Knowledge, Attitudes, Practices, and Prevention Barriers Related to Childhood Lead Poisoning Among Nepali-Speaking Bhutanese Parents in Northeast Ohio, United States.

The study objectives were: (i) to develop and administer a survey to assess childhood lead poisoning (CLP) knowledge, attitudes, practices and prevention barriers (KAP-B) among the Nepali-Speaking Bhutanese (NSB) community in Northeast Ohio; and (ii) to examine the association between socio-demographic characteristics of NSB parents and their understanding of CLP as measured by the constructs of knowledge and attitudes. A Nepali language KAP-B questionnaire was developed and 200 NSB parents with at least one child ≤ 7 years of age from the Akron Metropolitan Area, Ohio were interviewed. NSB parents demonstrated a low level of knowledge about CLP prevention measures. While 82% lived in pre-1978 houses, only 27.5% perceived their house/neighborhood to be potentially lead contaminated. Only 33% of the parents reported understanding lead-related information provided by their child's healthcare provider. Low-level CLP awareness among NSB community emphasizes a need for culturally tailored and linguistically appropriate community-level CLP educational intervention programs in this vulnerable community.

The effects of medical comorbidity, cognition, and age on patient-reported outcomes in Parkinson's disease.

OBJECTIVE: The purpose of this cross-sectional study was to compare the independent contributions of medical comorbidity, cognition, and age on patient-reported outcomes in Parkinson's disease (PD). METHODS: 572 PD patients completed the Patient-Reported Outcome Measurement Information System (PROMIS®)-29 v2.0 Profile (physical function, anxiety, depression, fatigue, sleep disturbance, satisfaction with participation in social roles, pain interference) and PROMIS Global Health (mental health and physical health) scales. Comorbidity was measured with the Cumulative Illness Rating Scale-Geriatric (CIRS-G) and cognition with the Montreal Cognitive Assessment (MoCA). Multiple regression models examined the 9 PROMIS measures as predicted by comorbidity, cognition, and age, adjusting for demographic and clinical characteristics (UPDRS and disease duration). RESULTS: Comorbidity was associated with poorer outcomes in all nine PROMIS domains. Cognition was associated with two of nine domains: physical function and anxiety. Age was associated with five domains: anxiety, depression, sleep disturbance, satisfaction with participation in social roles, and global mental health. Comorbidity showed greater effects on all nine domains than cognition or age (higher standardized beta coefficients). CONCLUSION: Medical comorbidity, cognition, and age have different impacts on patient-reported outcomes in PD. Medical comorbidity has a greater impact than either cognition or age on a range of patient-reported physical and mental health domains. Medical comorbidity is an important contributor to the patient's perspective of their physical and mental health.

Spirituality in Parkinson's Disease within a Sample from the USA.

Spirituality and religious beliefs are important for coping with medical conditions. The dopaminergic system is involved in reward behavior, and its dysfunction in Parkinson Disease (PD) raises questions about religiosity and spirituality in people with PD. This study examines the association between levels of spirituality and religiosity and the severity of PD motor and non-motor symptoms. The secondary aim investigates the perceived impact of PD diagnosis on spirituality and religiosity. This was a cross-sectional analysis of demographic, physical, mental, and spirituality and religiosity status in patients with PD recruited for the Health Outcomes Measurement (HOME) Study at the University of Maryland Parkinson Disease and Movement Disorders Center, Baltimore, USA. Spirituality and religiosity were assessed using the Spiritual Well-being Scale, and the World Health Organization Quality of Life Spiritual Religious and Personal Belief field-test instrument. The sample size was 85 PD patients. The mean age (standard deviation) was 65.5 (9.4) years and 67.1% were male. Higher levels of spirituality and religiosity were associated with younger age, sex (female), less education, religious affiliation (Christian), and mental health status. After adjusting for age, education, gender, race, marital status, religion, physical health, mental health, and comorbidity, only anxiety was associated with all of the spirituality/religiosity assessments. The majority of patients reported no change in their religious or spiritual beliefs following diagnosis. Greater spirituality and religiosity were associated with less anxiety. Also, younger women with PD showed higher levels of spirituality and religiosity. Longitudinal studies on more diverse populations are needed.

Relationship Between Primary Language Spoken at Home and Blood Lead Levels in Children from Northeast Ohio, United States: A Retrospective Cohort Study.

To estimate the prevalence and incidence of blood lead levels (BLL) ≥ 5 and ≥ 3.5 µg/dl and assess their association with primary language spoken at home in Northeast Ohio, U.S. children, a retrospective cohort study was conducted among 19,753 children aged < 6 years. Primary language spoken at home was used to define children from resettled refugee families (RRFs) and non-RRFs. The overall BLL ≥ 5 and ≥ 3.5 µg/dl prevalence were 3.22 and 6.10%, and incidence rates were 2.25 and 3.64 cases per 100 person-years, respectively. Compared to children from non-RRFs children from RRFs were 3.62-times [95% confidence interval (CI): 1.84, 7.13] as likely to have BLL ≥ 5 µg/dl prevalence, and 6.72-times [95% CI 2.60, 17.40] as likely to have BLL ≥ 5 µg/dl incidence during the follow-up period. The higher prevalence and incidence of BLL acquired in the United States among children from RRFs warrant further research to identify specific environmental and sociocultural lead sources for these children.

Weight loss and weight gain in Parkinson disease.

INTRODUCTION: Parkinson disease (PD) has been associated with both weight loss and gain in different stages of the disease. Our study aimed to determine the prevalence and associations with weight change over two years based on 3% and 5% weight change. METHODS: In this longitudinal analysis, weight at baseline and follow-up was used to classify patients into groups of weight loss, stable, and weight gain. Differences between these groups at baseline and then with change over time were tested. RESULTS: The sample was 668 patients with mean(SD) age 66.1(10) and disease duration 5.3(5.4) years. Using 3% weight change criteria: 32.6% lost, 23.1% gained, and 55.7% had stable weight. Using 5% criteria: 22.6% lost, 15.7% gained, and 61.7% had stable weight. Age was associated with both 3% and 5% change in weight. Other associations with 5% weight change were disease duration, Total and Motor Unified Parkinson's Disease Rating Scale, Older Americans Resource and Services disability, and Hoehn & Yahr staging. The effects of 3% weight loss on Motor UPDRS, IADLs, and depression, and the effects of 5% weight loss on IADLs remained statistically significant when controlling for baseline differences in age, levodopa use, and Total UPDRS. CONCLUSION: PD patients are more likely to experience 3% than 5% weight change and this lower threshold of weight change was associated with greater disease severity and disability over time. Attention to more subtle weight change may help identify those at greater risk of disability.

Same provider, different location: Variation in patient satisfaction scores between freestanding and hospital-based emergency departments.

BACKGROUND: Patient satisfaction scores have become quality benchmarks for hospitals, are publicly reported, and are often tied to financial incentives. We determined whether patient satisfaction scores for individual emergency medicine providers varied according to the clinical setting. METHODS: We obtained patient satisfaction survey results from January 1, 2018 to December 31, 2018 for patients treated at 6 freestanding (FED) and 11 hospital-based emergency departments (HBED). Differences in mean score by ED facility were tested for significance. Mean score differences with 95% confidence intervals are presented. Univariate and multivariable logistic regression analysis was conducted to predict the odds of receiving different scores by type of ED facility and adjusted for patient and provider demographics and ED length of stay. RESULTS: Sixty-six providers with 3743 total surveys were analyzed: FED (n = 1974) and HBED (n = 1769). Overall satisfaction scores were higher for FED compared to HBED surveys 1.13 [95% CI, 1.0-1.3]. In multivariable logistic regression, we found patients seen at the FEDs were 42% more likely to rate providers courtesy as "very good" compared to patients seen at a HBED [OR: 1.42, 95% CI (0.94-2.15)]. Similarly, patients from FEDs showed increased likelihood to rate providers as "very good" for keeping patients informed about treatment [OR: 1.70, 95% CI (1.21-2.39)], took time to listen to patients [OR: 1.66, 95% CI (0.72-1.60)] and concerned for patient's comfort [OR: 1.54, 95% CI (1.12-2.12)]. CONCLUSION: Individual providers, who practice at both types of facilities, consistently received higher satisfaction ratings from patients at FEDs compared to HBEDs.

Differences in patient population and length of stay between freestanding and hospital-based emergency departments.

BACKGROUND: Freestanding emergency departments (FEDs) represent over 10% of emergency departments (EDs) in the United States. Little is known about differences in encounter characteristics. We compared ED length of stay (LOS) clinical demographics, method of arrival, acuity level, and patient disposition for encounters to FEDs vs. hospital-based EDs (HBEDs). METHODS: A multi-center retrospective analysis was performed. Study sites included 6 FEDs and 13 HBEDs from 10/1/2017 to 9/30/2018. Data was abstracted from ED records and discharge summary within the electronic health record. Descriptive statistics were reported with prevalence (95% Confidence Interval [CI]) for categorical variables and mean (standard deviation [SD]) for continuous variables. Multivariable linear regression assessed the relationship between ED facility (FEDs vs. HBEDs) and ED length of stay (LOS). RESULTS: 1,263,297 encounters were analyzed. Mean ED LOS was shorter at FEDs (146.62 min (±97.04)) vs. HBED (249.70 min (+287.50)). Nine percent of FED encounters arrived via EMS vs. 21% at the HBEDs. FEDs saw 5.47% emergency severity index (ESI) level 2 vs. 13.76% at the HBEDs. Medicaid and Medicare patients were more prevalent in HBEDs (64.2%) than in FEDs (50.6%). FEDs admitted 13% of patients and HBEDs 27%. All results were significant (p < 0.001). After adjusting for potential confounding variables, patients utilizing FEDs had 16.2% shorter ED LOS vs. HBEDs (ß = -0.18 [95% CI: -0.18 to -0.17]). CONCLUSION: Overall ED LOS was significantly less for FED vs. HBED patients. Acuity level, insurance status, method of arrival, and patient disposition were significantly different at FEDs vs. HBEDs.

Elevated Blood Lead Levels Among Resettled Refugee Children in Ohio, 2009-2016.

Objectives. To assess the prevalence of and the demographic factors for elevated blood lead level (EBLL; ≥ 5 µg/dL) at resettlement among newly admitted refugee children. Methods. This cross-sectional study used data from the postresettlement refugee medical screening of 5661 children resettled in Ohio from 2009 to 2016. We computed prevalence of EBLL and adjusted prevalence ratio with modified Poisson regression modeling. Results. Overall, 22.3% of children younger than 18 years and 27.1% of those younger than 6 years had an EBLL. Children resettled from a South Asia region including Afghanistan (EBLL prevalence = 56.2%; 95% confidence interval [95% CI] = 48.1%, 64.3%), Nepal (44.0%; 95% CI = 33.7%, 54.1%), Bhutan (32.8%; 95% CI = 30.4%, 35.9%), and Burma (31.8%; 95% CI = 27.5%, 35.9%) had the highest prevalence of EBLLs. In addition, those younger than 6 years (prevalence ratio [PR] = 2.0; 95% CI = 1.6, 2.6), male (PR = 1.3; 95% CI = 1.1, 1.4), and screened within 30 days of arrival (PR = 1.7; 95% CI = 1.1, 2.5) had significantly higher EBLL prevalence than did children aged 13 years and older, female, and screened 90 days after arrival. Conclusions. The overall high proportion of EBLL and variation in EBLL by country of origin among resettled refugee children in the United States warrant comprehensive, yet tailored, guidelines for health professionals and resettlement and government agencies for better prevention and awareness programs targeting these high-risk children.

Comparison of critically ill patients from three freestanding ED's compared to a tertiary care hospital based ED.

BACKGROUND: Freestanding emergency departments (FEDs) care for all patients, including critically ill, 24/7/365. We characterized patients from three FEDs transferred to intensive care units (ICU) at a tertiary care hospital, and compared hospital length of stay(LOS) between patients admitted to ICUs from FEDs versus a hospital-based ED (HBED). METHODS: We performed a retrospective, observational cohort study from January 2014 to December 2016. Demographic and clinical information was compared between FED and HBED patients with chi-square and fisher's exact tests for categorical variables and Student's t-test for continuous variables. The main outcome of interest was hospital LOS. Multi-variable linear regression was performed to estimate association between LOS and emergency facility type, while adjusting for potential confounders. RESULTS: We included 500 critically ill patients (FED = 250 and HBED = 250). Patients did not differ by age, gender, or BMI. FED patients were more likely to be white (89.6% vs. 70.8%, p < 0.001) and have higher Charlson Co-morbidity Index scores (3.5 vs. 2.4, p < 0.001). Average LOS for FED patients was 5 days, compared to 7 days for HBED patients (p < 0.001). After adjusting for demographic and clinical confounders, there was significant correlation between ED facility type and LOS in hospital (p < 0.001). CONCLUSION: Patients transferred from FEDs to an ICU were similar in age and gender, but more likely to be white with a higher Charlson Comorbidity Index score. FED patients experienced shorter hospital length of stay compared to patients admitted from a HBED.

Relapsing Malaria: A Case Report of Primaquine Resistance.

Primaquine (an 8-aminoquinoline malarial therapy) is the only FDA-approved therapy to treat the hypnozoite stage of P. vivax. We think of relapse occurring because of parasitic resistance or poor compliance secondary to drug toxicities. However, in patients with repeated treatment failure, we must consider CYP-450 mutations affecting drug metabolism as an important cause of relapse. A 47-year-old man who travelled to a jungle in Venezuela was diagnosed with P. falciparum and P. vivax in July 2015. He was treated with seven rounds of primaquine-based therapy in the following year, all resulted in relapse without further exposure to endemic areas. On his eighth presentation, he was found to have CYP-4502D6 mutation that affected the metabolism and activation of primaquine. Thereafter, he was treated without relapse. Primaquine efficacy depends on many factors. Understanding the mechanism responsible for malaria relapse is paramount for successful treatment and reduction in morbidity and mortality. This case illustrates the importance of considering cytochrome mutations that affect drug efficacy in cases of relapsing malaria.

Variation in hospital admission rates between a tertiary care and two freestanding emergency departments.

BACKGROUND: Recently, freestanding emergency departments (FSEDs) have grown significantly in number. Critics have expressed concern that FSEDs may increase healthcare costs. OBJECTIVE: We determined whether admission rates for identical diagnoses varied among the same group of physicians according to clinical setting. METHODS: This was a retrospective comparison of adult admission rates (n=3230) for chest pain, chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure (CHF) between a hospital-based ED (HBED) and two FSEDs throughout 2015. Frequency distribution and proportions were reported for categorical variables stratified by facility type. For categories with cell frequency less or equal to 5, Fisher's Exact test was used to calculate a P value. Chi square tests were used to assess difference in proportions of potential predictor variables between the HBED and FSEDs. For continuous variables, the mean was reported and Student's t-test assessed the difference in means between HBED and FSED patients. Multivariate logistic regression analyses were performed to estimate the unadjusted and adjusted prevalence odds ratio with 95% confidence interval (CI) for patient disposition outcomes associated with type of ED facility visited. RESULTS: Of 3230 patients, 53% used the HBED and 47% used the FSED. Patients visiting the HBED and FSED varied significantly in gender, acuity levels, diagnosis, and number of visits. Age was not significantly different between facilities. Multivariable adjusted estimated prevalence odds ratio for patients admitted were 1.2 [95%CI: 1.0-1.4] in the HBED facility compared to patients using FSEDs. CONCLUSION: In our healthcare system, FSEDs showed a trend towards a 20% lower admission rate for chest pain, COPD, asthma and CHF.

Outcomes of a pilot hand hygiene randomized cluster trial to reduce communicable infections among US office-based employees.

OBJECTIVE: To determine the effectiveness of an office-based multimodal hand hygiene improvement intervention in reducing self-reported communicable infections and work-related absence. METHODS: A randomized cluster trial including an electronic training video, hand sanitizer, and educational posters (n = 131, intervention; n = 193, control). Primary outcomes include (1) self-reported acute respiratory infections (ARIs)/influenza-like illness (ILI) and/or gastrointestinal (GI) infections during the prior 30 days; and (2) related lost work days. Incidence rate ratios calculated using generalized linear mixed models with a Poisson distribution, adjusted for confounders and random cluster effects. RESULTS: A 31% relative reduction in self-reported combined ARI-ILI/GI infections (incidence rate ratio: 0.69; 95% confidence interval, 0.49 to 0.98). A 21% nonsignificant relative reduction in lost work days. CONCLUSIONS: An office-based multimodal hand hygiene improvement intervention demonstrated a substantive reduction in self-reported combined ARI-ILI/GI infections.

Chronic Disease Burden Among Bhutanese Refugee Women Aged 18-65 Years Resettled in Northeast Ohio, United States, 2008-2011.

The purpose of this community-based study was to assess the prevalence of chronic diseases among 18-65 year old Bhutanese refugee women resettled in Northeast Ohio, United States (US). A Nepali-language questionnaire was administered in a face-to-face mode. Anthropometric measurements included height, weight, and hip and waist circumferences. The overall prevalence (95 % confidence interval) of self-reported hypertension, diabetes, asthma, heart disease, and cancer were 15.3 % (9.2-23.4), 6.4 % (2.3-10.9), 5.5 % (2.0-11.5), 2.7 % (0.6-7.8), and 1.8 % (0.2-6.4), respectively. Overweight/obesity was observed in 64.8 % of the women; 69.5 and 74.1 % had waist circumference >80 cm and waist-to-hip ratio ≥85, respectively. Length of time in the US was not associated with the prevalence of the chronic conditions. This study suggests chronic conditions may be significant health issues among US resettled Bhutanese refugees and a larger population-based study to confirm the findings is warranted.

Association of being bullied in school with suicide ideation and planning among rural middle school adolescents.

BACKGROUND: This study examined the association of ever being bullied in school with suicide ideation (ever thinking about killing oneself) and ever seriously making a plan to kill oneself (suicide planning) among rural middle school adolescents. METHODS: Using the US Centers for Disease Control and Prevention's Middle School Youth Risk Behavior Survey instrument, 2 cross-sectional surveys were conducted among middle school adolescents (N = 1082) in a rural Appalachian county in Ohio in 2009 and 2012. Multivariable logistic regression models assessed the relationship of ever being bullied in school with suicide ideation and planning. RESULTS: Overall, a total of 468 participants (43.1%) reported ever being bullied in school, and 22.3% and 13.2% of the adolescents surveyed reported suicide ideation and planning, respectively. In the multivariable analyses, ever being bullied in school was significantly associated with both suicide ideation (odds ratio [OR] = 2.4; 95% confidence interval [CI]: 1.7-3.5) and planning (OR = 2.5; 95% CI: 1.6-3.8). CONCLUSIONS: The results show a strong association between being bullied in school and suicide ideation and planning among rural middle school adolescents. Prevention of bullying in school as early as in middle school should be a strategy for reducing suicide ideation and planning among adolescents.

Socio-demographic and dietary factors associated with excess body weight and abdominal obesity among resettled Bhutanese refugee women in Northeast Ohio, United States.

Studies of obesity and related health conditions among the Bhutanese, one of the largest refugee groups resettled in the United States in the past five years, are limited. This study examined the factors associated with excess body weight (body mass index ≥ 23 kg/m2) and abdominal obesity (waist circumference > 80 cm) in a community-based sample of 18-65 year old Bhutanese refugee women in Northeast Ohio. A Nepali-language questionnaire was used to measure socio-demographic and dietary factors. Height, weight, and waist circumference were measured to define excess body weight and abdominal obesity. The mean (±standard deviation) age of the 108 participants was 36.5 (±12.2) years and length of time in the U.S. was 19.4 (±11.9) months. Overall, 64.8% and 69.4% of the women had excess body weight and abdominal obesity, respectively. Age was significantly associated with both excess body weight (odds ratio: 1.10; 95% confidence interval: 1.05-1.16) and abdominal obesity (1.09; 1.04-1.14). Consuming meat (4.01; 1.14-14.60) was significantly associated with excess body weight but not abdominal obesity. These findings suggest the need for lifestyle and dietary change education programs among this new and vulnerable group to reduce the prevalence of excess body weight and abdominal obesity and their health consequences.