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OBJECTIVE: We introduced a multi-component cancer prevention awareness program to primary care practices across New York State to evaluate its impact on adolescent human papillomavirus (HPV) vaccination rates. METHODS: Eight pediatric and three family medicine practices were recruited to participate in this program. On-site training sessions were provided for all practice providers and staff to discuss the importance of HPV vaccine and cancer prevention and teach strategies for delivering a strong vaccine recommendation. Each practice received a study-specific booklet that included HPV vaccine information and other commonly provided cancer prevention guidance. These booklets were distributed to all adolescents and their parents during well visits over a one-year period. Practice specific and county-wide HPV vaccination rates were assessed before and 12 months after the program training session. RESULTS: One year after program initiation, aggregate data show statistically higher vaccine series initiation rates among 11–12 and 13–18-year-olds and higher vaccine series completion rates among 13–18-year-olds. The greatest and most consistent improvements were seen in vaccine initiation rates for the 11–12-year-old cohort. Disparities in vaccine uptake were observed by gender and medical specialty. CONCLUSION: Cancer prevention education targeting providers, office staff, patients, and parents, improved adolescent HPV vaccine series initiation rates.

Objective: To describe immunization attitudes and practices among family medicine providers across New York State. Methods: In this cross-sectional survey study, family medicine providers across New York State completed a questionnaire to assess vaccine beliefs and barriers and immunization practices. Statistical analysis: Descriptive statistical methods were used to define provider characteristics, knowledge and vaccine practices. Results: Completed questionnaires from 226 family medicine providers were included for analysis. As a group, 207/218 (95%) of providers who answered the question state they always recommend standard pediatric vaccines. Of the 209 providers who answered both questions, 47 (22%) state they always recommend standard pediatric vaccines but do not always recommend HPV vaccine to eligible 11–12 year-old patients. Only 75% of providers strongly disagreed with the statement ‘vaccinating adolescents against HPV increases the likelihood of unprotected sex'. Even though 178/190 (94%) and 164/188 (87%) of surveyed family medicine providers reported recommending that their pregnant patients receive influenza vaccine and Tdap vaccine, respectively, only 134/185 (72%) routinely do so in their office. Conclusion: Most family medicine providers self-report always recommending standard pediatric vaccines, however only a minority are following ACIP recommendations. Educational sessions to update family medicine providers on ACIP recommendations and address individual provider concerns may improve provider vaccine confidence and uptake of vaccines by their patients.

Purpose The purpose of this study is to identify barriers to weight loss and physical activity, as well as approaches used by coaches, in a real-world, community sample of adults with metabolic syndrome (at risk for type 2 diabetes) who participated in a Diabetes Prevention Program (DPP)–adapted weight loss intervention and compare findings to data from the screened and highly selected DPP sample. Methods SHINE (Support, Health Information, Nutrition, and Exercise) was a telephonic DPP adaptation. Primary care staff delivered the DPP curriculum, and lifestyle coaches provided monthly direction to achieve weight loss. For this substudy, barriers to weight loss and physical activity described by participants, as well as approaches coaches used to address them, were gathered. Groupings of barriers (DPP defined) were analyzed in relation to demographic characteristics and compared to data from the DPP sample. Results Top weight loss barriers were problems with self-monitoring, too little physical activity, internal thought/mood cues, vacation/holidays, and social cues. Percentages reporting a barrier were much higher in SHINE. Top physical activity barriers were problems with self-monitoring, access/weather, time management, aches/pains, and vacation/holidays. These did not correspond closely to DPP data. Coaches used problem solving, self-monitoring skills review, increased physical activity, and motivational strategies. SHINE coaches were more likely than DPP coaches to use alternative approaches. Conclusions Barriers to weight loss and physical activity in a community sample of persons at risk for diabetes occurred at much higher rates than in the highly screened DPP sample. Training coaches in a variety of patient-centered approaches may maximize their positive impact.

We examined self-determination theory (SDT) and weight loss, and hypothesized that the Diabetes Prevention Program's (DPP) intervention would result in an increase in autonomous regulation of motivation (AR) in participants. Further, that those with higher AR, and those who perceived educators as supporting SDT-defined needs, would lose more weight. Support, Health Information, Nutrition and Exercise (SHINE) Study data (N = 257) were analyzed. SHINE was a randomized, controlled DPP translation trial (2-years, telephonic, primary care staff). Autonomous motivation in males increased significantly, while females showed no change. Males with high AR, but not females, lost more weight. However, the significance of these relationships varied over time. Participants who perceived educators as more supportive of psychological needs lost more weight (especially males). However, effect of support on weight loss was not mediated by AR change. Autonomous motivation and educator support are relevant to male weight loss. Future research might develop interventions to enhance autonomous motivation and educator support, and understand change pathways.

OBJECTIVE To compare glycemic control and secondary outcomes of a 4-month telephonic couples behavioral intervention to individual intervention, and to education, for adults with type 2 diabetes. RESEARCH DESIGN AND METHODS A randomized trial with the following three arms: couples calls (CC) (n = 104); individual calls (IC) (n = 94); and diabetes education (DE) (n = 82). All arms had self-management education (two calls). CC and IC had 10 additional behavior change calls. CC addressed collaboration and relationships/communication. Participants consisted of 280 couples, among whom one partner had type 2 diabetes and an A1C level ≥7.5%. Blinded assessments occurred at 4, 8, and 12 months. The primary outcome was change in A1C; and secondary outcomes were BMI, waist circumference, blood pressure, depressive symptoms, diabetes self-efficacy, and diabetes distress. RESULTS Patients had a mean age of 56.8 years; 61.6% were male, and 30.4% were minorities. The baseline mean A1C level was 9.1%. Intention-to-treat analyses found significant A1C reductions for all (12 months: CC −0.47%, IC −0.52%, DE −0.57%), with no differences between arms. Preplanned within-arm analyses were stratified by baseline A1C tertiles: lowest tertile (7.5–8.2%), no change from baseline; middle tertile (8.3–9.2%), only CC led to significantly lower A1C level; and highest tertile (≥9.3%), significant improvement for all interventions. For BMI, CC showed significant improvement, and CC and DE led to decreased waist circumference. The IC group showed greater blood pressure improvement. Results for secondary psychosocial outcomes favored the CC group. CONCLUSIONS In adults with poorly controlled type 2 diabetes, a collaborative couples intervention resulted in significant, lasting improvement in A1C levels, obesity measures, and some psychosocial outcomes. For those with exceedingly high A1C levels, education alone was beneficial, but additional intervention is needed to achieve glycemic targets.

Background: Nasopharyngeal pneumococcal carriage rates among HIV-infected adults has not been described since conjugate pneumococcal vaccine-13 (PCV13) was added to the universal infant and childhood vaccination schedule in 2010. Methods: HIV-infected adults presenting for routine health care visits to the Designated AIDS Center in Syracuse, NY between December 2013 and June 2015 were eligible for enrollment. Demographic, medical, and social history were recorded after obtaining informed consent. Nasopharyngeal samples were collected and cultured for the presence of Streptococcus pneumoniae using standard microbiologic techniques. Antibiotic susceptibility testing was performed using E-test→. Results: 707 nasopharyngeal samples were collected from 414 HIV-infected adults. 18 samples were culture positive for S. pneumoniae; 1 (6%) isolate was of vaccine-type, 9 (50%) were non-vaccine types, and 8 (44%) were non-typeable. The 18 isolates were recovered from 15 different patients (4% of those enrolled). Three patients were culture positive for pneumococcus isolated from 2 consecutive samples, with non-typeable pneumococci identified consecutively from 2 patients and serotype 35B identified consecutively from 1 patient. The most commonly identified non-vaccine serotypes were 35B and 15B/C. Identified pneumococci were penicillin and cefotaxime susceptible. Conclusion: Four percent of HIV-infected adults in our study population were colonized with S. pneumoniae. The non-vaccine serotypes 35B and 15B/C predominated.

Purpose: We describe HPV vaccine attitudes among students of different education levels. Methods: High school, college, and graduate-level health care professional students were surveyed regarding HPV vaccine knowledge, attitudes, and receipt. Relationships between categorical variables were analyzed using chi-square tests of independence and z-tests for proportions. Means for quantitative variables were compared using t-tests and one-way analysis of variance. Results: 57% and 42% of the 889 students reported starting and completing HPV vaccine series, respectively, with no statistical difference by education level. 61% of students who reported receiving a provider recommendation had completed the series, compared to 6% of those who did not receive recommendation (p

Objective: To compare change in physical activity (PA) and dietary fat intake (DFI) in the SHINE (Support, Health Information, Nutrition and Exercise) Study. SHINE was a randomized, controlled weight loss trial (n=257) of 2 telephone (to increase reach) translations of the Diabetes Prevention Program (DPP) lifestyle change intervention, delivered at 5 diverse healthcare sites. Methods: Participants (metabolic syndrome, no diabetes) were randomized to the DPP lifestyle change program, participating individually (solo; n=129) or in a group conference call (group; n=128). The 16-session DPP curriculum was delivered in year-1 by trained primary care staff and coaches, with continued contact in year-2. Participants: mean age= 51.8 years, 74.3% female, 85.6% white, 44.1% employed, 36.9% annual income Results: Compared to baseline, the group arm increased PA at 6, 12 and 24 mos. (71.0, 139.5, 255.0 mets/week), the solo arm only improved at 24 mos. (102.0 mets/week). Compared to baseline, the group arm showed decreased DFI at 6, 12 and 24 mos. (1.4%, 1.4%, 1.4%); the solo arm improved at 6 and 12 mos. (2.6%, 2.9%) but not at 24 mos. There were no differences between arms in means for PA or DFI. Conclusions: Primary care staff can be trained to deliver a telephonic DPP translation that is effective to achieve significant PA and DFI behavior change. Despite anecdotal concerns that group contact may be less tailored to individuals and thus less effective, we found that group may be more effective than solo contact in achieving activity and diet changes associated with weight loss. Disclosure P.M. Trief: Research Support; Self; National Institute of Diabetes and Digestive and Kidney Diseases. L.M. Delahanty: Consultant; Self; Janssen Pharmaceuticals, Inc., Akcea Therapeutics, Nutrisystem, Inc.. Advisory Panel; Self; Jana Care Inc., Omada Health, Inc.. D.A. Cibula: None. R.S. Weinstock: Research Support; Self; Medtronic MiniMed, Inc., Mylan, Kowa Pharmaceuticals America, Inc., Diasome Pharmaceuticals, Inc., Calibra Medical, Dexcom, Inc., Ultradian Diagnostics LLC., JAEB Center For Health Research, JDRF, National Institute of Diabetes and Digestive and Kidney Diseases.

Politics play a role in the dissemination of public health information, including immunization-related issues. We aim to describe relationships between HPV vaccination rates and state voting patterns during the 2016 US presidential election.We classified each of the 50 states as either "Red" or "Blue," based on whether a higher proportion of the state's casted votes were for the Republican or Democratic nominee during the 2016 US presidential election. State-specific HPV, Tdap, and meningococcal vaccination rates were obtained from the 2016-National Immunization Survey-Teen. State socio-demographic factors and HPV vaccine legislation were obtained from the US Census Bureau and National Conference of State Legislatures. Vaccination rates and socio-demographic variables were compared using independent t-tests. Multiple linear regression compared vaccination rates between "Red" and "Blue" states, adjusting for percentage of both uninsured children and educational attainment.Compared to "Blue" states, "Red" states had significantly lower unadjusted HPV vaccine series initiation (56% vs 66%, p 0.05) and completion (39% vs 50%, p 0.05) rates; yet had similar rates of Tdap (88% vs 89%, p 0.05) and meningococcal (79% vs 83%, p 0.05) vaccinations. After adjusting for potential confounders, the regression-adjusted mean rate for HPV vaccine initiation and completion remained significantly lower for "Red" states compared to "Blue" states (57% vs 65%, p 0.05, and 41% vs 48%, p 0.05, respectively).HPV vaccination rates are associated with statewide-level voting patterns. Future interventions aimed at improving HPV vaccination rates should consider engaging local and national elected leaders to be proactive in disseminating accurate and authoritative immunization information.

In Brief Incorrect administration of insulin (e.g., too little, too much, or at wrong times) can result in transient and serious hypo- and hyperglycemia, wide glycemic excursions, and diabetic ketoacidosis. The authors systematically assessed the insulin-related knowledge and injection skills of a sample of adults with diabetes and found that errors in self-administering insulin, including choosing an incorrect insulin dose, were common. Injection site selection and diabetes numeracy were also concerns. Correct timing of injections and confidence in choosing correct doses, but not skills scores, related to better A1C and blood glucose levels.

Objectives The healthy immigrant effect is the phenomenon by which immigrants experience more positive health outcomes than the native-born population in developed countries. The strength of this effect appears to be related to country of origin, health outcome, healthcare and integration policies of receiving countries, as well as immigration class. This secondary analysis of birth records examines whether immigrants and mothers from refugee countries have lower adjusted risk of preterm births than US-born mothers in Syracuse, NY, a preferred refugee resettlement area. Methods This secondary analysis included 6354 electronic birth records for residents in the city of Syracuse, NY who gave birth to singleton infants between 2009 and 2011. Multivariate log-binomial regression was used to calculate the adjusted relative risk for preterm birth among foreign-born mothers and mothers from refugee countries, compared to US-born mothers. Results Infants born to both foreign-born women and to women from refugee countries had decreased risks of being born preterm compared to infants born to US mothers, controlling for race, late/no prenatal care, maternal age less than 18 years and smoking. Conclusion Our findings support a healthy immigrant effect for preterm births both among all foreign-born immigrants and among the subsample of women from refugee countries. Mother’s nativity is likely a proxy for unmeasured factors (e.g., prenatal stress, maternal diet, etc.) that may explain the relationship between mother’s nativity and preterm births. Additional research is needed to better understand the underlying factors.

To determine factors associated with obstetric provider recommendation of pertussis vaccine (Tdap) to their pregnant patients following the Advisory Committee on Immunization Practices (ACIP) recommendation that Tdap be given in the third trimester of each pregnancy. Obstetric providers across New York State anonymously completed a standard set of questions to assess vaccine recommendation knowledge and practice. Statistical analysis: Descriptive statistical methods were used to define provider characteristics, knowledge and vaccine practices. Factors associated with recommendation were analyzed using odds ratios. 133 obstetric providers were included in the study. 11% and 13% expressed concern with pertussis vaccine safety and efficacy, respectively, in pregnant women. 92% of obstetric providers stated that they knew ACIP recommendations for Tdap during pregnancy, 80% recommended Tdap to all eligible patients, but only 67% provided Tdap vaccine in their office. Provider knowledge of recommendation (OR 23.33), routine provider recommendation of influenza vaccine (OR 12.5), and administration of pertussis vaccine in the office (OR 7.01) were all factors strongly associated with routine provider recommendation of Tdap vaccine to eligible pregnant women (P < 0.05). Providers expressed concerns with cost of Tdap, the need to administer Tdap with each pregnancy, vaccine safety, low incidence of pertussis in the area, and administration of pertussis vaccine at the hospital after delivery. Educational programs are needed to improve provider vaccine confidence and recommendation.

OBJECTIVE—To examine the relationships between elevated depression symptoms (EDS) or stress and weight loss in SHINE, a telephonic, primary-care based, translation of the Diabetes Prevention Program. DESIGN AND METHODS—N=257 adults with metabolic syndrome were randomized to individual (IC) or group (CC) phone participation. We assessed weight, depression, antidepressant use (ADMs), and stress (baseline, 6 months, 1 and 2 years). Univariate analyses used linear and logistic regression, t-tests for continuous variables and exact tests for categorical variables. Stratified analyses assessed modifiers of effects of depression/stress on weight loss. RESULTS—Approximately 35% reported EDS, with no change over time. Approximately 28% of all participants used ADMs. Participants with EDS had lower mean % weight loss and a smaller % who achieved ≥ 5% weight loss. Participants with EDS were less likely to be “completers” (40.1 % vs. 61.5%, p=.002), coached (48.0% vs. 60.7%, p=.049), or log diet/activity (19.4% vs. 42.7%, p

Objective To develop a program to educate providers, office staff, patients, and parents on life-long cancer prevention strategies, including the use of human papillomavirus (HPV) vaccine to improve adolescent HPV vaccination rates. Study design A 2-phase program was implemented at 6 pediatric practices across upstate New York. Phase 1 included provider and staff education regarding practice-specific vaccination challenges and discussion of the contents of a study-specific cancer-prevention booklet, which included HPV vaccine information. Throughout phase 2, the booklets were distributed to all adolescents and their parents during office visits over a 12-month period. Practice-specific, countywide, and statewide HPV vaccination rates were assessed before phase 1, and 6 and 12 months after the launch of phase 2. Results One year after implementing phase 2 in 6 practices, adolescent HPV vaccine series initiation increased by at least 10% in 3 practices, and at least 5% in 5 practices. Similarly, adolescent vaccine series completion rates increased by more than 10% in 3 practices. The percent change in vaccine series completion rates across all study sites postintervention ranged from 12% to 20% for 11- to 12-year-olds, and from 7% to 23% for 13- to 18-year-olds. Conclusions Cancer prevention education targeting providers, office staff, patients, and parents was modestly effective for improving adolescent HPV vaccination rates.

Background Few occupational researchers have examined “return to work” among patients with work-related respiratory diseases. In addition, prior studies have emphasized individual patient characteristics rather than a more multi-dimensional approach that includes both clinical and structural factors. Methods A retrospective chart review identified patients with occupational respiratory diseases in the Occupational Health Clinical Center, Syracuse, NY between 1991 and 2009. We assessed predictors of work status using an exploratory, sequential mixed methods research design, multinomial (n = 188) and Cox regressions (n = 130). Results The findings suggest that patients with an increased number of diagnoses, non-union members, and those who took more than a year before clinical presentation had significantly poorer work status outcomes, after adjusting for age, education level, and relevant diagnoses. Conclusions Efforts to prevent slow return to work after developing occupational respiratory disease should recognize the importance of timely access to occupational health services, disease severity, union membership, and smoking status. Am. J. Ind. Med. 56:1371–1382, 2013. © 2013 Wiley Periodicals, Inc.

Background: Cognitive symptoms are some of the most distressing for patients who are depressed. The goal was to investigate whether depressed patients’ cognition changed depending on treatment with SSRIs (No-NOR) vs. Norepinephrine-enhancing medications (NOR) during an inpatient stay. Methods: This was an observational, naturalistic, pilot study that used a repeated measures design. 119 depressed inpatients, average age 39 years, 61% females, 77% Caucasian, 74% with mood disorders, 50% Cluster B traits/disorders and 32% psychoactive substance abuse disorders participated. The Trail Making Test (TMT), Hamilton Depression Rating Scale (HDRS), and Outcome Questionnaire-45(OQ-45) were used. Results: Revealed significant differences between admission and discharge in HDRS (MA=24, MD=9, t (98)=25.30, p

Background The Support, Health Information, Nutrition, and Exercise (SHINE) trial recently showed that a telephone adaptation of the Diabetes Prevention Program (DPP) lifestyle intervention was effective in reducing weight among patients with metabolic syndrome. The aim of this study is to determine whether a conference call (CC) adaptation was cost effective relative to an individual call (IC) adaptation of the DPP lifestyle intervention in the primary care setting. Methods We performed a stochastic cost-effectiveness analysis alongside a clinical trial comparing two telephone adaptations of the DPP lifestyle intervention. The primary outcomes were incremental cost-effectiveness ratios estimated for weight loss, body mass index (BMI), waist circumference, and quality-adjusted life years (QALYs). Costs were estimated from the perspective of society and included direct medical costs, indirect costs, and intervention costs. Results After one year, participants receiving the CC intervention accumulated fewer costs ($2,831 vs. $2,933) than the IC group, lost more weight (6.2 kg vs. 5.1 kg), had greater reduction in BMI (2.1 vs. 1.9), and had greater reduction in waist circumference (6.5 cm vs. 5.9 cm). However, participants in the CC group had fewer QALYs than those in the IC group (0.635 vs. 0.646). The incremental cost-effectiveness ratio for CC vs. IC was $9,250/QALY, with a 48% probability of being cost-effective at a willingness-to-pay of $100,000/QALY. Conclusions CC delivery of the DPP was cost effective relative to IC delivery in the first year in terms of cost per clinical measure (weight lost, BMI, and waist circumference) but not in terms of cost per QALY, most likely because of the short time horizon.

This paper investigates urban retail food markets and health in Syracuse, New York. A structured observational analysis found that a majority of corner markets do not sell fresh produce or low fat dairy products, but conduct a lively business selling lottery tickets, cigarettes, and liquor. A comparison of census tracts with and without access to supermarkets that sell fresh produce and other healthy food found that pregnant women living in proximity to a supermarket had significantly fewer low birth weight births than other pregnant women regardless of income level.

The purpose of this article is to provide a method of appraising skills in surveillance, assessment, and public health emergency investigation by using an examination based on an actual outbreak occurrence. This article presents an examination that uses a problem-based approach that works sequentially through the steps of an outbreak investigation to assess the investigation skills of individual students. Designed for graduate public heath students enrolled in a course in infectious disease epidemiology at East Carolina University, the examination can be used to appraise the outbreak investigation skills of medical students or practitioners.

Objective To describe vaccine attitudes among pediatric healthcare providers attending immunization conferences. Study design Attendees of 5 American Academy of Pediatrics (AAP)-sponsored vaccine conferences held between June and November 2013 anonymously completed a questionnaire assessing vaccine attitudes and practices prior to the opening of educational sessions. Pearson's chi-square tests and Fisher's exact tests were used to analyze associations between vaccine attitudes, vaccine practices and provider characteristics. Results 680 providers attending AAP-sponsored vaccine conferences were included. 661/666 (99%) enrolled providers state they routinely recommend standard pediatric vaccines, yet, 30 (5%) state that they do not routinely recommend influenza and/or human papillomavirus (HPV) vaccines. These providers expressed vaccine safety (87/680 (13%)) and efficacy (21/680 (31%)) concerns and stated belief in vaccine misperceptions: vaccine causes autism (34/668, 5%), multiple vaccines at a single visit reduces vaccine efficacy (43/680, 6%) or overwhelms the immune system (63/680, 9%), and administering HPV vaccine will increase the likelihood of unprotected adolescent sexual activity (29/680, 4%). Six percent of providers who do not routinely recommend all pediatric vaccines correctly identified themselves as vaccine hesitant. Conclusion Vaccine hesitancy is under-recognized among pediatric providers attending AAP-sponsored immunization conferences. Educational interventions tailored to address provider vaccine concerns are needed to improve provider vaccine confidence.

Syracuse Healthy Start, a federally funded infant mortality prevention project in Onondaga County, New York, has undertaken a range of interventions to address parental low literacy as a risk factor for infant mortality. A growing number of studies advocate for health-related information that is easy to read, of a low literacy level, and culturally appropriate. Creation of an evidence-based public health intervention involves analyzing local data, reviewing published studies, assessing available materials, initiating programmatic interventions, and evaluating the outcomes. Preparing health educational materials that are clear, culturally sensitive, and at appropriate reading levels follows Paulo Freire’s lead in empowering the disadvantaged to positively affect their health and the health of their infants toward the reduction of infant mortality.

Since 1996, state legislators, members of the U.S. Congress, and more recently President George W. Bush, have called for the protection of monogamous, heterosexual marriage and the promotion of marriage among poor women. The thrust of this policy making is directed at African American families, among which female headship doubled between 1965 and 1990. This doubling is temporally associated with enacting the legislation directed toward the War on Drugs, which resulted in a tripling of the African American prison population. In Syracuse, New York, the swelling African American population behind bars has resulted in a skewed sex ratio, in which women significantly outnumber men. The authors use national, state, and local epidemiological, environmental, and ethnographic data to argue that the proliferation of marriage-promotion policies is heterosexist and blames African American women for demographic realities over which they have little control.

Among women of color in the United States, infection with the human immunodeficiency virus (HIV) is rising. Most of the research on this topic, however, has focused on individual-level risk factors, which do not fully explain racial or ethnic differences in infection rates. This article uses structural violence as a conceptual framework to examine ecological-level risk factors leading to disparate rates of heterosexually transmitted HIV among women of color in Syracuse, New York. Three ecological pathways to disproportionate infection are discussed: community rates of infection, concurrent partnerships, and increased vulnerability. The discussion of the pathways considers the following macro- level risk factors: disproportionate incarceration rates of African American men, residential segregation, gang turf, constraints on access to sexually transmitted disease services, an African American sex ratio in which women outnumber men, social norms stigmatizing homosexuality, and commercial sales of douching products. The authors argue that health care providers and policy analysts must address ecological-level risk factors for HIV transmission in underserved communities.

This case-tuberculosis in a homeless men's shelter-is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Tuberculosis presents a significant public health challenge. In this teaching case, medical students are given information about four cases of active tuberculosis that occurred over a short period of time in residents of a homeless men's shelter. The students then walk through the steps that a local health department takes to identify and screen those individuals at risk for transmission of tuberculosis during an outbreak. During this process, they learn skills in epidemiology (such as defining "epidemic" and distinguishing uses for incidence and prevalence) as well as in population-based prevention of tuberculosis. Finally students discuss health policy as it relates to the control and prevention of tuberculosis.

This case-community health assessment-is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. Community health assessment is key to understanding the health problems and priorities of a population. This case outlines a process by which the participants can complete a health assessment of a community using indicator-based methods. Students construct a set of health indicators from a variety of domains, evaluate problems, and report on the health priorities for a community. The students relate identified health issues to underlying behavioral risk factors.

This case-prevention of adolescent suicide-is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. This teaching case examines the issue of prevention of adolescent and young adult suicide both at an individual and at a population or community level, using data from the Onondaga County Health Department. In the first section of the case, students are asked to determine whether five deaths related to falling or jumping at a local shopping mall should be considered to be suicidal deaths. Students then develop skills in the reporting as well as in the epidemiology of adolescent suicidal deaths in Onondaga County. As the case progresses, students analyze the results of a local surveillance study of suicidal attempts and ideation. The case concludes with students evaluating a hypothetical screening study intended to reduce the risk of suicidal death and discussing a research design to examine the effectiveness of this prevention strategy.

1. Rodriguez-Barradas MC, et al. Colonization by Streptococcus pneumoniae among human immunodeficiency virus-infected adults. JID. 1997; 175:590-7. 2. Janoff EN, et al. Streptococcus pneumoniae colonization, bacteremia, and immune response among persons with human immunodeficiency virus infection. JID.1993; 167: 49-56. Background: Before widespread use of pneumococcal conjugate vaccine (PCV) in children, 14-20% of HIV-infected adults were colonized with pneumococci. We characterized nasopharyngeal pneumococcal colonization among HIV-infected adults following the introduction of PCV-13. Methods: HIV-infected adults seeking care at the Designated AIDS Center in Syracuse, NY between December 2013 and March 2015 were eligible. Following informed consent, an NP sample was collected, and patient demographics, medical and social history including risk factors for invasive pneumococcal disease (IPD) recorded. Pneumococci were identified from the samples using standard microbiologic techniques. Results: 707 nasopharyngeal samples were collected from 414 HIVinfected adults; 301 (73%) were males. Mean and median ages were 46.3 and 48 years, respectively. 391 (94%) and 42 (10%) were taking anti-retroviral therapy and sulfamethoxazole/trimethoprim prophylaxis, respectively. In addition to HIV infection, 210 (51%) had another co-morbidity placing them at increased risk for IPD. 12 (3%) had received PCV-13 and 220 (53%) had received pneumococcal polysaccharide vaccine-23 as recommended. Pneumococcus was isolated from 18/707 (2.5%) of samples and from 15/414 (3.6%) of patients. Colonization status was not associated with gender, race, co-morbidities, antibiotic use, smoking, alcohol use, intravenous drug use, children in the household, vaccine status, absolute neutrophil count, CD4 count, or viral load, however, colonized adults were more likely to have respiratory symptoms than those who were not colonized (46% vs 27%, p=0.02). Conclusion: Current pneumococcal colonization rates in HIV-infected adults are below historical rates suggesting reduction due to the widespread use of PCV-13. When present, colonization may be associated with respiratory symptoms.

A telephone delivered translation of the DPP weight loss program, delivered by trained primary care staff over 2 years, resulted in significant weight loss for patients with metabolic syndrome. Participants in groups (conference calls) continued to lose weight a full year after the program ended, while those called individually regained.

Pertussis is a highly contagious vaccine preventable disease resulting in significant infant morbidity and mortality. Despite the recommendations for pertussis vaccine (Tdap) in adults, coverage rates in this age group remain suboptimal. We sought to determine factors associated with Tdap receipt among adults with children in the household who live in central New York.The study team surveyed Tdap immunization status of adults who accessed medical services for their children provided by Golisano Children's Hospital, Syracuse, New York. Adults who did not know their Tdap vaccine status were excluded. Each participant was asked a standard set of questions to determine factors associated with Tdap receipt. Logistic regression was used to calculate simple and adjusted odds ratios for Tdap receipt in relation to adults' demographic characteristics, knowledge of Tdap and physician recommendations.Eight hundred twenty four participants were included in this study; 34% had received Tdap in the past 5 years; 58% reported that their provider or child's pediatrician recommended adult Tdap vaccination. Tdap receipt was associated with knowing the symptoms of pertussis infection, female gender, younger age, and provider recommendation (p0.05). Participants whose provider recommended Tdap vaccine were 24.6 times more likely to receive vaccine when compared to those whose providers did not recommend vaccine (95% CI: 16.3, 37.2, p0.05).Tdap coverage rates are low among this study population, with provider recommendation most strongly associated with Tdap receipt. Future steps to improve vaccine coverage should include both increasing community awareness and determining barriers to provider recommendation.

Prenatal depression (PD) as a risk factor for adverse birth outcomes is well documented. Less is known about maternal risks for PD, which could inform preventive strategies for perinatal and interconceptional care. This exploratory study investigates associations between prenatal depression symptoms and unintended and mistimed pregnancies and other maternal risk factors for PD. A subset of birth records from the New York Statewide Perinatal Data System (n = 19,219) was used in this secondary analysis of cross-sectional data. Univariate and multivariate multinomial regression was used to identify factors that are independently associated with four self-reported levels of prenatal depression symptoms. Women with unintended pregnancies were more likely (AOR, 95 % CI) to report severe (3.6, 2.6–5.1) or moderate (2.0, 1.6–2.5) prenatal depression symptoms and less likely to report no symptoms, compared to women with intended pregnancies. Likewise, women with mistimed pregnancies were more likely to report severe (2.7, 2.2–3.5) or moderate (1.7, 1.5–2.1) prenatal depression symptoms than no symptoms, compared to women with intended pregnancies. Low education, drug use, smoking, minority race, being unmarried and having Medicaid insurance were also significant, independent predictors of PD symptoms. Results suggest that routine screening for depression, intendedness of pregnancy and other associated risk factors such as smoking and drug use during prenatal and interconceptional care visits may enable coordinated interventions that can reduce prenatal depression and unintended and mistimed pregnancies and improve pregnancy outcomes.

This article presents the multifaceted efforts of Syracuse Healthy Start, a federally funded initiative of the Onondaga County Health Department and over 20 partnering agencies to reduce racial and ethnic disparities in infant mortality. The analyses presented in this article demonstrate that many women--Caucasian, African American, and Hispanic--have serious risks for low birth weight and infant death. In many cases, multiple, simultaneous risks complicate a pregnant woman's situation and in other cases the longitudinal cumulative risks impact health across generations. Infant mortality decreased overall, and for both Caucasian and African American infants during the first 3 years of the project.

The gonorrhea infection rate among 15-19 year olds during 1993-1994 in an urban Upstate New York community was nearly twice the national norm. More than 50% of all the gonorrhea cases were concentrated in eight census tracts. This study was conducted to provide data regarding sexually transmitted diseases among high risk adolescents to increase successful public health interventions. The methodology consisted of six focus groups and a self-administered survey. The results determined the extent of accurate knowledge, their risk behaviors and beliefs, the barriers to treatment, and suggested interventions for clinic services and health education.

Few occupational researchers have examined "return to work" among patients with work-related respiratory diseases. In addition, prior studies have emphasized individual patient characteristics rather than a more multi-dimensional approach that includes both clinical and structural factors.A retrospective chart review identified patients with occupational respiratory diseases in the Occupational Health Clinical Center, Syracuse, NY between 1991 and 2009. We assessed predictors of work status using an exploratory, sequential mixed methods research design, multinomial (n = 188) and Cox regressions (n = 130).The findings suggest that patients with an increased number of diagnoses, non-union members, and those who took more than a year before clinical presentation had significantly poorer work status outcomes, after adjusting for age, education level, and relevant diagnoses.Efforts to prevent slow return to work after developing occupational respiratory disease should recognize the importance of timely access to occupational health services, disease severity, union membership, and smoking status.

The Diabetes Prevention Program (DPP) intensive lifestyle intervention resulted in significant weight loss, reducing the development of diabetes, but needs to be adapted to primary care provider (PCP) practices.To compare a DPP-translation using individual (IC) vs. conference (CC) calls delivered by PCP staff for the outcome of percent weight loss over 2 years.Randomized clinical trial.Five PCP sites.Obese patients with metabolic syndrome, without diabetes (IC, n = 129; CC, n = 128).Telephone delivery of the DPP Lifestyle Balance intervention [16-session core curriculum in year 1, 12-session continued telephone contact in year 2 plus telephone coaching sessions (dietitians).Weight (kg), body mass index (BMI), and waist circumference.age = 52 years, BMI = 39 kg/m(2), 75 % female, 85 % non-Hispanic White, 13 % non-Hispanic Black, and 48 % annual incomes$40,000/year. In the intention-to-treat analyses at year 2, mean percent weight loss was -5.6 % (CC, p 0.001) and -1.8 % (IC, p = 0.046) and was greater for CC than for IC (p = 0.016). At year 2, mean weight loss was 6.2 kg (CC) and 2.2 kg (IC) (p 0.001). There was similar weight loss at year 1, but between year 1 and year 2 CC participants continued to lose while IC participants regained. At year 2, 52 % and 43 % (CC) and 29 % and 22 % (IC) of participants lost at least 5 % and 7 % of initial weight. BMI also decreased more for CC than IC (-2.1 kg/m(2) vs. -0.8 kg/m(2) p 0.001). Waist circumference decreased by 3.1 cm (CC) and 2.4 cm (IC) at year 2. Completers (≥9 of 16 sessions; mean 13.3 sessions) lost significantly more weight than non-completers (mean 4.3 sessions).PCP staff delivery of the DPP lifestyle intervention by telephone can be effective in achieving weight loss in obese people with metabolic syndrome. Greater weight loss may be attained with a group telephone intervention.

A pilot study was conducted to assess the feasibility and potential efficacy of a couples focused diabetes intervention in which a collaborative problem-solving approach to diabetes self-care was promoted. Couples (N = 44), in which one partner had Type 2 diabetes and was in poor blood glucose control were randomly assigned to one of three groups: a couples intervention, an individual intervention, or individual diabetes education. The intervention included goal-setting, dietary behavior change, and a focus on emotions. For those in the couples arm, this was done within the framework of promoting collaborative communication between the partners. All intervention contacts were over the telephone to increase reach. Results showed that both the individual and couples interventions yielded meaningful clinical improvements in medical outcomes. Diabetes education also resulted in improved blood glucose control. Despite the small number, mixed-model regression analyses found statistically significant treatment effects for total cholesterol. This pilot demonstrates the feasibility and potential efficacy of a telephone intervention for Type 2 diabetes patients and their partners. Information from implementing this pilot led to refinement and further development of the intervention, which is being assessed in a larger, more comprehensive trial.

Purpose: This study investigates the persistent relationships between childhood lead exposure, repeat teen pregnancy, and tobacco use in a sample of teenage females in Syracuse, NY. Methods: We analyzed the association of childhood lead poisoning with repeat pregnancy and tobacco use among 536 teens (aged 15-19 years) in Syracuse, NY, who received services at Syracuse Healthy Start between 1998 and 2002. Results: The mothers' childhood lead exposure, controlling for race, age, and Medicaid status, was associated with repeat teen pregnancy and tobacco use. Conclusion: Long-term negative health outcomes associated with childhood lead exposure should not be underestimated. This study helps to shore up prior research that found lead poisoning to have a long-lasting impact on children's functioning and healthy development. Policy efforts focused on neighborhood development and health education continue to be sorely needed. © 2008 Society for Adolescent Medicine. All rights reserved.

This case-colorectal cancer screening-is one of a series of teaching cases in the Case-Based Series in Population-Oriented Prevention (C-POP). It has been developed for use in medical school and residency prevention curricula. The complete set of cases is presented in this supplement to the American Journal of Preventive Medicine. This preventive medicine teaching case discusses the concepts of diagnostic test evaluation, prevention, and screening using the example of colorectal cancer screening. Features of the case include a health policy exercise concerning community screening programs and an exercise in clinical prevention decision making.

Assessing orientation to population-based preventive alternatives is useful in the evaluation of preventive medicine curricula.An instrument was developed using hypothetical situations describing a health issue that could be encountered by a primary care physician. Options to be selected were in three categories: (1) treatment, (2) clinical prevention, or (3) population-based prevention. Respondents allocated 900 points among alternatives for nine situations (100 points per situation). Pilot testing of the instrument was implemented, comparing the responses of public health physicians with two groups (Syracuse and Baltimore) of family medicine physicians.For the overall instrument, the scores on the population scale and population-treatment differential showed statistically significant differences between the public health physicians and both groups of family medicine physicians (p0.01). For medical students taught the Case-Based Series in Population-Oriented Prevention (C-POP), there was an overall increase in the population scale (p0.0001) and the population-treatment differential (p0.0004).The development of a scenario-based tool to assess changes in population-based prevention orientation shows preliminary promise for future evaluation efforts involving preventive medicine curricula.

Host species preference tests were performed on two groups of the seed predator Hylemya (Della) sp. to determine oviposition choice. One group was captured in the field while ovipositing on Ipomopsis aggregata . The second group came from the confamilial Polemonium foliosissimum . A dimorphism was discovered, with each group preferring the plant species upon which it was originally found. However, egg mortality was greater on I. aggregata , suggesting that P. foliosissimum should always be the preferred host. These results are therefore evolutionarily paradoxical. Selection of a specific individual on which to oviposit is based on similar criteria in both plant species. There is a positive correlation between egg deposition and inflorescence size. There is also a positive association between inflorescence size and pollinator visitation frequency, making it likely that flowers chosen as oviposition sites will set enough seeds to ensure full larval development. Thus, regardless of host species preference, oviposition behavior within a species appears to be adaptive.

Bombus flavifrons utiliserait la densite de la plante butinee pour estimer le cout eventuel d'approvisionnement

The nectar-gathering foraging behavior of bumblebees (Bombus flavifrons and B. bifarius) was observed on control and nectar-enriched inflorescences of three Rocky Mountain herbs, Aconitum columbianum, Delphinium nelsonii and D. barbeyi, to determine whether bumblebees actually forage in a manner consistent with the learning mechanism proposed by Ollason. When gathering nectar from two of the three species, bumblebees encountering a series of enriched plants initially increased the number of flowers per inflorescence that they visited relative to control inflorescences. After the blossoms from a small number of enriched racemes were probed, the average number of flowers visited per plant returned to control levels. These results are consistent with the predictions made by Ollason and suggest that foragers' assessment of habitat quality is modified during a foraging bout. These results are used to estimate the extent of bumblebees' memories of previously encountered nectar rewards. The small estimated size of bumblebee memories may be adaptive under spatially heterogeneous reward schedules. INTRODUCTION Food resources for animals often occur in patches. Two problems shared by foraging organisms are, therefore, how to assess the quality of various food patches and how to decide when to leave one patch in search of another of higher quality. In an attempt to predict how an optimally foraging organism would deal with food patches of variable quality, Charnov (1976) formulated the marginal value theorem. In brief, the theorem states that a forager should leave its present patch when its rate of net energy intake drops below the average rate of net energy gain for the entire habitat. However, an animal's correct use of Charnov's rule requires a complete knowledge of the resource structure of the environment. It is unrealistic to expect that any organism would ever possess such knowledge, so how is it that observed foraging behavior is often consistent with the model's predictions (e.g., Krebs et al., 1974; Cowie, 1977; Pyke, 1978b, 1982; Heinrich, 1979; Hodges, 1981; Best and Bierzychudek, 1982; Cibula and Zimmerman, 1984)? Ollason (1980), recognizing that animals have incomplete knowledge of their environment, proposed a mechanism by which animals could make approximately optimal departure decisions. His rule states that foragers should continuously compare their current feeding rate with the average rate at which they remember feeding. When their current rate drops below their remembered average they should leave the patch in which they are feeding in search of another. A distinct assumption of Ollason's model is that animals, while gathering food, use the acquired information about reward schedules to continually update their estimate of overall habitat quality. Thus, Ollason's mechanism involves learning on the part of the foraging organism. The decisions actu'Address all correspondence to M. Zimmerman.