Identifying Migraine Phenotype Post Traumatic Headache (MPTH) to Guide Overall Recovery From Traumatic Brain Injury.

Objective: The primary aim of this study is to develop an easy way to identify migraine phenotype posttraumatic headache (MPTH) in children with traumatic brain injury, to treat headache in traumatic brain injury effectively, and to promote faster recovery from traumatic brain injury symptoms overall. Methods: We evaluated youth aged 7-20 years in a pediatric neurology traumatic brain injury (TBI) clinic, assigning a migraine phenotype for post-traumatic headache (MPTH) at the initial visit with the 3-item ID Migraine Screener. We stratified the sample by early (≤6 weeks) and late (>6 weeks) presenters, using days to recovery from concussion symptoms as the primary outcome variable. Results: 397 youth were assessed; 54% were female. Median age was 15.1 years (range 7.0-20.4 years), and 34% of the sample had sports-related injuries. Migraine phenotype for posttraumatic headache (MPTH) was assigned to 56.1% of those seen within 6 weeks of traumatic brain injury and 50.7% of those seen after the 6-week mark. Irrespective of whether they were early or late presenters to our clinic, patients with migraine phenotype (MPTH) took longer to recover from traumatic brain injury than those with posttraumatic headache (PTH) alone. Log rank test indicated that the survival (ie, recovery) distributions between those with migraine phenotype posttraumatic headache (MPTH) and those with posttraumatic headache (PTH) were statistically different, χ2(3) = 50.186 (P < .001). Conclusions: Early identification of migraine phenotype posttraumatic headache (MPTH) following concussion can help guide more effective treatment of headache in traumatic brain injury and provide a road map for the trajectory of recovery from traumatic brain injury symptoms. It will also help us understand better the mechanisms that underlie conversion to persistent posttraumatic headache and chronic migraine after traumatic brain injury.

PALS: peer support for community dwelling older people with chronic low back pain: a feasibility and acceptability study.

OBJECTIVES: (i) Examine the feasibility and acceptability of a peer support intervention (PALS) to facilitate self-management in community dwelling older adults with Chronic Low Back Pain (CLBP), and (ii) examine the feasibility of study methods in order to inform the design of a future randomised controlled trial. DESIGN: Mixed methods feasibility and acceptability study. SETTING: Community. PARTICIPANTS: 18 older adults (aged 65 to 79) with CLBP and 6 peer support volunteers (PSVs) aged 34 to 65. INTERVENTION: Six sessions of 1 to 3hours duration, approximately 2 weeks apart, delivered in mutually convenient public places, or by telephone. Each session had a suggested topic and each participant and PSV had a PALS manual detailing aims and target outcomes for each session. OUTCOME MEASURES: Recruitment, retention, integrity, acceptability and feasibility of the PALS intervention, feasibility of study processes, appropriateness and usefulness of outcome measures. RESULTS: We recruited to target and retained 2/3 of participants. PALS was delivered as intended and acceptable to people with CLBP and PSVs. Most participants were satisfied with PALS and would recommend it to someone else with CLBP. Study processes worked well, but recruitment procedures need to be refined. Outcome measures were returned and were mostly complete, but further work on the most appropriate measures is required. CONCLUSIONS: PALS was feasible to deliver and acceptable to the older people and PSVs who took part in this study. We identified amendments to PALS and the study processes that, once implemented, will allow the effectiveness of PALS to be tested in a large-scale study.

Offshore workers and health behaviour change: an exploration using the Theoretical Domains Framework.

BACKGROUND: Previous research has identified the importance of promoting behaviour change within the offshore workforce. This qualitative study sought to: identify self-care behaviours perceived to require behaviour change within the offshore workforce, and explore perceived potential behavioural determinants. MATERIALS AND METHODS: This study included the perspectives of both offshore workers (OWs, n = 16) and healthcare practitioners (HCPs, n = 12) from the global workforce. Telephone interviews were conducted, recorded electronically and transcribed. Transcripts were analysed independently by two researchers using a Framework Approach and the Theoretical Domains Framework (TDF) to support coding. RESULTS: Healthy eating and alcohol intake were behaviours perceived by OWs and HCPs to require change within the offshore workforce. Knowledge (e.g. availability of nutritional knowledge), intentions (e.g. role of motivation), memory, attention and decision process (e.g. effect of boredom), environmental context and resources (e.g. influence of environmental stressors), social influences (e.g. influence of others), emotion (e.g. influence of emotional state) and behavioural regulation (e.g. influence of willpower). TDF domains were reported by both OWs and HCPs in relation to OWs' healthy eating and physical activity behaviours. CONCLUSIONS: The determinants identified as mechanisms of behaviour may be targeted in future interventions which aim to promote engagement in self-care within the offshore workforce.

Health, self-care and the offshore workforce - opportunities for behaviour change interventions, an epidemiological survey.

INTRODUCTION: The high risk nature of offshore work and inherent occupational hazards necessitate that offshore workers engage in behaviours that promote health and wellbeing. The survey aimed to assess offshore workers' health, self-care, quality of life and mental wellbeing, and to identify associated areas requiring behaviour change. METHODS: Offshore workers attending a course at a training facility in Scotland were invited to complete a questionnaire comprising 11 validated measures of health, self-care, quality of life and mental wellbeing. RESULTS: A total of 352 offshore workers responded (completion rate 45.4%). Almost three-quarters were identified as overweight/obese (n=236, 74.4%). Median scores for SF-8 quality of life (physical=56.1, interquartile range (IQR)=4.8; mental=54.7, IQR=8.1) and Warwick-Edinburgh Mental Wellbeing scales were positive (52.0, IQR=9.0). The largest proportion of participants' scores across alcohol use (n=187, 53.4%) and sleep quality (n=229, 67.0%) domains were categorised as negative. The median number of self-care domains for which offshore workers scored negatively was 3 (IQR=2.0). CONCLUSIONS: There are key areas relating to the health, quality of life, mental wellbeing and self-care of the offshore workforce that warrant addressing.

Training peers to support older people with chronic low back pain following physiotherapy discharge: a feasibility study.

OBJECTIVE: To determine the feasibility and acceptability of a training programme for peer volunteers to support older adults with chronic low back pain (CLBP) following discharge from physiotherapy. DESIGN: Feasibility study. SETTING: Community-based. PARTICIPANTS: 17 adults (4 male, 13 female) with CLBP or experience of supporting someone with CLBP enrolled and 12 (2 male, 10 female) completed the volunteer training. INTERVENTION: Volunteers took part in a face-to-face or blended delivery peer support training programme based on the Mental Health Foundation's "Principles into Practice" and adapted for CLBP by the study team. MAIN OUTCOME MEASURES: Recruitment/retention rates; demographics; time & resources used to deliver training; training evaluation (questionnaire); knowledge questionnaire, and self-efficacy questionnaire. RESULTS: 17 participants enrolled on the training programme (11 face-to-face, 6 blended delivery). 12 (71%) completed the training (73% face-to-face, 67% blended delivery). The training was positively evaluated. All but two participants passed the knowledge quiz at the end of the training, and the majority of self-efficacy scores (90%) were high. CONCLUSIONS: It is feasible to develop, implement and evaluate a peer support training programme for the facilitation of CLBP self-management in older adults following discharge from physiotherapy. Blended delivery of training may facilitate the recruitment of greater numbers of peer support volunteers in future studies. Supported self-management of CLBP pain is widely recommended but can be difficult to achieve. Peer support might be a promising method of facilitating CLBP self-management without additional burden to health services, and should be further evaluated in a larger study.

Textual synthesis of policies and guidance statements for remote healthcare practitioners on managing medical emergencies in the oil and gas industry: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to collate, synthesize and present the available evidence on the policies and guidance statements for remote healthcare practitioners on managing medical emergencies in the offshore oil and gas industry.More specifically, the review seeks to answer the following questions.

Medical evacuations in the oil and gas industry: a retrospective review with implications for future evacuation and preventative strategies.

Background: Businesses increasingly conduct operations in remote areas where medical evacuation [Medevac(s)] carries more risk. Royal Dutch Shell developed a remote healthcare strategy whereby enhanced remote healthcare is made available to the patient through use of telemedicine and telemetry. To evaluate that strategy, a review of Medevacs of Shell International employees [i.e. expatriate employees (EEs) and frequent business travellers (FBTs)] was undertaken. Method: A retrospective review of Medevac data (period 2008-12) that were similar in operational constraints and population profile was conducted. Employee records and Human Resource data were used as a denominator for the population. Analogous Medevac data from specific locations were used to compare patterns of diagnoses. Results: A total of 130 Medevacs were conducted during the study period, resulting in a Medevac rate of 4 per 1000 of population with 16 per 1000 for females and 3 per 1000 for males, respectively. The youngest and oldest age-groups required Medevacs in larger proportions. The evacuation rates were highest for countries classified as 'high' or 'extreme risk'. The most frequent diagnostic categories for Medevac were: trauma, digestive, musculoskeletal, cardiac and neurological. In 9% of the total, a strong to moderate link could be made between the pre-existing medical condition and diagnosis leading to Medevac. Conclusion: This study uniquely provides a benchmark Medevac rate (4 per 1000) for EEs and FBTs and demonstrates that Medevac rates are highest from countries identified as 'high risk'; there is an age and gender bias, and pre-existing medical conditions are of notable relevance. It confirms a change in the trend from injury to illness as a reason for Medevac in the oil and gas industry and demonstrates that diagnoses of a digestive and traumatic nature are the most frequent. A holistic approach to health (as opposed to a predominant focus on fitness to work), more attention to female travellers, and the application of modern technology and communication will reduce the need for Medevacs.

Exploring peer-mentoring for community dwelling older adults with chronic low back pain: a qualitative study.

OBJECTIVES: To explore the perceptions of patients, physiotherapists, and potential peer mentors on the topic of peer-mentoring for self-management of chronic low back pain following discharge from physiotherapy. DESIGN: Exploratory, qualitative study. PARTICIPANTS: Twelve patients, 11 potential peer mentors and 13 physiotherapists recruited from physiotherapy departments and community locations in one health board area of the UK. INTERVENTIONS: Semi-structured interviews and focus groups. MAIN OUTCOME MEASURES: Participants' perceptions of the usefulness and appropriateness of peer-mentoring following discharge from physiotherapy. Data were processed and analysed using the framework method. RESULTS: Four key themes were identified: (i) self-management strategies, (ii) barriers to self-management and peer-mentoring, (iii) vision of peer-mentoring, and (iv) the voice of experience. Peer-mentoring may be beneficial for some older adults with chronic low back pain. Barriers to peer-mentoring were identified, and many solutions for overcoming them. No single format was identified as superior; participants emphasised the need for any intervention to be flexible and individualised. Important aspects to consider in developing a peer-mentoring intervention are recruitment and training of peer mentors and monitoring the mentor-mentee relationship. CONCLUSIONS: This study has generated important knowledge that is being used to design and test a peer-mentoring intervention on a group of older people with chronic low back pain and volunteer peer mentors. If successful, peer-mentoring could provide a cost effective method of facilitating longer-term self-management of a significant health condition in older people.

Effectiveness of interventions for preventing occupational irritant hand dermatitis: a quantitative systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this quantitative systematic review is to identify, appraise and synthesize the best available evidence on the effectiveness of moisturizers, barrier creams, protective gloves, skin protection education and complex interventions (a combination of two or more of the interventions listed) in preventing occupational irritant hand dermatitis (OIHD) in wet workers. These interventions will be compared to an alternative intervention or to usual care (workers regular skin care regime). The specific review question is: "What is the effectiveness of moisturizers, barrier creams, protective gloves, skin protection education and complex interventions in preventing OIHD in wet workers?"

A modified Delphi study of structures and processes related to medicines management for elderly hospitalised patients in the United Arab Emirates.

RATIONALE AND AIM: The structures and processes around the management of medicines for elderly, hospitalized patients are ill defined. This study aimed to determine consensus related to strategic and operational approaches in the United Arab Emirates. METHODS: A modified Delphi technique, consensus study with first round statements developed from systematic reviews related to medicines management. Normalization process theory and the theoretical domains framework were applied in the construction of statements, organized into key elements of medicines management: guidelines for medicines management, medicines reconciliation, medicines selection, prescribing and review, medicines adherence, medicines counselling, health professional training and evaluation research. Seventy per cent (summative agree and strongly agree) was set as the target for consensus. Thirty panellists were recruited, representing senior physicians working within geriatrics, hospital pharmacy and nursing directors, chief health professionals (including social workers) and policy makers within the Health Authority of Abu Dhabi and academics. RESULTS: A high level of consensus was obtained for most statements relating to the structures and processes of medicines management. While consensus was not achieved for targeting only those patients with medicines related issues, it was achieved for focusing on all elderly admissions. Similarly, consensus was not achieved for which professions were most suited to roles but was achieved for trained and competent staff. CONCLUSIONS: High levels of consensus were obtained for structures and processes of medicines management relating to elderly hospitalized patients. Trained and competent health professionals were preferred to specific professions for any tasks and that all elderly patients and not targeted patients should be the focus for medicines management.

The use of theory in research.

All researchers should consider the theoretical basis for their studies very early on in the planning stage. The aim of this paper is to describe and discuss how theory (a 'comprehensive explanation of some aspect of nature that is supported by a body of evidence') can inform and improve the quality and relevance of pharmacy-based research. Theories can be applied at many stages of quantitative and qualitative (and mixed) research processes, including: providing rationale for the study; defining the aim and research questions; considering the methodological stance; developing data collection and generation tools; providing a framework for data analysis, and interpretation. The focus of the paper is on the use of theoretical lenses, their selection and application. Two key theoretical lenses and their potential applications are described: the Theoretical Domains Framework in studies of behavioural change, and Normalization Process Theory in implementing, embedding and integrating interventions.

An exploration of health professionals' experiences of medicines management in elderly, hospitalised patients in Abu Dhabi.

BACKGROUND: Given the multiplicity of issues relating to medicines in the elderly, the structures and processes of medicines management should be clearly defined and described to optimise patient outcomes. There is a paucity of research which provides an in-depth exploration of these elements of medicines management for elderly patients. OBJECTIVES: This study explored health professionals' experiences of medicines management for elderly, hospitalised patients in Abu Dhabi. Setting The research was conducted in five major hospitals in Abu Dhabi, the United Arab Emirates. METHOD: Responses to an online sampling questionnaire were used to purposively select nurses, pharmacists and physicians for interview. A semi-structured interview schedule was developed with reference to normalization process theory (NPT) and the theoretical domains framework (TDF) to explore issues of medicines management structures, processes and outcomes. Face-to-face interviews of 20­30 min were audio-recorded, transcribed verbatim and analysed using the Framework Approach. MAIN OUTCOME MEASURES: Health professionals' in-depth experiences of structures, processes and outcomes relating to medicines management. Results Saturation of themes was deemed to occur at interview 27 (7 nurses, 13 pharmacists, 7 physicians). Six key themes and several subthemes emerged from the qualitative analysis, which pertained to the need for: appropriate polypharmacy; a systematic approach to medicines history taking; improved communication and documentation; improved patients' adherence to medicines; guidelines and policies to support medicines selection, and an educated and trained multidisciplinary team. The most dominant TDF behavioural determinants were issues around: professional role and identity; beliefs about capabilities; beliefs about consequences; environmental context and resources; knowledge, and goals. NPT construct identified little evidence of coherence, cognitive participation, collective action and reflexive monitoring. CONCLUSION: The key themes identified in this research indicate the need to develop a more structured approach to medicines management in elderly hospitalised patients in Abu Dhabi. The NPT constructs and the TDF behavioural determinants can be utilised as part of service development and implementing change.

Rapid RBE-Weighted Proton Radiation Dosimetry Risk Assessment.

Proton therapy dose is affected by relative biological effectiveness differently than X-ray therapies. The current clinically accepted weighting factor is 1.1 at all positions along the depth-dose profile. However, the relative biological effectiveness correlates with the linear energy transfer, cell or tissue type, and the dose per fraction causing variation of relative biological effectiveness along the depth-dose profile. In this article, we present a simple relative biological effectiveness-weighted treatment planning risk assessment algorithm in 2-dimensions and compare the results with those derived using the standard relative biological effectiveness of 1.1. The isodose distribution profiles for beams were accomplished using matrices that represent coplanar intersecting beams. These matrices were combined and contoured using MATLAB to achieve the distribution of dose. There are some important differences in dose distribution between the dose profiles resulting from the use of relative biological effectiveness = 1.1 and the empirically derived depth-dependent values of relative biological effectiveness. Significant hot spots of up to twice the intended dose are indicated in some beam configurations. This simple and rapid risk analysis could quickly evaluate the safety of various dose delivery schema.

Melkersson-Rosenthal syndrome: a facial nerve center perspective.

OBJECTIVES: Melkersson-Rosenthal syndrome (MRS) is a rare neuro-mucocutaneous granulomatous disorder of unknown etiology, characterized by the triad of facial palsy, lingua plicata (fissured tongue), and orofacial edema. Few articles in the literature report series with more than 20 patients or focus on the facial nerve dominant presentation of MRS. METHODS: We performed a retrospective review of the patients diagnosed with MRS at a university-based Facial Nerve Center. RESULTS: Twenty-one patients were identified from 1971 to 2010. The age of presentation ranged from 22 to 67 years (mean 44.1). Seven (33.3%) were male and 14 (66.7%) were female. All (100%) patients had facial paralysis. Fourteen (66.7%) patients who initially presented with unilateral paralysis subsequently developed metachronous contralateral paralysis (alternating unilateral facial paralysis). One (4.7%) patient had simultaneous bilateral facial paralysis. The number of episodes per patient ranged from 1 to 8 (mean 3.1). Laterality was relatively equal: 35 episodes occurred on the right side and 31 on the left. The patient with most episodes of facial paralysis had four on the left and four on the right (metachronous). This was followed by three patients with six episodes each. The age of first incidence of facial paralysis ranged from 2 to 60 years (mean 34.4, median of 39). The mean interval between episodes was 4.7 years (range 0-30, median 3). Six (28.5%) of the patients reported a family history of MRS. CONCLUSIONS: MRS is a rare disease of unknown pathogenesis in which oligosymptomatic forms predominate. Patients with this disease may present to different specialties complaining of different symptoms, and frequently, not all the classic features of the triad will be present. In our series of facial paralysis patients diagnosed with MRS, a higher proportion had the full triad of symptoms than has been previously reported in the literature.

Variations in the RBE for cell killing along the depth-dose profile of a modulated proton therapy beam.

Considerable evidence now exists to show that that the relative biological effectiveness (RBE) changes considerably along the proton depth-dose distribution, with progressively higher RBE values at the distal part of the modulated, or spread out Bragg peak (SOBP) and in the distal dose fall-off (DDF). However, the highly variable nature of the existing studies (with regards to cell lines, and to the physical properties and dosimetry of the various proton beams) precludes any consensus regarding the RBE weighting factor at any position in the depth-dose profile. We have thus conducted a systematic study on the variation in RBE for cell killing for two clinical modulated proton beams at Indiana University and have determined the relationship between the RBE and the dose-averaged linear energy transfer (LETd) of the protons at various positions along the depth-dose profiles. Clonogenic assays were performed on human Hep2 laryngeal cancer cells and V79 cells at various positions along the SOBPs of beams with incident energies of 87 and 200 MeV. There was a marked variation in the radiosensitivity of both cell lines along the SOBP depth-dose profile of the 87 MeV proton beam. Using Hep2 cells, the D(0.1) isoeffect dose RBE values (normalized against (60)Co) were 1.46 at the middle of SOBP, 2.1 at the distal end of the SOBP and 2.3 in the DDF. For V79 cells, the D(0.1) isoeffect RBE for the 87 MEV beam were 1.23 for the proximal end of the SOBP: 1.46 for the distal SOBP and 1.78 for the DDF. Similar D(0.1) isoeffect RBE values were found for Hep2 cells irradiated at various positions along the depth-dose profile of the 200 MeV beam. Our experimentally derived RBE values were significantly correlated (P = 0.001) with the mean LETd of the protons at the various depths, which confirmed that proton RBE is highly dependent on LETd. These in vitro data suggest that the RBE of the proton beam at certain depths is greater than 1.1, a value currently used in most treatment planning algorithms. Thus, the potential for increased cell killing and normal tissue damage in the distal regions of the proton SOBP may be greater than originally thought.

Nutrition environment measures survey-vending: development, dissemination, and reliability.

Researchers determined a need to develop an instrument to assess the vending machine environment that was comparably reliable and valid to other Nutrition Environment Measures Survey tools and that would provide consistent and comparable data for businesses, schools, and communities. Tool development, reliability testing, and dissemination of the Nutrition Environment Measures Survey-Vending (NEMS-V) involved a collaboration of students, professionals, and community leaders. Interrater reliability testing showed high levels of agreement among trained raters on the products and evaluations of products. NEMS-V can benefit public health partners implementing policy and environmental change initiatives as a part of their community wellness activities. The vending machine project will support a policy calling for state facilities to provide a minimum of 30% of foods and beverages in vending machines as healthy options, based on NEMS-V criteria, which will be used as a model for other businesses.

Body image, shape, and volumetric assessments using 3D whole body laser scanning and 2D digital photography in females with a diagnosed eating disorder: preliminary novel findings.

We piloted three-dimensional (3D) body scanning in eating disorder (ED) patients. Assessments of 22 ED patients (including nine anorexia nervosa (AN) patients, 12 bulimia nervosa (BN) patients, and one patient with eating disorder not otherwise specified) and 22 matched controls are presented. Volunteers underwent visual screening, two-dimensional (2D) digital photography to assess perception and dissatisfaction (via computerized image distortion), and adjunctive 3D full-body scanning. Patients and controls perceived themselves as bigger than their true shape (except in the chest region for controls and anorexia patients). All participants wished to be smaller across all body regions. Patients had poorer veridical perception and greater dissatisfaction than controls. Perception was generally poorer and dissatisfaction greater in bulimia compared with anorexia patients. 3D-volume:2D-area relationships showed that anorexia cases had least tissue on the torso and most on the arms and legs relative to frontal area. The engagement of patients with the scanning process suggests a validation study is viable. This would enable mental constructs of body image to be aligned with segmental volume of body areas, overcoming limitations, and errors associated with 2D instruments restricted to frontal (coronal) shapes. These novel data could inform the design of clinical trials in adjunctive treatments for eating disorders.

A randomized controlled trial to evaluate a structural intervention to promote the female condom in New York state.

We conducted a structural intervention to promote the female condom (FC), comparing 44 agencies randomized to a Minimal Intervention (MI) [developing action plans for promotion and free access] or an Enhanced Intervention (EI) [with the addition of counselor training]. Intervention effects were evaluated via surveys with agency directors, counselors and clients at baseline and 12 months. Agency-level outcomes of the FC did not differ between the two interventions at follow-up. Counselors in the EI showed significantly greater gains in FC knowledge and positive attitudes, although there was no difference in the proportion of clients counseled on the FC, which significantly increased in both conditions. There was a greater increase in intention to use the FC among clients in EI agencies. Intervention effects were stronger in medical agencies. Findings suggest that making subsidized FCs available and assisting agencies to formulate action plans led to increased FC promotion. Limitations and implications for future research and intervention efforts are discussed.

The costs of conflict: meeting the mental health needs of serving personnel and service veterans.

Military mental health has, until recently, been a neglected and marginalized area of interest and although both World Wars saw important advances, in peacetime we typically forget lessons learned in earlier conflicts. Since 2003 however, with high intensity war-fighting on two fronts involving the service personnel of many nations, attention has, once again focused on the immediate and long-term emotional and psychological impact of combat. Whilst we know a lot about posttraumatic stress disorder (PTSD), much less attention has been paid to a variety of other equally, if not more salient yet superficially less dramatic problems facing service personnel deployed on operations, but which are much more likely to lead to mental disorder than traumatic events and the 'horrors of war'. This article describes some of these broader yet less tangible and under-researched issues and discusses the provision of services for the burgeoning veteran community. The mental health of service personnel and veterans is politically sensitive and attracts significant public and media interest. Understanding and responding appropriately to the needs of this group should be of concern to all mental health professionals and it has important consequences, not only for affected individuals but, for the public perception of mental health services as a whole.

Program and policy interventions for preventing mother-to-child transmission of HIV in New York State.

Mother-to-child transmission (MTCT) of human immunodeficiency virus has been virtually eliminated in New York State (NYS) in a relatively short time. The dramatic reduction in MTCT was achieved through a comprehensive public health program that maximized the benefits of advances in both diagnosis and treatment of HIV infection. The multifaceted program encompassed interventions at multiple levels. It mobilized and engaged medical providers, and it changed clinical practice and the health care delivery system in NYS. Specific approaches were developed and modified over time by using data from multiple sources and in response to medical and scientific advances. This article describes factors associated with MTCT in NYS, the framework for program development, the evolution of NYS's public health program to prevent MTCT, remaining issues, and recommendations.