Publications

Abstract

Objectives. We examined the potential for glycemic control monitoring and screening for diabetes in a dental setting among adults (n = 408) with or at risk for diabetes. Methods. In 2013 and 2014, we performed hemoglobin A1c (HbA1c) tests on dried blood samples of gingival crevicular blood and compared these with paired "gold-standard" HbA1c tests with dried finger-stick blood samples in New York City dental clinic patients. We examined differences in sociodemographics and diabetes-related risk and health care characteristics for 3 groups of at-risk patients. Results. About half of the study sample had elevated HbA1c values in the combined prediabetes and diabetes ranges, with approximately one fourth of those in the diabetes range. With a correlation of 0.991 between gingival crevicular and finger-stick blood HbA1c, measures of concurrence between the tests were extremely high for both elevated HbA1c and diabetes-range HbA1c levels. Persons already diagnosed with diabetes and undiagnosed persons aged 45 years or older could especially benefit from HbA1c testing at dental visits. Conclusions. Gingival crevicular blood collected at the dental visit can be used to screen for diabetes and monitor glycemic control for many at-risk patients.

Abstract

Objective The SELF Trial examined the effect of adding individual self-efficacy (SE) enhancement sessions to standard behavioral weight loss treatment (SBT). Methods Participants were randomly assigned to SBT or SBT plus SE sessions (SBT+SE). Outcome measures were weight loss maintenance, quality of life, intervention adherence, and self-efficacy at 12 and 18 months. Results The sample (N = 130) was female (83.08%) with a mean (SD) body mass index of 33.15 (4.11) kg m2. There was a significant time effect for percent weight change (P = 0.002) yet no significant group or group-by-time effects. The weight loss for the SBT+SE group was 8.38% (7.48) at 12 months and 8.00% (7.87) at 18 months, with no significant difference between the two time points (P = 0.06). However, weight loss for the SBT group was 6.95% (6.67) at 12 months and 5.96% (7.35) at 18 months, which was significantly different between the two time points (P = 0.005), indicating that the SBT group had significant weight regain. Conclusions Both groups achieved clinically significant weight loss. The group receiving an intervention targeting enhanced self-efficacy had greater weight loss maintenance whereas the SBT group demonstrated significant weight regain possibly related to the greater attention provided to the SBT+SE group.

Abstract

Background: Evidence supports the role of feedback in reinforcing motivation for behavior change. Feedback that provides reinforcement has the potential to increase dietary self-monitoring and enhance attainment of recommended dietary intake.Objective: The aim of this study was to examine the impact of daily feedback (DFB) messages, delivered remotely, on changes in dietary intake.Methods: This was a secondary analysis of the Self- Monitoring And Recording using Technology (SMART) Trial, a single-center, 24-month randomized clinical trial of behavioral treatment for weight loss. Participants included 210 obese adults (mean body mass index, 34.0 kg/m2) who were randomized to either a paper diary (PD), personal digital assistant (PDA), or PDA plus daily tailored feedback messages (PDA + FB). To determine the role of daily tailored feedback in dietary intake, we compared the self-monitoring with DFB group (DFB group; n = 70) with the self-monitoring without DFB group (no-DFB group, n = 140). All participants received a standard behavioral intervention for weight loss. Self-reported changes in dietary intake were compared between the DFB and no-DFB groups and were measured at baseline and at 6, 12, 18, and 24 months. Linear mixed modeling was used to examine percentage changes in dietary intake from baseline.Results: Compared with the no-DFB group, the DFB group achieved a larger reduction in energy (-22.8% vs -14.0%; P = .02) and saturated fat (-11.3% vs -0.5%; P = .03) intake and a trend toward a greater decrease in total fat intake (-10.4% vs -4.7%; P = .09). There were significant improvements over time in carbohydrate intake and total fat intake for both groups (P values < .05).Conclusion: Daily tailored feedback messages designed to target energy and fat intake and delivered remotely in real time using mobile devices may play an important role in the reduction of energy and fat intake.

Abstract

Background: Schools of nursing spend considerable time and finances pursuing federal research funding, yet the costs of such efforts are unknown. Purpose: The purpose of this study was to determine the time and costs to a school of nursing to prepare a National Institutes of Health grant application. Method: We prospectively recorded time and calculated costs in grant preparation undertaken by principal investigators and research administrators in one school of nursing. Results: Principal investigators' time ranged from 69.8 to 162.3 hr, research administrators' time ranged from 33.9 to 56.4 hr, and costs ranged from $4,784 to $13,512 per grant. With funding rates of 5% to 15%, costs for one funded R01 would be $72,460 to $270,240. Discussion: Grant writing activities represent a major time commitment to faculty and staff and costs to the school. To maximize potential for success, schools of nursing must provide costly resources to support its grant writing enterprise. Conclusions: Less costly and more efficient models of attaining research funding are needed for the sustainability of the nursing profession.

Abstract

Context Fatigue is a distressing persistent sense of physical tiredness that is not proportional to a person's recent activity. Fatigue impacts patients' treatment decisions and can limit their self-care activities. Although significant interindividual variability in fatigue severity has been noted, little is known about predictors of interindividual variability in initial levels and trajectories of evening fatigue severity in oncology patients receiving chemotherapy. Objectives To determine whether demographic, clinical, and symptom characteristics were associated with initial levels and the trajectories of evening fatigue. Methods A sample of outpatients with breast, gastrointestinal, gynecological, and lung cancer (N = 586) completed demographic and symptom questionnaires a total of six times over two cycles of chemotherapy. Fatigue severity was evaluated using the Lee Fatigue Scale. Hierarchical linear modeling was used to answer the study objectives. Results A large amount of interindividual variability was found in the evening fatigue trajectories. A piecewise model fit the data best. Patients who were white, diagnosed with breast, gynecological, or lung cancer, and who had more years of education, childcare responsibilities, lower functional status, and higher levels of sleep disturbance and depression reported higher levels of evening fatigue at enrollment. Conclusion This study identified both nonmodifiable (e.g., ethnicity) and modifiable (e.g., childcare responsibilities, depressive symptoms, sleep disturbance) risk factors for more severe evening fatigue. Using this information, clinicians can identify patients at higher risk for more severe evening fatigue, provide individualized patient education, and tailor interventions to address the modifiable risk factors.

Abstract

Purpose: Although fear of recurrence (FCR) is common among cancer survivors, it remains unclear what factors predict initial levels (e.g., prior to surgery) or changes in FCR in the post-treatment period. Among women treated for breast cancer, this study evaluated the effects of demographic, clinical, symptom, and psychosocial adjustment characteristics on the initial (preoperative) levels of FCR and trajectories of FCR over 6 months following surgery. Methods: Prior to and for 6 months following breast cancer surgery, 396 women were assessed for demographic and clinical (disease and treatment) characteristics, symptoms, psychological adjustment characteristics, and quality of life (QOL). FCR was assessed using a four-item subscale from the QOL instrument. Hierarchical linear modeling was used to examine changes in FCR scores and to identify predictors of inter-individual differences in preoperative FCR levels and trajectories over 6 months. Results: From before surgery to 6 months post-operatively, women with breast cancer showed a high degree of inter-individual variability in FCR. Preoperatively, women who lived with someone, experienced greater changes in spiritual life, had higher state anxiety, had more difficulty coping, or experienced more distress due to diagnosis or distress to family members reported higher FCR scores. Patients who reported better overall physical health and higher FCR scores at enrollment demonstrated a steeper decrease in FCR scores over time. Conclusions: These findings highlight inter-individual heterogeneity in initial levels and changes in FCR over time among women undergoing breast cancer surgery. Further work is needed to identify and provide interventions for women experiencing FCR during and after breast cancer treatment.

Abstract

Effective, patient-centered communication facilitates interception and correction of potentially harmful conditions and errors. All team members, including women, their families, physicians, midwives, nurses, and support staff, have roles in identifying the potential for harm during labor and birth. However, the results of collaborative research studies conducted by organizations that represent professionals who care for women during labor and birth indicate that health care providers may frequently witness, but may not always report, problems with safety or clinical performance. Some of these health care providers felt resigned to the continuation of such problems and fearful of retribution if they tried to address them. Speaking up to address safety and quality concerns is a dynamic social process. Every team member must feel empowered to speak up about concerns without fear of put-downs, retribution, or receiving poor-quality care. Patient safety requires mutual accountability: individuals, teams, health care facilities, and professional associations have a shared responsibility for creating and sustaining environments of mutual respect and engaging in highly reliable perinatal care. Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality. The problem is well-known; the time for action is now.

Abstract

Effective, patient-centered communication facilitates interception and correction of potentially harmful conditions and errors. All team members, including women, their families, physicians, midwives, nurses, and support staff, have a role in identifying the potential for harm during labor and birth. However, the results of collaborative research studies conducted by organizations that represent professionals who care for women during labor and birth indicate that health care providers may frequently witness, but may not always report, problems with safety or clinical performance. Some of these health care providers felt resigned to the continuation of such problems and fearful of retribution if they tried to address them. Speaking up to address safety and quality concerns is a dynamic social process. Every team member must feel empowered to speak up about concerns without fear of put-downs, retribution, or receiving poor-quality care. Patient safety requires mutual accountability: individuals, teams, health care facilities, and professional associations have a shared responsibility for creating and sustaining environments of mutual respect and engaging in highly reliable perinatal care. Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality. The problem is well-known; the time for action is now.

Abstract

Objectives: This study aimed to document clinical use of Traditional Chinese Medicine (TCM) for chronic conditions in all TCM hospitals in a Chinese province and to recommend treatments most in need of evaluation for use in community health centers. Design: A cross-sectional survey was conducted in the summer of 2010. It included 119 of 132 TCM hospitals in Hubei Province, China. TCM physicians were asked to recommend specific TCM treatments for common chronic conditions. Nine types of chronic conditions recommended more than 3.7 times (mean of frequencies of chronic conditions) are included in this analysis. Frequency of each TCM treatment and the number of visits by type of chronic conditions were calculated. Results: The total number of recommendations by TCM physicians was 411. For seven types of treatments, six were recommended for musculoskeletal pain, five for soft tissue injuries, four for visceral pain and fractures, three for stroke and asthma, two for hemorrhoids, and one for hypertension. The most frequently recommended treatments for specific conditions include orally ingested herbs for visceral pain (n=3), type 2 diabetes (n=5), and hypertension (n=7); herbs for external use for soft tissue injuries (n=10), asthma (n=6), and hemorrhoids (n=8); acupuncture for musculoskeletal pains (n=43) and for stroke (n=10); and Chinese external fixation for fractures (n=24). The number of visits for recommended treatments per year of was 671,759. The most frequently recommended treatments for specific chronic conditions have most visits, except for chronic conditions such as musculoskeletal pains, visceral pains, soft tissue injuries, and asthma. Conclusions: Patients with musculoskeletal pain have more treatment options than other patients. Herbal medicine is the option most commonly used for chronic conditions. These treatments for these conditions should be targeted for further evaluation of effectiveness and, only if found effective, considered for use in primary care settings.

Abstract

Based on the 2005 and 2008 Chinese Longitudinal Healthy Longevity Survey, this study examined the prevalence of undermet needs for assistance in personal activities of daily living (ADL) and its associated risk factors among the oldest old aged 80+. Multilevel multinomial logistic modeling was used to analyze the risk factors and changes of undermet needs over time. The results show that the prevalence of slightly undermet needs decreased in urban China from 2005 to 2008. However, the prevalence of undermet needs remained high; 50% or more for both rural and urban residents. Compared to 2005, the likelihood of having slightly undermet needs in 2008 significantly decreased by 28% among rural residents and 22% among urban residents. The common risk factors of undermet needs among rural and urban residents included financial dependence, living alone, having unwilling caregivers, more ADL disabilities, and having poor self-rated health.

Abstract

Adolescents and young adults are the fastest-growing age group of people living with HIV infection in the United States. Yet many adolescents and young adults with high-risk behaviors for HIV are unaware of their HIV status and have never had an HIV test. The purpose of our work was to understand minority adolescents' beliefs, attitudes, and behaviors related to HIV testing. We conducted focus group sessions with 41 minority adolescents to assess their perceptions about HIV testing. We triangulated the findings from our focus group data with data from a 125-question survey. Analysis of focus group data demonstrated that Perceived Susceptibility, Perceived Severity, Perceived Benefits, Perceived Barriers, and Cues to Action influenced adolescents' decisions to get tested for HIV. Findings support the need to design interventions that address adolescents' perceived barriers to HIV testing and increase access to and knowledge about HIV testing.

Abstract

Infections have been identified as a priority issue in nursing homes (NHs). We conducted a qualitative study purposively sampling 10 NHs across the country where 6-8 employees were recruited (N = 73). Semi-structured, open-ended guides were used to conduct in-depth interviews. Data were audiotaped, transcribed and a content analysis was performed. Five themes emerged: 'Residents' Needs', 'Roles and Training' 'Using Infection Data,' 'External Resources' and 'Focus on Hand Hygiene.' Infection prevention was a priority in the NHs visited. While all sites had hand hygiene programs, other recommended areas were not a focus and many sites were not aware of available resources. Developing ways to ensure effective, efficient and standardized infection prevention and control in NHs continues to be a national priority.

Abstract

Behavioral counseling interventions can address significant causes of preventable morbidity and mortality. However, despite a growing evidence base for behavioral counseling interventions, there remain significant research gaps that limit translating the evidence into clinical practice. Using U.S. Preventive Services Task Force (USPSTF) examples, we address how researchers and funders can move the research portfolio forward to achieve better application of behavioral counseling interventions to address substantial health burdens in the U.S. This paper describes the types of gaps that the USPSTF encounters across its behavioral counseling intervention topics and provides suggestions for opportunities to address these gaps to enhance the evidence base for primary care-based behavioral counseling recommendations. To accomplish this, we draw from both the USPSTF experience and issues identified by researchers and clinicians during the USPSTF-sponsored Behavioral Counseling Intervention Forum. We also discuss the dilemma posed by having "insufficient" evidence with which to make a behavioral counseling intervention-related recommendation, and describe two case examples (screening for alcohol misuse in adolescence and screening for child maltreatment), detailing the research gaps that remain. Recommendations are outlined for researchers, funders, and practice implementers to improve behavioral counseling intervention research and application.

Abstract

Background Decades of research has yielded few clues about causes of sudden infant death syndrome (SIDS). While some studies have shown a link to inborn errors of metabolism (IEMs), few have examined the link in a large population-based sample. This population-based case-control study assessed the association between undiagnosed IEMs and SIDS. Methods Children born in California during 2005-08 who died from SIDS were obtained from death records and linked to the newborn screening, birth certificate, and hospital discharge databases. Individuals with known chromosomal and neural tube defects, genetic disorders, and non-singleton births were excluded. Five controls were matched to each case on tandem mass spectrometry testing date and lab code. Rates of undiagnosed IEMs were compared between cases and controls using conditional logistic regression adjusting for known confounding factors. Results After adjusting for known confounding factors, SIDS cases had similar risk of having IEMs as controls (adjusted hazard ratio [HR] 1.3, 95% confidence interval [CI] 0.3, 5.5). Infants who were male, Black, and born preterm had higher risk of SIDS with the highest risk observed for those born preterm [adjusted HR=1.7, 95% CI 1.3, 2.2]. Younger maternal age at delivery, mother being born in the US, parity after current birth >3, and delayed prenatal care were also significantly associated with higher risk of SIDS. Conclusions While many maternal and infant factors are associated with an increased risk of SIDS, there is no evidence that undiagnosed IEMs are associated with increased risk.

Abstract

Increasing multicultural diversity generates a challenge on providing culturally competent (CC) care for both nurses and patients. Multicultural nursing education is the key to achieve new perspectives in nursing care, and therefore, it has gained importance lately. As nurse educators play a significant role in developing the nursing workforce to meet cultural awareness, knowledge, and competency in students, they must appropriately provide culturally specific nursing care, which is customized to fit the patient's own cultural values, beliefs, traditions, practices, and lifestyles. Clinical simulation is an effective educational tool in nursing education to master the principles of CC nursing care. The author conducted a literature review to identify the best practices in the utilization of simulation to enhance CC nursing care. Results revealed that the use of simulation can support CC nursing care by providing a safe environment to conduct a cultural assessment, elicit students' attitudes toward cross-cultural situations, and improve communication, critical thinking, and nursing skills. With these skills, one can recognize cross-cultural issues in interviewing, communicating medical information, and providing treatment and CC nursing care for patients from diverse ethnic and racial backgrounds. Gaps in research still exist regarding the effectiveness of clinical simulation to enhance CC nursing care.

Abstract

Background: Very brief single-item screening questions (SISQs) for alcohol and other drug use can facilitate screening in health care settings, but are not widely used. Self-administered versions of the SISQs could ease barriers to their implementation. Objective: We sought to validate SISQs for self-administration in primary care patients. Design: Participants completed SISQs for alcohol and drugs (illicit and prescription misuse) on touchscreen tablet computers. Self-reported reference standard measures of unhealthy use, and more specifically of risky consumption, problem use, and substance use disorders, were then administered by an interviewer, and saliva drug tests were collected. Participants: Adult patients aged 21–65 years were consecutively enrolled from two urban safety-net primary care clinics. Main Measures: The SISQs were compared against reference standards to determine sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for alcohol and drug use. Key Results: Among the 459 participants, 22 % reported unhealthy alcohol use and 25 % reported drug use in the past year. The SISQ-alcohol had sensitivity of 73.3 % (95 % CI 65.3–80.3) and specificity of 84.7 % (95 % CI 80.2–88.5), AUC = 0.79 (95 % CI 0.75–0.83), for detecting unhealthy alcohol use, and sensitivity of 86.7 % (95 % CI 75.4–94.1) and specificity of 74.2 % (95 % CI 69.6–78.4), AUC = 0.80 (95 % CI 0.76–0.85), for alcohol use disorder. The SISQ-drug had sensitivity of 71.3 % (95 % CI 62.4–79.1) and specificity of 94.3 % (95 % CI 91.3–96.6), AUC = 0.83 (95 % CI 0.79–0.87), for detecting unhealthy drug use, and sensitivity of 85.1 (95 % CI 75.0–92.3) and specificity of 88.6 % (95 % CI 85.0–91.6), AUC = 0.87 (95 % CI 0.83–0.91), for drug use disorder. Conclusions: The self-administered SISQs are a valid approach to detecting unhealthy alcohol and other drug use in primary care patients. Although self-administered SISQs may be less accurate than the previously validated interviewer-administered versions, they are potentially easier to implement and more likely to retain their fidelity in real-world practice settings.

Abstract

Persistent pain after breast cancer surgery is a common clinical problem. Given the role of potassium channels in modulating neuronal excitability, coupled with recently published genetic associations with preoperative breast pain, we hypothesized that variations in potassium channel genes will be associated with persistent postsurgical breast pain. In this study, associations between 10 potassium channel genes and persistent breast pain were evaluated. Using growth mixture modeling (GMM), 4 distinct latent classes of patients, who were assessed before and monthly for 6 months after breast cancer surgery, were identified previously (ie, No Pain, Mild Pain, Moderate Pain, Severe Pain). Genotyping was done using a custom array. Using logistic regression analyses, significant differences in a number of genotype or haplotype frequencies were found between: Mild Pain vs No Pain and Severe Pain vs No Pain classes. Seven single-nucleotide polymorphisms (SNPs) across 5 genes (ie, potassium voltage-gated channel, subfamily A, member 1 [KCNA1], potassium voltage-gated channel, subfamily D, member 2 [KCND2], potassium inwardly rectifying channel, subfamily J, members 3 and 6 (KCNJ3 and KCNJ6), potassium channel, subfamily K, member 9 [KCNK9]) were associated with membership in the Mild Pain class. In addition, 3 SNPs and 1 haplotype across 4 genes (ie, KCND2, KCNJ3, KCNJ6, KCNK9) were associated with membership in the Severe Pain class. These findings suggest that variations in potassium channel genes are associated with both mild and severe persistent breast pain after breast cancer surgery. Although findings from this study warrant replication, they provide intriguing preliminary information on potential therapeutic targets.

Abstract

Gluten-free diets are increasing in popularity among consumers and fueling a global market of gluten-free products. A gluten-free diet is the only treatment for celiac disease (CD). However, many patients are self-reporting and suspecting "gluten sensitivity" after gastrointestinal symptoms, such as bloating, abdominal pain, or diarrhea, resolve on a gluten-free diet without formal evaluation testing for food allergies or CD. The terms related to gluten and/or wheat intolerance, nonceliac gluten sensitivity or wheat sensitivity, CD, and wheat allergy can be confusing. These forms of intolerance combined affect approximately 10% of the United States population. In this article we clarify the range of gluten and/or wheat disorders, clinical features, diagnosis, and management.

Abstract

Objective: The purpose of the pilot study was to assess the feasibility and efficacy of a 4- month community health worker (CHW) intervention to improve hypertension management among Filipino immigrants in New York and New Jersey. Design: Single-arm CHW pilot intervention using a pre-post design delivered by 5 CHWs. Setting: New York City, NY and Jersey City, NJ. Participants: Of 88 Filipino individuals recruited for the study, 39 received the full pilot intervention, 18 received a partial intervention, and 31 dropped out; 13 Filipino participants, 10 CHW Trainers, and 3 Filipino CHWs were interviewed for qualitative analysis. Intervention: Individuals participated in 4 workshops related to hypertension management and cardiovascular disease (CVD) risk factors and received monthly in-person visits, and twice monthly phone calls individually from a CHW. Main Outcome Measures: Primary outcomes included blood pressure (BP) reduction and control, appointment keeping, and medication adherence; secondary outcomes included weight, body mass index (BMI), self-efficacy related to diet, exercise, and medication taking, CVD knowledge, and nutrition (salt/ sodium and cholesterol/fat). Results: A mixed method analysis was used to assess the intervention, utilizing quantitative and qualitative methods. By the end of the intervention, significant changes were exhibited for systolic and diastolic BP, weight, and BMI (P<.01). Significant changes were not seen for medication adherence and appointment keeping, however, CVD knowledge and self-efficacy related to diet and weight management all improved significantly (P<.01). Qualitative findings provided additional information on the acceptability, feasibility, and efficacy of the intervention. Conclusions: This pilot CHW intervention showed evidence of feasibility, as well as efficacy, in improving hypertension management and reducing CVD factors in Filipino Americans.

Abstract

Introduction: Gaining too much weight in pregnancy is associated with perinatal complications and increases the risks of future obesity for both women and their infants. Unfortunately, women enrolled in intervention trials have seen little improvement in adherence to prenatal weight gain recommendations compared to women receiving standard prenatal care. Therefore, the purpose of this descriptive mixed-methods study was to explore factors related to excessive weight gain in pregnancy. Methods: Nonpregnant nulliparous women, currently pregnant women, and postpartum women (N = 43) were recruited from a health center serving an inner-city minority community. Women completed questionnaires on knowledge, self-efficacy, and behaviors related to nutrition, exercise, and prenatal weight gain. Fifteen of these women participated in focus groups. Focus group data were analyzed using ATLAS.ti (Scientific Software Development GmbH, Berlin, Germany). Codes were created, themes were identified, and consensus was reached through multiple iterations of the analysis by study personnel. Results: Excessive weight gain was common. Nutritional knowledge was poor and significantly lower among nonpregnant nulliparous women. Women felt sure that they could engage in healthy behaviors, but few did so. Participants in focus groups identified multiple barriers to healthy behaviors in pregnancy and made suggestions on how to help women more readily make improvements in these behaviors. Discussion: Strategies identified in this study such as providing focused education directed at nonpregnant nulliparous women, stressing portion control, helping women better manage their cravings, and providing more pragmatic support and resources need to be explored in future research.