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This article describes the factors that contribute to Kansas county jails' tobacco culture to identify reasons for high tobacco use and intervention opportunities. Kansas sheriffs' offices were asked to complete a novel 26-item survey from August through November 2019, and 40% responded. A few reported that tobacco cessation counseling was available to staff (31%) or incarcerated individuals (12%). Seventy-nine percent reported that staff were permitted to use tobacco in designated places outside, whereas 24% reported that tobacco use by incarcerated individuals was permitted in designated places outside. In the jails' commissaries, 5% reported selling nicotine gum or nicotine lozenges and 26% reported selling e-cigarettes. The lack of tobacco cessation counseling and nicotine replacement therapy, weak policies, and availability of tobacco all contribute to Kansas county jails' prevalent tobacco culture.

Sedentary behavior negatively impacts mental health, which can decrease employee productivity. Employee mental well-being and work performance may improve with sedentary reduction interventions, especially strategies that include environmental workplace modifications and behavior-changing strategies. However, such interventions have not been examined among employees working remotely during the COVID-19 pandemic. As part of the Stand Up Kansas program, 95 sedentary university employees working from home were randomized into one of four intervention arms: height-adjustable desk provision (Desk Only), online sedentary behavior modification program (Program Only), Desk + Program, or Control. The outcomes were measured at a baseline (November 2020) and following the 12-week intervention (February 2021). Employees reported mood (positive and negative affect), stress, fatigue (duration, interference with activities and severity) and work performance (irritability, focus, work satisfaction, non-work satisfaction and productivity) were measured using established self-report instruments. The effect sizes, by comparing the Control arm to the Desk + Program arm, revealed large improvements in mood (positive affect, d = 1.106). Moderate improvements were also seen in fatigue (duration, d = -0.533, and interference with activities, d = -0.648) and several aspects of work performance (focus, d = 0.702, work satisfaction, d = 0.751, and productivity, d = 0.572). Moderate effect sizes were also seen for positive affect ( d = 0.566) and fatigue severity ( d = 0.577) among the Program Only arm, whereas no noteworthy effect sizes were observed among the Desk Only arm. Combining an online sedentary behavior modification program with height-adjustable desk provisions appeared to positively affect mental well-being and work performance among remote employees.

Introduction: In 2019, diabetes was the seventh leading cause of death in the United States. The association between diabetes risk and socio-economic factors in the U.S. has been examined primarily at the national level; little is known about this association at the regional level. This study examined and compared the association between diabetes risk and previously established socio-economic factors across four geographic regions (South, Midwest, West, and Northwest)., Methods: This study analyzed the 2014 Behavioral Risk Factor Surveillance System (BRFSS) data stratified by four geographic regions of the U.S. The risk estimates of diabetes associated with previously established socio-economic factors, as well as diabetes prevalence, were compared across four geographic regions., Results: There was marked variation in association between diabetes risk and previously established risk factors across the four geographic regions. In the South, rural residency was associated with increased diabetes risk, whereas in the other geographic regions rural residency had a protective effect. In the South, the diabetes risk for males was 22% higher compared to females, whereas the risk for males was 41% higher than females in the Northeast. Independently, age had the strongest discriminative ability to distinguish between a person with diabetes and a person without diabetes, whereas ethnicity, race, and sex had the weakest discriminative abilities., Conclusions: These findings suggested a higher prevalence of diabetes by race/ethnicity (non-Hispanic Black and Hispanic) and income across all four regions. Rural residency was highest in the South, but protective in other regions. Overall, age and income provided the highest predictive ability for diabetes risk. This study highlighted differences in diabetes prevalence in association between previously established socio-economic variables and diabetes risk across four geographic regions. These findings could help public health professionals and policy makers in understanding the dynamic relationship between diabetes and risk factors at the regional level., (© 2022 The University of Kansas Medical Center.)

Introduction: In 2019, 25.8% of Kansas high school youth reported using any form of tobacco product. Schools can prevent and reduce youth tobacco use by adopting comprehensive tobacco policies, which include all tobacco products, on school grounds and at school-sponsored, off-campus events, for all individuals at all times, and integrate cessation services for students who violate the tobacco policy. The purpose of this study was to determine the prevalence of comprehensive tobacco policies in unified school districts (USD) across Kansas to determine how many schools have adopted such policies., Methods: All 286 USDs in Kansas were eligible to participate in this study including elementary, middle, and high schools. Participating schools were asked to upload their policies to a website developed by the Kansas Department of Health and Environment (KDHE). Frequencies and percentages were computed to identify the type of tobacco products prohibited, the locations where tobacco use is prohibited, who is prohibited from using tobacco, when tobacco is prohibited, and consequences of students' violation of the tobacco policy., Results: Several USD policies met some of these comprehensive recommendations; however, 97.9% (n = 280) did not. In other words, 2.1% of USD policies (n = 6) were comprehensive in Kansas. Most districts (98.3%, n = 281) presented policies prohibiting use of all forms of tobacco for students, but policies often offered more leniency for faculty/staff and visitors. Fewer districts presented policies prohibiting use of all tobacco products for staff/faculty (73.1%, n = 209) and visitors (45.8%, n = 131) of policies., Conclusions: Nearly all USDs in Kansas have an opportunity to strengthen their tobacco policies. Relatively simple edits can be made to prohibit all tobacco products, prohibit use on school grounds and at school-sponsored, off-campus events, ensure these policies apply to everyone, at all times, and integrate cessation resources for students who violate the tobacco policy., (© 2022 The University of Kansas Medical Center.)

Introduction: Modern laboratory techniques cannot differentiate between Clostridium difficile colonization and infection; therefore, testing must be indicated clinically. To reduce hospital-onset of C. difficile infections (HO-CDI), Ascension Via Christi Hospitals (AVCH) in Wichita intervened in three stages by introducing: 1) a C. diflcile testing algorithm; 2) an electronic medical record (EMR)-based decision support system to enforce said algorithm; and 3) phone calls from the infection prevention department to providers to discontinue tests not collected within 24 hours of the order. The goal of this study was to determine if these interventions improved the HO-CDI rate., Methods: At AVCH, the three study periods were compared: baseline with algorithm training only, the EMR intervention, and the EMR intervention with additional phone calls (EMR with phone calls). Data were abstracted from the hospital EMR., Results: A total of 311 charts were reviewed. Adherence to the algorithm increased from 34% at baseline to 52% after the EMR intervention (p = 0.010). During the EMR with phone calls period, more tests were discontinued (87%; n = 39) compared to baseline (54%; n = 15) and EMR (54%; n = 15; p = 0.003). The HO-CDI rate ranged from 8.5 cases per 10,000 patient-days at baseline, to 7.9 during EMR, to 4.0 during EMR with phone calls (p = 0.007)., Conclusions: The EMR and EMR with phone call interventions were associated with a significant decrease in the HO-CDI rate and an increase in provider adherence to the algorithm., (© 2022 The University of Kansas Medical Center.)

Introduction: Tractional retinal detachment remains a leading cause of severe, persistent vision loss in those with diabetic retinopathy. The purpose of this study was to investigate factors in treatment history associated with outcomes of surgical repair for diabetic tractional retinal detachments., Methods: A retrospective, cohort study design was used. Data on 64 eyes that underwent surgical correction for diabetic tractional retinal detachment were analyzed. For eyes that received any treatment within three months of surgery, the entire treatment history was recorded and analyzed. Eyes with no recorded treatment or only remote treatment outside of three months prior to surgery were considered treatment naïve., Results: Of all eyes, 56% (n = 36) had received treatment for proliferative diabetic retinopathy in the three months prior to surgery. Among those treated, 50% (n = 18) of eyes had both laser and bevacizumab treatments and 44% (n = 16) had only bevacizumab injections. Average best corrected visual acuity (BCVA) for all eyes improved from 1.68 LogMAR (20/1,000) pre-operatively to 1.34 (20/400) post-operatively, p = 0.0017. Average BCVA in eyes with pre-operative treatment history improved from 1.73 (20/1,000) pre-operatively to 1.09 (20/250) post-operatively, p = 0.0006. Average BCVA in treatment-naïve eyes was 1.60 (20/800) pre-operatively and 1.66 (20/1,000) post-operatively, p = 0.638. Eyes treated only with intravitreal injections had an improvement in BCVA from 1.81 (20/1,200) pre-operatively to 0.91 (20/160) post-operatively, p = 0.006. There was no difference between tamponade agents when comparing mean change in BCVA, p = 0.944., Conclusions: There was a relationship between intravitreal injection treatment history and a large improvement in BCVA, and a similar association between combined laser and injection treatment history and improvement in BCVA. These relationships, however, were not present when controlling for confounders in multivariate analysis. There were likely other factors in the patient's treatment history such as timing, quantity, and order of treatments that played a role in the bivariate association observed in this study., (© 2022 The University of Kansas Medical Center.)

Introduction: By 2050, more than 580,000 children in the United States will be diagnosed with type 1 diabetes (T1D). Management of T1D requires careful and continuous intervention, and children with T1D experience unique challenges in disease management compared to their adult counterparts. Diabetes camps are designed to help those with T1D learn diabetes management skills while experiencing summer camp. Psychological aspects are not addressed explicitly in diabetes camps located in Kansas. The purpose of this study was to evaluate the psychological state of past campers and camp counselors from one diabetes camp in Kansas., Methods: Campers and counselors, all of whom had T1D, and attended diabetes camp from 2015 to 2019 in Kansas were recruited to complete a survey about diabetes-related stress, diabetes management self-efficacy, and symptoms of depression. A link to the online survey was distributed to previous campers and counselors by email and through Facebook., Results: A total of 24 camp counselors and 10 campers were surveyed, 100% of whom reported having T1D and attending camp at least once. One-third of respondents (n = 8) reported having severe diabetes-related stress, and 100% (n = 34) reported high levels of diabetes management self-efficacy. Most participants reported moderate levels of depression, and 9% (n = 3) reported a past suicide attempt. These results suggested a relatively high prevalence in signs of psychological distress from former campers and camp counselors with T1D., Conclusions: This study suggested that campers and counselors with T1D have high levels of diabetes-related stress, high diabetes management self-efficacy, and many signs of depression., (© 2022 The University of Kansas Medical Center.)

Introduction Electronic cigarette (e-cigarette) use has many potential effects, including damage to the skin. Limited research has assessed e-cigarette use with the incidence of nonmelanoma skin cancer. The current study was conducted to determine if a relationship exists between nonmelanoma skin cancer diagnosis and e-cigarette use among US adults. Methods Data from the National Health Interview Survey (NHIS) were used to assess if a relationship exists between e-cigarette use and the diagnosis of nonmelanoma skin cancer. Data within the sample adult files for years 2014 through 2018, along with the adult cancer file for the year 2015, were analyzed. Participants who reported having a diagnosis of nonmelanoma skin cancer were included. Participants who reported never being diagnosed with any type of cancer were included as a comparison group. Results Males and those of older age were significantly more likely to be diagnosed with nonmelanoma skin cancer compared to females and younger adults. Cigarette use was significantly associated with an increased risk of nonmelanoma skin cancer. There was no relationship between e-cigarette use and diagnosis of nonmelanoma skin cancer. Conclusions Although the current study did not find an association between e-cigarette use and nonmelanoma skin cancer diagnosis, a longer study period and larger sample size may more clearly determine if an association exists., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Dugan et al.)

Introduction: Glycemic control is associated with better health outcomes among patients with diabetes. No previous research has examined the relationship between knowledge of one's insulin dose and glycemic control. This study sought to determine if patients who accurately recalled their insulin dose achieved better glycemic control than patients who could not remember their dose., Methods: Interviews were conducted with 106 patients. Data were collected during patients' appointments at two endocrinology clinics in Wichita, Kansas from May 29, 2018 to February 15, 2019. Adequate glycemic control was defined as an HbA1c of less than 7.5%. A multiple logistic regression model was developed to identify factors associated with glycemic control., Results: Of the 109 patients asked to participate, 105 agreed to participate in the study. About half (45%, n = 48) were male. Patients' mean age was 50 years (SD = 17). Seventy-seven percent (n = 81) were overweight (body mass index (BMI) of 25 to 29.9) or obese (BMI >30). Patients who correctly stated their insulin dose had a mean Hemoglobin A1c (HbA1c) of 6.9% (SD = 0.98), whereas those who incorrectly stated their dose had a mean HbA1c of 9.5% (SD = 1.9; p <0.0001)., Conclusions: There was a significant relationship between knowledge of one's insulin dose and adequate glycemic control., (© 2021 The University of Kansas Medical Center.)

Introduction: Open Streets is an event that promotes physical activity among populations by encouraging city residents to walk and bicycle in streets blocked from motor vehicles. Engagement of businesses is a critical component of Open Streets. This study sought to evaluate the Open Streets ICT 2019 event's impact on adjacent businesses., Methods: A 12-item novel survey was developed for this study. Businesses eligible for study participation included retail and non-retail (e.g., non-profits, churches) sites along the Open Streets ICT route in Wichita, Kansas. To understand how Open Streets ICT impacted businesses, the survey used Likert scale questions to prompt respondents to report sales and visitors experiences during the event. Additionally, respondents reported a percent difference in sales compared to a typical Sunday. A phenomenological approach was used to convey the experiences among study participants during Open Streets ICT., Results: A total of 102 surveys were completed, a 42% response rate. Most businesses (56%, n = 56) reported being open during Open Streets ICT. Many businesses (72%) reported having "more" visitors compared to a typical Sunday. More than half reported they experienced new and regular visitors (54%, n = 30) from the event. Most businesses (64%, n = 36) reported a positive financial impact, and (52%, n = 29) having more sales than a typical Sunday., Conclusions: Open Streets ICT increased sales and the number of visitors among businesses. Respondents reported they plan to participate in the 2020 Open Streets ICT, and if Open Streets ICT was offered twice a year. Finally, most participating businesses reported they recommend that other businesses participate in Open Streets ICT., (© 2021 The University of Kansas Medical Center.)

Introduction: This project sought to compare patient-reported outcomes between patients who received intra-operative radiation therapy (IORT) and those who qualified for IORT but received whole-breast external beam radiation therapy (EBRT) following breast-conserving surgery (BCS)., Methods: Three scales from the BREAST-Q Breast Cancer BCT Module Version 2.0 questionnaire were used to collect patient-reported outcomes regarding post-operative physical well-being of the chest, post-operative satisfaction with breast cosmesis, and post-operative adverse effects of radiation., Results: Patients who received EBRT travelled farther on average than patients who received IORT to complete treatment. Respondents who received IORT reported better physical well-being of the chest than those who received EBRT. Regression revealed that the respondent's age was the determining factor in the difference between IORT and EBRT post-operative physical well-being scores, where younger patients report poorer well-being. There was no difference in patient-reported outcomes regarding post-operative satisfaction with breast cosmesis or adverse effects of radiation., Conclusions: Patients who received IORT reported better physical well-being of the chest than patients who received EBRT. There appeared to be a relationship between age and physical well-being of chest. This study suggested that there was no difference in patient-reported outcomes concerning post-operative satisfaction with breast cosmesis or post-operative adverse effects of radiation between patients who received IORT and those who received EBRT., (© 2021 The University of Kansas Medical Center.)

Introduction: Based upon two large randomized international clinical trials (German Dermatologic Cooperative Oncology Group (DeCOG-SLT) and Multicenter Selective Lymphadenectomy Trial II (MSLT-II)) published in 2016 and 2017, respectively, active surveillance has been demonstrated to have equivalent survival outcomes to completion lymphadenectomy (CLND) for a subset of patients who have microscopic lymph node disease. In this study, the changes in national practice patterns were examined regarding the utilization of CLND after positive sentinel lymph node biopsy (SLNB)., Methods: Using the National Cancer Database, CLND utilization was examined in SLN-positive patients diagnosed with melanoma between 2012 and 2016. A hierarchal logistical regression model with hospital-level random intercepts was constructed to examine the factors associated with SLNB followed by observation vs. SLNB with CLND., Results: Of the 148,982 patients identified, 43% (n = 63,358) underwent SLNB and 10.3% (n = 6,551) had a SLNB with microscopic disease. CLND was performed for 57% (n = 2,817) of these patients. Patients were more likely to undergo CLND if they were ≤ 55 years of age (OR, 1.454; p ≤ 0.0001), ages 56 - 65 (OR, 1.127; p = 0.026), Charlson Deyo Score = 0 (OR, 2.088; p = 0.043), or were diagnosed with melanoma in 2012 (OR, 2.259, p ≤ 0.0001)., Conclusions: The utilization of CLND among patients with microscopic nodal melanoma was significantly lower in 2016 compared to 2012. Younger age, lack of comorbidities, and primary tumor location on the trunk or head/neck were associated with higher utilization of CLND., (© 2021 The University of Kansas Medical Center.)

Introduction: Opioid overdose caused 47,600 deaths in 2017 in the United States. Emergency departments (EDs) are one source of opioids that could be abused or diverted for non-medical use. Bills to reduce opioid use in EDs have been passed in multiple states; however, Kansas does not have a bill regulating opioid administration. This study sought to identify characteristics that influence opioid administration and prescription at EDs in Wichita, Kansas., Methods: This was a retrospective chart review analyzing patient encounters from EDs of three hospitals in Wichita, Kansas during May 2018. Information collected from charts included demographic and insurance information, as well as pain evaluation, diagnosis, disposition, provider education, and provider documentation of efforts to limit opioid abuse., Results: Of the 1,444 encounters included in the analysis, providers administered opioids in the ED during 17.4% of visits and prescribed opioids for outpatient treatment for 10.6% of ED patient encounters. Subjective pain rating and provider credentials were associated significantly with opioid prescription., Conclusion: The prevalence of opioid administration and prescription in participating emergency departments is roughly equivalent to current best-practice data from hospitals utilizing strong opioid-reduction protocols., (© 2021 The University of Kansas Medical Center.)

Objective: The purpose of this study was to determine the reliability of a comprehensive worksite-level assessment and identify which worksite wellness best practices were implemented following a workshop., Methods: Kansas worksites attended a WorkWell Kansas Phase I workshop from 2012 through 2014 and completed a 155-item assessment before the workshop and 1 year later. Cronbach alpha measured the internal consistency of the WorkWell KS Phase I Assessment, and McNemar test assessed differences in proportions from baseline to follow-up., Results: Two hundred eighty five worksites completed a baseline assessment, of which, 109 completed the follow-up assessment (32%). The internal consistency of the instrument was 0.96, and worksites reported significant improvements at follow-up from baseline for nine variables., Conclusions: Improvements predominantly included creating a wellness committee, assessing needs, and developing goals. There was a lack of policy and systems level improvements at the worksite.

Objective: The Pandemic and All-Hazards Preparedness Act calls for establishing a competency-based training program to train public health practitioners. To inform such training, the Centers for Disease Control and Prevention and the Association of Schools of Public Health managed groups of experts to produce a competency model which could function as a national standard of behaviorally based, observable skills for the public health workforce to prevent, protect against, respond to, and recover from all hazards., Design: A systematic review of existing competency models generated a competency model of proposed domains and competencies., Participants: National stakeholders were engaged to obtain consensus through a three-stage Delphi-like process., Results: The Delphi-like process achieved 84 percent, 82 percent, and 79 percent response rates in its three stages. Three hundred sixty six unique individuals responded to the three-round process, with 45 percent (n = 166) responding to all three rounds. The resulting competency model features 18 competencies within four core learning domains targeted at midlevel public health workers., Conclusions: Practitioners and academics have adopted the Public Health Preparedness and Response Core Competency Model, some of whom have formed workgroups to develop curricula based on the model. Efforts will be needed to develop evaluation materials for training and education programs to refine the model as well as for future training and education initiatives.

Background: Many nonpublic water well users unknowingly consume contaminated groundwater containing unsafe levels of pollutants. This has important implications for more than 13 million households in the United States that rely upon nonpublic water wells for drinking, cooking, and other household uses. Although public water quality is regulated through the Safe Drinking Water Act, there are no drinking water standards for nonpublic water well quality in Kansas, nor is there an adequate public health infrastructure in place to prevent or address potential exposures to contamination., Objectives: This project was conducted to identify promising action steps that would protect Kansans relying on nonpublic water wells for drinking, cooking, and other household purposes., Methods: The project team consisted of public health, environmental health, and legal professionals with experience working on groundwater quality issues impacting nonpublic water wells in Kansas. From 2015 through 2018, the team established and convened an advisory group; reviewed relevant state statutes and regulations, all Kansas county environmental codes, and a representative sample of 23 city water well codes; conducted an extensive review of academic literature to identify best practices; conducted dozens of key informant interviews; proposed recommendations; engaged dozens of stakeholders through a survey of these proposed recommendations; and conducted interactive webinars to identify which organizations need to lead each of the recommendations., Discussion: The project team developed 18 recommendations. The recommendations are organized by survey respondents' perceptions of potential public health impact. There are very few standard practices in Kansas that ensure safe water for nonpublic household water wells. Although not all of the 18 recommendations may be applicable to other communities and states, many likely would be useful for governmental agencies, academic institutions, nonprofit organizations, and others to consider. These recommendations offer more protections for nonpublic household water well users than any resource we have found. https://doi.org/10.1289/EHP5507.

Recruiting for wellness initiatives is challenging. WorkWell KS, a statewide worksite wellness initiative, offers unique worksite recruitment strategies that may serve as lessons. From 2012 to 2018, WorkWell KS utilized champions, well-connected local leaders, to recruit worksites. A total of 784 worksites were recruited for at least one WorkWell KS workshop. A survey of champions requested identification of strategies, barriers and facilitators for successful recruitment and continued engagement. Forty-three champions reported on recruitment experiences. Sixty-three percent of respondents attributed recruitment success to having funding to complete their work. Face-to-face meetings was the most commonly reported successful strategy. Eighty-six percent of respondents reported that improving employee health was motivation for worksites to participate. Champions with a significant funding incentive for worksites commonly indicated that funding was a motivating factor. The most commonly selected factor for continued engagement was having a worksite staff member with wellness in their job description (67% of respondents). Forty-nine percent of respondents reported worksites' lack of time as a barrier to participation. The WorkWell KS initiative has implemented innovative recruitment methods that leverage well-connected leaders to recruit worksites to participate in a comprehensive worksite wellness initiative. Future worksite-based initiatives may benefit from adopting recruitment strategies presented here., (� The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Introduction: Traditional evaluation of meningitis includes cerebrospinal fluid (CSF) culture and gram stain to pinpoint specific causal organisms. The BioFire ® FilmArray ® Meningitis/Encephalitis (ME) Panel has been implemented as a more timely evaluation method. This study sought to assess if the BioFire ® ME Panel was associated with a decreased length of stay or decreased antimicrobial duration when used in the diagnosis of meningitis or encephalitis., Methods: A case, historical-control, chart review was performed on patients admitted to a regional medical center with CSF pleocytosis during Cohort 1 (the year prior to BioFire ® ME Panel implementation) and Cohort 2 (the year after BioFire ® ME Panel implementation). Length of hospital stay, duration of antimicrobials, and BioFire ® ME Panel result were gathered and analyzed., Results: Average length of stay for both cohorts was about four hospital days. Approximately three-fourths of all patients received antibiotic/antiviral treatment with an average of three days duration. No significant differences were observed between groups. The mean (median) duration of antimicrobials in the year prior to and after the BioFire ® ME Panel implementation was 3.6 (3) and 3.1 (2) days, respectively (p = 0.835). The mean (median) length of stay in the year prior to and after the BioFire ® ME Panel implementation was 5.8 (4) and 5.4 (4) days, respectively (p = 0.941). Among the patients admitted after the implementation of the BioFire ® ME Panel, 4.3 % (n = 2) had a positive bacterial result, 38.3% (n = 18) had a positive viral result, and 57.4% (n = 27) had a negative result. Of the 27 negative results, 77.8% (n = 21) were treated with antimicrobial medication., Conclusions: This study suggested there is no difference between length of stay or antimicrobial duration in presumed meningitis cases assessed with traditional methods as compared to the BioFire ® ME Panel.

Introduction: Recent studies have provided guidelines on the use of head computed tomography (CT) scans in pediatric trauma patients. The purpose of this study was to identify the prevalence of these guidelines among concussed pediatric patients., Methods: A retrospective review was conducted of patients four years or younger with a concussion from blunt trauma. Demographics, head injury characteristics, clinical indicators for head CT scan (severe mechanism, physical exam findings of basilar skull fracture, non-frontal scalp hematoma, Glasgow Coma Scale score, loss of consciousness, neurologic deficit, altered mental status, vomiting, headache, amnesia, irritability, behavioral changes, seizures, lethargy), CT results, and hospital course were collected., Results: One-hundred thirty-three patients (78.2%) received a head CT scan, 7 (5.3%) of which demonstrated fractures and/or bleeds. All patients with skull fractures and/or bleeds had at least one clinical indicator present on arrival. Clinical indicators that were observed more commonly in patients with positive CT findings than in those with negative CT findings included severe mechanism (100% vs. 54.8%, respectively, p = 0.020) and signs of a basilar skull fracture (28.6% vs. 0.8%, respectively, p = 0.007). Severe mechanism alone was found to be sensitive, but not specific, whereas signs of a basilar skull fracture, headache, behavioral changes, and vomiting were specific, but not sensitive. No neurosurgical procedures were necessary, and there were no deaths., Conclusion: Clinical indicators were present in patients with positive and negative CT findings. However, severe mechanism of injury and signs of basilar skull fracture were more common for patients with positive CT findings.

Introduction: This study compared outcomes between patients injured at a motorbike track, which requires riders to follow safety equipment guidelines, and those involved in recreational riding where safety equipment usage is voluntary., Methods: A retrospective review was conducted of all patients presenting with motorbike-related injuries at an American College of Surgeons verified level-I trauma center between January 1, 2009 and December 31, 2013. Data collected included demographics, injury details, safety equipment use, hospitalization details, and discharge disposition. Comparisons were made regarding protective equipment usage., Results: Among the 115 patients admitted, more than half (54.8%, n = 63) were injured on a motorbike track, and 45.2% (n = 52) were injured in a recreational setting. The majority of patients were male (93.9%), Caucasian (97.4%), and between the ages of 18 to 54 (64.4%). Helmet usage was higher among track riders (95.2%, n = 60) than recreational riders (46.2%, n = 24, p < 0.0001). Comparisons of injury severity and outcomes between those who wore protective equipment and those who did not were not significant., Conclusion: Even though track riders wore protective equipment more than recreational riders, there was no difference between the groups regarding injury severity or hospital outcomes. These results suggested that motocross riders should not rely on protective equipment as the only measure of injury prevention.

Background: Evidence from physical activity interventions suggests that women, in particular, may overcompensate for exercise energy expenditure by increasing caloric intake. Sedentary behavior and poor dietary quality are independent risk factors for many major chronic diseases, including cardiovascular disease (CVD). The primary purpose of this study was to determine whether insufficiently active women, accumulating less than 60 min per week of moderate-to-vigorous physical activity, alter caloric intake or dietary quality when participating in an 8-week intervention to reduce sedentary behavior and CVD risk. A secondary aim was to determine whether the two treatment groups differed from one another in dietary intake while participating in the intervention., Methods: Insufficiently active women ( n  = 49) working full-time sedentary jobs were randomized to one of two treatment groups to reduce sedentary behavior during the workweek: short-break (1-2 min breaks from sitting every half hour, SB), or long-break (15 min breaks from sitting twice daily, LB). Three-day food records were collected at baseline, week 4 and week 8. Dietary quality was assessed using the Alternative Healthy Eating Index 2010 (AHEI-2010). Risk factors for CVD were assessed at baseline and week 8., Results: For all participants, average caloric intake decreased significantly from baseline to week 8 by approximately 12% (∆ = - 216.0 kcals, p  = 0.003). Average caloric intake decreased significantly over time for the SB group (∆ = - 369.6 kcals, p  = 0.004), but not the LB group (∆ = - 179.5 kcals, p  = 0.17). There was no significant difference between SB and LB groups with regard to calories from baseline to week 8 (F = 0.51, p  = 0.48). Total AHEI-2010 scores did not decrease significantly for all participants (∆ = - 4.0, p  = 0.14), SB (∆ = - 5.2, p  = 0.16), or LB groups (∆ = - 4.5, p  = 0.67)., Conclusions: Following an 8-week intervention to reduce sedentary time, insufficiently active women decreased caloric intake over time, however there were no differences between SB and LB groups. In all participants, dietary quality was not altered over time. Future studies should explore sedentary reduction interventions compared to physical activity interventions as a means to create negative energy balance, as frequent sedentary breaks may be effective for improving health outcomes in women., Trial Registration: ClinicalTrials.gov registration number NCT02609438, retrospectively registered November 20, 2015., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2018.)

Introduction: Sedgwick County, KS, has one of the highest infant mortality rates (IMR) in the USA, of which sudden infant death syndrome (SIDS) is a large component. The purpose of this study was to assess local key informants' awareness of the high IMR overall, their knowledge and beliefs about SIDS risk factors specifically, and their recommendations for ways to increase physician and community awareness of SIDS within Sedgwick County, KS., Methods: Structured interviews were conducted with key informants from Sedgwick County, KS., Results: Four themes emerged from key informant interviews: low level of awareness of infant mortality and SIDS, target population most at risk for SIDS/infant mortality, and barriers to and importance of SIDS education. Key informants were in consensus that there was a lack of general community awareness surrounding the high IMR in Sedgwick County. Strategies were identified to address this issue, including consistent SIDS education of medical providers and parents, social support to moms, use of social media, and involving the faith community in educating target populations about risk factors., Conclusions: Health and public health key informants provided an overall view of their perception of the SIDS problem in Sedgwick County, KS. Based on collected interviews, the consensus was there are significant problems within Sedgwick County around the issue of SIDS awareness (severity of the problem), SIDS risk, and barriers to increasing SIDS education among professional and community members. African-Americans were identified as the population with the highest infant mortality and SIDS rates in Sedgwick County by health and public health key informant participants. A concerted, educational approach was recommended as the best way forward to reduce SIDS risk within this community.

Intervention: In an effort to increase physical activity, 15 workplaces participated in a minimal-contact 10,000-steps-a-day program sponsored by the Sedgwick County Health Department in 2007 and 2008. Pedometers were provided to measure participants' weekly steps for the 10-week intervention., Method: Participants were defined as those who completed the preregistration survey and logged at least 1 week of results. Registrants were defined as those who completed a registration survey but did not log any weekly results. The primary dependent variable was whether or not participants achieved weekly success, as measured by achieving at least 70,000 steps in a week. A secondary dependent variable was participants' number of steps each week during the weeks they logged results. Repeated measures logistic regression analysis was conducted to identify factors associated with weekly success., Results: Of the 2,515 registrants, 1,292 (51%) were participants. The average number of weeks of participation for this 10-week intervention was 5.6 weeks (SD = 3.4). Those from small employers (n < 750) were more likely (OR = 2.0) than those from large organizations (n > 750) to become participants. Participants who achieved at least 70,000 steps in the first week of the intervention were 7.3 times more likely than participants who walked less than 70,000 steps in the first week to achieve 70,000 steps each week for all 10 weeks., Conclusions: Results from implementing a minimal-contact 10,000-step intervention can be maximized by targeting small worksites and supporting employees to achieve 70,000 steps in their first week., (© 2015 Society for Public Health Education.)

Purpose: To determine the prevalence of active epilepsy in two southeastern rural Kansas counties., Methods: Medical records were abstracted from the emergency rooms, out- and inpatient services and clinics of 9 hospitals, from 10 doctors' offices, and 1 nursing home in and surrounding the two counties. Letters were mailed from hospitals and doctors' offices to invite their potentially eligible patients to participate in an interview. Medical record information and the interview, when available, were used for the final determination of active epilepsy, seizure type, etiology, syndrome, age, and gender in consensus conferences. Prevalence of epilepsy was calculated, and capture-recapture methodology, which estimates prevalence based on what is known about the population, was employed to assess active epilepsy in the two counties., Results: This study identified 404 individuals with active prevalent epilepsy who visited at least one of the 20 facilities during the observation period. The overall prevalence of active epilepsy was 7.2 per 1000. The seizure type for 71.3% of prevalent cases was unknown; among the 76 cases with known and classifiable seizure type, 55.3% had focal with secondary generalized seizures. Among the 222 cases with classifiable etiology, 53.1% were idiopathic/cryptogenic. About 75% (n=301) were captured at only one center, 72% (n=75) of the remaining 103 patients were captured at two centers, and 28 patients were identified at three or more centers. The capture-recapture assessment yielded an estimation of 982 prevalent patients. The overall estimated prevalence of epilepsy in the two Kansas counties using capture-recapture was 17 per 1000., Conclusions: The crude prevalence of epilepsy, using medical record survey methods, was similar to, but on the high end, of other total population prevalence studies in the United States. The capture-recapture assessment suggested that epilepsy prevalence might be considerably higher than the crude prevalence., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Objective: Identify perceptions regarding benefits of and barriers to receiving text messages for immunization reminders and preferred content for such text messages., Design: Structured interviews., Setting: Outpatient pediatric resident and faculty clinic., Participants: A convenience sample of 54 low-income urban Latino parents of children aged < or = 2 years., Main Outcome Measures: Parent perspectives on text message reminders., Results: Most respondents were female (70%), married (63%), and fluent only in Spanish (89%). Most (83%) had a health literacy score in the adequate range. All (100%) reported being interested in receiving immunization reminders by text message, and 81% reported being willing to receive general appointment reminders by text message. Parents made 72 comments regarding benefits of text message immunization reminders. The most common sub-category was usefulness of the reminders (53%). These comments reflected participants' busy schedules and the beneficial nature of text messages in reminding parents of appointments. Fifty-six comments were provided regarding barriers to receiving text message reminders. Most comments (77%) indicated no identifiable barriers. Twenty percent described barriers related to technology, such as costs or lack of text messaging service. Parents generated 108 comments regarding preferred content of reminders. The topics most frequently identified were appointment date and time (32%), names of the vaccines (19%), and the child's name (11%)., Conclusions: Low-income Latino parents perceive text message immunization reminders as a feasible alternative to more traditional forms of communication.

Although global health is a recommended content area for the future of education in public health, no standardized global health competency model existed for master-level public health students. Without such a competency model, academic institutions are challenged to ensure that students are able to demonstrate the knowledge, skills, and attitudes (KSAs) needed for successful performance in today's global health workforce. The Association of Schools of Public Health (ASPH) sought to address this need by facilitating the development of a global health competency model through a multistage modified-Delphi process. Practitioners and academic global health experts provided leadership and guidance throughout the competency development process. The resulting product, the Global Health Competency Model 1.1, includes seven domains and 36 competencies. The Global Health Competency Model 1.1 provides a platform for engaging educators, students, and global health employers in discussion of the KSAs needed to improve human health on a global scale.

Objective: The Pandemic and All-Hazards Preparedness Act calls for establishing a competency-based training program to train public health practitioners. To inform such training, the Centers for Disease Control and Prevention and the Association of Schools of Public Health managed groups of experts to produce a competency model which could function as a national standard of behaviorally based, observable skills for the public health workforce to prevent, protect against, respond to, and recover from all hazards., Design: A systematic review of existing competency models generated a competency model of proposed domains and competencies., Participants: National stakeholders were engaged to obtain consensus through a three-stage Delphi-like process., Results: The Delphi-like process achieved 84 percent, 82 percent, and 79 percent response rates in its three stages. Three hundred sixty six unique individuals responded to the three-round process, with 45 percent (n = 166) responding to all three rounds. The resulting competency model features 18 competencies within four core learning domains targeted at midlevel public health workers., Conclusions: Practitioners and academics have adopted the Public Health Preparedness and Response Core Competency Model, some of whom have formed workgroups to develop curricula based on the model. Efforts will be needed to develop evaluation materials for training and education programs to refine the model as well as for future training and education initiatives.

Objective: The study objective was to determine the prevalence of diabetes and prediabetes among rural and urban populations in Kansas., Research Design and Methods: This study utilized 2009 BRFSS data and included 18,912 respondents. Participants were identified through a stratified random sample of adult Kansans, living in a non-institutionalized setting, and with access to a land-based telephone line. Analyses were conducted using SAS to provide descriptive statistics for groups based on diabetes status. A logistic regression was conducted to explore significant variables associated with the likelihood of diabetes., Results: Diabetes prevalence was lower among urban (11.8%) populations than rural (12.7%) areas of Kansas, but the inverse was true for pre-diabetes (3.7% urban, 3.1% in rural). Lower income and lower levels of educational attainment were associated with increased rates of diabetes and pre-diabetes, with the highest prevalence levels overall found among rural Latinos (19.3%) and urban African Americans (22.9%). Multivariate regression suggests that age, income, ethnicity, education, sex, rural vs urban status, and race all served as significant predicators of diabetes, net of other factors., Conclusions: Rural residents were more likely than urban residents to report having diabetes, whereas urban residents were more likely than rural residents to report having pre-diabetes. Although rural vs urban status played a significant role in the model's predicative ability for diabetes and pre-diabetes diagnosis, increased age was by far the most significant factor in diabetes and pre-diabetes diagnosis.

Aims: The purpose of this study was to assess compliance with American Diabetes Association screening recommendations at Salina Family Healthcare (SFHC) in Salina, Kansas, a large rural town, and to evaluate the impact of point-of-care (POC) dilated eye exams for uninsured patients. POC exams are those performed in the location where patients are treated., Methods: There were 462 type II diabetic (DM2) patients seen at SFHC in 2009 and 537 DM2 patients seen in 2010. A chart review of all patients with DM2 was done to assess rates of recommended screening exams, including dilated eye exams and foot exams., Results: In 2009/2010 urine microalbumin was checked in 57%/75% of DM2 patients. HbA1c and low density lipoprotein (LDL) levels at goal were 46%/48% and 58%/58%, respectively. 47%/67% of DM@ patients received foot exams and 21%/30% received eye exams. In 2009, 23% of the 155 uninsured diabetic patients at SFHC received a dilated eye exam. The following year, after implementation of on-site ophthalmologic services, rates of dilated eye exams increased 1.6 fold to 37% of the 196 uninsured patients., Conclusions: SFHC performed similarly to national rates on some diabetic screening exams, but there is room for improvement in all recommended screening exams. The implementation of a novel approach to increasing dilated eye exam rates indicates that expanded POC services can improve outcomes for diabetic patients., (Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Public health care practitioners and organizations are a part of community readiness for, response to, and recovery from emergencies and disasters of all kinds. Although response to health threats, particularly communicable disease outbreaks, have long been a part of public health practice, 2 advancements in preparedness, including the integration of public health into the broader community emergency response system and the clarification of exactly what knowledge, skills, and attitudes a public health professional brings to the response, have been made since 2001. This article presents the newly affirmed core competencies to be attained and maintained by the majority of the public health workforce and discusses some of the many ways in which these competencies influence practice, research, and education.

Objective: To examine the extent of compliance to the proposed monitoring protocol among practicing psychiatrists for second generation antipsychotics., Methods: Questionnaire was sent through Survey Monkey to practicing psychiatrists in the states of Iowa, Kansas, Missouri, Nebraska, Oklahoma and Texas. Also paper surveys were distributed to individual psychiatrists of Kansas and Nebraska at their grand rounds, inpatient settings, and outpatient clinics., Results: Ninety eight responses were received of which 51 participants completed the survey on Survey Monkey and 47 completed the paper surveys. Fifty-one percent reported that 25% to 50% of their patients were taking SGAs. About two thirds (69.4%) reported familiarity with the proposed protocol, 17.3% were unfamiliar, and 13% were not sure. Of those who were familiar, 63% percent reported their adherence to the protocol, 21% did not follow the protocol, and 16% were not sure. However, when their responses were closely examined, only five (5%) of the respondents were found completely adherent to the protocol., Conclusions: Majority of participants were aware of the proposed protocol to protect their patients from metabolic side effects but many of them did not follow it completely. A large study at the national level needs to be done to replicate these findings.

Due to their access to medically underserved and vulnerable populations, community health centers (CHCs) can play an essential role in emergency response. CHCs often fill this role in partnership with other local health resources, such as local health departments (LHD). Little research has been done to understand the success of these partnerships as it relates to emergency planning and emergency response. This study compares CHC and LHD personnel regarding past, present, and future collaborative preparedness and response activities. Surveys were distributed electronically to 1,265 clinical and clerical staff at LHDs and CHCs in 23 states who met the study criteria. Of the 522 respondents, 287 (55%) reported having engaged in collaborative preparedness activities in general, with CHCs more likely to report partnering than LHDs. LHDs were more likely than CHCs to report taking part in specific preparedness activities, such as planning activities (91, 79%), (chi(2)(1, N = 280) = 7.395, P < 0.05), mass dispensing drill/exercises (65, 42%), (chi(2)(1, N = 279) = 14.019, P < 0.001), and communication drill/exercises (69, 47%), (chi(2)(1, N = 280) = 13.059, P < 0.001). This study suggests that collaborations between CHCs and LHDs in general are occurring, but these general collaboration are not being translated into participation in functional drills or exercises. Additional efforts to ensure a more comprehensive partnership between CHCs and LHDs in emergency preparedness are warranted.

Points of dispensing (PODs) are vital for responding to events that require mass chemoprophylaxis, such as bioterrorist attacks or pandemic influenza. This article evaluates the operational success of a large-scale dispensing drill for first responders and first receivers, focusing on differences in functioning of PODs by practice discipline and POD model. PODs were operated by either first responders (EMS, fire, or police) or first receivers (hospitals). Facilities could operate a centralized POD model, a decentralized POD model, or a combination, or "hybrid," model. Evaluation consisted of having evaluators at every POD, conducting a survey of POD individuals, and reviewing retrospectively the medications dispensed during the drill. Throughput counts, satisfaction with POD functioning, and errors in medication dispensing at each site are reported by practice discipline and facility model. During the drill, 23 PODs successfully processed more than 4,000 individuals. Centralized PODs and first responder facilities had faster throughput times than hybrid and hospital facilities, but hospital facilities had a lower incidence of medication error. Nominal differences in patient satisfaction were found. Assessing a combination of throughput, medical errors, and patient satisfaction with first responders and first receivers as points of dispensing can provide valuable insight into the feasibility of providing chemoprophylaxis to first responders and first receivers in advance of POD operations for the general public.

Using amalgamated Behavioral Risk Factor Surveillance System (BRFSS) data from nine states in 2006, this study examined the differences in demographics, health conditions, health behaviors, and quality of life among persons with active epilepsy (PWAE) and persons with a lifetime prevalence of epilepsy (PWLE), compared with persons without epilepsy (PWOE). Frequencies for PWAE, PWLE, and PWOE by selected health behaviors, health conditions, quality of life, and demographic variables were produced. Differences between persons with and without epilepsy were analyzed. Results indicated smoking and unemployment rates were significantly higher among PWLE/PWAE than among PWOE. PWLE/PWAE were also less likely than PWOE to report advanced educational attainment, and more likely to report suffering physical, mental, or emotional limitations that affected their activities in some way. Hispanics were less likely to report a lifetime or active prevalence of epilepsy than people without epilepsy. PWLE/PWAE report several differences in demographics, health conditions, health behaviors, and quality of life compared to people without epilepsy.

Disasters pose a very real threat to every individual in the United States. One way to mitigate the threat of disasters is through personal preparedness, yet numerous studies indicate that individual Americans are not prepared for a disaster. This study attempted to identify the factors most likely to predict individual disaster preparedness. We used 2006 Behavioral Risk Factor Surveillance System (BRFSS) data from the 5 states that included the optional general preparedness module. Respondents were defined as being "prepared" if they were deficient in no more than 1 of the 6 actionable preparedness measures included on the BRFSS. Analyses were conducted comparing preparedness rates based on medical and demographic factors. Using logistic regression, a predictive model was constructed to identify which factors most strongly predicted an individual's likelihood of being prepared. Although 78% of respondents reported feeling prepared for a disaster, just 45% of respondents were actually prepared by objective measures. Factors predicting an increased likelihood of preparedness included feeling "well prepared" (OR 9.417), having a disability or health condition requiring special equipment (OR 1.298), being 55 to 64 years old (OR 1.794), and having an annual income above $50,000 (OR 1.286). Among racial and ethnic minorities, an inability to afford medical care in the previous year (OR .581) was an important factor in predicting a decreased likelihood of being prepared. This study revealed a pervasive lack of disaster preparedness overall and a substantial gap between perceived and objective preparedness. Income and age were important predictors of disaster preparedness.

Obesity and lack of physical activity are an increasing problem. In addition to common barriers to physical activity, people with epilepsy also face fear of exercise-induced seizures, medication side effects, and, often, confusing advice regarding the safety of exercise. To explore barriers faced by people with epilepsy, we mailed a survey to 412 adult patients with epilepsy from an epilepsy center in Kansas. Survey items assessed patients' exercise habits, attitudes regarding exercise, and barriers to exercise. Forty-seven percent completed the survey. Most respondents reported that they did exercise, though most did so 3 or fewer days per week and at light intensity. Respondents who reported seizures as a barrier to exercise did not exercise with less frequency or intensity than those who did not report seizures as a barrier, but these respondents reported greater fear of seizures. Patient-specific education about the benefits of exercise needs to be initiated by physicians.

Objective: Concerns have been raised about the safety of switching from a branded antiepileptic drug (AED) to a generic AED. The goal of the study described here was to understand patients' experiences with generic AEDs in the Midwestern United States., Methods: A one-page, six-item survey was mailed to 356 patients to determine patients' awareness of the existence and their usage of generic AEDs., Results: Twenty-eight percent (27.8%) of respondents (N=179) reported breakthrough seizures they believed were a direct result of the switch from a brand to a generic AED, and 33.7% reported side effects due to the switch. Thirty-one percent (31.2%) returned to a brand-name AED as a result. Sixty-nine percent (68.8%) reported being unaware that some pharmacies switch to generic AEDs without a patient's or physician's consent, and 78.7% expressed concern over this., Conclusion: A significant percentage of patients reported that generic AEDs were responsible for breakthrough seizures and increased side effects. A significant percentage of patients also reported switching back to a brand-name AED and expressed concern over pharmacies switching to generic AEDs without a patient's or physician's consent.

Context: Coronary heart disease causes approximately 45% of firefighter deaths annually. Although firefighters have clinically significant cardiac risks, a paucity of research and data exists., Objective: To evaluate firefighters' cardiac risk factors as well as their motivation to resolve these risk factors., Methods: During a 3-month period, volunteer firefighters representing the 79 fire departments serving Nassau and Suffolk counties in Long Island, NY, were asked to complete a nonvalidated, 19-item questionnaire regarding their health habits, medical history, and demographics., Results: A total of 730 surveys were returned among a potential study population of 20,590 volunteer firefighters. More than three-quarters of respondents met the criteria for being overweight or obese, and nearly 40% reported having high blood pressure, high cholesterol, or both. Most respondents expressed at least some interest in attending a fire department-sponsored health lecture and participating in a fitness program., Conclusion: Firefighters expressed desire to learn more about risk factor modifications and have fire departments take a more active role in helping firefighters improve their health. The effectiveness of resources and intervention programs should be assessed.

Natural zoonotic outbreaks can cause widespread devastation, and several zoonoses can be transmitted as agents of bioterrorism. Although veterinarians can be vital in controlling the transmission of zoonotic diseases, many lack knowledge about their roles in emergency response and about zoonoses. A training session titled "Prevention of Zoonotic Disease Transmission" was provided for New York veterinarians. The training was evaluated using pre-training, post-training, and follow-up surveys, which measured increase in and retention of knowledge. Seventy-five (75) veterinary professionals participated in the training, and 91% responded on pre- and post-training surveys. The percentage of respondents who correctly answered the objective knowledge questions increased from pre-training to post-training. Furthermore, follow-up surveys demonstrated that participants were able to retain much of the information from the training session. Very little research has been found that evaluates a similar training event. As knowledge increases, additional training conferences could benefit veterinarians and supplement this research. The results of the pre-training, post-training, and follow-up surveys indicate that veterinary professionals' knowledge of zoonoses can be significantly improved after receiving training; participants found the training to be useful and requested additional training, indicating that veterinary professionals have a desire to learn about emergency preparedness topics.

Much research has been done into tobacco use portrayals in film since the mid-twentieth century, but the earlier years of Hollywood history have been overlooked. Yet the first decades of the twentieth century saw annual per capita cigarette consumption increase from under 100 in 1900 upto 1,500 in 1930. The current study looks at frequency and context (gender, age range, socioeconomic status, type of portrayal) of tobacco use in 20 top-grossing silent films spanning the silent feature era (1915-1928). The sample averaged 23.31 tobacco uses per hour. Tobacco use was most often associated with positive characterizations, working/middle class status, masculinity, and youth. Previous research has verified the influence of the film industry on tobacco consumption in modern years, and this potential connection should not be ignored for the silent film era. Top-grossing silent films set a precedent for positive media portrayals of substance use that have persisted to the present day.

Introduction: To assess the impact of regionalization of Kansas counties associated with emergency preparedness since 2002 via local health departments (LHDs)., Methods: Three focus groups were conducted in May 2005 with 31 Kansas health department employees. Most participants were public health administrators, women, and 40 years or older., Results: Regionalization was perceived as "absolutely necessary" by participants and resulted in improved collaboration and communication among LHDs. The process supported the development of relationships, trust, and mutual respect among LHDs and other governmental agencies. Participants agreed that LHD functioning has improved the delivery and availability of public health services, increased the efficiency and timeliness of operations, and enhanced public health's visibility in emergency preparedness efforts. Moreover, regionalization added resources to LHDs including personnel, knowledge, technology, technical expertise, and fiscal resources. Dissatisfaction with regionalization was associated with insufficient funding, frustration with changing preparedness guidelines, and differences between state and local expectations. Participants identified four issues necessary to sustain regions: funding, documented benefits, commitment from LHDs and their communities, and engagement from local elected officials., Discussion: The regionalization process has been beneficial for LHDs and produced tangible and intangible benefits. Barriers to regionalization expansion should be addressed for additional collaborative ventures.

In this study, we examined the tobacco cessation efforts of nurses working in primary care settings. A 43-item questionnaire was mailed to 1,036 office-based nurses located throughout Kansas. With a response rate of 50.1%, 415 questionnaires were available for analysis. Although 89% of respondents encountered patients who smoked on a daily or weekly basis, only 51% reported documenting their patients' tobacco use, and 38% assessed patients' readiness to quit. Two thirds (66%) of nurses believed that tobacco management was part of their role but only 35% provided cessation advice, 23% recommended nicotine replacement therapy, and 14% provided coping techniques. Nurses cited barriers such as perceiving patients as disinterested or unmotivated to quit (65%) and having little time (55%), skills (32%), or knowledge (25%). Most (91%) agreed that they needed additional tobacco control education. Nurses who were advanced registered nurse practitioners or clinical nurse specialists were more likely to feel confident about their smoking cessation counseling skills compared to nurses with less education (66.7 vs. 31.2%, p =.010). Office-based nurses identified specific barriers that could be addressed through professional education about tobacco management.