Over The Hills And Through The Hollers: How One Program Is Assisting Residents Of Appalachia With Opioid Use Recovery, Aubrey E. Jones, Jayme E. Walters, Aaron R. Brown

Journal of Appalachian Health

Introduction: The consequences of increasing opioid misuse in the U.S. over the last two decades have been severe, contributing to hundreds of thousands of lives lost and heavy tolls on individuals, families, and society. The Appalachian Region has been hit particularly hard, with its predominantly rural landscape seeing disproportionate increases in opioid misuse and overdoses. These cases have been difficult to address due to poor treatment access and capacity constraints in many areas of Appalachia.

Purpose: The current study focuses on evaluating The Kentucky Access to Recovery Program (KATR), which provides services to individuals recovering from opioid addiction residing in …

Contraception And Healthcare Utilization By Reproductive-Age Women Who Use Drugs In Rural Communities: A Cross-Sectional Survey., Ximena A. Levander, Canyon A. Foot, Sara L. Magnusson, Ryan R. Cook, Jerel M. Ezell, Judith Feinberg, Vivian F. Go, Kathryn E. Lancaster, Elizabeth Salisbury-Afshar, Gordon S. Smith, Ryan P. Westergaard, April M. Young, Judith I. Tsui, P. Todd Korthuis

Epidemiology and Environmental Health Faculty Publications

BACKGROUND: Women who use drugs (WWUD) have low rates of contraceptive use and high rates of unintended pregnancy. Drug use is common among women in rural U.S. communities, with limited data on how they utilize reproductive, substance use disorder (SUD), and healthcare services.

OBJECTIVE: We determined contraceptive use prevalence among WWUD in rural communities then compared estimates to women from similar rural areas. We investigated characteristics of those using contraceptives, and associations between contraceptive use and SUD treatment, healthcare utilization, and substance use.

DESIGN: Rural Opioids Initiative (ROI) - cross-sectional survey using respondent-driven sampling (RDS) involving eight rural U.S. regions …

Exploration Of Factors Associated With Rural Appalachian Women's Use Of Buprenorphine Prior To Incarceration, Kelsey A. Redmayne

Theses and Dissertations--Educational, School, and Counseling Psychology

The Gelberg-Anderson Behavioral Model for Vulnerable Populations was used to identify factors related to buprenorphine use in general and through diversion (versus formal treatment) among rural Appalachian women using substances in the six months prior to their incarceration. This study is a secondary analysis of data from interviews completed with rural Appalachian women (N=400) residing in rural Kentucky jails. Independent variables were analyzed using chi square and independent t-tests for buprenorphine use generally and diverted buprenorphine use. The significant predictors were then evaluated through hierarchical logistic regression to explore which factors account for the most variance in general …

Writing New Normals: A Study Of American Pandemic Fiction In The Wake Of Covid-19, Riley E. Droppleman

Gaines Fellow Senior Theses

The purpose of this thesis is to explore the aspects of pandemic fiction that extend beyond the illness itself. In this thesis, I show that while the disease that spreads is a large focus of pandemic fiction, the truths that spring from these novels reveal larger societal issues, such as class hierarchies, racial inequalities, and failings of the government to fight the pandemic. In fact, pandemics act as catalysts for the uncovering of these societal ills, and the authors of pandemic fictions bring these greater faults of society to the forefront of their novels. I analyze three novels from the …

Massachusetts Prevalence Of Opioid Use Disorder Estimation Revisited: Comparing A Bayesian Approach To Standard Capture-Recapture Methods, Jianing Wang, Nathan Doogan, Katherine L. Thompson, Dana Bernson, Daniel Feaster, Jennifer Villani, Redonna Chandler, Laura F. White, David Kline, Joshua A. Barocas

Statistics Faculty Publications

Background: The National Survey on Drug Use and Health (NSDUH) estimated the prevalence of opioid use disorder (OUD) among the civilian, noninstitutionalized people aged 12 years or older in Massachusetts as 1.2% between 2015 and 2017. Accurate estimation of the prevalence of OUD is critical to the success of treatment and resource planning. Various indirect estimation approaches have been used but are subject to data availability and infrastructure-related issues.

Methods: We used 2015 data from the Massachusetts Public Health Data Warehouse (PHD) to compare the results of two approaches to estimating OUD prevalence in the Massachusetts population. First, we used …

Relative Adrenal Insufficiency Is A Risk Factor And Endotype Of Sepsis - A Proof-Of- Concept Study To Support A Precision Medicine Approach To Guide Glucocorticoid Therapy For Sepsis, Chia-Hua Wu, Ling Guo, Dan Hao, Qian Wang, Xiang Ye, Misa Ito, Bin Huang, Chieko Mineo, Philip W. Shaul, Xiang-An Li

Saha Cardiovascular Research Center Faculty Publications

Introduction: 25-60% of septic patients experience relative adrenal insufficiency (RAI) and glucocorticoid (GC) is frequently used in septic patients. However, the efficacy of GC therapy and whether GC therapy should be based on the status of RAI are highly controversial. Our poor understanding about the pathogenesis of RAI and a lack of RAI animal model present significant barriers to address these critical issues.

Methods: Scavenger receptor BI (SR-BI) regulates stress-induced GC (iGC) production in response to stress. We generated SF1CreSR-BIfl/fl mice and utilized the mice as a RAI model to elucidate the pathogenesis of RAI and GC therapy in sepsis. …

Creating Change In Pediatric Health Disparities: Utilizing Systemsbased Thinking To Overcome Disparities Affecting Pediatric Type 1 Diabetes In Kentucky, Sydney Speed

Lewis Honors College Thesis Collection

Healthcare disparities are perpetuated and upheld for patients with type 1 diabetes (T1D) in rural and underserved urban areas of Kentucky. By adopting systems-based thinking, we can identify areas of the healthcare system to change to eliminate these disparities. Namely, key leverage points of this system include distribution and utilization of resources, finances and the movement of money, and communication pathways. To address the disparities surrounding pediatric T1D in Kentucky, a state-wide medical event called Kentucky Diabetes Family Day (KDFD) was hosted. The focus of this event was to lessen the effects of these specific healthcare disparities by altering key …

Hmgb2 Regulates The Differentiation And Stemness Of Exhausted Cd8+ T Cells During Chronic Viral Infection And Cancer, Emily N. Neubert, Julia M. Derogatis, Sloan A. Lewis, Karla M. Viramontes, Pedro Ortega, Monique L. Henriquez, Rémi Buisson, Ilhem Messaoudi, Roberto Tinoco

Microbiology, Immunology, and Molecular Genetics Faculty Publications

Chronic infections and cancers evade the host immune system through mechanisms that induce T cell exhaustion. The heterogeneity within the exhausted CD8⁺ T cell pool has revealed the importance of stem-like progenitor (Tpex) and terminal (Tex) exhausted T cells, although the mechanisms underlying their development are not fully known. Here we report High Mobility Group Box 2 (HMGB2) protein expression is upregulated and sustained in exhausted CD8⁺ T cells, and HMGB2 expression is critical for their differentiation. Through epigenetic and transcriptional programming, we identify HMGB2 as a cell-intrinsic regulator of the differentiation and maintenance of Tpex cells during …

Profiling The Cell Wall Polysaccharides Of Hemp (Cannabis Sativa L.) Inflorescence And Hempseed And Exploring Their Application As Ruminant Feed Ingredients, Miranda Agbana

Theses and Dissertations--Animal and Food Sciences

Hemp (Cannabis sativa L.) is used in the United States as a source of CBD oil, fiber, and grain. While hempseeds are consumed whole or as dehulled hemp hearts, hempseed oil is also a desirable seed oil in human nutrition. The process of collecting hempseed oil leaves behind hempseed cakes that are abundant in protein and fiber. Feeding of hempseed cakes to animals, including ruminants, has only initially been explored. Extraction of CBD from hemp inflorescences generates organic waste that may find a second purpose as a fiber feed for cattle. Little is known about the exact fiber composition …

Monoclonal Antibody Therapy Of Breastfeeding Patient Infected With Sars-Cov-2: A Case Report, Nicole E. Marshall, Madison B. Blanton, Brianna M. Doratt, Delphine C. Malherbe, Monica Rincon, Ilhem Messaoudi

Microbiology, Immunology, and Molecular Genetics Faculty Publications

Introduction: Although safety data demonstrated the efficacy and effectiveness of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination for all individuals over 6 months of age, including pregnant and breastfeeding individuals, optimal treatment courses for symptomatic pregnant and lactating individuals infected with SARS-CoV-2 remain to be defined. Case Description: A coronavirus disease 2019 (COVID-19)-vaccinated breastfeeding woman received anti-SARS-CoV-2 monoclonal antibody treatment casirivimab–imdevimab 5 days after diagnosis of a symptomatic breakthrough SARS-CoV-2 infection. Results and Conclusions: The patient did not present with obvious defects in innate or adaptive cellular subsets, but compared with controls had minimal maternal antibody response to recommended …

Mild/Asymptomatic Covid-19 In Unvaccinated Pregnant Mothers Impairs Neonatal Immune Responses, Brianna M. Doratt, Suhas Sureshchandra, Heather E. True, Monica Rincon, Nicole E. Marshall, Ilhem Messaoudi

Microbiology, Immunology, and Molecular Genetics Faculty Publications

Maternal SARS-CoV-2 infection triggers placental inflammation and alters cord blood immune cell composition. However, most studies focus on outcomes of severe maternal infection. Therefore, we analyzed cord blood and chorionic villi from newborns of unvaccinated mothers who experienced mild/asymptomatic SARS-CoV-2 infection during pregnancy. We investigated immune cell rewiring using flow cytometry, single-cell RNA sequencing, and functional readouts using ex vivo stimulation with TLR agonists and pathogens. Maternal infection was associated with increased frequency of memory T and B cells and nonclassical monocytes in cord blood. Ex vivo T and B cell responses to stimulation were attenuated, suggesting a tolerogenic state. …

Hoarding Lifesaving Knowledge While Millions Die: The Political Economy Of Global Covid-19 Vaccine Apartheid, Kenneth Stancil

Theses and Dissertations--Geography

Coronavirus vaccines saved millions of lives, but experts estimate that the suboptimal production and inequitable distribution of shots resulted in nearly 3 million preventable Covid-19 deaths in 2021 and 2022 as well as millions of indirect deaths during the pandemic. These avoidable fatalities are inseparable from the grotesquely unequal vaccination rates between rich and poor nations. Dose hoarding by high-income countries contributed to vaccine inequality, but the “vaccine apartheid” inflicted on low-income countries reflects an even more fundamental injustice: knowledge hoarding by profit-maximizing pharmaceutical corporations—aided and abetted by wealthy governments—which deprived generic manufacturers of the right to produce additional lifesaving …

The Prepare Mobile Program For Hiv Prevention In Washington D.C., Gabrielle Cochran

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Incidence rates of HIV have decreased in the United States in the past decade, but the southern United States has higher rates of HIV than other regions, and cities in the south, like Washington D.C., have some of the highest rates of HIV incidence in the nation. Risky sexual behavior, needle sharing, and substance use increase the risk of transmitting or acquiring HIV, and these behaviors are more common among unhoused people (CDC, 2021; CPPH, 2022).

Expansion of community resources in cities with high levels of HIV have allowed for many people at high risk for HIV to comply with …

Pfas Clinical Guidance, John Bingham

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Introduction

A broad category of synthetic organic compounds, per- and polyfluorinated alkyl substances (PFAS), forms the impetus for this project. Known compounds in this category are numerous and diverse, with over 4700 identified molecular entities (Panieri, Baralic, Djukic-Cosic, Buha Djordjevic, & Saso, 2022). Their only commonality is the presence of at least one carbon atom that is saturated with fluoride groups. These chemical bonds are exceptionally difficult to break (Tansel, 2022), which incepts both the utility of PFAS compounds and the concerns they raise for human health (Cousins et al., 2020). While PFAS are …

Breastfeeding Promotion In The Workplace, Katie C. Nettesheim

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Breastfeeding is one of the best things a mother can do for her baby. It has many protective qualities including a reduced risk of sudden infant death syndrome (SIDS), asthma, obesity, type 1 diabetes, respiratory infections, ear infections, and stomach bugs for the baby (CDC, 2022). There are also protective qualities for the mother as well, including a reduced risk of high blood pressure, breast and ovarian cancer, and type II diabetes. Breastfeeding exclusively, the infant only receives breastmilk and no other supplementation for 6 months, which maximizes the many benefits that breastfeeding has.

Rural areas of the United States …

Therapeutic Neutralizing Monoclonal Antibody Administration Protects Against Lethal Yellow Fever Virus Infection, Michael J. Ricciardi, Lauren N. Rust, Nuria Pedreño-Lopez, Sofiya Yusova, Sreya Biswas, Gabriela M. Webb, Lucas Gonzalez-Nieto, Thomas B. Voigt, Johan J. Louw, Fernanda D. Laurino, John R. Dibello, Hans-Peter Raué, Aaron M. Barber-Axthelm, Kimberly Chun, Samantha Uttke, Lidiane M. S. Raphael, Aaron Yrizarry-Medina, Brandon C. Rosen, Rebecca Agnor, Lina Gao, Caralyn Labriola, Michael Axthelm, Jeremy Smedley, Justin G. Julander, Myrna C. Bonaldo, Laura M. Walker, Ilhem Messaoudi, Mark K. Slifka, Dennis R. Burton, Esper G. Kallas, Jonah B. Sacha, David I. Watkins, Benjamin J. Burwitz

Microbiology, Immunology, and Molecular Genetics Faculty Publications

Yellow fever virus (YFV) is a reemerging global health threat, driven by several factors, including increased spread of the mosquito vector and rapid urbanization. Although a prophylactic vaccine exists, vaccine hesitancy, supply deficits, and distribution difficulties leave specific populations at risk of severe YFV disease, as evidenced by recent outbreaks in South America. To establish a treatment for patients with severe YFV infection, we tested 37 YFV-specific monoclonal antibodies isolated from vaccinated humans and identified two capable of potently neutralizing multiple pathogenic primary YFV isolates. Using both hamster and nonhuman primate models of lethal YFV infection, we demonstrate that a …

Epidemiology Of Sars-Cov-2 Breakthrough Infections In Kentucky March 1st 2021 - December 31st, 2022, Harrison Hynes

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Objective: Provide epidemiologic overview of SARS-CoV-2 breakthrough infections in Kentucky considering both demographic and geographic variables.

Background: We believe descriptive information of breakthrough cases for a defined population will provide public health practitioners with useful information relating to SARS-CoV-2 infection control and vaccination efforts.

Methods: We obtained SARS-CoV-2 case data from the Kentucky Department for Public Health COVID-19 case repository, which mirrors National Electronic Disease Surveillance System (NEDSS) data. The study sample used for analysis comprised 147,000 individuals who tested positive for SARS-CoV-2 in Kentucky between the dates of March 1^st, 2021 and December 31^st, 2022. …

Digital Twins For Ancillary Transportation Asset Data Management, Ashtarout Ammar

Theses and Dissertations--Civil Engineering

Transportation Asset Management (TAM) is a data-driven decision-making process to maintain and extend the serviceability of transportation assets throughout their lifecycle. TAM is an extensive data process requiring accurate, high-quality information for better decision-making. A significant challenge that state Departments of Transportation (DOTs) face is allocating limited funds to optimize their assets’ performance. The criticality of this challenge increases when state DOTs need to manage a wide variety of assets distributed along with a vast network; thus, they prioritize the management of high-value assets and visible ones such as bridges, and they pay less attention to ancillary assets even though …

Investigating The Relationship Between Metabolic Reprogramming And Peripheral Cd4+ T-Cell Inflammation In Human Type 2 Diabetes Pathogenesis, Gabriella Kalantar

Theses and Dissertations--Microbiology, Immunology, and Molecular Genetics

Chronic, low-grade systemic inflammation rises in obesity and promotes type 2 diabetes (T2D). Circulating immune cells are key indicators of obesity and T2D pathogenesis. T cells outnumber monocytes, in blood, suggesting that T cells might fuel peripheral inflammation in obesity/T2D. Our lab’s work supports this idea by identification of a Th17 cytokine profile in T2D from T-cell stimulated peripheral blood mononuclear cells. Work described herein further supported this work by demonstrating that T cells dominate peripheral inflammation over monocytes across the spectrum of obesity and glycemic control. Our lab has also recently shown that inflammation changes during prediabetes (preT2D), identified …

Striving For Appropriate Antibiotic Use: A Biomarker Initiative, And Outcomes Associated With Azithromycin Exposure, Amanda Gusovsky

Theses and Dissertations--Pharmacy

The introduction of antibiotics into clinical practice is considered the greatest medical breakthrough of the 20^thcentury. However, the use of antibiotics can contribute to the development of resistance. In the United States (U.S.), approximately 2.8 million people are infected with antibiotic-resistant bacteria each year, and more than 35,000 people die as a result. Moreover, some antibiotics are known to cause cardiac side effects including QT prolongation, hypotension, and ventricular arrythmias. The U.S. Centers for Disease Control and Prevention (CDC) defines appropriate antibiotic use as the effort to use “the right antibiotic, at the right dose, for the right …

Investigation Of Folate-Poly(Glutamic Acid)/Polyethylenimine/Dna Complexes For In Vitro Gene Delivery, Caleb Akers

Theses and Dissertations--Pharmacy

Gene therapy is currently being studied as a treatment for a variety of indications, including cancer, infectious disease, and cardiovascular diseases, among others. While many of the early treatments in the field involved the use of viral delivery methods, various safety, ethical, and financial concerns limit the potential uses of this methodology. As such, more recent research has focused on developing non-viral delivery platforms to alleviate some of the issues inherent in viral delivery. Recently, the release of the COVID-19 vaccines from Pfizer and Moderna represents a promising use of non-viral delivery as both utilized a lipid-based delivery vector.

Despite …

Developing A Biocatalytic Toolbox To Aid In Understanding Nucleoside Antibiotics, Jasmine Brianna Woods

Theses and Dissertations--Pharmacy

Antibiotic resistance happens when bacteria develop the ability to survive medications that normally terminate them. Instead, these super germs are able to survive in the body and produce a community of antibiotic resistance germs which can cause human fatalities. It is important to discover and develop new compounds and molecules that will improve this clinical obstacle. This research focused on analyzing the biosynthesis that incorporates distinctive chemical characteristic of various nucleoside antibiotics, ß-hydroxy amino acids and α-methyl-amino acids. ß-hydroxy amino acids and α-methyl-amino acids are considered an important class of industrially useful compounds, particularly for pharmaceutical development, and are found …

Relative Adrenal Insufficiency In Sepsis, Dan Hao

Theses and Dissertations--Pharmacology and Nutritional Sciences

Sepsis is a leading cause of death in children. Glucocorticoid (GC) therapy had been strongly recommended for the pediatric sepsis (grade 1A). However, the recommendation was changed to grade 2C in 2020 due to weak evidence. Relative adrenal insufficiency (RAI) is a condition characterized by impaired inducible glucocorticoid (iGC) production in response to stress. It develops in 32.8% of pediatric septic patients. Unfortunately, little is known about the pathogenesis of RAI in pediatric sepsis, and whether GC therapy should be based on the status of RAI is controversial. In this study, we utilized 21-day-old SF1CreSRBI^fl/fl mice as the first …

Age-Associated Increase Of Gamma Delta T Cells In Visceral Adipose Tissue And Mechanisms Of Their Accumulation, Sujata Mukherjee

Theses and Dissertations--Pharmacology and Nutritional Sciences

Chronic systemic inflammation, known as inflammaging is considered a hallmark of aging and associated diseases. While adipose tissue has long been considered only as a caloric reservoir regulating systemic energy homeostasis, research in the past couple of decades substantiate its endocrine function to secrete an array of inflammatory mediators and hormones, which have physiological effects on multiple organ systems, and contribute to inflammaging. Redistribution of adipose tissue from subcutaneous to visceral depots, changes in the immune profile and the chronic inflammatory state are among the major sources of adipose tissue dysfunction with aging.

This dissertation is focused on identifying and …

Sex Dimorphisms Of Aldosterone And High Salt Induced Aortic Aneurysms In Mice, Xufang Mu

Theses and Dissertations--Pharmacology and Nutritional Sciences

Aortic aneurysms, a permanent enlargement in the aorta, is a devastating disease with a high mortality rate after rupture. Aortic aneurysms exhibit strong sex dimorphisms: men are at higher risk than women while women experience worse outcomes if diagnosed. Currently, the only intervention is by open surgery or endovascular repair, and no drugs are approved for blunting the disease progression. This highlights the needs for mechanistic studies for sex-specific therapeutic targets.

Our lab established the mouse model in which mineralocorticoid receptor (MR) agonist aldosterone induces aortic aneurysms in the presence of high salt in male mice age-dependently, mimicking the aging …

Exploring The Distinction Between Support And Enabling In Families With Substance Use Disorder, Krystal N. King

Theses and Dissertations--Family Sciences

Substance use disorders (SUD) are a pervasive public health problem facing families in the United States. Although families are frequently urged to support loved ones who have SUD and cautioned against enabling them, there is a dearth of literature that distinguishes between supporting and enabling. Through qualitative interviews, this phenomenological study examined the experiences of eight parents with adult children with SUD who were currently in recovery. Five themes emerged from the data including: (a) living in despair, (b) addiction and recovery knowledge, (c) support group philosophy, (d) coping with addiction, and (e) differentiation. The results from this study suggest …

Equine Fecal Microbiota Response To Short Term Antibiotic Administration, Jordan Lacey Parker

Theses and Dissertations--Veterinary Science

Though generally regarded as safe, research continues to demonstrate negative side effects of antibiotic administration on the gastrointestinal (GIT) microbiota across species. In horses, antibiotic associated diarrhea (AAD) is a life-threatening side effect linked to the GIT microbiota. This study tested the hypothesis that short term antibiotic administration to healthy horses would negatively impact the fecal microbiota as measured by their ability to digest nutrients and produce short chain fatty acids (SCFAs). Twenty-four horses were assigned to one of four treatments: control (CO); potassium penicillin/gentamicin sulfate (KPG); ceftiofur crystalline free acid (EX); trimethoprim/sulfamethoxazole (SMZ); and treated for 4 days. Fecal …

Receptor Usage And Infection Biology Of Influenza D Virus, Tirth Uprety

Theses and Dissertations--Veterinary Science

Influenza D virus (IDV) utilizes bovines as a primary reservoir with periodical spillover to other hosts. We have previously demonstrated by the traditional hemagglutination assay coupled with sialoglycan microarray and functional assays that IDV can recognize and bind both 9-O-acetylated N-acetylneuraminic acid (Neu5,9Ac₂) and 9-O-acetylated N-glycolylneuraminic acid (Neu5Gc9Ac). Agricultural animals such as cattle can produce both Neu5,9Ac₂ and Neu5Gc9Ac, while humans are genetically unable to synthesize Neu5Gc9Ac. The bifunctional enzyme, glucosamine (UDP-N-acetyl)-2-epimerase/N-acetylmannosamine kinase (GNE) is a master regulator of de-novo sialic acid synthesis while 9-O-Acetylation of sialic acids is catalyzed by …

The Effect Of Land-Cover/Land-Use And Habitat Fragmentation On Spatial Patterns Of Lyme Disease In The Eastern United States, Maria Elizabeth Topmiller

Theses and Dissertations--Forestry and Natural Resources

Lyme disease has been of national concern for the past few decades. As our understanding of the role of landscape structure in epidemiology expands, it is essential to apply the principles of landscape ecology to the research of vector-borne and zoonotic disease. This study examined the strength of the relationship between land-cover class, degree of habitat fragmentation and county-level Lyme disease cases. Forest, agricultural, and urban land cover types were the categories of interest, while percent cover, edge density, and patch density were the landscape metric used to measure habitat amount and fragmentation. The general linear trends were modelled with …

Fate And Transport Of Emerging Contaminants Entering, Leaving, And Flowing Past Wastewater Treatment Plants In Central Kentucky, Kyra Sigler

Theses and Dissertations--Biosystems and Agricultural Engineering

Per- and polyfluoroalkyl substances (PFAS) and neonicotinoid insecticides are two classes of emerging contaminants that have been recently detected in many environmental compartments. Both have been associated with negative impacts on humans and the environment. Wastewater treatment plants (WWTPs) have been identified as likely hotspots for introduction of these contaminants into the environment. Thus, the aim of this study was to investigate the occurrence of PFAS and neonicotinoids in two WWTPs in Central Kentucky. Polar organic chemical integrative samplers (POCIS) were deployed in WWTP influent and effluent and placed upstream and downstream of the effluent mixing zone (EMZ) for two …