OBJECTIVE: The objective of our study was to identify and characterize barriers to mifepristone use among obstetrician-gynecologists (OB-GYNs) for early pregnancy loss in a southern US state.
METHODS: In this qualitative study, we conducted semistructured interviews with 19 OB-GYNs in Alabama who manage early pregnancy loss. The interviews explored participants\' knowledge of and experience with mifepristone use for miscarriage management and abortion, along with barriers to and facilitators of clinical mifepristone use. The interviews were coded by multiple study staff using inductive and deductive thematic coding.
RESULTS: Nearly all of the interviewees identified abortion-related stigma as a barrier to mifepristone use. Interviewees often attributed stigma to a lack of knowledge about the clinical use of mifepristone for early pregnancy loss. The stigmatization of mifepristone due to its association with abortion was related to religious and political objections. Many interviewees also described stigma associated with misoprostol use. Although providers believed that mifepristone use for abortion would not be accepted in their practice, most believed that mifepristone could be used successfully for miscarriage management after practice-wide education on its use.
CONCLUSIONS: Mifepristone is strongly associated with abortion stigma among OB-GYNs in Alabama, which is a barrier to its use for miscarriage management. Interventions to decrease abortion stigma and associated stigma surrounding mifepristone are needed to optimize early pregnancy loss care.

This exploratory study is a follow-up to a 2014 study that investigated factors associated with large truck at-fault crash outcomes in Alabama. To assess unobserved temporal changes in the effects of the crash factors, this study re-creates the original crash models developed in the 2014 study using crash data from 2017 to 2019. Four mixed logit models were re-created using the same variables used in the previous study to analyze contributing crash factors to injury severity of single-vehicle (SV) and multi-vehicle-involved (MV) large truck at-fault crashes in urban and rural settings. It was found that there have been temporal changes in how many of the factors influenced crash severity with some of them no longer showing any significant association with crash outcomes, while others remained significant. Further, it was observed that some of the variables that remained significant had different relationships with crash injury severity in the newer severity models. For instance, while factors such as fatigued driver (in rural crashes), clear weather (in urban crashes), single-unit truck (in rural SV crashes), truck rollover (in urban SV crashes) maintained consistent significance over time, the effects of variables such as at-fault male drivers (in urban MV crashes), at-fault female drivers (in urban MV crashes), and hitting fixed object (in rural MV crashes) have changed. One such notable difference is the variable for absence of traffic control which increased the probability of major injury in rural SV crashes by 49.50% in the 2014 model but decreased the probability of recording major injuries by 108.90% using the 2017-2019 data. Considering the temporal changes that were observed in the recreated models, newer models were developed, revealing the emergence of new variables such as truck age that are significantly associated with truck crash severity. The findings of this study provide evidence to suggest that some crash severity factors for at-fault large truck collisions vary over time, with newer ones also emerging over time. These findings can also help trucking companies, transportation engineers, and other industry experts in developing measures to reduce large truck crashes.

UNASSIGNED: Epidemiologic data suggest an association of obesity with breast cancer (BC); however, obesity\'s contribution to early onset and risk of diagnosis with specific molecular subtypes by race is uncertain.
UNASSIGNED: To examine the race-specific association of body mass index with early onset and diagnosis of specific molecular subtypes.
UNASSIGNED: This retrospective cohort study included patients with BC diagnosed between October 1, 2017, and March 31, 2022, at 3 University of South Alabama Mitchell Cancer Institute clinics. Participants were also prospectively enrolled for serum leptin measurement.
UNASSIGNED: The primary outcome was age at BC onset and specific subtype diagnosis. The secondary outcome was race-specific differences. Odds ratios (ORs) for associations of body mass index with age at onset and subtype were estimated using the Fisher exact test. Race was self-reported.
UNASSIGNED: Of the 1085 study patients, 332 (30.6%) were Black with a median age of 58 (IQR, 50-66) years, and 753 (69.4%) were White with a median age of 63 (IQR, 53-71) years. A total of 499 patients (46.0%) had obesity, with Black women with obesity receiving more frequent BC diagnosis than their White counterparts (OR, 2.40; 95% CI, 1.87-3.15; P < .001). In addition, Black women had a significantly higher incidence of early-onset disease (OR, 1.95; 95% CI, 1.33-2.86; P = .001) than White women, and obesity increased this risk significantly in Black women (OR, 2.92; 95% CI, 1.35-6.22; P = .006). Black women with obesity also had a significantly higher risk of luminal A BC (OR, 2.53; 95% CI, 1.81-3.56; P < .001) and triple-negative BC (TNBC) (OR, 2.48; 95% CI, 1.43-4.22; P = .002) diagnosis than White counterparts. Black women, with or without BC, had significantly higher serum leptin levels (median [IQR], 55.3 [40.3-66.2] ng/mL and 29.1 [21.1-46.5] ng/mL, respectively, P < .001) than White women (median [IQR], 33.4 [18.9-47.7] ng/mL and 16.5 [10.0-22.9] ng/mL, respectively), which was associated with higher odds of luminal A disease (OR, 5.25; 95% CI, 1.69-14.32, P = .003). Higher odds of early-onset disease (OR, 3.50; 95% CI, 0.43-23.15; P = .33 for trend), and TNBC diagnosis (OR, 6.00; 95% CI, 0.83-37.27; P = .14 for trend) were also seen, although these outcomes were not statistically significant.
UNASSIGNED: In this cohort study of patients with BC, obesity and high serum leptin levels were associated with an enhanced risk of early-onset BC and diagnosis of luminal A and TNBC subtypes in Black women. These findings should help in developing strategies to narrow the existing disparity gaps.

OBJECTIVE: This study aimed to analyze the association between physical therapists\' recommended number of visits for a full recovery from common orthopedic injuries/surgeries and the extent of insurance coverage for these visits.
METHODS: A prospective observational study was conducted with board-certified physical therapists. A qualitative questionnaire was used to gather physical therapists\' demographics and the recommended number of physical therapy visits to achieve a full recovery after 11 common orthopedic diagnoses. Physical therapists also were asked to report whether they believe that insurance provides an adequate number of visits overall. In addition to the qualitative survey, insurance coverage details of major Alabama companies were obtained for comparison. Descriptive statistics of the participating therapists were analyzed for sex, age, degree/training, and years of experience. Kruskal-Wallis statistics were used to analyze variance between the aforementioned groupings when compared with the reported average number of sessions.
RESULTS: The survey (N = 251) collected data on the average number of physical therapy sessions that are necessary for a complete recovery as recommended by physical therapists for 11 common orthopedic diagnoses. From this survey, the average number of necessary visits ranged from 11.3 visits (ankle sprains) to 37.3 visits (anterior cruciate ligament reconstruction), with the overall average number of visits being 23.8. Only 24% of physical therapists believed that insurance companies provided enough coverage. Insurance coverage varied but often required additional procedures to allocate the adequate number of visits for the studied orthopedic pathologies.
CONCLUSIONS: The majority of practicing physical therapists in Alabama perceive insufficient insurance coverage for physical therapy visits for most orthopedic diagnoses. This study has implications for healthcare decision making and patient-centered rehabilitation goals. Physicians and physical therapists can use this information to optimize treatment decisions and rehabilitation goals. Patients will benefit from improved physical and economic well-being. This study has the potential to drive further research and influence national insurance policies to better serve patients\' needs.

UNASSIGNED: Speed of processing (SOP) cognitive training may improve indicators of the quality of life (QoL) in people living with HIV. In this 2-year, longitudinal, randomized, controlled trial, 216 participants ages 40 years and older with HIV-associated neurocognitive disorder or borderline HIV-associated neurocognitive disorder were assigned to one of three groups: (a) 10 hr of SOP training (n = 70); (b) 20 hr of SOP training (n = 73), or (c) 10 hr of internet navigation control training (a contact control group; n = 73). Participants completed several QoL measures at baseline, posttest, and Year 1 and Year 2 follow-ups. Using linear mixed-effect models, no strong pattern of training effects across QoL outcomes was apparent, with small-magnitude, nonsignificant, between-group differences in depression, locus of control, and Medical Outcomes Study-HIV scales. In conclusion, despite prior work showing some transfer of SOP cognitive training improving QoL, that was not observed. Implications for research and practice are posited.

UNASSIGNED: Cancer survivors experience accelerated functional decline that threatens independence and quality of life. Previous studies have suggested that vegetable gardening may improve diet, physical activity, and physical function in this vulnerable population, which comprises more than 5% of the US population.
UNASSIGNED: To assess whether diet, physical activity and functioning, and other outcomes improved in older cancer survivors assigned to a vegetable gardening intervention compared with a waitlist.
UNASSIGNED: From May 11, 2016, to May 2, 2022, a 2-arm, assessor-blinded, crossover-designed, intent-to-treat, randomized clinical trial was conducted at cancer survivors\' homes across Alabama. Medicare-eligible survivors of cancers with 5-year survival of 60% or more were registry ascertained and screened for suboptimal vegetable and fruit consumption (<5 servings per day), physical activity (<150 moderate-to-vigorous minutes per week), and physical function (36-Item Short Form Health Survey [SF-36] subscale score ≤90). Consented participants underwent baseline assessments, were randomly assigned to intervention or waitlisted arms, and were reassessed at 1-year follow-up.
UNASSIGNED: One-year, home-based vegetable gardening intervention providing gardening supplies and mentorship by cooperative extension-certified master gardeners to plant and maintain spring, summer, and fall gardens. Waitlisted participants received the identical intervention after 12 months.
UNASSIGNED: The main outcome was a composite index of improvements in self-reported vegetable and fruit consumption, physical activity, and physical function corroborated by plasma α-carotene levels, accelerometry, and physical performance assessments, respectively.
UNASSIGNED: Of 381 enrolled participants (mean [SD] age, 69.8 [6.4] years; range, 50-95 years; 263 [69.0%] female), 194 were assigned to the gardening intervention and 187 were waitlisted (attrition rates, 7.2% and 7.0%, respectively). Intent-to-treat analyses did not detect a significant improvement in the composite index of vegetable and fruit intake, moderate-vigorous physical activity, and physical function (intervention arm vs waitlisted arm, 4.5% vs 3.1%; P = .53) or between-arm differences in vegetable and fruit intake (mean difference, 0.3 [95% CI, -0.1 to 0.7] servings per day; P = .10). The intervention arm experienced a significant improvement in vegetable and fruit intake (mean increase, 0.3 [95% CI, 0.0-0.6] servings per day; P = .04). Significant improvements also were observed in the intervention arm vs waitlisted arm in physical performance (mean difference for 2-minute step test, 6.0 [95% CI, 0.8-11.2] steps; P = .03; for 30-second chair stand, 0.8 [95% CI, 0.1-1.5] repetitions; P = .02), perceived health (8.4 [95% CI, 3.0-13.9] points on a 100-point scale [higher scores indicate better health]; P = .003), and gut microbiome alpha diversity (84.1 [95% CI, 20.5-147.6] more observed species; P = .01). The COVID-19 pandemic significantly moderated effects (eg, odds of improvement in self-reported physical functioning were greater before vs during the pandemic: odds ratio, 2.17; 95% CI, 1.12-4.22; P = .02).
UNASSIGNED: In this randomized clinical trial including older cancer survivors, a vegetable gardening intervention did not significantly improve a composite index of diet, physical activity, and physical function; however, survivors assigned to the intervention had significantly increased vegetable and fruit consumption and, compared with waitlisted survivors, experienced significant improvements in perceived health and physical performance. Further study in broader populations and during pandemic-free periods is needed to determine definitive benefits.
UNASSIGNED: ClinicalTrials.gov Identifier: NCT02985411.

Alabama (AL) is a hotspot in the Gulf of Mexico (GoM) for human interaction-related cetacean strandings, including harassment, vessel strikes, and fisheries interactions. We examined four bottlenose dolphins (Tursiops truncatus) stranded dead along the AL coast during 2012-2017 with severed peduncles suspected to be related to human interaction (HI). Evidence from each case, including photographs, gross necropsy results, and histopathologic findings when available, was reviewed to determine the mode of severance and whether it contributed to death. In each case, the severance site had smooth, clean edges on at least one side, indicating the use of a sharp instrument to remove the caudal peduncle and flukes. Three cases also had evidence of fisheries interactions, including linear impressions around the rostrum, fins and/or flukes, indicating that these animals may have been entangled in fisheries gear prior to death. Histopathology in one of these cases revealed that the severance occurred perimortem; speculatively, the caudal peduncle and flukes may have been cut off to facilitate removing the dolphin from its entanglement. Although cases of amputation and mutilation are not uncommon globally among stranding reports, few cases have been described and analyzed in the literature. This paper is the first to document and compare multiple cases of severed peduncles with evidence of HI, including fisheries, in the GoM. This case series enhances our understanding of the types of HI occurring in bottlenose dolphins and highlights the need for continued public education, policy, and management to address cases like these.

In June 2022, Alabama legalized fentanyl test strips (FTS). In response to this new opportunity to prevent overdoses, Project Linkage, Education, and Prevention (LEAP)-an academic-community partnership providing substance use prevention services-quickly purchased FTS and started distributing them in the Birmingham area. We describe how the Addiction Prevention Coalition, a substance use education and harm reduction provider, distributed 7300 FTS in the first year of legalization via Project LEAP and discuss its efforts to decrease substance use among young people. (Am J Public Health. 2024;114(8):785-788. https://doi.org/10.2105/AJPH.2024.307681).

OBJECTIVE: This study aimed to assess the association between insurance type and permanent contraception fulfillment among those with cesarean deliveries. Additionally, we sought to examine modification by the scheduled status of the cesarean.
METHODS: We used data from a multi-site cohort study of patients who delivered in 2018-2019 at Northwestern Memorial Hospital in Illinois, MetroHealth Medical System in Ohio, or University of Alabama at Birmingham in Alabama. All patients had permanent contraception as their contraceptive plan in their medical chart during delivery hospitalization. We used logistic regression to model the association between insurance type, scheduled status of cesarean and permanent contraception fulfillment by hospital discharge. The scheduled status of cesarean delivery was examined as an effect modifier.
RESULTS: Compared to patients with private insurance, those with Medicaid were less likely to have their desired permanent contraception procedure fulfilled by hospital discharge (89.3% vs. 96.8%, p < 0.001). After adjusting for covariates, patients with Medicaid had a lower odds of permanent contraception fulfillment by hospital discharge (OR: 0.41; 95% CI: 0.21, 0.77). This association was stronger among those who had unscheduled cesarean deliveries (OR: 0.29; 95% CI: 0.12, 0.74) than those with scheduled cesarean deliveries (OR: 0.77; 95% CI: 0.32, 1.88).
CONCLUSIONS: Compared to patients with private insurance undergoing a cesarean delivery, those with Medicaid insurance were less likely to have their desired permanent contraception fulfilled. Physicians and hospitals must examine their practices surrounding Medicaid forms to ensure that patients have valid consent forms available at the time of delivery.

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