Background: Adverse Childhood Experiences (ACEs) are a risk factor for the development of future physical and mental health problems. Programs are needed that prevent and address the impact of ACEs on a population-based level. As a pediatric primary care clinic serving Northeast Tennessee, our goal was to better understand the knowledge and perceptions of the effects of ACEs among parents/caregivers and health professionals in Northeast Tennessee. Methods: During the summer of 2017, 51 parents/caregivers visiting a health education table at a family event in a local public library completed an anonymous survey to help us understand what people think about how ACEs affect children and adults. 20 health care professionals at a local pediatric primary care clinic completed the same anonymous survey. Survey results were entered into Excel and analyzed using Excel and SPSS. Results: Fewer than one-third of parents/caregivers in this sample had heard of the term "ACEs" prior to receiving this survey. However, after being provided with a definition of ACEs, most respondents agreed that ACEs could affect children's behavior and adult mental health. Agreement was less for perceptions of effects on physical health in adults. Most respondents recognized that a parent’s own ACE exposure could make parenting more difficult and that having a strong support system is helpful in counteracting these negative effects. Healthcare providers were more likely than parents/caregivers to have heard of the term ACEs before, however only half were familiar with the term. After being provided with a definition of ACEs, most healthcare providers agreed on their effects on children and adults. Perceptions that having a strong support system could counteract the effects of ACEs were slightly lower among health care providers as compared to parents/caregivers. Conclusion: The low awareness of ACEs found by our survey confirms the need for a new initiative to screen for ACEs and provide trauma-informed care in our clinic. The project, Baby Steps for Success, will involve screening children and parents/caregivers for ACEs, providing brief education on ACEs, and building resilience. Engaging and supporting families around healthy behaviors and interactions will be accomplished using Reach Out and Read and ReadNPlay for a Bright Future beginning in early infancy. Intervention with the Incredible Years program and Ecomap assessments will be provided to high-risk families with 2 or more ACEs. Families with four or more ACEs will be offered the Nurturing Parenting curriculum through a series of home and group visits. Partners for this project will include ETSU Pediatrics, Families Free, and the Northeast TN Regional Health Office.

Introduction. Inflammation is characterized by complex interactions between pro- and anti- inflammatory cytokines. Recent research has probed the role of the nervous system in inflammation, part of which includes the cholinergic anti-inflammatory pathway that regulates immunologically-mediated inflammation. In this pathway, norepinephrine release from the splenic nerves binds to beta-2-adrenergic receptors on T cells, causing release of acetylcholine (ACh). ACh subsequently suppresses macrophage production and release of pro-inflammatory cytokines. In this project, we aim to develop a method to quantify the ACh release in splenocytes when challenged with different mediators in this pathway. Our method utilizes liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) for quantification of ACh and choline (Ch) in cell culture media. Methods. Literature review revealed that the hydrophilic interaction liquid chromatography (HILIC) is the most appropriate separation mechanism for ACh and Ch. The developed LC-MS/MS method utilizes an isocratic separation (14% 10mM ammonium formate, pH 3, and 86% acetonitrile) on an Atlantis HILIC column (2.1 x 100 mm, 3 micron). The MS operates in positive electrospray (+ESI) mode, monitoring ions specific for ACh, Ch, and their corresponding deuterium labeled internal standards. The calibration range for ACh was 0.5 - 5 micrograms/ml (3.4 - 34 mM) and 10 - 50 micrograms/ml (96 - 480 mM) for Ch. Cell culture media contained neostigmine to inhibit cholinesterase. Cell culture media samples are prepared by freeze drying, reconstituting in acetonitrile, and filtering (0.2micron). Potential loss of ACh through degradation during cell culture was evaluated by monitoring d4-labeled ACh with and without the presence of splenocytes for 4 and 24 hours. Results. Correlation coefficients (R2) indicate linearity for ACh and Ch in acetonitrile and culture media in the aforementioned calibration range. This linearity applies to external calibration as well as calibration utilizing the deuterium labeled internal standard. Calibration curve slopes differed between samples prepared in culture media and those prepared in acetonitrile. As such, experimental samples will be matrix matched by preparing calibrants in media. During the six-min separation, ACh elutes at 3.8 min and Ch at 5.1 min. Deuterium-labeled ACh, when incubated for 4 and 24 hours, showed statistically significant loss, compared to control, of ACh after 24 hours in media and media + splenocytes. Despite this, the average loss of ACh by hydrolysis averaged less than 10%. Media and media + splenocyte samples incubated for 4 hr showed no statistically significant difference from control. Conclusions. The developed LC-MS/MS assay for quantification of ACh and Ch in cell culture media can be applied to the investigation of the cholinergic anti-inflammatory pathway. The method provides a rapid separation of ACh and Ch, with the successful incorporation of stable-isotope labeled internal standards.

ABSTRACT Objectives There is a growing concern about the increasing incidence of weapon-related injuries among middle and high school students in the United States, but the association with substance use remains unclear. This study aimed to examine the association between substance use and weapon-related injuries among middle and high school students in the United States. Design Population-based cross-sectional study Setting Public and private middle and high schools in all 50 states of the United States and District of Columbia Methods Data were obtained from the 2015 Youth Behavioral Risk Survey (YRBS) (n=15,624). Weapon-related injuries were injuries caused by any weapon. Substance use was defined as when someone uses psychoactive substances including alcohol and illicit drugs. Substances in this study included marijuana, heroin, cocaine, amphetamine, ecstasy, alcohol and injected illegal drugs. Substance abuse referred to the harmful use of any of these substances. Multiple logistic regression analyses were used to examine the association between substance use and weapon-related injuries after adjustment for covariates. Results There were 574 (7.70%) cases of weapon-related injuries among the males and 361 (4.85%) cases of weapon-related injuries among the female population. The highest proportion of weapon-related injuries was among the American Indians (10.42%) while the lowest proportion was among the whites (5.74%). Of all the substance use groups, alcohol users had the highest number of cases of weapon-related injuries (N= 689, 7.37%) but the highest proportion of weapon-related injuries was among heroin users (N= 147, 45.51%). The use of marijuana (Odd Ratio (OR) = 1.45, 95% confidence interval (CI) =1.16 -1.80) and illegal drug injection (OR =3.71, 95% CI = 2.28 -6.03) were associated with increased odds of weapon-related injuries. Carrying weapon on school property (OR =2.21, 95% CI =1.69 – 2.89) and alcohol use (OR = 1.53, 95% CI =1.3 – 1.8) were also found to be positively associated with weapon-related injuries. However, being female (OR = 0.8, 95% CI = 0.7 – 0.98) was associated with lower odds of weapon-related injuries. Conclusion Marijuana use, illegal drug injection, alcohol use and carrying weapon on school property were positively associated with weapon-related injuries among middle and high school students in the United States. The findings may help reduce weapon-related injuries in middle and high schools if policy makers enact laws that limit access to weapons especially those involved in substance use and prohibit bringing of weapons into the school properties.

A pattern of health insurance policy among smokers in the United States Abdulrasak Ejiwumi, Nathan Hale and Melissa White, Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN Previous research has noted that Medicaid expansion has had a positive impact health care access and the quality of healthcare services among individuals with lower incomes. However, only a few studies have been conducted to describe the association between smoking and having any type of healthcare insurance in the United States. Health insurance provides access to important smoking cessation programs that are critical for enabling quit attempts. This study examines the extent to which insurance is associated with smoking cessation. We obtained data from the 2021 nationally representative Behavioral Risk Surveillance System Dataset. A descriptive analysis was conducted on adult smoking status and enrollment in any health insurance policy and variation based on race, gender, income, marital status, and level of education was examined using a Chi-square test. Current smoking status and any health insurance enrollment was also examined using an adjusted logistic regression analysis controlling for age, sex, income, marital status, and race/ethnic group. Among adult smokers in the United States (Sample size 167,079), 85.7% have health insurance while 10.2% do not have any type of health insurance. Approximately 69.5% of individuals with health insurance reported quitting smoking compared to 42.8% of those who do not have health insurance (p=0.001). Adjusting for additional covariates of interest, the odds of quitting smoking was 1.6 times higher for respondents with any type of health insurance compared to uninsured respondents (AOR 1.55, 95% CI=1.49 – 1.61). This study found that the access to health insurance is an important predictor of quitting smoking, even when adjusting for age, race, gender, marital status, levels of education, and income. Insurance remains an important enabling factor that provides the resources and supports necessary to enable smoking cessation programs and ultimately support smoking cessation. Continued efforts to increase access to health insurance are needed.

Multiple sclerosis (MS) is a chronic neurological disease where immune cells from the periphery enter the central nervous system and attack the myelin sheaths resulting in damage to the axons. It is an unpredictable disease that affects each person differently. One of the symptoms of MS includes muscle spasticity and depending on the severity it can cause gait and mobility issues. Oral baclofen is the first-line recommendation to treat spasticity in people with MS whose treatment goals include improving mobility or easing pain and discomfort. Baclofen works pre- and post-synaptically as a gamma aminobutyric acid-B agonist at the spinal cord to reduce the amount of excitatory neurotransmitters that are responsible for muscle contractions. Oral baclofen has been used to treat spasticity, however its short half-life of 2-6 hours warrants its need for three times a day dosing schedule. The multiple daily dosing can be a burden to the patient taking it and for the caregiver who will be giving the medication which can negatively affect adherence and acceptability. The goal of the current study was to design and assess baclofen loaded dissolving microneedle (MN) patch on the amount permeated and sustained delivery of baclofen in the management of spasticity. A 1.5 mg/mL MN patch was initially made by dissolving baclofen in polyvinylpyrrolidone (PVP) and fabricated using the mold casting technique. The permeation profile of fabricated baclofen loaded MNs over a predetermined time was assessed in vitro through dermatomed porcine ear skin using Franz Diffusion cells. Employing the use of MNs significantly increased the flux from 2.10 ± 0.35 µg/sq.cm/h to 5.92 ± 4.17 µg/sq.cm/h and the average cumulative amount permeated from 92.67 ± 11.25 µg/sq.cm to 457.11 ± 111.47 µg/sq.cm over 72 h (p<0.05). However, because of baclofen’s hydrophilic nature, drug permeation across skin is limited, so a nanosuspension with reduced particle size was formulated to be used for MN fabrication to increase drug loading and permeation. Baclofen was formulated into a suspension through wet media milling followed by mechanical homogenization using PVP K30 and sodium dodecyl sulfate as stabilizers. The suspension was successfully loaded in dissolving PVP-based MNs. The donor chamber of the cell contained the MN patch mounted onto the porcine skin and the receptor chamber contained phosphate buffered saline. The receptor was sampled over 72 h and analyzed using HPLC. The baclofen suspension loaded MNs produced an average drug flux of 26.51 ± 4.17 µg/sq.cm/h and an average cumulative amount of 1718.96 ± 217.12 µg/sq.cm over 72 h. The use of suspension loaded MNs was found to enhance the permeation and produce a sustained delivery of baclofen across skin and depicts the applicability of fabricated needles for sustained delivery in the management of muscle spasticity in multiple sclerosis.

Vision impairment is one of the most common disabilities among older adults and leads to excess disability. Roughly 12 million older Americans (60 years and older) report vision loss resulting in deficits in physical and cognitive functioning. Furthermore, visual impairment and blindness cases are expected to double by 2050. The CDC estimates that vision impairment is among the costliest conditions in the U.S. at $145 billion annually. Approximately 195,000 Tennesseans are blind or visually impaired (B/VI) and report having severe difficulty seeing even with glasses. B/VI Tennesseans are more likely to be in poor health, have mobility issues, and report having a fall in the previous year. The current study aimed to assess the prevalence of vision impairment and identify barriers to routine eye exams among older adults in Northeast Tennessee. A cross-sectional survey was carried out in March 2023 on a convenience sample of older adults (50 years and older) in Hawkins, Greene, Sullivan, and Washington Counties. We developed a survey in collaboration with representatives from the Aging and Vision Loss National Coalition (AVLNC) that was administered in community and senior centers. The study questionnaire included a series of questions on vision health, eye screenings, and barriers to eye care services. Data were also gathered on demographic characteristics, insurance status, and self-reported chronic conditions. Preliminary data from 123 participants have been analyzed. The majority of participants were 65 and older (71.5%), non-Hispanic White (91.8%), and female (70.7%) with income of <$24,000 (70.0%). One-third (33.1%) report their health as fair or poor and nearly half (48.2%) of participants have 4 or more chronic conditions. Underlying conditions are linked to eye problems. Half of participants have hypertension (53.5%) or hypercholesterolemia (47.4%) and nearly one-third (30.7%) have diabetes. The overall prevalence of difficulty seeing even with glasses was 26.3%. Two-thirds (67.9%) report at least one eye condition (cataracts, glaucoma, macular degeneration, and glaucoma). Twenty percent of participants do not see an eye care provider. Overall, two-thirds (66.7%) indicated at least one obstacle to eye care: cost (35.7%), limited/no insurance coverage (23.8%), transportation (16.7%), and distance (11.9%). Forty percent of participants report traveling 10 miles or less to see an eye care provider. reliminary analyses suggests that B/VI in older adults represents an overlooked and yet rapidly growing public health crisis that impacts healthy aging. Given the high prevalence of chronic comorbidities and eye-related diseases among participants, greater attention is needed on the importance of a healthy lifestyle, routine eye exams, and expanded access to affordable care to address known barriers to care. Multivariate analysis will be used to determine independent predictors of poor vision health in the study population.

Ensuring adequate and timely follow-up is one of the essential parts of providing good patient care in a primary care setting. If the next visit is not scheduled prior to a patient leaving the clinic, it often results in them being “lost to follow-up.” This results in inadequate care, delays in treatment, and increased burden of disease. Using the currently available scheduling mechanism in our EHR is a tedious and time-consuming process that makes it difficult to arrange for follow up visits prior to the patient arriving at the checkout window after they leave the exam room. This often resulted in no appointment being scheduled at all or one much later than the provider intended. Our proposed solution to this problem was to replace the electronic scheduling mechanism with small paper “follow-up cards” that patients are given to take to the checkout desk with them. We implemented this new process in our clinic for a 3-month period and evaluated resident satisfaction with follow-up and checkout procedures before and after the change. We found that residents preferred using the card system because they felt it improved their workflow in clinic and improved efficiency of scheduling follow up visits. Given the positive reviews, it was decided to implement the follow up cards as a permanent mechanism for scheduling appointments in our clinic until a more efficient electronic system can be arranged.

Background: Hypercholesterolemia is a leading risk factor for cardiovascular diseases, with an average of 102.3 million American diagnosed with Hypercholesterolemia. Medical conditions, lifestyle habits, hereditary factors, and psychiatric illnesses have been associated with Hypercholesterolemia. A few studies postulate that Hypercholesterolemia leads to brain changes that underlie depressive illness. Depression is anticipated to overtake chronic diseases like hypertension in developed nations by 2030, and over 17 million US adults suffer from depression. Tennessee ranks 9th (22.36%) out of 50 states with the highest depression rates, with the incidence rising steadily. As a major public health concern needing urgent attention, it is imperative to establish the association between depression and Hypercholesterolemia among adults in Tennessee. Methods: We used cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System a nationally representative U.S. telephone-based survey of adults aged 18 years, and extracted data for Tennessee (n=4,788). Logistic regression analyses were conducted to test the association between diet, physical activity, depression, no past month exercise, high body mass index, substance use, and high cholesterol (outcome). We controlled for income, race, educational status, health insurance status, and age. Results: Overall, 36.1% (n=1,726) of participants in our sample reported high cholesterol. Results of our logistic regression model revealed that depression (OR =1.37, 95% CI, 1.19, 1.58), High body mass index (OR=1.75, 95% CI, 1.52,1.99), no past month exercise (OR=1.45, 95% CI, 1.27,1.66), male gender (OR =1.16, 95% CI, 1.03, 1.32) and low income (OR =1.33, 95% CI, 1.15, 1.53) were associated with high cholesterol. Furthermore, participants with high cholesterol are 37% more likely to report depression. On the other hand, cigarette use, e-cigarette use, alcohol use, no insurance, and marijuana use were not significantly linked. Conclusions: There is a need for awareness and prevention of Hypercholesterolemia in patients managed for depression, as they might die from the complications of high cholesterol rather than the psychiatric illness itself. It is important to intensify the existing programs and interventions for the prevention of Hypercholesterolemia, which would favorably impact on the burden of depression among adults in Tennessee. Also, studies should be done on the outcomes of cholesterol-reducing medications to prevent Hypercholesterolemia in patients with chronic diseases and depressed patients.

HIV/AIDS is considered the deadliest epidemic in the 21st century and has proved to be of major public health importance. Per the 2000 Zambia census, the people affected by HIV/AIDS constituted 15% of the total population, amounting to one million, of which 60% were women. Previous studies have identified sexual contact, significant exposure to infected body fluids or tissues, mother to child transmission during pregnancy, delivery, or breastfeeding as leading ways of transmission. The purpose of this study was to determine the socioeconomic factors that affect the prevalence of HIV in Zambian women. This research will help to provide more insight into this topic and aid in identifying areas that could be targeted by future intervention strategies to reduce the HIV burden. We used a cross-sectional study based on data from the 2018 Zambia Demographic and Health Survey (ZDHS). Secondary data analysis was conducted based on data for women aged 15-50 years (n=14922). Factors predicting HIV prevalence such as the age of household members, current marital status, place of residence, and the highest educational level attained were included in the analysis. Outcome variables included the result of determine HIV1/2 RDT and unigold HIV1/2 RDT. Descriptive, bivariate, and multivariate analyses were performed on all variables. Bivariate analysis was performed to determine the relationship between each predictor variable and HIV prevalence in women, using a chi-square test. Multivariate logistic regression analysis was performed using HIV test results and all predictor variables, odds ratio, confidence intervals, and P-value were reported. The prevalence of HIV in women aged 15-50 in Zambia was 9.9% in the study sample. Overall, our analysis showed that being aged 35-50 (4.7%), residing in an urban setting (6.53%), being married (6.1%), and having attained at least secondary education (4.68%) were associated with a higher HIV prevalence. All relationships were significant in the chi-square analysis at the p

Background: Juvenile idiopathic arthritis (JIA) refers to a group of auto-immune conditions involving joint inflammation that first appears before the age of 16. In the United States, about 294,000 children are affected. Although JIA can be widely attributed to genetic factors, the consensus is that environmental factors also play a role. Attempts to assess the role of environmental factors, though scarce, have focused on the role of infections, smoking exposure, and breastfeeding. Hygiene hypothesis, which suggests that adaptive immunological response improves with higher frequencies of pathogen exposure in early childhood, has been used to try to explain the risk of JIA. Common markers of microbe exposure in early life include sibling number, pet number, and maternal parity. Some prior studies conducted outside the U.S. suggests that increasing sibling number is protective against the risk of JIA. This study aimed to evaluate prior findings, using data from the U.S. Methods: The study used data from the 2017 Centers for Disease Control and Prevention National Survey for Child Health. The survey used a sample size of 21599 children to estimate the number of children in the U.S. Descriptive statistics was carried out, and logistic regression was used to determine the association between family number and the odds of developing JIA, while adjusting for sociodemographic variables. Family number was used as a proxy for sibling number. SAS v 9.4 was used for analysis. Results: Complete data on all the variables of interest were available for 17618 children, of which 67 had JIA. Although there was a marginal association between sibling number and JIA in the unadjusted model (OR [95% CI] 0.983-1.602) (P=0.068), in the adjusted model, there was no significant association between JIA and sibling number ([OR 95% CI] 0.8985-1.447) (P=0.29). There was a significant association between JIA and age, low birth weight, highest education level in the family, while sex had a marginal association. Conclusion: There was no association between family size and the development of JIA in this study. While some prior results have supported the observed significant effect of low birth weight, the disparity in results between this study and the Australian study could be due to the use of family number instead of sibling number. Further studies should assess the association of sibling number and developing JIA in the U.S.