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Publicly funded voucher programs attempt to target low-income families, but concern exists as to whether such programs actually "cream" students from public schools. Data collected as part of the evaluation of the Cleveland Scholarship and Tutoring Program are used to examine whether differences exist between three subgroups of applicants and entrants to the Cleveland voucher program within and across time. This research suggests that voucher recipients who choose not to use their voucher tend to be more minority and lower income than those who are awarded and use a voucher and those who apply for but are not awarded a voucher. Across time, individuals who receive and use a voucher tend to attend a private school prior to applying for a voucher, whereas individuals who apply and are not awarded or who choose not to use an awarded voucher tend to attend public schools prior to applying for a voucher. (Contains 6 tables.)

Research suggests that families who make active choices regarding their child's education differ from families who do not. Differences between families of private (voucher), charter, and public school students were examined using data collected as part of the evaluation of the Cleveland Scholarship and Tutoring Program. While both voucher and charter school families were more satisfied than public school families with their child's school, charter school families were found to differ from both voucher and public school students in that they were more White, were of higher income, were more likely to be married, and were more highly educated. (Contains 1 table.)

Objective: Three-dimensional ultrasound (3D-US) has already demonstrated improved reproducibility with a high degree of agreement (intermodality variability), reproducibility (interoperator variability), and repeatability (intraoperator variability) compared with conventional two-dimensional ultrasound (2D-US) when estimating the maximum diameter of native abdominal aortic aneurysms (AAAs). The aim of the present study was, in a clinical, multicenter setting, to evaluate the accuracy of 3D-US with aneurysm model quantification software (3D-US abdominal aortic aneurysm [AAA] model) for endovascular aortic aneurysm repair (EVAR) sac diameter assessment vs that of computed tomography angiography (CTA) and 2D-US., Methods: A total of 182 patients who had undergone EVAR from April 2016 to December 2017 and were compliant with a standardized EVAR surveillance program were enrolled from five different vascular centers (Rigshospitalet, Copenhagen, Denmark; Catharina Ziekenhuis, Eindhoven, Netherlands; L'hospital de la Timone, Paris, France; Cleveland Clinic, Cleveland, Ohio; and The Christ Hospital, Cincinnati, Ohio) in four countries. All image acquisitions were performed at the local sites (ie, 2D-US, 3D-US, CTA). Only the 2D-US and CTA readings were performed both locally and centrally. All images were read centrally by the US and CTA core laboratory. Anonymized image data were read in a randomized and blinded manner., Results: The sample used to estimate the accuracy of the 3D-US AAA model and 2D-US included 164 patients and 177 patients, respectively. The Bland-Altman analysis revealed that the mean difference between CTA and 3D-US was -2.43 mm (95% confidence interval [CI], -5.20 to 0.14; P = .07) with a lower and upper limit of agreement of -8.9 mm (95% CI, -9.3 to -8.4) and 2.7 mm (95% CI, 2.3-3.2), respectively. For 2D-US and CTA, the mean difference was -3.62 mm (95% CI, -6.14 to -1.10; P = .002), with a lower and upper limit of agreement of -10.3 mm (95% CI, -10.8 to -9.8) and 2.5 mm (95% CI, 2-2.9), respectively., Conclusions: The 3D-US AAA model showed no significant difference compared with CTA for measuring the anteroposterior diameter, indicating less bias for 3D-US compared with 2D-US. Thus, 3D-US with AAA model software is a viable modality for anteroposterior diameter assessment for surveillance after EVAR., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The main objective of this study is to evaluate the relationship of perfluoroalkyl substances with stroke and any modifying influence of diabetes., Methods: Data on 3921 adults aged ⩾20 years with and 44,285 without diabetes were drawn from the C8 Health Project. Four perfluoroalkyl substances were investigated: perfluorohexane sulphate, C8 - perfluorooctanoic acid, perfluoroctane sulfonate and perfluorononaoic acid., Results: There were 238 cases of stroke among those with and 643 among those without diabetes. In analyses controlled for age, sex, race, diabetes duration, body mass index, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, C-reactive protein, kidney function and a history of smoking, a history of stroke was significantly inversely associated with serum perfluorohexane sulphate (odds ratio = 0.75, 0.64-0.88) and perfluoroctane sulfonate (odds ratio = 0.81, 0.70-0.90), but not perfluorooctanoic acid (odds ratio = 1.04, 0.94-1.15) or perfluorononaoic acid (odds ratio = 0.89, 0.70-1.14) among those with diabetes. Perfluoroalkyl substances demonstrated no association with stroke among those without diabetes ( p interaction = 0.006 and 0.01 for perfluorohexane sulphate and perfluorooctanoic acid, respectively)., Conclusion: In this large cross-sectional study, serum levels of perfluorohexane sulphate and perfluoroctane sulfonate were inversely associated with stroke among those with diabetes. Although mechanisms and implications for this diabetes-specific inverse relationship need to be further explored, our data suggest that perfluoroalkyl substances do not increase risk of stroke among persons with or without diabetes.

On April 21, 2015, the Fairfield Medical Center (FMC) and Fairfield Department of Health contacted the Ohio Department of Health (ODH) about a patient suspected of having botulism in Fairfield County, Ohio. Botulism is a severe, potentially fatal neuroparalytic illness.* A single case is a public health emergency, because it can signal an outbreak. Within 2 hours of health department notification, four more patients with similar clinical features arrived at FMC's emergency department. Later that afternoon, one patient died of respiratory failure shortly after arriving at the emergency department. All affected persons had eaten at the same widely attended church potluck meal on April 19. CDC's Strategic National Stockpile sent 50 doses of botulinum antitoxin to Ohio. FMC, the Fairfield Department of Health, ODH, and CDC rapidly responded to confirm the diagnosis, identify and treat additional patients, and determine the source.

Objective: Hyperphosphatemia in end-stage renal disease is associated with significant morbidity and mortality. Because phosphorus is not effectively dialyzed, dietary adherence remains a significant problem. Previous studies have examined the health belief model, but none have looked at stages of change and dietary adherence in patients undergoing hemodialysis (HD)., Design: Cross-sectional survey., Setting: Three dialysis centers in Columbus, Ohio, between August 2012 and March 2013., Subjects: English-speaking patients age 18 or older on HD without dementia or developmental delay., Intervention: None., Main Outcome Measure: Associations between dietary adherence based on the Precaution Adoption Process Model (stages of change) and serum phosphorus levels via a conceptual model incorporating modifying factors and individual health beliefs., Results: Ninety-five patients completed the survey; 59 (62%) endorsed adherence to a low-phosphorus diet and 32 (34%) had phosphorus values ≤5.5 mg/dL. Modifying factors associated with diet adherence included nonminority status odds ratio (OR), 95%CI 8.99 (1.08-74.60), greater level of education OR 18.23 (1.62-205.00), better quality of life OR 9.28 (1.35-63.71), and time on dialysis OR 1.04 (1.01-1.07). Individual health beliefs associated with diet adherence included perceived benefits OR 3.18 (1.47-6.88) and self-efficacy OR 1.22 (1.09-1.38). Modifying factors associated with phosphorus control included: age OR 0.94 (0.90-0.99), minority status OR 0.11 (0.02-0.68), greater level of education OR 6.60 (1.41-31.04), knowledge about chronic kidney disease OR 1.48 (1.03-2.13), and time on dialysis OR 0.98 (0.96-0.99). Individual health beliefs associated with phosphorus control included self-efficacy OR 1.08 (1.01-1.16)., Conclusion: HD clinicians and educators may obtain better results with dietary adherence and phosphorus control if they focus not only toward disease and dietary education but also on understanding modifying factors and individual health beliefs. Assessing where the patient is with regard to stages of change may assist health care providers in better matching interventions that build patients' self-efficacy., (Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: When a parent is terminally ill, one of the major challenges facing families is informing children of the parent's condition and prognosis. This study describes four ways in which parents disclose information about a parent's life-threatening illness to their adolescent children., Methods: We audio-recorded and transcribed 61 individual interviews with hospice patients who were recruited from a large hospice in northeastern Ohio, their spouses/partners, and their adolescent children. The interviews were coded and analyzed using a constant comparison approach., Results and Conclusions: Families inform adolescents about the progression of a parent's terminal illness in characteristic ways that remain fairly consistent throughout the illness, and are aimed at easing the adolescents' burden and distress. The families engaged in the process of disclosure in one of four ways: measured telling, skirted telling, matter-of-fact telling, and inconsistent telling. These results will inform the development of interventions that assist families with disclosure and are tailored to each family's communication style.

Objective: To explore whether racial disparity in osteoporosis drug therapy maintenance varies by health insurance coverage status., Design: Longitudinal observation study., Setting: Cleveland Clinic Health System (Cleveland, OH) from January 2006 to December 2009., Patients: 3,901 black and white female Medicare beneficiaries starting osteoporosis drug therapy., Intervention: Analysis of the health system's integrated electronic medical records., Main Outcome Measures: Drug therapy adherence (medication possession ratio ≥80%) for more than 12 of 15 surveillance units and occurrence of extended nonadherence gaps for at least two surveillance units in a row., Results: Among patients with supplementary health insurance (n = 2,278), no difference was observed for drug therapy adherence ( P = 0.17) and extended nonadherence gaps ( P = 0.53) between black and white participants. When patients did not have supplementary health insurance (n = 1,623), blacks (36% [95% CI 28-47]) were less likely to adhere to drug therapy than whites (47% [38-57]; odds ratio [OR] 0.34 [95% CI 0.09-0.92], P = 0.004). Blacks (25% [19-32]) also were more likely to have an extended nonadherence gap episode than whites (18% [11-26]; OR 2.42 [1.13-3.50], P = 0.03)., Conclusion: Similar to previous research on racial disparity in health services, racial disparity in osteoporosis drug therapy maintenance between black and white female older patients existed when supplementary health insurance was not affordable.

During the summer of 2005, an increase in reports of human cases of Salmonella enterica serovar Ohio infection was observed in Belgium. During 11 weeks, between 1 July and 13 September, 60 cases of laboratory-confirmed Salmonella Ohio infection were reported to the National Reference Centre for Salmonella, with a peak onset of symptoms in the third week of July. All clinical isolates caused self-limiting gastroenteritis; both genders (32 males and 28 females) and all age groups (three children <5 years of age, three children 5 to 14 years of age, 32 adults 15 to 64 years of age, and 22 adults >65 years of age) were affected. The isolates were distributed throughout Belgium but a cluster of several cases was observed around Brussels. At the same time, an increase in the incidence of this serovar was observed in the Salmonella isolates originating from the official surveillance campaign conducted by the Federal Agency for the Safety of the Food Chain, which identified pork as a likely source of the outbreak strain. Pulsed-field gel electrophoresis typing confirmed the clonal relationship between the human isolates, the isolates from samples collected in the cutting plants, and the isolates from pork meat in distribution. Further epidemiological investigations indicated that one particular slaughterhouse was involved. In that slaughterhouse, the carcasses were contaminated during the evisceration process because of contaminated equipment and uncontrolled environmental conditions. This study highlights the importance of a centralized surveillance laboratory in the management of outbreaks and the need of strict implementation of hygienic rules to avoid this type of outbreak.

Purpose: We examined the associations among risk factors (e.g., behavioral problems, family conflict) and outcomes (e.g., overload, depression) commonly used in the research literature in order to inform the design of caregiver assessment and interventions., Methods: A sample of 67 caregivers caring for a family member in the middle stages of dementia were assessed on 15 risk factors and six outcome measures., Results: Risk factors were at best only moderately correlated with one another, suggesting their relative independence. Outcome measures showed somewhat higher correlations with one another, but participants varied in terms of the number and type of outcomes that were elevated. Multivariate results showed that risk factors differed in their contribution to models, predicting various outcomes., Implications: Caregivers possess unique combinations of risk factors and outcomes that suggest the need for individualized or tailored interventions. Designing an effective caregiver assessment and corresponding targeted intervention requires careful planning and selection of appropriate risk factors and outcomes.

Parenteral nutrition (PN) is a complex therapy that requires expertise and experience to avoid errors in prescribing and management. Because of care coordination issues, one medical center has developed and implemented a Web-based application to manage PN patients. PN orders have already been programmed into the physician order entry system, but the nutrition support service (NSS) consult and daily PN management have been performed using paper forms. The Web system is developed for ease of use by clinicians and accessibility at any computer within the medical center. The database consists of 12 tables interrelated by the patient medical record number, admission number, or location. The NSS consult is the main table used to navigate to the other tables. Update of the laboratory and PN formula table must be done through the consult table. The system is compliant with the Health Insurance Portability and Accountability Act guidelines, and has been developed so that the forms that are required to be placed in the patient's permanent record can be printed. Demographic information and laboratory data are automatically populated via a link to the medical center's medication management system. At present, there are 1393 patients in the database and 21,000 pages are viewed each month during daily PN management by clinicians. Data can be easily retrieved for management reports. Data elements can be exported directly from the database to worksheets. This function has been used for projects designed to improve the efficiency of this PN system.

Context: Healthcare data suggest that the incidence and severity of Clostridium difficile infection (CDI) in hospitals are increasing. However, the overall burden of disease and the mortality rate associated with CDI, including the contribution from cases of infection that occur in nursing homes, are poorly understood., Objective: To describe the epidemiology, disease burden, and mortality rate of healthcare-onset CDI., Methods: In 2006, active public reporting of healthcare-onset CDI, using standardized case definitions, was mandated for all Ohio hospitals and nursing homes. Incidence rates were determined and stratified according to healthcare facility characteristics. Death certificates that listed CDI were analyzed for trends., Results: There were 14,329 CDI cases reported, including 6,376 cases at 210 hospitals (5,217 initial cases [ie, cases identified more than 48 hours after admission to a healthcare facility in patients who had not had CDI during the previous 6 months] and 1,159 recurrent cases [ie, cases involving patients who had had CDI during the previous 6 months]) and 7,953 cases at 955 nursing homes (4,880 initial and 3,073 recurrent cases) . After adjusting for missing data, the estimated total was 18,200 cases of CDI, which included 7,000 hospital cases (5,700 initial and 1,300 recurrent cases) and 11,200 nursing homes cases (6,900 initial and 4,300 recurrent cases). The rate for initial cases was 6.4-7.9 cases/10,000 patient-days for hospitals and 1.7-2.9 cases/10,000 patient-days for nursing homes. The rate for initial cases in nursing homes decreased during the study (P < .001). Nonpediatric hospital status (P = .011), a smaller number of beds (P = .003), and location in the eastern or northeastern region of the state (P = .011) were each independently associated with a higher rate of initial cases in hospitals. Death certificates for 2006 listed CDI among the causes of death for 893 Ohio residents; between 2000 and 2006, this number increased more than 4-fold., Conclusion: Healthcare-onset CDI represents a major public health threat that, when considered in the context of an increasing mortality rate, should justify a major focus on prevention efforts.

Urinary metabolites of pyrethroid pesticides have been used as biomarkers to estimate human exposure to the parent insecticide. It is important to establish whether these markers are present in environments or media to which humans are exposed routinely. Failure to account for the contribution of pre-existing markers to urinary concentrations could result in risk assessments that overestimate exposure. The purpose of this study was to quantify the concentrations of 13 selected pyrethroid pesticides and their degradation products in samples of indoor dust that had been collected in vacuum cleaner bags during the children's total exposure to persistent pesticides and other persistent organic pollutants (CTEPP) study of homes and day cares in North Carolina and Ohio. Sieved contents of 85 vacuum cleaner bags were analyzed, and permethrin was found in all samples. Sixty-nine samples contained at least one additional pyrethroid, but none contained more than five pyrethroids in detectable concentrations. Resmethrin, prallethrin, and fenpropathrin were not detected in any samples, while 36 contained phenothrin. The median concentration of permethrin in the samples was 1454ng/g of dust. Excluding permethrin, pyrethroid concentrations were typically less than or equal to 100ng/g of dust. The majority of degradates were present in more than half of the dust samples, usually at concentrations of less than or equal to 100ng/g of dust. For those pyrethroids with a characteristic oxydibenzene group, the cyclopropane degradates were present at higher concentrations than the corresponding benzoic acid moieties. Using urinary concentrations of these metabolites to model human exposure to the parent pyrethroids, may over-estimate risk due to the presence of pre-existing degradates in dust.

Although literature on the subject is scant, in practice, pressure ulcers in the pediatric burn population remain a challenge. An interdisciplinary team at an urban pediatric burn institution treats a population (average age 8 years, range 1 month to 21 years) that includes children too young or unable to articulate pressure-related pain from dressings or positioning techniques. After pressure ulcer data collection procedures were instituted, it was observed that elastic bandages, wet operating room dressings, and positioning appeared to contribute to pressure ulcer occurrence. To better understand the patient's experience and educate staff, an informal study was conducted by an interdisciplinary committee of clinicians to assess the amount of pressure in mm Hg created on bony prominences by care procedures. Three staff members volunteered and were placed in elastic dressings and various commonly used positions for several minutes and three pressure measurements were obtained. Pressure readings of 40 and 56 mm Hg were common, causing pain and placing a person at risk for skin ulceration. The information was used to educate staff on how to maintain therapeutic efficacy without compromising skin integrity and causing pain. Lectures and hands-on demonstrations elucidated correct dressing application. The committee continues to provide education to all staff members on methods to prevent pressure ulcers from occurring in the high-risk burn patient population and ways to reduce the use of elastic wraps and improve patient positioning.

We studied early clinical features of the West Nile virus (WNV) infection. Case patients were Ohio residents who reported to the Ohio Department of Health from August 14 to December 31, 2002, with a positive serum or cerebrospinal fluid for anti-WNV IgM. Of 441 WNV cases, medical records of 224 (85.5%) hospitalized patients were available for review. Most frequent symptoms were fever at a temperature of 38.0 degrees C or higher (n = 155; 69.2%), headache (n = 114; 50.9%), and mental status changes (n = 113; 50.4%). At least one neurological symptom, one gastrointestinal symptom, and one respiratory symptom was present in 186 (83.0%), 119 (53.1%), and 46 (20.5%) patients, respectively. Using multivariate logistic regression and controlling for age, we found that the initial diagnosis of encephalitis (P = .001) or reporting abdominal pain (P < .001) was associated with death. Because initial symptoms of WNV infection are not specific, physicians should maintain a high index of suspicion during the epidemic season, particularly in elderly patients with compatible symptoms.

Objective: To describe the establishment of a community pharmacy-based patient medication assistance program to improve access to medications by indigent patients, lessen the burden placed on physicians in obtaining such medications, reduce the amount of money spent on such medications by area charitable organizations, and improve therapeutic outcomes by improving patient adherence with therapy., Setting: Supermarket-based pharmacy in Ashland, Ohio., Practice Description: Community pharmacy., Practice Innovation: A partnership was developed among Buehler's Pharmacy #3, United Way of Ashland County, and United Way Affiliates to establish a community pharmacy-based medication assistance program to help indigent patients obtain needed medications through manufacturer assistance programs and discount card programs., Interventions: Following initial screening by a United Way affiliate agency, patients are seen by appointment by a Certified Pharmacy Technician at the pharmacy. An electronic application is completed, printed, and sent to the patient's physician for signatures and medication orders. The paperwork is returned to the pharmacy, where it is completed, signed by the patient, and filed. The patient pays the United Way agency $10 and the pharmacy $15 for these services., Main Outcome Measures: Number of prescriptions dispensed cumulatively from April 1, 2003, to July 31, 2003, within the program, patients' cumulative savings, and community response., Results: Between April 1, 2003, and July 31, 2003, a total of 123 patients and 47 physicians were served, and 512 medications valued at $112,139.00 were applied for and/or procured. The time lapse between filing of paperwork and receipt of medications varies from 1 to 6 weeks. While some manufacturers ship product to physicians or directly to patients, the process works better when the product is sent to the pharmacy, where it can be added to the patient's profile, screened for drug interactions and allergies, and dispensed with proper labels and counseling., Conclusion: Establishing a community pharmacy-based medication assistance program is an innovative spin on the traditional physician office, advocacy, or health-system setting and was found to be beneficial to the patients, physicians and other health care providers, and the community it served.

Background: The peripherally inserted central catheter (PICC) is commonly used in children for medication and fluid administration. In addition, PICCs are used occasionally for blood sampling as an alternative to venipuncture. Blood sampling from these catheters carries the hypothetical risk of catheter occlusion caused by blood remaining in the catheter, and this practice is not supported by PICC manufacturers. Children often undergo multiple needle punctures, which are associated with pain, anxiety, and dissatisfaction with care. The authors hypothesized that blood sampling through 3-Fr PICC devices is effective and safe for children., Methods: After placement of a 3-Fr PICC, all the children were sequentially enrolled in one of two groups. The control group included patients that had 3-Fr PICC devices without blood sampling. The blood sampling group included patients with 3-Fr PICC devices through which blood samples were obtained. Demographic data, PICC placement and sampling data, infusate composition, catheter occlusion, mechanical complications, and blood stream infections were recorded. The primary outcome variable was the difference in occlusion rates between the two groups., Results: The analysis included 204 children with 3-Fr PICCs (120 in the blood sampling group and 84 in the control group) who had a mean age, 117.7 +/- 4.9 months. The mean PICC duration was 15.6 +/- 1.0 days. Blood sampling was successful more than 98% of the time from all blood sampling group catheters, with a mean of 4.4 +/- 0.5 samples removed from each catheter. There was a higher occlusion rate in the blood sampling group. However, this result did not reach statistical significance. There were no significant differences between the groups in terms of infection or mechanical complication rates., Conclusions: Blood sampling is feasible and effective through 3-Fr PICC devices in children. This practice is not associated with a significant increase in occlusion, infection, or mechanical complication rates.

The mother/baby unit of Ohio's Good Samaritan Hospital instituted a wireless communication system. Here, review its benefits.

Data on squamous carcinoma of the cervix from a 20 year study period (1955 to 1974) in metropolitan Toledo revealed a 66% reduction of the average annual age-adjusted incidence rate and a 61% reduction in death rate of cervical squamous carcinoma when the first time period (1955 to 1958) was compared with the last time period (1971 to 1974). The decrease for both morbidity and mortality rates was more pronounced in women age 50 years and younger. The age-adjusted death rate during this study period revealed 15.5/100,000 for black women and 8.7/100,000 for white women. The reduction in death rate of 83% in black women is more prominent than 54.5% in white women. The decrease in both morbidity and mortality for cervical squamous carcinoma has a close relation to cytologic screening activity. The factors of age and race, probably related to socioeconomic status, are two known determinants of risk for cervical squamous carcinoma. Data for endometrial carcinoma during this study period revealed 15.5/100,000 women in the average age-adjusted incidence and an increase of 13.8% in average yearly rates when the first time period (1955 to 1958) were compared with the last time period (1971 to 1974). The peak age was 60 to 64 years old in the first time period and shifted to 70 to 74 years old in the last time period. The trend in metropolitan Toledo is comparable to that of Louisville, Kentucky. The mass cytologic screening program which contributed to a remarkable reduction in morbidity and mortality for the cervical squamous carcinoma, did not have any beneficial effect on endometrial carcinoma.