Using latent variables to improve the management of depression among hemodialysis patients.

BACKGROUND: Screening for depression can be challenging among hemodialysis patients due to the overlap of depressive symptoms with dialysis or kidney disease related symptoms. The aim of this study was to understand these overlapping symptoms and develop a depression screening tool for better clinical assessment of depressive symptoms in dialysis patients. METHODS: We surveyed 1,085 dialysis patients between March 1, 2018 and February 28, 2023 at 15 dialysis facilities in Northeast Ohio with the 9-item patient health questionnaire (PHQ-9) and kidney disease quality of life (KDQOL) instrument. To evaluate overlap across questionnaire items, we used structural equation modeling (SEM). We predicted and transformed factor scores to create a hemodialysis-adjusted PHQ-9 (hdPHQ-9). In exploratory analysis (N = 173), we evaluated the performance of the hdPHQ-9 relative to the PHQ-9 that also received a Mini-International Neuropsychiatric Interview. RESULTS: Our study sample included a high percentage of Black patients (74.6%) and 157 (14.5%) survey participants screened positive for depression (PHQ-9 ≥ 10). The magnitude of overlap was small for (respectively, PHQ-9 item with KDQOLTM item) fatigue with washed out, guilt with burden on family, appetite with nausea and movement with lightheaded. The hdPHQ-9 showed reasonably high sensitivity (0.81 with 95% confidence interval [CI] 0.58, 0.95) and specificity (0.84 with 95% CI 0.77, 0.89); however, this was not a significant improvement from the PHQ-9. CONCLUSION: There is little overlap between depressive symptoms and dialysis or kidney disease symptoms. The PHQ-9 was found to be an appropriate depression screening instrument for dialysis patients.

Buprenorphine Prescribing Characteristics Following Relaxation of X-Waiver Training Requirements.

Importance: Local-level data are needed to understand whether the relaxation of X-waiver training requirements for prescribing buprenorphine in April 2021 translated to increased buprenorphine treatment. Objective: To assess whether relaxation of X-waiver training requirements was associated with changes in the number of clinicians waivered to and who prescribe buprenorphine for opioid use disorder and the number of patients receiving treatment. Design, Setting, and Participants: This serial cross-sectional study uses an interrupted time series analysis of 2020-2022 data from the HEALing Communities Study (HCS), a cluster-randomized, wait-list-controlled trial. Urban and rural communities in 4 states (Kentucky, Massachusetts, New York, and Ohio) with a high burden of opioid overdoses that had not yet received the HCS intervention were included. Exposure: Relaxation of X-waiver training requirements (ie, allowing training-exempt X-waivers) on April 28, 2021. Main Outcomes and Measures: The monthly number of X-waivered clinicians, X-waivered buprenorphine prescribers, and patients receiving buprenorphine were each summed across communities within a state. Segmented linear regression models to estimate pre- and post-policy change by state were used. Results: The number of individuals in 33 participating HCS communities included 347 863 in Massachusetts, 815 794 in Kentucky, 971 490 in New York, and 1 623 958 in Ohio. The distribution of age (18-35 years: range, 29.4%-32.4%; 35-54 years: range, 29.9%-32.5%; ≥55 years: range, 35.7%-39.3%) and sex (female: range, 51.1%-52.6%) was similar across communities. There was a temporal increase in the number of X-waivered clinicians in the pre-policy change period in all states, which further increased in the post-policy change period in each state except Ohio, ranging from 5.2% (95% CI, 3.1%-7.3%) in Massachusetts communities to 8.4% (95% CI, 6.5%-10.3%) in Kentucky communities. Only communities in Kentucky showed an increase in the number of X-waivered clinicians prescribing buprenorphine associated with the policy change (relative increase, 3.2%; 95% CI, 1.5%-4.9%), while communities in other states showed no change or a decrease. Similarly, only communities in Massachusetts experienced an increase in patients receiving buprenorphine associated with the policy change (relative increase, 1.7%; 95% CI, 0.8%-2.6%), while communities in other states showed no change. Conclusions and Relevance: In this serial cross-sectional study, relaxation of X-waiver training requirements was associated with an increase in the number of X-waivered clinicians but was not consistently associated with an increase in the number of buprenorphine prescribers or patients receiving buprenorphine. These findings suggest that training requirements may not be the primary barrier to expanding buprenorphine treatment.

Filled Opioid Prescriptions Following Pediatric Dental Procedures Among Medicaid-Insured Children in Ohio.

Purpose: To investigate opioid prescription fills following pediatric/adolescent dental procedures in central/southeastern Ohio. Methods: This population-based, retrospective cohort study utilized health insurance claims from a pediatric public accountable care organization (???Medicaid???) in central/southeastern Ohio. Patients aged 18 years and younger who had a dental procedure between January 2012 and February 2019 were identified, and claims were searched for opioid prescription fills within 14 days post-procedure. Trends in prescription fill percentages, types of opioid, procedure classification and patient characteristics were examined. Results: A total of 512,922 encounters among 212,813 patients were included. The overall opioid prescription fill was 4.9 percent. Percentages decreased throughout the study period from 6.1 percent (95 percent confidence interval [95% CI]=5.9 to 6.3) in 2012 to 3.4 percent (95% CI=3.1 to 3.8) in early 2019. When limited to extractions and endodontic procedures, the overall prescription fill percentage fell from 15.7 percent (95% CI=15.2 to 16.1) in 2012 to 9.5 percent (95% CI=8.5 to 10.4) in early 2019. The most common opioids were hydrocodone (68.6 percent) and codeine (24.7 percent), with marked annual reductions in codeine prescription fills among children younger than 14 years. From 2017 to 2018, surgical extractions compared to endodontics-only procedures (risk difference [RD]=40.7; 95% CI=38.6 to 42.9) and older patient age (RD for 18-year-olds versus 13-year-olds=21.9; 95% CI=19.8 to 24.0) were strong risk factors for filling an opioid prescription. Conclusion: Post-procedure opioid prescription fill percentages have decreased since 2012 among pediatric/adolescent Medicaid enrollees undergoing dental procedures in central/southeastern Ohio. Substantial differences in the likelihood of filling a prescription remained by procedural and demographic variables. There were marked trends in the types of opioid for which prescriptions were filled, which varied by patient age.

Multilevel Interventions and Dental Attendance in Pediatric Primary Care: A Cluster Randomized Clinical Trial.

Importance: Untreated tooth decay is disproportionately present among low-income young children. While American Academy of Pediatrics (AAP) guidelines require pediatric clinicians to implement oral health care, the effectiveness of these oral health interventions has been inconclusive. Objective: To test the effectiveness of multilevel interventions in increasing dental attendance and reducing untreated decay among young children attending well-child visits (WCVs). Design, Setting, and Participants: The Pediatric Providers Against Cavities in Children's Teeth study is a cluster randomized clinical trial that was conducted at 18 pediatric primary care practices in northeast Ohio. The trial data were collected between November 2017 and July 2022, with data analyses conducted from August 2022 to March 2023. Eligible participants included Medicaid-enrolled preschoolers aged 3 to 6 years attending WCVs at participating practices who were enrolled at baseline (WCV 1) and followed-up for 2 consecutive examinations (WCV 2 and WCV 3). Interventions: Clinicians in the intervention group received both the practice-level (electronic medical record changes to document oral health) and clinician-level (common-sense model of self-regulation theory-based oral health education and skills training) interventions. Control group clinicians received AAP-based standard oral health education alone. Main Outcomes and Measures: Dental attendance was determined through clinical dental examinations conducted by hygienists utilizing International Caries Detection and Assessment System criteria and also from Medicaid claims data. Untreated decay was determined through clinical examinations. A generalized estimating equations (GEE) approach was used for both clinical examinations and Medicaid claims data. Results: Eighteen practices were randomized to either intervention or control. Participants included 63 clinicians (mean [SD] age, 47.0 [11.3] years; 48 female [76.2%] and 15 male [23.8%]; 28 in the intervention group [44.4%]; 35 in the control group [55.6%]) and 1023 parent-child dyads (mean [SD] child age, 56.1 [14.0] months; 555 male children [54.4%] and 466 female children [45.6%]; 517 in the intervention group [50.5%]; 506 in the control group [49.5%]). Dental attendance from clinical examinations was significantly higher in the intervention group (170 children [52.0%]) vs control group (150 children [43.1%]) with a difference of 8.9% (95% CI, 1.4% to 16.4%; P = .02). The GEE model using clinical examinations showed a significant increase in dental attendance in the intervention group vs control group (adjusted odds ratio, 1.34; 95% CI, 1.07 to 1.69). From Medicaid claims, the control group had significantly higher dental attendance than the intervention group at 2 years (332 children [79.6%] vs 330 children [73.7%]; P = .04) but not at 3 years. A clinically but not statistically significant reduction in mean number of untreated decay was found in the intervention group compared with controls (B = -0.27; 95% CI, -0.56 to 0.02). Conclusions and Relevance: In this cluster randomized clinical trial, children in the intervention group had better dental outcomes as was evidenced by increased dental attendance and lower untreated decay. These findings suggest that intervention group clinicians comprehensively integrated oral health services into WCVs. Trial Registration: ClinicalTrials.gov Identifier: NCT03385629.

Psychological capital variables as protective factors in indigenous youth experiencing homelessness.

Indigenous youth in the United States are at high-risk for experiencing homelessness related to adverse childhood experiences such as parental substance use and low educational attainment. Such experiences may lead to adverse physical and mental health issues; these youth also have positive attributes of psychological capita (hope, self-efficacy, resilience, optimism) that are related to health outcomes. The purpose of this secondary analysis was to describe demographic attributes and psychological capital in Indigenous youth experiencing homelessness (IYEH) who participated in a longitudinal intervention study related to safe sex behaviors and life satisfaction. From a total of 602, Indigenous participants (n = 111; mean age 21.25 ± 1.82 years) were recruited from drop-in centers in Austin, Texas and Columbus, Ohio. Data were collected immediately after the intervention and at 3- and 6-month intervals. For this analysis, only data collected at the final time-point were used. Valid scales with Cronbach alphas of 0.75-0.92 (Hope, Resilience, Optimism, Self-efficacy for Substance Refusal, Self-efficacy for Safer Sex, Safe Sex Behaviors, Social Connectedness, and Life Satisfaction) were used. The majority of the IYEH reported smoking, drinking, and using drugs. Psychological capital variables of hope, self-efficacy for negotiating safer sex, resilience, and optimism were significantly related to one another, but not to safe sex behaviors or intention to use condoms. Resilience and optimism were significantly related to social connectedness but not to other psychological capital variables. Life satisfaction was significantly associated with hope, resilience, and optimism. Findings have implications for further theory and research development.

Incongruence between residential uses and perceptions of fertilizers and deicers.

Fertilizers and deicers are common materials for property maintenance in the Midwest, however, their application contributes to negative environmental impacts when applied incorrectly. While fertilizer use is well researched, deicer use on private properties is not. This research aims to ascertain whether patterns of fertilizer use are different from those of deicer use in Hamilton County, Ohio, and determine what factors influence a resident's decision to use these materials. Survey data were collected from 110 single-family households (38.9% response rate). Respondents are motivated by property appearance to apply fertilizers. Deicer use stems from safety concerns. Respondents were significantly more likely to consider the environmental impact of fertilizers than deicers. Respondents felt that using deicers is a more neighborly practice while using fertilizers reflects more positively on them in their neighborhood. This information can be used to develop outreach programs to reduce the environmental impacts of fertilizers and deicers.

A cross-sectional study of physicians on fluoride-related beliefs and practices, and experiences with fluoride-hesitant caregivers.

The goal of this study was to describe medical providers' fluoride-related beliefs and practices, experiences with fluoride-hesitant caregivers, and barriers to incorporating oral health activities into their practice. In this cross-sectional study, we specifically tested the hypothesis of whether these factors differed between pediatric and family medicine providers. A 39-item online survey was administered to a convenience sample of pediatric and family medicine providers in Washington state and Ohio (U.S.A.). Responses to the fluoride survey were compared between pediatric and family medicine providers with a chi-square test (α = 0.05). Of the 354 study participants, 45% were pediatric providers and 55% were family medicine providers. About 61.9% of providers believed fluoridated water was highly effective at preventing tooth decay while only 29.1% believed prescription fluoride supplements were highly effective. Nearly all providers recommend over-the-counter fluoride toothpaste (87.3%), 44.1% apply topical fluoride in clinic, and 30.8% prescribe fluoride supplements. Most providers reported fluoride hesitancy was a small problem or not a problem (82.5%) and the most common concerns patients raise about fluoride were similar to those raised about vaccines. Lack of time was the most commonly reported barrier to incorporating oral health into practice, which was more commonly reported by family medicine providers than pediatric providers (65.6% vs. 50.3%; p = .005). Pediatric and family medicine providers have early and frequent access to children before children visit a dentist. Improving the use of fluorides through children's medical visits could improve pediatric oral health and reduce oral health inequities, especially for vulnerable populations at increased risk for tooth decay.

Evaluation of high-fidelity and virtual reality simulation platforms for assessing fourth-year medical students' encounters with patients in need of urgent or emergent care.

BACKGROUND: Medical students in the U.S. must demonstrate urgent and emergent care competence before graduation. Urgent and emergent care competence involves recognizing, evaluating and initiating management of an unstable patient. High-fidelity (HF) simulation can improve urgent and emergent care skills, but because it is resource intense, alternative methods are needed. STUDY OBJECTIVE: Our primary purpose was to use program evaluations to compare medical student experiences with HF and virtual reality (VR) simulations as assessment platforms for urgent and emergent care skills. METHODS: During their emergency medicine clerkship, students at The Ohio State University College of Medicine must demonstrate on HF manikins, competence in recognizing and initiating care of a patient requiring urgent or emergent care. Students evaluated these simulations on a five-point quality scale and answered open-ended questions about simulation strengths and weaknesses. Faculty provided feedback on student competence in delivering urgent or emergent care. In 2022, we introduced VR as an alternative assessment platform. We used Wilcoxon Signed Ranks and Boxplots to compare ratings of HF to VR and McNemar Test to compare competence ratings. Comments were analyzed with summative content analysis or thematic coding. RESULTS: We received at least one evaluation survey from 160 of 216 (74.1%) emergency medicine clerkship students. We were able to match 125 of 216 (57.9%) evaluation surveys for students who completed both. Average ratings of HF simulations were 4.6 of 5, while ratings of VR simulations were slightly lower at 4.4. Comments suggested that feedback from both simulation platforms was valued. Students described VR as novel, immersive, and good preparation for clinical practice. Constructive criticism identified the need for additional practice in the VR environment. Student performance between platforms was significantly different with 91.7% of students achieving competence in HF, but only 65.5% in VR (p≤.001, odds-ratio = 5.75). CONCLUSION: VR simulation functions similarly to HF for formative assessment of urgent and emergent care competence. However, using VR simulation for summative assessment of urgent and emergent care competence must be considered with caution because students require considerable practice and acclimation to the virtual environment.

Medical students found value in using virtual reality simulation as a platform for practice and feedback in a formative assessment arrangement.Students described the virtual reality simulation as immersive and good preparation for clinical practice.Technical difficulties were common and the student learning curve for acclimating and learning how to function in the virtual environment was noteworthy.

Sacred breath: Ohio nurses respond to COVID-19.

In the fall of 2021, the Wick Poetry Center, a recognized international leader in creative writing interventions, launched the website Sacred Breath: Voices of Ohio Nurses in Response to COVID-19 (sacredbreathproject.com) with funding from the Ohio Nurses Foundation. The purpose of the website was to offer Ohio nurses an accessible platform to reflect on their personal and professional lived experiences as caregivers during an historic time of pandemic, sacrifice, uncertainty, and scarcity, and to share their voice with others. What resulted was 204 submissions over a three-month period with participant responses touching on widespread sentiments including grief, fatigue, anger, and resilience. It was from the gap in the current literature on pandemic narratives that the researchers of this study began a basic qualitative thematic analysis of the Sacred Breath project website (SBP) responses to gain a better understanding of how nurses, nurse educators, and nursing students made sense of and gave voice to their personal and professional lived experiences during the ongoing COVID-19 pandemic. While stories of nursing during the Covid-19 pandemic have been widely available and disseminated by popular media, academic studies have been slower to utilize qualitative and experimental methods to specifically address pandemic narratives and the resulting discourses by nurses working in and around clinical settings. The Wick Poetry Center at Kent State University has spent nearly forty years working in the community to address urgent social needs using expressive writing methods that are often overlooked by traditional social and arts outreach. The Wick Poetry Center engaged local academic networks and community health partners to invite nurses, nursing students, and nurse educators the Sacred Breath Project By evaluating responses to the intervention website, this qualitative study is aimed to fill this gap in the current literature as well as begin to understand how nurses made sense of their work lives during the ongoing Covid-19 pandemic. What does this paper contribute to the wider global clinical community? What is already known: What this paper adds.

Temporal Trends and Racial Disparities in Long-Term Survival After Stroke.

BACKGROUND AND OBJECTIVES: Few studies have examined trends and disparities in long-term outcome after stroke in a representative US population. We used a population-based stroke study in the Greater Cincinnati Northern Kentucky region to examine trends and racial disparities in poststroke 5-year mortality. METHODS: All patients with acute ischemic strokes (AISs) and intracerebral hemorrhages (ICHs) among residents ≥20 years old were ascertained using ICD codes and physician-adjudicated using a consistent case definition during 5 periods: July 1993-June 1994 and calendar years 1999, 2005, 2010, and 2015. Race was obtained from the medical record; only those identified as White or Black were included. Premorbid functional status was assessed using the modified Rankin Scale, with a score of 0-1 being considered "good." Mortality was assessed with the National Death Index. Trends and racial disparities for each subtype were analyzed with logistic regression. RESULTS: We identified 8,428 AIS cases (19.3% Black, 56.3% female, median age 72) and 1,501 ICH cases (23.5% Black, 54.8% female, median age 72). Among patients with AIS, 5-year mortality improved after adjustment for age, race, and sex (53% in 1993/94 to 48.3% in 2015, overall effect of study year p = 0.009). The absolute decline in 5-year mortality in patients with AIS was larger than what would be expected in the general population (5.1% vs 2.8%). Black individuals were at a higher risk of death after AIS (odds ratio [OR] 1.23, 95% CI 1.08-1.39) even after adjustment for age and sex, and this effect was consistent across study years. When premorbid functional status and comorbidities were included in the model, the primary effect of Black race was attenuated but race interacted with sex and premorbid functional status. Among male patients with a good baseline functional status, Black race remained associated with 5-year mortality (OR 1.4, 95% CI 1.1-1.7, p = 0.002). There were no changes in 5-year mortality after ICH over time (64.4% in 1993/94 to 69.2% in 2015, overall effect of study year p = 0.32). DISCUSSION: Long-term survival improved after AIS but not after ICH. Black individuals, particularly Black male patients with good premorbid function, have a higher mortality after AIS, and this disparity did not change over time.

Implementing Self-Measured Blood Pressure Monitoring With Clinical Support: A Qualitative Study of Federally Qualified Health Centers.

CONTEXT: Self-measured blood pressure monitoring (SMBP) with clinical support is effective at reducing blood pressure for people with hypertension. Although strengths and challenges around SMBP are well-documented, few studies describe the complexities of real-world implementation of SMBP with clinical support in the Federally Qualified Health Center (FQHC) setting. PROGRAM: Between 2019 and 2023, the Ohio Department of Health funded the Ohio Association of Community Health Centers to manage a multiyear quality improvement (QI) project with 21 FQHCs. The project aimed to improve the identification and management of patients with hypertension, diabetes, and prediabetes. This study focuses on the activities implemented to provide SMBP support to patients with hypertension. IMPLEMENTATION: FQHCs implemented clinical SMBP support using multiple roles, approaches, and resources. FQHCs established a process to identify patients eligible for SMBP support, provide blood pressure monitors, train patients on SMBP, track blood pressure readings, follow up with patients, and connect patients to resources. EVALUATION: External evaluators interviewed 13 staff members within seven FQHCs from the QI project. Interviewed FQHCs were located across Ohio and represented urban, rural, suburban, and Appalachian areas. Clinical activities to support SMBP, facilitators, and barriers were identified with thematic analysis. The National Association of Community Health Centers SMBP Implementation Toolkit was used as a framework to assess SMBP activities. Facilitators included team-based care, health information technology capacity, funding for blood pressure monitors and staff time, leadership and staff support, and external support. Barriers included technology challenges, staffing shortages, low patient engagement, sustainability, and the COVID-19 pandemic. DISCUSSION: This study demonstrates how FQHCs can use a variety of staff, processes, and resources to implement clinical SMBP support across a range of geographic regions. To facilitate this, FQHCs and patients may need more comprehensive insurance coverage of blood pressure monitors, reimbursement for staff time, and technology support.

An Assessment of the Ocular Toxicity of Two Major Sources of Environmental Exposure.

The effect of airborne exposure on the eye surface is an area in need of exploration, particularly in light of the increasing number of incidents occurring in both civilian and military settings. In this study, in silico methods based on a platform comprising a portfolio of software applications and a technology ecosystem are used to test potential surface ocular toxicity in data presented from Iraqi burn pits and the East Palestine, Ohio, train derailment. The purpose of this analysis is to gain a better understanding of the long-term impact of such an exposure to the ocular surface and the manifestation of surface irritation, including dry eye disease. In silico methods were used to determine ocular irritation to chemical compounds. A list of such chemicals was introduced from a number of publicly available sources for burn pits and train derailment. The results demonstrated high ocular irritation scores for some chemicals present in these exposure events. Such an analysis is designed to provide guidance related to the needed ophthalmologic care and follow-up in individuals who have been in proximity to burn pits or the train derailment and those who will experience future toxic exposure.

A Quality Improvement Project to Increase Infection Control Compliance Among Endoscopy Staff at a Large Urban Medical Center.

Although nurses and other healthcare professionals play a key role in preventing hospital-associated infections, studies show that infection control compliance rates have remained low. The purpose of this quality improvement project was to increase infection control compliance of hand hygiene and procedure room disinfection among endoscopy staff at a large urban medical center in Cincinnati, Ohio. This quality improvement project provided an education session on current evidence-based infection control guidelines to 20 participants, including registered nurses and technicians within the endoscopy department. Direct observational audits were conducted 4 weeks before and 4 weeks after the education session, measuring compliance with hand sanitizer, soap and water, and procedure room disinfection, over a period of 150 days. The project goals were met, as hand sanitizer compliance improved by 12%-83%; overall soap and water compliance improved by 20%-75%; and endoscopy procedure room disinfection compliance improved by 14%-92%.

Medical-Dental Integration in Ohio: Improving prevention and coordination at the local level.

Access to high-quality, preventive oral health care is fundamental for an individual to achieve positive health outcomes. Recognizing that health is influenced by where a person lives, it is important to consider how systems of care must adapt to meet the changing needs of a community over time. Medical-dental integration is a critical component designed to enhance and broaden the oral health care delivery model. MORE Care® is a framework for communities to leverage their resources and relationships by providing tools and resources to integrate preventive oral health services into primary care settings. This report will show how local stakeholders advocated for an innovative approach to improve oral health gaps for children in Ohio. The MORE Care Ohio pilot is expanding access to preventive oral health services by featuring medical-dental integration to close patient care gaps and build an integrated oral health network. Providing a framework for medical and dental teams to collaborate, seven clinical practices (three medical and four dental) agreed to participate in a 9-month learning collaborative and 16-months of performance monitoring.

Ohio Presents Opportunities For Understanding Hospital Alignment With Public Health Agencies On Community Health Assessments.

Multisector collaboration is critical for improving population health. Improving alignment between nonprofit hospitals and local health departments is one promising approach to achieving health improvement, and a number of states are exploring policies to facilitate such collaboration. Using public documents, we evaluated the alignment between Ohio nonprofit hospitals and local health departments in the community health needs they identify and those they prioritize. The top three needs identified by hospitals and health departments were mental health, substance use, and obesity. Alignment across organizations was high among the top needs, but it varied more among less commonly identified needs. Alignment related to social determinants of health was low, with health departments being more responsive to social determinants than hospitals. Given the different strengths and capacities of hospitals and health departments, this divergence may be in the best interests of the communities they serve. Community benefit policies should consider how to promote collaboration between hospitals and health departments while also encouraging organizations to use their own expertise to meet community needs.

Longitudinal Analysis of Urban Stormwater Microbiome and Resistome from Watersheds with and without Green Infrastructure using Long-Read Sequencing.

Since stormwater conveys a variety of contaminants into water bodies, green infrastructure (GI) is increasingly being adopted as an on-site treatment solution in addition to controlling peak flows. The purpose of this study was to identify differences in microbial water quality of stormwater in watersheds retrofitted with GI vs. those without GI. Considering stormwater is recently recognized as a contributor to the antibiotic resistance (AR) threat, another goal of this study was to characterize changes in the microbiome and collection of AR genes (resistome) of urban stormwater with season, rainfall characteristics, and fecal contamination. MinION long-read sequencing was used to analyze stormwater microbiome and resistome from watersheds with and without GI in Columbus, Ohio, United States, over 18 months. We characterized fecal contamination in stormwater via culturing Escherichia coli and with molecular microbial source tracking (MST) to identify sources of fecal contamination. Overall, season and storm event (rainfall) characteristics had the strongest relationships with changes in the stormwater microbiome and resistome. We found no significant differences in microbial water quality or the microbiome of stormwater in watersheds with and without GI implemented. However, there were differences between the communities of microorganisms hosting antibiotic resistance genes (ARGs) in stormwater from watersheds with and without GI, indicating the potential sensitivity of AR bacteria to treatment. Stormwater was contaminated with high concentrations of human-associated fecal bacterial genes, and the ARG host bacterial community had considerable similarities to human feces/wastewater. We also identified 15 potential pathogens hosting ARGs in these stormwater resistome, including vancomycin-resistant Enterococcus faecium (VRE) and multidrug-resistant Pseudomonas aeruginosa. In summary, urban stormwater is highly contaminated and has a great potential to spread AR and microbial hazards to nearby environments. This study presents the most comprehensive analysis of stormwater microbiome and resistome to date, which is crucial to understanding the potential microbial risk from this matrix. This information can be used to guide future public health policy, stormwater reuse programs, and urban runoff treatment initiatives.

Holistic evaluation of inlet protection devices for sediment control on construction sites.

To address the deleterious impacts of excess soil erosion from the construction sites, the United States Clean Water Act requires that erosion and sediment control measures (ESCs) be implemented on construction projects disturbing more than 0.4 ha. Inlet protection devices (IPDs) are a common ESC utilized on construction projects to reduce the amount of sediment entering storm sewers. In Ohio, regulatory agencies use approved, non-proprietary IPDs made from commonly available materials (e.g., silt fence, geotextile, lumber, and aggregate) to mitigate sediment on construction projects; however, these IPDs often rely on extended ponding to remove sediment and require frequent maintenance making these unsuitable for road construction projects. Commercially manufactured (i.e., proprietary) IPDs which rely on filtration to quickly dewater following rainfall may prove more practical for road construction projects. However, little research which quantitatively compares the holistic performance of these two types of IPDs in field settings has been performed to date. To address this knowledge gap, the performance of 24 proprietary IPDs was evaluated at field-scale using simulated construction site runoff and compared to three non-proprietary IPDs currently approved for use in Ohio. Bypass flows, which typically occurred due to poor IPD fit to standard drainage inlets used in Ohio transportation settings, significantly increased effluent total suspended solids (TSS) and turbidity compared to tests of IPDs where bypass did not occur. Overflow, or intentional bypass around primary IPD flow pathways during high flows, did not significantly impact effluent water quality. Despite differences in treatment mechanisms (i.e., sedimentation versus filtration), the water quality performance of non-proprietary and proprietary IPDs were not statistically different, indicating comparable sediment removal was provided by both categories. Findings from this research can provide design engineers and state regulatory agencies the necessary tools to evaluate IPD performance in road construction settings and, ultimately, alleviate the impact of excess sediment discharged from construction sites.

Fulfillment of Permanent Contraception among Patients with Cesarean Delivery in a Multi-Site Cohort.

OBJECTIVES: This study aimed to assess the association between insurance type and permanent contraception fulfillment among those with cesarean deliveries. Additionally, we sought to examine modification by the scheduled status of the cesarean. STUDY DESIGN: We used data from a multi-site cohort study of patients who delivered in 2018-2019 at Northwestern Memorial Hospital in Illinois, MetroHealth Medical System in Ohio, or University of Alabama at Birmingham in Alabama. All patients had permanent contraception as their contraceptive plan in their medical chart during delivery hospitalization. We used logistic regression to model the association between insurance type, scheduled status of cesarean and permanent contraception fulfillment by hospital discharge. The scheduled status of cesarean delivery was examined as an effect modifier. RESULTS: Compared to patients with private insurance, those with Medicaid were less likely to have their desired permanent contraception procedure fulfilled by hospital discharge (89.3% vs. 96.8%, p < 0.001). After adjusting for covariates, patients with Medicaid had a lower odds of permanent contraception fulfillment by hospital discharge (OR: 0.41; 95% CI: 0.21, 0.77). This association was stronger among those who had unscheduled cesarean deliveries (OR: 0.29; 95% CI: 0.12, 0.74) than those with scheduled cesarean deliveries (OR: 0.77; 95% CI: 0.32, 1.88). CONCLUSIONS FOR PRACTICE: Compared to patients with private insurance undergoing a cesarean delivery, those with Medicaid insurance were less likely to have their desired permanent contraception fulfilled. Physicians and hospitals must examine their practices surrounding Medicaid forms to ensure that patients have valid consent forms available at the time of delivery.

Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias.

OBJECTIVES: To examine the relationship between changes in nursing staff-hours per resident-day and injury-related emergency department (ED) visits among assisted living (AL) residents with Alzheimer disease and related dementias (ADRD). DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: We leveraged a data set of AL community characteristics in Ohio linked to Medicare claims data from 2007 to 2015. METHODS: We estimated Poisson models examining the relationships of personal care aide, registered nurse (RN), licensed practical nurse (LPN), and total nursing hours with injury-related ED visits. Models were adjusted for resident characteristics (ie, age, race, sex, dual eligibility, presence and number of chronic conditions), AL community characteristics (percentage of residents on Medicaid, average resident acuity), year fixed effects, and assisted living fixed effects. We examined all injury-related ED visits and injury-related ED visits resulting in hospital admission as separate outcomes. RESULTS: The sample included 122,700 person-months, representing 12,144 fee-for-service Medicare beneficiaries with ADRD within 455 different AL communities in Ohio between 2007 and 2015. Median total nursing hours increased from 1.34 in 2007 to 1.69 in 2015. In the fully adjusted model, an increase in 1 RN-hour per resident-day was associated with a decrease in the risk of any injury-related ED visit (incidence rate ratio 0.59, 95% CI 0.36-0.96), representing a 53% decrease. Changes in RN-hours were not associated with injury-related inpatient hospitalizations. Changes in total nursing, LPN, and personal care aide hours were not associated with changes in the risk of injury-related ED visits or inpatient hospitalizations. CONCLUSIONS AND IMPLICATIONS: Increases in RN staffing hours were associated with reduced injury-related ED use among AL residents with ADRD. RNs provide surveillance and care oversight that may help mitigate injury risk, and they are able to physically assess residents at the time of a fall and/or injury, which can preempt unnecessary ED transfers.

Variability in personal exposure to ultrafine and fine particles by microenvironment among adolescents in Cincinnati.

Personal exposure to air pollution is influenced by an individual's time-activity patterns, but data regarding personal exposure to air pollution among children populations is lacking. The objective of this study was to characterize personal exposure to both PM2.5 and ultrafine particles (UFPs) using two portable real-time monitors, combined with GPS logging, and describe the relationship between these exposures across time and microenvironments among adolescents with asthma. Participants completed personal exposure monitoring for seven consecutive days and PM2.5 and UFP concentrations experienced in five microenvironments were determined using GPS location and mobility data. Average UFP and PM2.5 exposure varied across microenvironments with the highest average UFP exposure concentrations observed in transit (10,910 ± 27,297 p/cc), though correlations between UFP and PM2.5 concentrations in transit were low (0.24) and did not reach statistical significance (p > 0.05). We calculated exposure time ratios for each participant. Across participants, UFP exposures within the transit environment demonstrated the highest ratio (average exposure-time ratio = 1.91) though only 3 % of overall sampling time among all participants was monitored in transit (74/2840 h). We did not observe similar trends among PM2.5 exposures. The correlations between UFP and PM2.5 exposures varied throughout the day, with an overall correlation ranging from moderate to high among participants. Identifying microenvironments and activities where high exposure to PM occurs may offer potential targets for interventions to reduce overall exposures among sensitive groups.