Research has shown that many patients find it difficult to understand and retain information that is conveyed verbally by medical professionals. One solution to this problem is to give patients this information in a written form so that it can be reviewed when needed to maximize retention and understanding. When implementing this solution, care should be taken that the patient education materials (PEMs) are written in a way that is easily understood by the patient. PEMs should also be of good quality, meaning that they are comprehensive, without bias, evidence based, relevant, and balanced. Well written PEMs are especially important within the field of audiology as many patients find it particularly difficult to understand audiological and vestibular information. PEMs related to many different diagnoses and treatment within the field of audiology have been evaluated to ensure that they are appropriate for patients, but this evaluation has not yet been done for PEMs pertaining to benign paroxysmal positional vertigo (BPPV). BPPV is a common cause of dizziness where episodes are triggered by head movements such as tipping the head back. For this study, 11 PEMs pertaining to BPPV were gathered from professional organizations online and 3 were gathered from audiology clinics local to East Tennessee. Reading grade level was determined using the Fry Method and the Simple Measure of Gobbledygook (SMOG). Quality was determined using the DISCERN. The results of this study indicate that the current PEMs related to BPPV are not written at an appropriate reading level for patients as determined by the Agency for Healthcare Research and Quality (AHRQ). The conclusion of this study is that while some of the PEMs analyzed were found to be of good quality, many can and should be improved. Organizations such as the CDC and AHRQ have created materials to guide medical professionals through the process of improving their PEMs.

Management of very low rectal cancer is one of the most challenging issues faced by colorectal surgeons. For tumors in the mid and upper rectum, procedures can be done to resect the cancer while maintaining continence, a major determinant of post-operative quality of life. In the low rectum, however, to optimize oncologic outcomes, many surgeons feel compelled to pursue abdominoperineal (APR) over low anterior resection (LAR), a sphincter-preserving procedure. It was hypothesized that after robust adjustment, procedure choice will not be associated with a difference in disease-free survival in the resection of tumors in the low rectum. To analyze this, the US Rectal Cancer Collaborative Database, a comprehensive, multi-center dataset obtained from six institutions between 2010 and 2016, was queried. Patients undergoing TME resection for Stage I-III very low rectal cancers (involvement) were selected for this study. Patients were categorized by procedure- LAR vs APR. Primary outcome was five-year disease-free survival. Secondary outcomes included overall survival, recurrence, length of stay, and complications. An adjusted analysis was performed to account for all known potential confounders. 431 patients with very low rectal cancer treated by either APR or LAR were identified. 154 (35.7%) underwent APR. The overall recurrence rate was 19.6%. Median follow-up time was 42.5 months. An analysis adjusted for age, gender, BMI, ASA class, and pathologic stage observed no difference in disease free survival between operative types (HR=0.90, 95% CI [0.53-1.52], p=0.70). Similarly, secondary outcomes demonstrated no significant difference between operation types, including length of stay (Beta: 0.04, Std. error = 0.25, p = 0.54), overall survival (HR=1.29, 95% CI [0.71-2.32], p=0.39), or complications (OR = 1.53, 95% CI [0.94 - 2.50], p=0.09). In this analysis, no significant difference in disease-free survival or overall survival was observed between patients undergoing APR or LAR for very low rectal cancer. This comprehensive study supports the treatment of very low rectal cancer, less than 5cm from the anorectal ring with no sphincter involvement, by either abdominal perineal or low anterior resection. Further studies may focus on patient-reported and quality of life outcomes which may influence decision-making.

Title: Improving Diabetes Self-Management Education and Support (DSMES) Referrals in the Primary Care Setting Authors: Stephanie Sossong and Dr. Jean Hemphill, College of Nursing, East Tennessee State University, Johnson City, TN. Purpose: The purpose of this quality improvement project is to implement a standardized referral process to DSMES in primary care. DSMES decreases complications from T2DM and reduces healthcare costs. However, patients diagnosed with T2DM are referred <7% of the time. Aim: To assure that patients diagnosed with T2DM receive referrals to an accredited DSMES program. Processes: Baseline data of the number of patients with T2DM referred to DSMES was collected from a primary care clinic for 4 weeks. An educational in-service highlighting the benefits of DSMES, guidelines for referrals, and the process improvement was presented to providers and medical assistants. Data regarding referrals to DSMES after the process implementation will be collected for 4 weeks, numbers will be compared to pre-implementation data and reported using percent frequency. The IRB determined that the activities of this project are not defined as research involving human subjects. Results: The results of this project have not been determined yet, however; the expected outcome is an increased number of referrals to DSMES. Limitations: The limitations of this project include a small sample size and a short length of study. Conclusions: Implementing a standardized referral process in primary care increases referral rates to DSMES. This is important because DSMES has been proven to reduce diabetes related complications, healthcare spending, and prevalence of other comorbidities.

Hearing loss and tinnitus are the two most common service-connected disabilities in Veterans. Patients with a chief complaint of hearing loss and/or tinnitus typically undergo a hearing evaluation to determine the severity and type of hearing loss. The standard treatment for sensorineural hearing loss is the fitting of personal amplification.Up to 95% of tinnitus patients have an underlying hearing loss and could benefit from hearing aids for both improved communication and as an effective treatment to reduce the impact of tinnitus, ((Shargorodsky, Curhan, & Farwell, 2010). It is not uncommon, however, for some of these patients to decline hearing aids although they elect to undergo tinnitus counseling. The observation that some of these patients elected to obtain hearing aids following tinnitus counseling compelled an investigation of tinnitus counseling’s role in the patient’s revised decision to accept hearing aid fitting. An electronic medical records review (2015- 2020) identified Veterans meeting the following criteria: (1) diagnosis of sensorineural hearing loss and tinnitus, (2) declined hearing aids at the time of the hearing evaluation, (3) received tinnitus counseling, (4) elected to obtain hearing aids following tinnitus counseling, and (5) affirmed regular use of the hearing aids for more than one year. 30 qualified veterans provided informed consent to participate. Enrolled participants were interviewed using a brief survey that allowed patients to report a variety of tinnitus and hearing-related challenges. Participants also completed a validated tinnitus intake form, the tinnitus handicap inventory (THI), which reports a patient’s self-assessed tinnitus handicap. A total of six Veterans (white males, average age of 60 years, with bilateral sensorineural hearing loss and bothersome tinnitus) participated. The number of hours of daily hearing aid use was related to the self-perceived benefit of hearing aids for the management of tinnitus, as the 5 participants who wore their hearing aids >5 hours/day reported benefit in contrast to the single participant who wore their hearing aids /day. The reported benefit of tinnitus counseling, however, was not reflected as a significant improvement in the post-counseling THI score. All participants reported the counseling was useful and recommended that other veterans experiencing tinnitus and hearing loss undergo a trial with hearing aids . A narrative analysis of additional information provided by participants was made to identify counseling elements that supported the use of hearing aids for tinnitus management. In general, the analysis indicated that when patients were provided accurate information regarding tinnitus management strategy options, then they might be more likely than uninformed patients to accept and act upon hearing aid recommendations in a timely manner. All participants suggested that the provision of more information regarding tinnitus and management options at the time of the hearing evaluation would have likely expedited hearing aid acceptance. The preliminary findings of this survey suggest that patients with a diagnosis of sensorineural hearing loss and tinnitus might benefit from some form of tinnitus management counseling at the time of the initial hearing evaluation, and that the counseling might facilitate uptake of hearing aids.

Both audiologists and hearing instrument specialists (HIS) can assess hearing loss and fit hearing aids; consumers interested in purchasing hearing aids can choose the type of hearing professional they see. However, there are vast differences in required training and scope of practice for each professional and advanced test batteries, such as those associated with vestibular assessment and tinnitus management, may distinguish the two professional groups more thoroughly than standard hearing testing and hearing aid fitting. This study aimed to determine the knowledge and opinions the average individual possesses regarding differences between these two types of hearing professionals in order to identify areas in which audiologists can more effectively differentiate themselves from hearing instrument specialists. A one-time survey was administered at 3 locations to a total of 47 English-speaking participants over the age of 18. Locations included the 2018 Remote Area Medical event in Gray, TN; the Johnson City Senior Center, and the Bristol Public Library. The survey consisted of 8 demographic questions with 3 additional questions if the participant wore hearing aids, followed by 18 questions that covered “Diagnostics,” “Intervention,” and “Interpersonal Patient Interactions.” Responses were analyzed for trends in overall data as well as in sub-categories for gender, household income, education level, age, and hearing aid use. Overall, participants tended to believe audiologists were most likely to perform tasks in the “Diagnostic” category, while a majority of participants believed both professionals could perform tasks in the “Intervention” category. There was no clear trend within the “Interpersonal Patient Interactions” category. Most participants believed that either both professional groups, or only audiologists, could perform most tasks adequately, indicating subjects likely do understand differences between the two professionals. In analyzing results, two issues emerged. The first was that the majority of participants believed that they would not be likely to pay a reasonable price for hearing aids when visiting either professional. One reason may be that only a few hearing aid companies produce most of the world’s hearing aids, leaving little room for low-cost competition. The “bundled” method which most hearing healthcare providers use for selling hearing aids along with services might also exert an influence on the perception of hearing aid pricing and may not be clear to patients who try to understand the actual cost of devices and services. Another issue identified in this survey was access. A significant number of respondents believed it was difficult to make and attend appointments with either professional, signifying a possible deficit in this area in access to hearing healthcare. The barriers to access included income, availability of transportation, inconvenient provider hours, and lack of insurance coverage. The results suggested that audiologists and HISs face challenges when recommending personal hearing devices to support rehabilitative efforts. Additionally, the provision of services that utilize advanced diagnostic batteries, such as balance assessment and tinnitus services, may offer audiologists an opportunity to distinguish their practices from those managed by HISs.

Introduction: Cardiovascular diseases (CVD) remain the leading cause of death in the United States (U.S.), accounting for one in three deaths annually. Within the U.S., disparities in CVD outcomes and risk factors exist across demographic groups and geographic areas, such as the Central Appalachian region where the burden is higher than state and national rates. Patient-centered care (PCC), is a model of health care delivery that has been shown to improves disease outcomes and quality of life, and is critical in addressing disparities in health care. However, little is known about how high-risk Central Appalachian populations understand or perceive such a model. As such, the objective of this study was to examine the perceptions of PCC among community-dwelling CVD patients/caregivers in the region. Methods: A qualitative study design applying thematic analysis was utilized for data collection and analysis. Seven focus group discussions across six states in Central Appalachia were conducted, and comprised of 78 middle-aged participants selected through purposive sampling. Sessions were guided by standardized instrument regarding current efforts in their communities concerning CVD; challenges and needs; appropriate approaches to their cardiovascular issues; understanding and views about patient-centeredness; and related priorities. The discussions were audio-recorded, transcribed, and then coded for thematic analysis using NVivo qualitative data analysis software. Dependability of data analysis was achieved through an audit trail tracking the NVivo process. Results: Data analysis identified interpersonal relationships with health care providers (HCPs) as the most important aspect of PCC among participants. When asked what PCC meant to them, each group discussed the interpersonal relationship they wanted from HCPs, barriers that kept them from achieving this relationship, and how it impacted their care. Within this theme, two overarching subthemes emerged: (1) developing long-term relationships with HCPs, and (2) developing partnerships with HCPs. The first theme had subthemes that included: turnover of HCPs in their geographical location, the disappearance of family physicians, and preferences related to seeing a physician versus a physician’s assistant or nurse practitioner. The second theme’s subthemes included: communication, feeling cared for as an individual, and input into care. Conclusion: Patients/caregivers stressed the importance of interpersonal relationships with providers in the delivery of PCC. However, patients recognized when PCC was not being provided, provided examples of interactions that were not conducive to providing PCC, and reported feeling disempowered as a person and a patient. The results of this research can be utilized to understand patient/caregiver perceptions of PCC, and indicates the need for further research to reconcile these viewpoints with those of providers to improve the delivery of care, and health outcomes.

When families use a listening and spoken language communication modality to communicate with their child, access to a rich linguistic environment through an intact auditory system is essential. In children with hearing loss, optimal auditory access is achieved through the consistent use of appropriately fitted hearing devices or other assistive hearing technology, allowing these children access to an ample language environment. Parents or caregivers of children with hearing loss or hearing concerns play a large role in facilitating their child’s use of hearing device, as well as supporting their child’s speech and language development, a potentially overwhelming experience for these families. The aim of this study was to continue a similar, previously completed project within the Audiology and Speech Language Pathology program at ETSU. The purpose of both studies was to improve parent self-efficacy, i.e., their confidence in their ability to optimize their child’s amplification use and linguistic exposure, increase family knowledge on language outcomes, and increase consistent use of amplification/treatment options by providing an educational workshop to families with children identified with hearing loss and/or hearing concerns. The current study was adapted based on caregiver feedback from the previous study. The hypothesis of this study was to see an enhancement of self-efficacy skills in parent participants. An educational workshop encompassing 1. the impact of hearing loss and/or hearing concerns on language development; 2. the importance of language exposure; 3. use and care of amplification/treatment options, and 4. empowerment to establish consistent device use in families that utilize amplification or other technology was delivered through a virtual meeting with participants. The participants’ self-efficacy skills regarding their child’s device use and language development were assessed and measured through a pre- and post-survey, the Scale of Parent Involvement and Self-Efficacy-Revised (SPISE-R). The SPISE-R surveys caregivers about their child’s device use as well as their perceptions of their own beliefs, knowledge, confidence, and actions pertaining to supporting their child’s auditory access and spoken language development. The assessment and workshop incorporated in this study were modeled after Ambrose et al. (J Early Hear Detect Interv, 2020) who developed the SPISE-R as a promising tool for use in early intervention to better understand and further support parent’s strengths and needs concerning their young child’s auditory access and spoken language development. Participants were recruited via email from an Early Intervention Specialist. A total of three pre-surveys were completed. Four parents attended the virtual workshop but none of them completed a post-survey. Therefore, data analysis was based on a comparison between the pre-surveys completed in the previous study (n=3) and in the current project. The results revealed that the participants from the current study rated themselves as having lower self-efficacy in supporting their child’s device use and language development than the participants of the previous project. Based on these results, future studies should consider: 1. recruiting from a larger pool of parents 2. hosting the workshops in-person instead of virtually 3. offering workshops multiple times to better accommodate parent schedules, and 4. shortening the survey.

Ceftriaxone is the most used third-generation cephalosporin anti-microbial agent in treating infections caused by gram-positive and gram-negative organisms. Chorea is a movement disorder characterized by involuntary and hyperkinetic movements of the affected body parts due to rapid and unpredictable contractions. We report an uncommon case of ceftriaxone-induced acute reversible chorea. 84-year-old male with a medical history of diabetes mellitus, hypertension, previous myocardial infarction, and gouty arthritis was admitted to the hospital with complaints of altered mental status (AMS) and right 1st metacarpal-phalangeal joint (MTP) swelling, erythema and ruptured wound draining pus-like fluid. The patient was febrile with a temperature of 101.3 F. The rest of the vitals were normal. The patient had an initial workup and was empirically started on ceftriaxone and vancomycin for skin and soft tissue infection. His wound cultures and blood cultures grew pan-sensitive streptococcus agalactiae. His antibiotics were de-escalated to ceftriaxone. X-ray showed severe soft tissue swelling and erosive changes at the base of the proximal phalanx of the first digit secondary to gout or osteomyelitis. MRI of the right foot was attempted, but the patient could not tolerate it. TTE was negative for Endocarditis. The patient had initial improvement in his AMS, but 72 hours later, he became increasingly confused with choreiform movements. Ceftriaxone was discontinued, and Ertapenem was started. Patient’s confusion and choreiform movements improved after the discontinuation of ceftriaxone. Patient was discharged to a rehabilitation facility with four weeks of IV Ertapenem. Ceftriaxone is a third-generation cephalosporin that inhibits mucopeptide synthesis in the bacterial cell wall. Ceftriaxone is a well-tolerated anti-microbial agent with a low toxicity profile. Common adverse effects include gastrointestinal disturbances, skin rashes, and hematological disorders. Neurological symptoms like encephalopathy is an uncommon adverse effect. Chorea is a movement disorder due to hereditary or acquired causes. Drug-induced chorea is one of the rare causes of acquired chorea. History and physical examination are essential in diagnosing acquired causes of chorea. Further workup with laboratory tests and neuroimaging are required to evaluate secondary causes. Chorea due to ceftriaxone is described in a patient with end-stage renal disease on hemodialysis in a case report previously, but our patient did not have any chronic kidney disease [1]. It is postulated that beta-lactam antibiotics increase neurological hyperexcitability by increased glutamate release in the striatum and cerebral cortex, causing movement disorders [2]. It is noted that pre-existing neurological conditions and excessive dosage are shown to be significant risk factors for cephalosporin neurotoxicity. Our patient, however, did not have any neurological condition but was treated with 2 grams of ceftriaxone daily before he had choreiform movements. Upon removal, the patient improved significantly within 36-48 hours. Ceftriaxone is a widely used anti-microbial with broad coverage. Although uncommon, recognizing that neurotoxicity due to third generation cephalosporins is essential. Prompt diagnosis and withdrawal of the offending agent is critical in improving the patient’s symptoms. Age, prior neurological conditions, kidney disease, and dosage must be carefully evaluated before administration.

Background: The etiology of pulmonary disease is complex and influenced by various factors, resulting in a significant public health issue, with 16 million Americans living with chronic obstructive pulmonary disease (COPD) and 24 million with asthma, and cases are on the rise. The purpose of this study was to explore demographic, health status, and lifestyle behaviors with pulmonary disease so patterns of risk can be understood and inform interventions. Methods: This cross-sectional study utilized the National Inpatient Sample Data from 2019 (NIS 2019). The predictor variables consisted of: demographics (age (18+), sex, race), health status (obesity, depression, diabetes), lifestyle behaviors (smoking, alcohol use, and aspirin use), and the outcome variable was pulmonary disease. To ensure accuracy, the data was weighted by the variable discharge weight (DISCWT), and chi-square analyses and ANOVA tests were conducted to determine the independence of categorical and numerical predictor variables. Descriptive statistics were conducted for all variables, simple and multiple logistic regression analyses were performed to identify factors that contribute to the likelihood of having pulmonary disease. Results: The sample of the NIS 2019 data included 6,043,654 cases of which, 22.65% of inpatients had pulmonary disease. The collective sample demographic characteristics were: mean age of 58.4 years, and more than half of inpatients were females (57.05% compared to 42.95% males). In terms of health, 17.75% of the sample were obese, 28.8% had diabetes, and 14.25% were depressed. Within the collective sample, 16.8% of inpatients reported smoking, 9.09% drank alcohol, and 14.51% consumed aspirin (long-term (current) use of aspirin). Results of the multivariate statistical analyses reveal that individuals who were obese were 68.3% more likely to have pulmonary disease compared to non-obese patients (aOR = 1.683, CI 1.679-1.686, pConclusion: Results of our study provide important insights between pulmonary disease and associated risk patterns. As pulmonary symptoms have risen in the wake of the COVID-19 pandemic, there is an urgent public health need to explore disruption of risk pathways to avoid overwhelming fragile global healthcare systems.

Introduction: The consequences of the opioid epidemic and various prevention, mitigation, and treatment strategies have a strong hold on Appalachian communities. However, limited research has been conducted to understand the experiences of special populations impacted by opioids in this region, such as women of childbearing age living with opioid use disorder (OUD) prior to and during pregnancy. The objective of this review is to summarize existing literature on the care experience for women of childbearing age receiving treatment with medications for opioid use disorder (MOUD) in rural east Tennessee. This literature review will allow for better understanding of current treatment practices, potential gaps in care, and needed care system improvements for this patient population. Methods: A systematic PubMed search identified studies focused on MOUD and pregnancy in the rural eastern Tennessee region. Search results were screened to remove publications older than five years or from outside the region. Relevant information concerning the MOUD care experience for women of childbearing age in the area was collected from these studies. Results: Five studies were included: four surveys and a systematic review. All were published within the last five years and described experiences spanning preconception to postnatal care as well as Tennessee opioid laws that affect women of childbearing age. Two studies detailed the pre-pregnancy care experience, including information about prior pregnancies, intention of conception, contraceptive use, and perceived barriers to contraception access among women receiving MOUD. Two studies described the care experience during pregnancy and its evolution in recent years with changes in acceptance of insurance for MOUD treatment, rates of MOUD-positive prenatal drug screens, and MOUD tapering practices during pregnancy. The final included study reviewed several Tennessee opioid laws enacted over the years to combat prenatal substance use and neonatal abstinence syndrome (NAS). Notably, while total reported cases of NAS have decreased statewide in recent years, the highest rates continue to be observed in east Tennessee, with a majority of cases linked to MOUD exposure. The requirements and enforcement of NAS-related legislation in Tennessee have changed over time but their existence may deter pregnant women from seeking treatment due to fear of punitive consequences. Conclusion: The evidence compiled in this literature review points to many areas in which the care experience can be improved for women of childbearing age receiving MOUD in east Tennessee. There are concerns regarding pregnancy planning, contraceptive access, availability of evidence-based OUD treatment, cost of treatment, and fear of actual or potential negative repercussions from opioid use during pregnancy. These findings suggest multiple efforts can be undertaken by clinicians, researchers, and policymakers to enhance the experience of care for women of childbearing age living with OUD, and consequently improve the health of the population in general, in this region of Appalachia.