Utilization of a zoo for mosquito (Diptera: Culicidae) diversity analysis, arboviral surveillance, and blood feeding patterns.

Zoos provide a unique opportunity to study mosquito feeding ecology as they represent areas where exotic animals, free-roaming native animals, humans, and mosquito habitats overlap. Therefore, these locations are a concern for arbovirus transmission to both valuable zoo animals and human visitors. We sampled mosquitoes in and around The Nashville Zoo at Grassmere in Tennessee, USA, over 4 months in 2020 using 4 mosquito trap methods and 12 sampling locations. Mosquitoes were identified to species, Culex mosquitoes were analyzed for arboviruses, and all engorged mosquitoes were preserved for host usage analysis. We captured over 9,000 mosquitoes representing 27 different species, including a new species record for Davidson County, TN (Culex nigripalpus Theobald). Minimum infection rates for West Nile virus (WNV) (Flaviviridae: Flavivirus), St. Louis encephalitis virus (Flaviviridae: Flavivirus), and Flanders virus (Hapavirus: Rhabdoviridae) were 0.79, 0, and 4.17, respectively. The collection of 100 engorged mosquitoes was dominated by Culex pipiens pipiens Linnaeus (38%), Culex erraticus Dyar and Knab (23%), and Culex pipiens pipiens-Culex pipiens quinquefasciatus hybrids (10%). Host DNA from 84 engorged mosquitoes was successfully matched to a variety of host species (n = 23), with just 8 species belonging to the zoo. Wild birds were the most frequently fed upon host, in particular northern cardinals (Cardinalis cardinalis L. Passeriformes: Cardinalidae), which are competent WNV reservoirs. Taken together, our results demonstrate the utility of zoos as sentinels for emerging pathogens, for studying wildlife and human risk of zoonotic diseases, and for assessing vector diversity.

Northeast Regional Center for Excellence in Vector-Borne Diseases' Master of Science training program: a curriculum to support future capacity in public health entomology.

A major lack of expertise in vector biology, surveillance, and control for public health professionals has been acknowledged over the past several decades, especially in light of the introduction of West Nile and Zika viruses to the United States. To address this growing need, the Northeast Regional Center for Excellence in Vector-Borne Diseases (NEVBD) designed a unique educational program to cross-train students in the fundamentals of vector biology and public health. Here, we summarize the formation, evaluation, and outcomes of NEVBD's Master of Science in Entomology: Vector-Borne Disease Biology program and provide details on core competencies to enable adoption and adaptation of the program to other institutions and contexts. A discussion of major barriers to filling the nation's need for public health personnel with medical entomology training, such as financial barriers and recruitment of underrepresented students, is presented. We conclude with considerations for administering these training programs.

Spatiotemporal distribution of Borrelia miyamotoi (Spirochaetales: Spirochaetaceae) and coinfection with other tick-borne pathogens in host-seeking Ixodes scapularis (Acari: Ixodidae) from New York State, USA.

Blacklegged ticks (Ixodes scapularis Say, Acari: Ixodidae) were collected from 432 locations across New York State (NYS) during the summer and autumn of 2015-2020 to determine the prevalence and geographic distribution of Borrelia miyamotoi (Spirochaetales: Spirochaetaceae) and coinfections with other tick-borne pathogens. A total of 48,386 I. scapularis were individually analyzed using a multiplex real-time polymerase chain reaction assay to simultaneously detect the presence of Bo. miyamotoi, Borrelia burgdorferi (Spirochaetales: Spirochaetaceae), Anaplasma phagocytophilum (Rickettsiales: Anaplasmataceae), and Babesia microti (Piroplasmida: Babesiidae). Overall prevalence of Bo. miyamotoi in host-seeking nymphs and adults varied geographically and temporally at the regional level. The rate of polymicrobial infection in Bo. miyamotoi-infected ticks varied by developmental stage, with certain co-infections occurring more frequently than expected by chance. Entomological risk of exposure to Bo. miyamotoi-infected nymphal and adult ticks (entomological risk index [ERI]) across NYS regions in relation to human cases of Bo. miyamotoi disease identified during the study period demonstrated spatial and temporal variation. The relationship between select environmental factors and Bo. miyamotoi ERI was explored using generalized linear mixed effects models, resulting in different factors significantly impacting ERI for nymphs and adult ticks. These results can inform estimates of Bo. miyamotoi disease risk and further our understanding of Bo. miyamotoi ecological dynamics in regions where this pathogen is known to occur.

New York State Tick Blitz: harnessing community-based science to understand range expansion of ticks.

Ticks and tick-borne diseases are an immense public health burden in New York State (NYS), United States. Tick species and associated pathogens are expanding into new areas, shifting threats to human, and animal health across the state. For example, the invasive tick, Haemaphysalis longicornis Neumann (Acari: Ixodidae), was first detected in the United States in 2017 and has since been identified in 17 states, including NYS. In addition, Amblyomma americanum (L.) (Acari: Ixodidae) is a native tick thought to be reestablishing historical populations in NYS. We implemented a community-based science project called the "NYS Tick Blitz" to determine the distribution of A. americanum and H. longicornis in NYS. Community volunteers were recruited, provided with education, training, and materials to conduct active tick sampling during a 2-wk period in June 2021. Fifty-nine volunteers sampled 164 sites across 15 counties, for a total of 179 separate collection events and 3,759 ticks collected. The most frequently collected species was H. longicornis, followed by Dermacentor variabilis Say (Acari: Ixodidae), Ixodes scapularis Say (Acari: Ixodidae), and A. americanum, respectively. Through the NYS Tick Blitz collections, H. longicornis was identified for the first time in Putnam County. We conducted pooled pathogen testing on a subset of specimens, with the highest rates of infection detected for pathogens transmitted by I. scapularis, including Borrelia burgdorferi, Anaplasma phagocytophilum, and Babesia microti. Most participants who completed a follow-up survey (n = 23, 71.9%) were promoters of the NYS Tick Blitz and 50% (n = 15) reported that they enjoyed participating in meaningful science.

Review of Continuing Medical Education in Tick-Borne Disease for Front-Line Providers.

Introduction: Considering increasing rates of tick-borne diseases (TBDs) in the United States, we investigated the scope of continuing medical education (CME) available to physicians on these infections. Methods: We surveyed online medical board and society databases serving front-line primary and emergency/urgent care providers for the availability of TBD-specific CME between March 2022 and June 2022. We recorded and analyzed opportunity title, author, web address, publication year, learning objectives, CME credit values, and CME credit type. Results: We identified 70 opportunities across seven databases. Thirty-seven opportunities focused on Lyme disease; 17 covered nine non-Lyme TBDs, and 16 covered general topics on TBDs. Most activities were hosted through family medicine and internal medicine specialty databases. Conclusion: These findings suggest limited availability of continuing education for multiple life-threatening TBDs of increasing importance in the United States. Increasing the availability of CME materials covering the broad scope of TBDs in targeted specialty areas is essential for increased content exposure and a necessary step to ensure our clinical workforce is adequately prepared to address this growing public health threat.

Knowledge, attitudes, and practices for tick bite prevention and tick control among residents of Long Island, New York, USA.

In the United States, tick-borne diseases (TBDs) are a major public health concern and a source of significant morbidity. To reduce tick-borne disease incidence, understanding factors associated with increased risk in humans for tick bites is necessary. These risk factors can include TBD knowledge, attitudes about prevention and care, and associated practices of individuals and their communities, including paying for preventive services. Our study focused on Long Island, New York, a region with high endemicity of ticks and TBDs. The purpose of our study was to identify gaps in the knowledge, attitudes, and practices regarding TBDs in residents of this region to inform priorities for TBD interventions. To this end, we performed a knowledge, attitudes, and practices (KAP) survey and collected 803 responses from Long Island residents. Our survey results demonstrated that Long Island residents had a low to moderate level of knowledge regarding ticks and TBDs. Still, residents expressed concern regarding TBDs, with increased levels of concern associated with increased likelihood of paying for tick control and for practicing tick bite prevention strategies. Individuals with pets were more likely to practice these tick bite prevention strategies. Residents with more frequent exposure to ticks, with a history of TBD in their household, and with higher general concern over ticks were also more likely to pay for tick control services. These findings highlight gaps in resident knowledge, differences in attitudes towards tick preventative behavior, and potential factors affecting motivation towards implementing tick control measures, which can inform future public health messaging regarding tick bite prevention.

Southwestern national park service employee risk, knowledge, and concern for triatomine exposure: A qualitative analysis using a novel knowledge, attitudes, and practices survey.

Chagas disease (CD), caused by the parasite Trypanosoma cruzi, is a neglected parasitic infection in the United States (US). In the Southwestern US, National Park Service (NPS) employees are a unique population with potential exposure to CD. This population lives in close contact with several species of sylvatic triatomine bugs, the vectors of T. cruzi, that may enter residential buildings at night. Despite the higher potential risk of CD transmission for southwestern NPS employees, the socio-cultural factors that impact autochthonous CD transmission in the US remain unknown. To address this gap, we investigated how NPS employee knowledge and attitudes impact their triatomine preventive behaviors. We distributed a 42-item online questionnaire to NPS employees at four national parks in Arizona and Texas. We detected high self-reported bite exposure in NPS housing, despite moderate- to high-frequency of prevention behaviors. Specific behaviors, such as often or always repairing window screens, were associated with a decreased risk of putative triatomine bug exposure. Additionally, NPS employees had low knowledge of CD. For those with greater knowledge of CD, it was not associated with increased frequency of prevention behavior. We found that increased CD anxiety was associated with increased personal agency to reduce the risk of CD. These results demonstrate the influence of knowledge and attitudes regarding CD on triatomine prevention behavior within a potential high-risk population in the US, and the importance of utilizing strategies beyond provision of education to influence behaviors.

Primary care clinical provider knowledge and experiences in the diagnosis and treatment of tick-borne illness: a qualitative assessment from a Lyme disease endemic community.

BACKGROUND: Primary care and frontline healthcare providers are often the first point of contact for patients experiencing tick-borne disease (TBD) but face challenges when recognizing and diagnosing these diseases. The specific aim of this study was to gain a qualitative understanding of frontline and primary care providers' knowledge and practices for identifying TBDs in patients. METHODS: From fall 2018 to spring 2019, three focus groups were conducted with primary care providers practicing in a small-town community endemic to Lyme disease (LD) and with emerging incidence of additional TBDs. A follow up online survey was distributed to urgent and emergency care providers in the small-town community and an academic medical center within the referral network of the local clinical community in spring and summer 2019. Qualitative analysis of focus group data was performed following a grounded theory approach and survey responses were analyzed through the calculation of descriptive statistics. RESULTS: Fourteen clinicians from three primary care practices participated in focus groups, and 24 urgent and emergency care clinicians completed the survey questionnaire. Four overarching themes emerged from focus group data which were corroborated by survey data. Themes highlighted a moderate level of awareness on diagnosis and treatment of LD among participants and limited knowledge of diagnosis and treatment for two other regionally relevant TBDs, anaplasmosis and babesiosis. Providers described challenges and frustrations in counseling patients with strong preconceptions of LD diagnosis and treatment in the context of chronic infection. Providers desired additional point-of-care resources to facilitate patient education and correct misinformation on the diagnosis and treatment of TBDs. CONCLUSIONS: Through this small study, it appears that clinicians in the small-town and academic medical center settings are experiencing uncertainties related to TBD recognition, diagnosis, and patient communication. These findings can inform the development of point-of-care resources to aid in patient-provider communication regarding TBDs and inform the development of continuing medical education programs for frontline and primary care providers.

A Survey of Tick Surveillance and Control Practices in the United States.

Tickborne diseases are an increasing public health threat in the United States. Prevention and diagnosis of tickborne diseases are improved by access to current and accurate information on where medically important ticks and their associated human and veterinary pathogens are present, their local abundance or prevalence, and when ticks are actively seeking hosts. The true extent of tick and tickborne pathogen expansion is poorly defined, in part because of a lack of nationally standardized tick surveillance. We surveyed 140 vector-borne disease professionals working in state, county, and local public health and vector control agencies to assess their 1) tick surveillance program objectives, 2) pathogen testing methods, 3) tick control practices, 4) data communication strategies, and 5) barriers to program development and operation. Fewer than half of respondents reported that their jurisdiction was engaged in routine, active tick surveillance, but nearly two-thirds reported engaging in passive tick surveillance. Detection of tick presence was the most commonly stated current surveillance objective (76.2%). Most of the programs currently supporting tick pathogen testing were in the Northeast (70.8%), Upper and Central Midwest (64.3%), and the West (71.4%) regions. The most common pathogens screened for were Rickettsia spp. (Rickettsiales: Rickettsiaceae) and bacterial and viral agents transmitted by Ixodes (Acari: Ixodidae) ticks. Only 12% of respondents indicated their jurisdiction directly conducts or otherwise financially supports tick control. Responses indicated that their ability to expand the capacity of tick surveillance and control programs was impeded by inconsistent funding, limited infrastructure, guidance on best practices, and institutional capacity to perform these functions.

Experience and knowledge of Lyme disease: A scoping review of patient-provider communication.

There has been limited research on patient-provider communication dynamics regarding Lyme disease (LD) diagnosis and treatment. Evidence suggests communication in the clinical encounter improves when both patient and healthcare provider (HCP) have concordant orientations (or beliefs) on discussed topics, resulting in higher patient satisfaction and care outcomes. The purpose of this scoping review was to characterize and summarize current research findings on patient and provider knowledge and experiences regarding LD - two factors that may influence the orientation of both patients and providers toward LD in the clinical setting. None of the articles included in the review specifically addressed patient-provider interaction and relationships as the main objective. However, the existing literature indicates notable HCP uncertainty regarding LD diagnosis, treatment, and applied practice patterns. Current research also describes limited knowledge of LD among patient populations and a high prevalence of negative perceptions of care received in mainstream healthcare settings among individuals with persistent symptoms. We identified a critical gap in research that seeks to understand the dynamic of patients and HCPs communicating on the topic of LD in the clinical setting. Future research may identify opportunities where the patient-provider communication dynamic can be improved.

Examining an Evidence-Based Medicine Culture in Residency Education.

BACKGROUND AND OBJECTIVES: Reports of innovations in evidence-based medicine (EBM) training have focused on curriculum design and knowledge gained. Little is known about the educational culture and environment for EBM training and the extent to which those environments exist in family medicine residencies in the United States. METHODS: A literature review on this topic identified a validated EBM environment scale intended for learner use. This scale was adapted for completion by family medicine residency program directors (PDs) and administered through an omnibus survey. Responses to this scale were analyzed descriptively with program and PD demographics. An EBM culture score was calculated for each program and the results were regressed with the correlated demographics. RESULTS: In our adapted survey, family medicine PDs generally rated their residencies high on the EBM culture scale, but admitted to challenges with faculty feedback to residents about EBM skills, ability to protect time for EBM instruction, and clinician skepticism about EBM. In linear regression analysis, the mean summary score on the EBM scale was lower for female PDs and in programs with a higher proportion of international medical school graduates. CONCLUSIONS: To improve the culture for EBM teaching, family medicine residency programs should focus on faculty engagement and support and the allocation of sufficient time for EBM education.

Immunization Mandates, Vaccination Coverage, and Exemption Rates in the United States.

BACKGROUND: Vaccination coverage among children entering kindergarten in the United States is high, but interstate variations exist. The relationship between state immunization laws and vaccination coverage has not been fully assessed. We evaluated associations of state laws on both measles, mumps, and rubella (MMR) and diphtheria, tetanus, and pertussis (DTaP) vaccination coverage and exemptions to school immunization requirements. METHODS: We conducted a retrospective, longitudinal analysis of the effect of state immunization laws on vaccination coverage and exemptions among US kindergarteners from SY 2008 to SY 2014. The primary outcome measures were state-level kindergarten entry vaccination coverage rates for 2-dose MMR and 4-dose DTaP vaccines. Secondary outcome measures included rates of state-level exemptions (ie, medical, religious, philosophical) to school immunization requirements. RESULTS: We found that state policies that refer to Advisory Committee on Immunization Practices recommendations were associated with 3.5% and 2.8% increases in MMR and DTaP vaccination rates. Health Department-led parental education was associated with 5.1% and 4.5% increases in vaccination rates. Permission of religious and philosophical exemptions was associated with 2.3% and 1.9% decreases in MMR and DTaP coverage, respectively, and a 1.5% increase in both total exemptions and nonmedical exemptions, respectively. CONCLUSIONS: We found higher vaccination coverage and lower nonmedical exemption rates for MMR and DTaP vaccines in states adopting Advisory Committee on Immunization Practices guidelines for school entry. Adherence to these best practices was a successful strategy to increase vaccination coverage and reduce vaccination exemptions.

Analysis of the association between millennium development goals 4 & 5 and the physician workforce across international economic strata.

BACKGROUND: The Millennium Development Goals (MDGs) are 8 international development goals voluntarily adopted by 189 nations. The goals included health related aims to reduce the under-five child mortality rate by two-thirds (MDG4), and to reduce the maternal mortality ratio by three-quarters (MDG5). To assess the relationship between the healthcare workforce and MDGs 4-5, we examined the physician workforces of countries around the globe, in terms of the Physician Density Level (PDL, or number of physicians per 1000 population), and compared this rate across a number of years to several indicator variables specified as markers of progress towards MDG4 and MDG5. METHODS: Data for each variable of interest were obtained from the World Bank's Millennium Development Goals and World Development Indicators databases for 208 countries and territories from 2004 to 2014, representing a ten-year period for which the most information is available. We analyzed the relationships between MDG outcomes and PDL, controlling for national income levels and other covariates, using linear mixed model regression. Dependent variables were logarithmically transformed to meet assumptions necessary for multivariate analysis. RESULTS: In unadjusted models, an increase of every one physician per 1000 population (one unit change in PDL) lowered the risk of not being vaccinated for measles-mumps-rubella (MMR) to 29.3% (p < 0.001, 95% CI: 22.2%-38.7%) and for not receiving diphtheria-tetanus-pertussis (DTaP) vaccination rate decreased to 38.5% (p < 0.001, 95% CI: 28.7% - 51.7%). Maternal mortality rate decreased to 76.6% (p < 0.001, 95% CI: 74.3% - 79.0%), neonatal mortality decreased to 58.8% (p < 0.001, 95% CI: 54.8% - 63.2%) and under-5 mortality rate decreased to 52.1% (p < 0.001, 95% CI: 48.0% - 56.4%), with every one-unit change in PDL. Adjusted models tended to reflect unadjusted risk assessments. CONCLUSION: The maintenance and improvement of the health workforce is a vital consideration when assessing how to achieve global development goals related to health outcomes.

Qualitative insights into how men with low-risk prostate cancer choosing active surveillance negotiate stress and uncertainty.

BACKGROUND: Active surveillance is a management strategy for men diagnosed with early-stage, low-risk prostate cancer in which their cancer is monitored and treatment is delayed. This study investigated the primary coping mechanisms for men following the active surveillance treatment plan, with a specific focus on how these men interact with their social network as they negotiate the stress and uncertainty of their diagnosis and treatment approach. METHODS: Thematic analysis of semi-structured interviews at two academic institutions located in the northeastern US. Participants include 15 men diagnosed with low-risk prostate cancer following active surveillance. RESULTS: The decision to follow active surveillance reflects the desire to avoid potentially life-altering side effects associated with active treatment options. Men on active surveillance cope with their prostate cancer diagnosis by both maintaining a sense of control over their daily lives, as well as relying on the support provided them by their social networks and the medical community. Social networks support men on active surveillance by encouraging lifestyle changes and serving as a resource to discuss and ease cancer-related stress. CONCLUSIONS: Support systems for men with low-risk prostate cancer do not always interface directly with the medical community. Spousal and social support play important roles in helping men understand and accept their prostate cancer diagnosis and chosen care plan. It may be beneficial to highlight the role of social support in interventions targeting the psychosocial health of men on active surveillance.

Cognitive and Affective Representations of Active Surveillance as a Treatment Option for Low-Risk Prostate Cancer.

Benefits of early diagnosis and treatment remain debatable for men with low-risk prostate cancer. Active surveillance (AS) is an alternative to treatment. The goal of AS is to identify patients whose cancer is progressing rapidly while avoiding treatment in the majority of patients. The purpose of this study was to explore cognitive and affective representations of AS within a clinical environment that promotes AS a viable option for men with low-risk prostate cancer. Participants included patients for whom AS and active treatment were equally viable options, as well as practitioners who were involved in consultations for prostate cancer. Data were generated from semistructured interviews and audits of consultation notes and were analyzed using thematic analysis. Nineteen patients and 16 practitioners completed a semistructured interview. Patients generally viewed AS as a temporary strategy that was largely equated with inaction. There was variation in the degree to which inaction was viewed as warranted or favorable. Patient perceptions of AS were generally malleable and able to be influenced by information from trusted sources. Encouraging slow deliberation and multiple consultations may facilitate greater understanding and acceptance of AS as a viable treatment option for low-risk prostate cancer.

A Practice Facilitation and Academic Detailing Intervention Can Improve Cancer Screening Rates in Primary Care Safety Net Clinics.

BACKGROUND: Despite the current evidence of preventive screening effectiveness, rates of breast, cervical, and colorectal cancer in the United States fall below national targets. We evaluated the efficacy and feasibility of combining practice facilitation and academic detailing quality improvement (QI) strategies to help primary care practices increase breast, cervical, and colorectal cancer screening among patients. METHODS: Practices received a 1-hour academic detailing session addressing current cancer screening guidelines and best practices, followed by 6 months of practice facilitation to implement evidence-based interventions aimed at increasing patient screening. One-way repeated measures analysis of variance compared screening rates before and after the intervention, provider surveys, and TRANSLATE model scores. Qualitative data were gathered via participant focus groups and interviews. RESULTS: Twenty-three practices enrolled in the project: 4 federally qualified health centers, 10 practices affiliated with larger health systems, 4 physician-owned practices, 4 university hospital clinics, and 1 nonprofit clinic. Average screening rates for breast cancer increased by 13% (P = .001), and rates for colorectal cancer increased by 5.6% (P = .001). Practices implemented a mix of electronic health record data cleaning workflows, provider audits and feedback, reminder systems streamlining, and patient education and outreach interventions. Practice facilitators assisted practices in tailoring interventions to practice-specific priorities and constraints and in connecting with community resources. Practices with resource constraints benefited from the engagement of all levels of staff in the quality improvement processes and from team-based adaptations to office workflows and policies. Many practices aligned quality improvement interventions in this project with patient-centered medical home and other regulatory reporting targets. CONCLUSIONS: Combining practice facilitation and academic detailing is 1 method through which primary care practices can achieve systems-level changes to better manage patient population health.

Clinical training in the rural setting: using photovoice to understand student experiences.

INTRODUCTION: Attracting and retaining healthcare providers in rural locations in the USA has been an issue for more than two decades. In response to this need, many health sciences education institutions in the USA have developed special programs to encourage students to become healthcare providers in rural locations. One approach is the use of community-based education experiences through rural track programs. Rural track programs seek to address the shortage of healthcare providers working in rural areas by nurturing and educating students interested in rural practice and primary care. Such programs serve both medical students and students of other health professions. Yet, little is known about student experiences in rural track programs. As such, this study aimed to generate discourse on student experiences in the rural training environment and gain insight into the impact of rural environments on student learning. METHODS: An exploratory qualitative analysis of medical and physician assistant student experiences in two rural medical education training programs was conducted using the photovoice methodology. Photovoice is a participatory research method combining photography with participant commentary and focus groups. RESULTS: Twenty-two third-year medical and six second-year physician assistant students participated in the study. Students noted that in their rural sites the learning environment extended beyond direct clinical teaching in four primary ways: (1) relationships with clinical faculty translated to a sense of meaningful participation in healthcare teams; (2) connections with community members outside of clinical settings led to increased awareness of healthcare concerns; (3) rural settings provided important space to reflect on their experiences; and (4) the importance of infrastructure was highlighted. Students also believed that diversity of occupation, education, attitude, and perception of medical care impact learning in rural environments. CONCLUSIONS: The photovoice participatory research methodology allowed for a deeper understanding of the aspects of the rural training experience that resonated most among students in real time, using visual representations of students' lived experiences as defined by the students.

Status of underrepresented minority and female faculty at medical schools located within Historically Black Colleges and in Puerto Rico.

BACKGROUND AND OBJECTIVES: To assess the impact of medical school location in Historically Black Colleges and Universities (HBCU) and Puerto Rico (PR) on the proportion of underrepresented minorities in medicine (URMM) and women hired in faculty and leadership positions at academic medical institutions. METHOD: AAMC 2013 faculty roster data for allopathic medical schools were used to compare the racial/ethnic and gender composition of faculty and chair positions at medical schools located within HBCU and PR to that of other medical schools in the United States. Data were compared using independent sample t-tests. RESULTS: Women were more highly represented in HBCU faculty (mean HBCU 43.5% vs. non-HBCU 36.5%, p=0.024) and chair (mean HBCU 30.1% vs. non-HBCU 15.6%, p=0.005) positions and in PR chair positions (mean PR 38.23% vs. non-PR 15.38%, p=0.016) compared with other allopathic institutions. HBCU were associated with increased African American representation in faculty (mean HBCU 59.5% vs. non-HBCU 2.6%, p=0.011) and chair (mean HBCU 73.1% vs. non-HBCU 2.2%, p≤0.001) positions. PR designation was associated with increased faculty (mean PR 75.40% vs. non-PR 3.72%, p≤0.001) and chair (mean PR 75.00% vs. non-PR 3.54%, p≤0.001) positions filled by Latinos/Hispanics. CONCLUSIONS: Women and African Americans are better represented in faculty and leadership positions at HBCU, and women and Latino/Hispanics at PR medical schools, than they are at allopathic peer institutions.

Update on Performance in Tobacco Control: A Longitudinal Analysis of the Impact of Tobacco Control Policy and the US Adult Smoking Rate, 2011-2013.

CONTEXT: Tobacco use remains the leading cause of preventable death in the United States. States and municipalities have instituted a variety of tobacco control measures (TCMs) to address the significant impact tobacco use has on population health. The American Lung Association annually grades state performance of tobacco control using the State of Tobacco Control grading framework. OBJECTIVE: To gain an updated understanding of how recent efforts in tobacco control have impacted tobacco use across the United States, using yearly State of Tobacco Control TCM assessments. DESIGN: The independent TCM variables of smoke-free air score, cessation score, excise tax, and percentage of recommended funding were selected from the American Lung Association State of Tobacco Control reports. Predictors of adult smoking rates were determined by a mixed-effects model. SETTING/PARTICIPANTS: The 50 US states and District of Columbia. MAIN OUTCOME MEASURE: Adult smoking rate in each state from 2011 to 2013. RESULTS: The average adult smoking rate decreased significantly from 2011 to 2013 (21.3% [SD: 3.5] to 19.3% [SD: 3.5], P = .016). All forms of TCMs varied widely in implementation levels across states. Excise taxes (ß = -.812, P = .006) and smoke-free air regulations (ß = -.057, P = .008) were significant, negative predictors of adult smoking. Cessation services (ß = .015, P = .46) did not have a measurable effect on adult smoking. CONCLUSION: Tobacco control measures with the strongest influence on adult smoking include the state excise tax and state smoke-free air regulations. The lack of robust funding for tobacco cessation services across the majority of US states highlights an important shortfall in current tobacco control policy.

The social mission in medical school mission statements: associations with graduate outcomes.

BACKGROUND AND OBJECTIVES: Mission statements of medical schools vary considerably. These statements reflect institutional values and may also be reflected in the outputs of their institutions. The authors explored the relationship between US medical school mission statement content and outcomes in terms of graduate location and specialty choices. METHODS: A panel of stakeholders (medical school deans, faculty, medical students, and administrators) completed a Web-based instrument to create a linear scale of social mission content (SMC scale), scoring the degree to which medical school mission statements reflect the social mission of medical education to address inequities. The SMC scale and targeted medical school outputs were analyzed via OLS regression, controlling for allopathic/osteopathic and public/private school designation. The medical school outputs of interest included percent physician output in primary care specialties (family medicine, pediatrics, and general internal medicine), as well as percent physician output in designated Health Professional Shortage Areas (HPSA) and Medically Underserved Areas/Populations (MUA/P). RESULTS: SMC scale was a statistically significant, positive predictor of the percent of physician graduates entering primary care (?=2.526, P=.001). When examining the specialties within primary care, the SMC scale only significantly predicted percent of graduating physicians entering family medicine (?=1.936, P=.003). SMC scale was also a statistically significant predictor of several measures of physician output to work in underserved areas and populations, the strongest of which was the percent of graduating physicians working in MUA/Ps (?=4.256, P?.01). CONCLUSIONS: Mission statements that are diligently utilized by leaders in medical education may produce a higher degree of alignment between institutional structure, ideology, and workforce outcomes.