Public Health Commons^™

Serious Mental Illness Among Young Adult Women Who Use Drugs In The Club Scene: Co-Occurring Biopsychosocial Factors, Maayan Lawental, Hilary L. Surratt, Mance E. Buttram, Steven P. Kurtz

Center for Health Services Research Faculty Publications

Young women who regularly attend nightclubs are at risk for numerous health and social consequences, including mental distress, sexual and physical victimization and substance dependence. This paper uses a biopsychosocial framework to examine co-occurring mental health problems, victimization, substance dependence, sexual risk and physical pain among a sample of young women who use drugs (N = 222) in Miami’s club scene. The majority of women were under 24 years old, Hispanic, and identified as heterosexual. Almost all the women reported past 90-day use of alcohol, ecstasy/MDMA, marijuana, cocaine and prescription opioids and benzodiazepines; 32% of women reported being in a …

Single-Trait And Multi-Trait Genome-Wide Association Analyses Identify Novel Loci For Blood Pressure In African-Ancestry Populations, Jingjing Liang, Thu H. Le, Digna R. Velez Edwards, Bamidele O. Tayo, Kyle J. Gaulton, Jennifer A. Smith, Yingchang Lu, Richard A. Jensen, Guanjie Chen, Lisa R. Yanek, Karen Schwander, Salman M. Tajuddin, Tamar Sofer, Wonji Kim, James Kayima, Colin A. Mckenzie, Ervin Fox, Michael A. Nalls, J. Hunter Young, Yan V. Sun, Jacqueline M. Lane, Sylvia Cechova, Jie Zhou, Hua Tang, Myriam Fornage, Solomon K. Musani, Heming Wang, Juyoung Lee, Adebowale Adeyemo, Albert W. Dreisbach, Donna K. Arnett

Epidemiology and Environmental Health Faculty Publications

Hypertension is a leading cause of global disease, mortality, and disability. While individuals of African descent suffer a disproportionate burden of hypertension and its complications, they have been underrepresented in genetic studies. To identify novel susceptibility loci for blood pressure and hypertension in people of African ancestry, we performed both single and multiple-trait genome-wide association analyses. We analyzed 21 genome-wide association studies comprised of 31,968 individuals of African ancestry, and validated our results with additional 54,395 individuals from multi-ethnic studies. These analyses identified nine loci with eleven independent variants which reached genome-wide significance (P < 1.25×10⁻⁸) for either systolic and …

Contextual Factors And Sexual Risk Behaviors Among Young, Black Men, Jamal Jones, Laura F. Salazar, Richard A. Crosby

Health, Behavior & Society Faculty Publications

Young Black men (YBM), aged 13 to 24 years, face a disproportionate burden of sexually transmitted infections (STIs). STI acquisition among YBM is due to incorrect and inconsistent condom use and is exacerbated by multiple sexual partners. Sexual and reproductive health is influenced by a complex interaction of biological, psychological, and social determinants that contribute to increased risk for STI acquisition. However, there are key social determinants of sexual health that play a major role in adolescent sexual risk-taking behaviors: gender norms, environment, peers, and families as well as a desire to impregnate a woman. Associations between contextual factors (risky …

Tuberculosis And Risk Of Acute Myocardial Infarction: A Propensity Score-Matched Analysis, Moises A. Huaman, Richard J. Kryscio, Carl J. Fichtenbaum, David Henson, Elizabeth G. Salt, Timothy R. Sterling, Beth A. Garvy

Biostatistics Faculty Publications

Several pathogens have been associated with increased cardiovascular disease (CVD) risk. Whether this occurs with Mycobacterium tuberculosis infection is unclear. We assessed if tuberculosis disease increased the risk of acute myocardial infarction (AMI). We identified patients with tuberculosis index claims from a large de-identified database of ~15 million adults enrolled in a U.S. commercial insurance policy between 2008 and 2010. Tuberculosis patients were 1:1 matched to patients without tuberculosis claims using propensity scores. We compared the occurrence of index AMI claims between the tuberculosis and non-tuberculosis cohorts using Kaplan–Meier curves and Cox Proportional Hazard models. Data on 2026 patients with …

Discovery And Fine-Mapping Of Adiposity Loci Using High Density Imputation Of Genome-Wide Association Studies In Individuals Of African Ancestry: African Ancestry Anthropometry Genetics Consortium, Maggie C. Y. Ng, Mariaelisa Graff, Yingchang Lu, Anne E. Justice, Poorva Mudgal, Ching-Ti Liu, Kristin Young, Lisa R. Yanek, Mary F. Feitosa, Mary K. Wojczynski, Kristin Rand, Jennifer A. Brody, Brian E. Cade, Latchezar Dimitrov, Qing Duan, Xiuqing Guo, Leslie A. Lange, Michael A. Nalls, Hayrettin Okut, Salman M. Tajuddin, Bamidele O. Tayo, Sailaja Vedantam, Jonathan P. Bradfield, Guanjie Chen, Wei-Min Chen, Alessandra Chesi, Marguerite R. Irvin, Badri Padhukasahasram, Jennifer A. Smith, Wei Zheng, Donna K. Arnett

Epidemiology and Environmental Health Faculty Publications

Genome-wide association studies (GWAS) have identified > 300 loci associated with measures of adiposity including body mass index (BMI) and waist-to-hip ratio (adjusted for BMI, WHR_adjBMI), but few have been identified through screening of the African ancestry genomes. We performed large scale meta-analyses and replications in up to 52,895 individuals for BMI and up to 23,095 individuals for WHR_adjBMI from the African Ancestry Anthropometry Genetics Consortium (AAAGC) using 1000 Genomes phase 1 imputed GWAS to improve coverage of both common and low frequency variants in the low linkage disequilibrium African ancestry genomes. In the sex-combined analyses, we identified …

Outcomes After Diagnosis Of Mild Cognitive Impairment In A Large Autopsy Series, Erin L. Abner, Richard J. Kryscio, Frederick A. Schmitt, David W. Fardo, Daniela C. Moga, Eseosa T. Ighodaro, Gregory A. Jicha, Lei Yu, Hiroko H. Dodge, Chengjie Xiong, Randall L. Woltjer, Julie A. Schneider, Nigel J. Cairns, David A. Bennett, Peter T. Nelson

Epidemiology and Environmental Health Faculty Publications

OBJECTIVE: To determine clinical and neuropathological outcomes following a clinical diagnosis of mild cognitive impairment (MCI).

METHODS: Data were drawn from a large autopsy series (N = 1,337) of individuals followed longitudinally from normal or MCI status to death, derived from 4 Alzheimer Disease (AD) Centers in the United States.

RESULTS: Mean follow‐up was 7.9 years. Of the 874 individuals ever diagnosed with MCI, final clinical diagnoses were varied: 39.2% died with an MCI diagnosis, 46.8% with a dementia diagnosis, and 13.9% with a diagnosis of intact cognition. The latter group had pathological features resembling those with a final clinical …

Biokinetics Of Nanomaterials: The Role Of Biopersistence, Peter Laux, Christian Riebeling, Andy M. Booth, Joseph D. Brain, Josephine Brunner, Cristina Cerrillo, Otto Creutzenberg, Irina Estrela-Lopis, Thomas Gebel, Gunnar Johanson, Harald Jungnickel, Heiko Kock, Jutta Tentschert, Ahmed Tlili, Andreas Schäffer, Adriënne J. A. M. Sips, Robert A. Yokel, Andreas Luch

Pharmaceutical Sciences Faculty Publications

Nanotechnology risk management strategies and environmental regulations continue to rely on hazard and exposure assessment protocols developed for bulk materials, including larger size particles, while commercial application of nanomaterials (NMs) increases. In order to support and corroborate risk assessment of NMs for workers, consumers, and the environment it is crucial to establish the impact of biopersistence of NMs at realistic doses. In the future, such data will allow a more refined categorization of NMs. Despite many experiments on NM characterization and numerous in vitro and in vivo studies, several questions remain unanswered including the influence of biopersistence on the toxicity …

Buprenorphine Physician Supply: Relationship With State-Level Prescription Opioid Mortality, Hannah K. Knudsen, Jennifer R. Havens, Michelle R. Lofwall, Jamie L. Studts, Sharon L. Walsh

Behavioral Science Faculty Publications

Background: Buprenorphine is an effective treatment for opioid use disorder but the supply of buprenorphine physicians is currently inadequate to address the nation’s prescription opioid crisis. Perception of need due to rising opioid overdose rates is one possible reason for physicians to adopt buprenorphine. This study examined associations between rates of growth in buprenorphine physicians and prescription opioid overdose mortality rates in US states.

Methods: The total buprenorphine physician supply and number of physicians approved to treat 100 patients (per 100,000 population) were measured from June 2013 to January 2016. States were divided into two groups: those with rates of …

Cpt1a Methylation Is Associated With Plasma Adiponectin, S. Aslibekyan, A. N. Do, H. Xu, S. Li, M. R. Irvin, D Zhi, H. K. Tiwari, D. M. Absher, A. R. Shuldiner, T. Zhang, W. Chen, K. Tanner, C. Hong, B. D. Mitchell, G. Berenson, Donna K. Arnett

Epidemiology and Environmental Health Faculty Publications

Background and Aims—Adiponectin, an adipose-secreted protein that has been linked to insulin sensitivity, plasma lipids, and inflammatory patterns, is an established biomarker for metabolic health. Despite clinical relevance and high heritability, the determinants of plasma adiponectin levels remain poorly understood.

Methods and Results—We conducted the first epigenome-wide cross-sectional study of adiponectin levels using methylation data on 368,051 cytosine-phosphate-guanine (CpG) sites in CD4+ T-cells from the Genetics of Lipid Lowering Drugs and Diet Network (GOLDN, n= 991). We fit linear mixed models, adjusting for age, sex, study site, T-cell purity, and family. We have identified a positive association (regression …

Exploring Individual And Structural Factors Associated With Employment Among Young Transgender Women Of Color Using A No-Cost Transgender Legal Resource Center, Brandon J. Hill, Kris Rosentel, Trevor Bak, Michael Silverman, Richard A. Crosby, Laura Salazar, Michele Kipke

Health, Behavior & Society Faculty Publications

Purpose: The purpose of this study was to explore individual and structural factors associated with employment among young transgender women (TW) of color.

Methods: Sixty-five trans women of color were recruited from the Transgender Legal Defense and Education Fund to complete a 30-min interviewer-assisted survey assessing sociodemographics, housing, workplace discrimination, job-seeking self-efficacy, self-esteem, perceived public passability, and transactional sex work.

Results: Logistic regression models revealed that stable housing (structural factor) and job-seeking self-efficacy (individual factor) were significantly associated with currently being employed.

Conclusion: Our findings underscore the need for multilevel approaches to assist TW of color gain employment.

Sensemaking, Stakeholder Discord, And Long-Term Risk Communication At A Us Superfund Site, Anna Goodman Hoover

Preventive Medicine and Environmental Health Faculty Publications

Introduction: Risk communication can help reduce exposures to environmental contaminants, mitigate negative health outcomes, and inform community-based decisions about hazardous waste sites. While communication best practices have long guided such efforts, little research has examined unintended consequences arising from such guidelines. As rhetoric informs stakeholder sensemaking, the language used in and reinforced by these guidelines can challenge relationships and exacerbate stakeholder tensions.

Objectives: This study evaluates risk communication at a U.S. Superfund site to identify unintended consequences arising from current risk communication practices.

Methods: This qualitative case study crystallizes data spanning 6 years from three sources: 1) local newspaper coverage …

The Juvenile Justice Behavioral Health Services Cascade: A New Framework For Measuring Unmet Substance Use Treatment Services Needs Among Adolescent Offenders, Steven Belenko, Danica Knight, Gail A. Wasserman, Michael L. Dennis, Tisha Wiley, Faye S. Taxman, Carrie B. Oser, Richard Dembo, Angela A. Robertson, Jessica Sales

Sociology Faculty Publications

Overview—Substance use and substance use disorders are highly prevalent among youth under juvenile justice (JJ) supervision, and related to delinquency, psychopathology, social problems, risky sex and sexually transmitted infections, and health problems. However, numerous gaps exist in the identification of behavioral health (BH) problems and in the subsequent referral, initiation and retention in treatment for youth in community justice settings. This reflects both organizational and systems factors, including coordination between justice and BH agencies.

Methods and Results—This paper presents a new framework, the Juvenile Justice Behavioral Health Services Cascade (“Cascade”), for measuring unmet substance use treatment needs to …

Community To Clinic Navigation To Improve Diabetes Outcomes, Nancy E. Schoenberg, Gabriele Ciciurkaite, Mary Kate Greenwood

Behavioral Science Faculty Publications

Rural residents experience rates of Type 2 Diabetes Mellitus (T2DM) that are considerably higher than their urban or suburban counterparts. Two primary modifiable factors, self-management and formal clinical management, have potential to greatly improve diabetes outcomes. “Community to Clinic Navigation to Improve Diabetes Outcomes,” is the first known randomized clinical trial pilot study to test a hybrid model of diabetes self-management education plus clinical navigation among rural residents with T2DM. Forty-one adults with T2DM were recruited from two federally qualified health centers in rural Appalachia from November 2014–January 2015. Community health workers provided navigation, including helping participants understand and implement …

Promoting Teen Contraceptive Use By Intervention With Their Mothers, Richard A. Crosby, Tom Collins, Lindsay R. Stradtman

Health, Behavior & Society Faculty Publications

Introduction: The purpose of this pilot study was to test a community outreach model designed to help mothers in a rural, medically underserved area navigate their teen daughters to health department services for long-acting reversible contraception (LARC) or alternative contraception.

Methods: The pilot study used a single-group, post-test only design. Mothers of teen daughters (N=142) received a 1-hour, one-to-one intervention session (in outreach settings) from Community Liaisons. Mothers received training on how to communicate with their daughters about LARC and other contraceptive methods. Data were collected from June through October 2014, and analyzed in September 2015.

Results: The authors re-contacted …

Acceptability Of Hiv Testing Sites Among Rural And Urban African Americans Who Use Cocaine, D. Keith Branham, Tyrone F. Borders, Katharine E. Stewart, Geoffrey M. Curran, Brenda M. Booth

Health Management and Policy Faculty Publications

African Americans (AAs) who use cocaine in the Southern region of the U.S. have a relatively high risk of HIV and need for HIV testing. Among this group, those residing in rural areas may have less favorable opinions about common HIV testing sites, which could inhibit HIV testing. We examined rural/urban variations in their acceptability of multiple HIV testing sites (private physician clinic, local health department, community health center, community HIV fair, hospital emergency department, blood plasma donation center, drug abuse treatment facility, and mobile van or community outreach worker). Results from partial proportional odds and logistic regression analyses indicate …

Terminate Lung Cancer (Tlc) Study—A Mixed-Methods Population Approach To Increase Lung Cancer Screening Awareness And Low-Dose Computed Tomography In Eastern Kentucky, Roberto Cardarelli, David Reese, Karen L. Roper, Kathryn Cardarelli, Frances J. Feltner, Jamie L. Studts, Jennifer R. Knight, Debra Armstrong, Anthony D. Weaver, Dana Shaffer

Family and Community Medicine Faculty Publications

For low dose CT lung cancer screening to be effective in curbing disease mortality, efforts are needed to overcome barriers to awareness and facilitate uptake of the current evidence-based screening guidelines. A sequential mixed-methods approach was employed to design a screening campaign utilizing messages developed from community focus groups, followed by implementation of the outreach campaign intervention in two high-risk Kentucky regions. This study reports on rates of awareness and screening in intervention regions, as compared to a control region.

The Healthy Flea Market, Robin L. Cooper, Kimberly J. Zeidler-Watters, Diane Johnson, Jennifer Wilson

Biology Faculty Publications

Learn how rural students in Kentucky shared their classroom knowledge by presenting on health topics and new technologies at flea markets, swap meets, and specialty events such as car shows.

Association Of Body Mass Index With Dna Methylation And Gene Expression In Blood Cells And Relations To Cardiometabolic Disease: A Mendelian Randomization Approach, Michael M. Mendelson, Riccardo E. Marioni, Roby Joehanes, Chunyu Liu, Åsa K. Hedman, Stella Aslibekyan, Ellen W. Demerath, Weihua Guan, Degui Zhi, Chen Yao, Tianxiao Huan, Christine Willinger, Brian Chen, Paul Courchesne, Michael Multhaup, Marguerite R. Irvin, Ariella Cohain, Eric E. Schadt, Megan L. Grove, Jan Bressler, Kari North, Johan Sundström, Stefan Gustafsson, Sonia Shah, Allan F. Mcrae, Sarah E. Harris, Jude Gibson, Paul Redmond, Janie Corley, Lee Murphy, Donna K. Arnett

Epidemiology and Environmental Health Faculty Publications

Background

The link between DNA methylation, obesity, and adiposity-related diseases in the general population remains uncertain.

Methods and Findings

We conducted an association study of body mass index (BMI) and differential methylation for over 400,000 CpGs assayed by microarray in whole-blood-derived DNA from 3,743 participants in the Framingham Heart Study and the Lothian Birth Cohorts, with independent replication in three external cohorts of 4,055 participants. We examined variations in whole blood gene expression and conducted Mendelian randomization analyses to investigate the functional and clinical relevance of the findings. We identified novel and previously reported BMI-related differential methylation at 83 CpGs …

An Evaluation Of The Mpowerment Evidence-Based Program In Congruence With Chicago-Specific Mobile App On Reducing Hiv Transmission And Acquisition, Katelyn Elizabeth Mason

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

Black Men who have sex with Men are at higher risk of contracting HIV than other populations, and thus require programs that focus of their need. Chicago, Illinois has incidence and prevalence rates 3 times higher than the national average, with a large burden of the disease falling on BMSM. Mpowerment is an evidence-based intervention that utilizes formal and informal meetings at a home base and local venues, and has found promising effects in reducing unprotected anal intercourse. Mobile applications have also shown promise in increasing adherence, and will be adapted into the Mpowerment program to create a High Impact …

Sociodemographic And Clinical Predictors Of Triple Negative Breast Cancer, Madison Ries

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

Background and Objectives

Breast cancer has the highest incidence rates among women and is the second leading cause of death due to cancer in women. Of all breast cancers, triple negative breast cancer (TNBC) accounts for about one-fifth of breast cancer and tends to result in an aggressive form with larger tumors and rates of metastasis and is more frequently found in younger women. This results in an important need in information regarding the risk of diagnosis with triple negative breast cancer over other forms and covariates associated with death and TNBC. This paper studies the relationship between race, tobacco …

The Role Of Stress In The Relationship Between Shift Worked And Hypertension, Madison Liford

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

Purpose: Individuals working non-daytime shifts have been reported to have an increased risk for many negative health outcomes, including poor cardiovascular health. This study aims to examine the relationship between shift worked and hypertension—a major risk factor for cardiovascular disease. Of particular interest in this study was the role of stress and type of shift worked (day, evening, night, or rotating) in this relationship.

Methods: The study utilized National Health and Nutrition Examination Survey data collected between 2005 and 2010. The study population was limited to adult workers 20 years of age and older (n=9356). Initial descriptive statistics of …

Malignant Melanoma In Kentucky: An Analysis Of The Individual And Social Factors On Disease Stage And Treatment, Virginia Valentin

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

Introduction: In 2016 there will be an estimated 76,380 new cases of malignant melanoma and 10,130 deaths in the United States (US). ¹ Malignant melanoma incidence is increasing faster than any other preventable cancer in the US with an expected 112,000 new cases a year by 2030. ^2,3 This capstone attempts to quantify the association of individual and social factors on melanoma late-stage diagnosis and non-adherence to surgical treatment guidelines for early-stage lesions in Kentucky.

Methods: The analysis combines three datasets: individual level data from the Kentucky Cancer Registry, census tract level data from the US Census and …

A Diabetes-Free Breathitt County: Implementation Of The National Diabetes Prevention Program In Pharmacies, Urvi Patel

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

The National Diabetes Prevention Program (NDPP) is a primary prevention program endorsed by the Centers for Disease Control and Prevention (CDC). The program’s purpose is to promote dietary modification and physical activity to reduce the incidence of diabetes. NDPP is currently offered by national organizations such as the Young Men’s Christian Association and Weight Watchers. However, NDPP is not commonly available in geographic areas that are in the most need of such preventive health programming such as rural communities. One such area where NDPP is not widely offered is the Diabetes Belt, an area within the Appalachian region of the …

Dealing With Pre-Exposure Prophylaxis-Associated Condom Migration: Changing The Paradigm For Men Who Have Sex With Men, Richard A. Crosby

Health, Behavior & Society Faculty Publications

The behavioural aspects of pre-exposure prophylaxis (PrEP) are challenging, particularly the issue of condom migration. Three vital questions are: (1) at the population-level, will condom migration lead to increases in non-viral sexually transmissible infections?; (2) how can clinic-based counselling best promote the dual use of condoms and PrEP?; and (3) in future PrEP trials, what are the ‘best practices’ that should be used to avoid type 1 and type 2 errors that arise without accounting for condom use behaviours? This communication piece addresses each question and suggests the risk of a ‘PrEP only’ focus to widening health disparities.

A History Of The Long-Term Care Ombudsman Program In America: A Changing Aging Population, Caitlin Dorris

Oswald Research and Creativity Competition

No abstract provided.

Examining The Activities, Effectiveness, And Contribution Of Local Health Departments Using A National Longitudinal Survey Of Public Health Systems, Lava R. Timsina

Theses and Dissertations--Epidemiology and Biostatistics

Health services research and public health services and systems research in the past have contributed to a strong foundation of evidence-based progress in organizing, financing, and delivering medical care and public health strategies across the United States. The purpose of this dissertation was to examine disparities in public health systems and in the delivery of population health services in communities served by these systems using nationally representative data from the National Longitudinal Survey of Local Public Health Systems (1998, 2006, 2012, and 2014).

Data from the 1998 cohort of 497 local health jurisdictions serving at least 100,000 residents, and from …

Mixture Modeling With Applications In Alzheimer's Disease, Frank Appiah

Theses and Dissertations--Epidemiology and Biostatistics

This dissertation involves an application of mixture of regression models to 114 individuals who are cognitively intact (from the Alzheimer's Disease and Neuroimaging Initiative-ADNI, data). The correct number of components in the model were estimated with the Singular BIC (SBIC), marking the first time it has been applied to such a problem. The smallest true model in conjunction with the approximation of SBIC was fixed at 1. The resulting posterior probabilities from the model were used to estimate the probability of a person transitioning and risk plots were obtained that could in principle be used by clinicians to identify patients …

Understanding And Promoting Parent-Child Sexual Health Communication, Shannon Phelps

Theses and Dissertations--Education Sciences

Parent-child sexual health communication (PCSHC) can have a positive impact on adolescents’ sexual health choices, outcomes, and capabilities for communicating with others about sexual health. Many parents are hesitant and feel unprepared for and uncomfortable with communicating about sexual health with their children. Other parental factors as well as child factors can impact the quality, frequency, coverage, and effectiveness of PCSHC. Some adolescent sexual health outcomes have improved, however, teen birth rates in the United States are elevated compared to other developed countries and half of all sexually transmitted infection (STI) diagnoses are made to adolescents and emerging adults. This …

Planet Health: A School-Based Health Promotion Program, Jane Katherine Landon

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

The Kentucky River District Health Department (KRDHD) proposes implementation of Planet Health, a school-based intervention aimed at increasing healthful nutrition and fitness behaviors in middle- and high-school aged students. Planet Health’s core messaging (increasing fruit and vegetable intake, increasing physical activity, decreasing screen time, decreasing sugar-sweetened beverage and trans-fat intake) contributes to our long-term goal of decreasing childhood obesity in our service area. Planet Health will be offered to 3 counties in our service area (Lee, Letcher and Wolfe) with planned expansion to all counties in the KRDHD service area within 5 years of the original pilot. This project will …

Spatio-Temporal Analysis Of Childhood Retinoblastoma And Cns Tumors In Kentucky, From 1995 Through 2014, Jennifer A. Khoury

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

Objectives

Childhood cancer poses a significant public health burden, both globally and in the United States (US). The most common childhood cancers affect the brain and central nervous system (CNS). Age-adjusted childhood brain tumor (CBT) incidence rates in Kentucky are larger than in the rest of the US; these rates are also higher in Appalachian Kentucky than in the rest of the state. This study determined if high-rate clusters of either CNS tumor or retinoblastoma existed in Kentucky.

Methods

Data for this study were retrieved from the Kentucky Cancer Registry for the years 1995 through 2014. Cases were individuals between …