Publications

Abstract

While up to 45% of women quit smoking during pregnancy, nearly 80% return to smoking within a year after delivery. Interventions to prevent relapse have had limited success. The study objective was to understand what influences return to smoking after pregnancy among women who quit smoking during pregnancy, with a focus on the role of social networks. We conducted in-depth, semi-structured interviews during the postpartum hospital stay with women who quit smoking while pregnant. Over 300 pages of transcripts were analyzed using qualitative methods to identify common themes. Respondents [n = 24] were predominately white (63%), had at least some college education (54%) and a mean age of 26 years (range = 18-36). When reflecting on the experience of being a smoker who quit smoking during pregnancy, all participants emphasized the importance of their relationships with other smokers and the changes in these relationships that ensued once they quit smoking. Three common themes were: (1) being enmeshed in social networks with prominent smoking norms (2) being tempted to smoke by members of their social networks, and (3) changing relationships with the smokers in their social networks as a result of their non-smoking status. We found that women who quit smoking during pregnancy found themselves confronted by a change in their social network since most of those in their social network were smokers. For this reason, smoking cessation interventions may be most successful if they help women consider restructuring or reframing their social network.

Abstract

Objectives: This study assessed the prevalence of insomnia symptoms among women with and without HIV-infection and examined factors associated with insomnia. Design: Participants (n = 1682) were enrolled in the Women's Interagency HIV Study (WIHS); 69% were infected with HIV. This was a crosssectional analysis of data from standardized interviewer-administered instruments and physical/gynecological exams. Analysis focused on sociodemographics, sleep measures, depressive symptoms, drug use, alcohol consumption, medications, and HIV-related clinical variables. Women were classified as having symptoms of insomnia if they reported either difficulty initiating sleep, difficulty maintaining sleep, or early morning awakening ≥ 3 times a week in the past 2 weeks. Results: Overall, HIV-infected women were 17% more likely to endorse insomnia symptoms than uninfected women (OR = 1.17, 95% CI: 1.04-1.34, P < 0.05). The adjusted prevalence of insomnia symptoms varied by HIV status and age groups. Among women ages 31-40 years, those with HIV infection were 26% more likely to endorse insomnia symptoms than their counterparts (OR = 1.26, 95% CI: 1.01-1.59, P < 0.05). No significant differences were observed in the likelihood of reporting insomnia symptoms based on HIV treatment type. Multivariate-adjusted regression analyses showed that depression was the most consistent and significant independent predictor of the likelihood of reporting insomnia symptoms across all age strata. Conclusions: Insomnia symptoms are common among both HIV-infected and uninfected women. Prevalence of insomnia did not vary significantly by HIV status, except among younger women. Younger women with HIV infection are at greater risk for experiencing insomnia symptoms.

Abstract

Ongoing antiretroviral therapy (ART) adherence and secondary HIV transmission-risk reduction (positiveprevention) support are needed in resource-limited settings. We evaluated a nurse-delivered counseling intervention in Kenya. We trained 90 nurses on a brief counseling algorithm that comprised ART and sexual-risk assessment, risk-reduction messages, and health-promotion planning. Self-reported measures were assessed before, immediately after, and 2 months post-training. Consistent ART adherence assessment was reported by 29% of nurses at baseline and 66% at 2 months post-training (p < .001). Assessment of patient sexual behaviors was 25% at baseline and 60% at 2 months post-training (p < .001). Nurse practice behaviors recommended in the counseling algorithm improved significantly at 2 months post-training compared with baseline, odds ratios 4.30-10.50. We found that training nurses in clinical counseling for ART adherence and positive prevention is feasible. Future studies should test impact of nurse counseling on patient outcomes in resource-limited settings.

Abstract

This study examined how life satisfaction and grandparent caregiving intensity changed over time among rural Chinese older adults, and whether there was a leading predictor between grandparent caregiving intensity and life satisfaction. Using 4 waves of data from the Well-being of Elderly in Anhui Province of China (N = 1704), we applied latent difference score analysis to explore this relationship. Results indicated that grandparent caregiving intensity decreased and life satisfaction increased over time. There was a lagged effect between grandparent caregiving intensity and life satisfaction, and life satisfaction demonstrated a leading prediction role between these 2 variables. This study confirmed the potentially rewarding aspect of grandparent caregiving, which may lead to greater life satisfaction. The results also revealed that psychological well-being among grandparents is very important for performing activities, such as caregiving.

Abstract

Irritable bowel syndrome (IBS), a chronic disorder, greatly impacts the lives of those affected. Approximately one quarter of the North American population suffers from this condition that includes abdominal pain, discomfort and alterations in normal bowel function. Constipation-subtype IBS (IBS-C) is often found to be a prevalent subtype; however, a lack of knowledge and effective treatment options remains surrounding this disorder. In the course of an ongoing study conducted by our research team on the use of acupuncture and moxibustion in the management of IBS symptoms, a considerable number of screened patients have met the widely accepted Rome III criteria for IBS-C.

Abstract

Good oral health is important to overall health. Oral and pharyngeal cancers account for 2% of all cancers, yet no signify cant improvement in mortality has been demonstrated over the past 30 years. Nurses are in a unique position to integrate and conduct oral health assessments across a wide range of practice settings. Although nursing programs include health assessment and promotion in their curricula, there is poor integration of oral health as a focus. This study aimed to identify the knowledge, attitudes, and practices of baccalaureate nursing students about oral health assessment. A convenience sample of 163 students in two undergraduate courses within a baccalaureate nursing education program was surveyed. Findings indicated that these nursing students felt that oral health was essential to their nursing practice; however, they did not have a full understanding of the key components of an oral health examination or about effective smoking cessation strategies.

Abstract

Extended work shifts of twelve hours or longer are common and even popular with hospital staff nurses, but little is known about how such extended hours affect the care that patients receive or the wellbeing of nurses. Survey data from nurses in four states showed that more than 80 percent of the nurses were satisfied with scheduling practices at their hospital. However, as the proportion of hospital nurses working shifts of more than thirteen hours increased, patients' dissatisfaction with care increased. Furthermore, nurses working shifts of ten hours or longer were up to two and a half times more likely than nurses working shorter shifts to experience burnout and job dissatisfaction and to intend to leave the job. Extended shifts undermine nurses' well-being, may result in expensive job turnover, and can negatively affect patient care. Policies regulating work hours for nurses, similar to those set for resident physicians, may be warranted. Nursing leaders should also encourage workplace cultures that respect nurses' days off and vacation time, promote nurses' prompt departure at the end of a shift, and allow nurses to refuse to work overtime without retribution.

Abstract

Longitudinal associations between leisure-time physical activity (LTPA) and overall cancer mortality were evaluated within the Third National Health and Nutrition Examination Survey (NHANES III; 1988-2006; n = 15,535). Mortality status was ascertained using the National Death Index. Self-reported LTPA was divided into inactive, regular low-to-moderate and vigorous activity. A frequency-weighted metabolic equivalents (METS/week) variable was also computed. Hazard ratios (HRs) and 95 confidence intervals (CI) were calculated for overall cancer mortality in the whole sample, by body mass index categories and insulin resistance (IR) status. Nonsignificant protective associations were observed for regular low-to-moderate and vigorous activity, and for the highest quartile of METS/week (HRs range: 0.66-0.95). Individuals without IR engaging in regular vigorous activity had a 48 decreased risk of cancer mortality (HR: 0.52; 95 CI: 0.28-0.98) in multivariate analyses. Conversely, nonsignificant positive associations were observed in people with IR. In conclusion, regular vigorous activity may reduce risk of cancer mortality among persons with normal insulin-glucose metabolism in this national sample.

Abstract

Context: Sleep disturbance is a significant problem in oncology patients. Objectives: To examine how actigraphy and self-report ratings of sleep disturbance changed over the course of and after radiation therapy (RT); investigate whether specific patient, disease, and symptom characteristics predicted the initial levels and/or the characteristics of the trajectories of sleep disturbance; and compare predictors of subjective and objective sleep disturbance. Methods: Patients (n = 73) completed self-report questionnaires that assessed sleep disturbance, fatigue, depressive symptoms, anxiety, and pain before the initiation of RT through four months after the completion of RT. Wrist actigraphy was used as the objective measure of sleep disturbance. Hierarchical linear modeling was used for data analyses. Results: Mean wake after sleep onset was 11.9% and mean total score on the General Sleep Disturbance Scale was 45. More than 85% of the patients had an abnormally high number of nighttime awakenings. Substantial interindividual variability was found for both objective and subjective measures of sleep disturbance. Body mass index predicted baseline levels of objective sleep disturbance. Comorbidity, evening fatigue, and depressive symptoms predicted baseline levels of subjective sleep disturbance, and depressive symptoms predicted the trajectory of subjective sleep disturbance. Conclusion: Different variables predicted sleep disturbance using subjective and objective measures. The slightly elevated wake after sleep onset found may be an underestimation of the degree of sleep disturbance when it is evaluated in the context of the high number of nighttime awakenings and patient's perception of poor sleep quality and quantity.

Abstract

Hepcidin regulation is linked to both iron and inflammatory signals and may influence iron loading in nonalcoholic steatohepatitis (NASH). The aim of this study was to examine the relationships among HFE genotype, serum hepcidin level, hepatic iron deposition, and histology in nonalcoholic fatty liver disease (NAFLD). Single-nucleotide polymorphism genotyping for C282Y (rs1800562) and H63D (rs1799945) HFE mutations was performed in 786 adult subjects in the NASH Clinical Research Network (CRN). Clinical, histologic, and laboratory data were compared using nonparametric statistics and multivariate logistic regression. NAFLD patients with C282Y, but not H63D mutations, had lower median serum hepcidin levels (57 versus 65 ng/mL; P = 0.01) and higher mean hepatocellular (HC) iron grades (0.59 versus 0.28; P < 0.001), compared to wild-type (WT) subjects. Subjects with hepatic iron deposition had higher serum hepcidin levels than subjects without iron for all HFE genotypes (P < 0.0001). Hepcidin levels were highest among patients with mixed HC/reticuloendothelial system cell (RES) iron deposition. H63D mutations were associated with higher steatosis grades and NAFLD activity scores (odds ratio [OR], ≥1.4; 95% confidence interval [CI]: >1.0, ≤2.5; P ≤ 0.041), compared to WT, but not with either HC or RES iron. NAFLD patients with C282Y mutations had less ballooning or NASH (OR, ≤0.62; 95% CI: >0.39, <0.94; P ≤ 0.024), compared to WT subjects. Conclusions: The presence of C282Y mutations in patients with NAFLD is associated with greater HC iron deposition and decreased serum hepcidin levels, and there is a positive relationship between hepatic iron stores and serum hepcidin level across all HFE genotypes. These data suggest that body iron stores are the major determinant of hepcidin regulation in NAFLD, regardless of HFE genotype. A potential role for H63D mutations in NAFLD pathogenesis is possible through iron-independent mechanisms.

Abstract

Objective: To determine the incidence and risk factors for maternal morbidity during childbirth hospitalization. Methods: Maternal morbidities were determined using ICD9-CM and vital records codes from linked hospital discharge and vital records data for 1,572,909 singleton births in California during 2005-2007. Socio-demographic, obstetric and hospital volume risk factors were estimated using mixed effects logistic regression models. Results: The maternal morbidity rate was 241/1000 births. The most common morbidities were episiotomy, pelvic trauma, maternal infection, postpartum hemorrhage and severe laceration. Preeclampsia (adjusted odds ratio [AOR]: 2.96; 95% confidence interval 2.8,3.13), maternal age over 35 years, (AOR: 1.92; 1.79,2.06), vaginal birth after cesarean, (AOR: 1.81; 1.47,2.23) and repeat cesarean birth (AOR: 1.99; 1.87,2.12) conferred the highest odds of severe morbidity. Non-white women were more likely to suffer morbidity. Conclusions: Nearly one in four California women experienced complications during childbirth hospitalization. Significant health disparities in maternal childbirth outcomes persist in the USA.

Abstract

Objective: This project describes the development and testing of the actual scope of nursing practice questionnaire. Background: Underutilization of the skill sets of registered nurses (RNs) is a widespread concern. Cost-effective, safe, and efficient care requires support by management to facilitate the implementation of nursing practice at the full scope. Methods: Literature review, expert consultation, and face validity testing were used in item development. The instrument was tested with 285 nurses in 22 medical units in 11 hospitals in Canada. Results: The 26-item, 6-dimension questionnaire demonstrated validity and reliability. The responses suggest that nurses practice at less than their optimal scope, with key dimensions of professional practice being implemented infrequently. Conclusions: This instrument can help nurse leaders increase the effective use of RN time in carrying out the full scope of their professional practice.

Abstract

Objective: We sought to identify the characteristics of patients who experience medical emergency team calls in the radiology department (MET-RD) and the relationship between these characteristics and patient outcomes. Design/participants: Retrospective review of 111 inpatient MET-RD calls (May 2008eApril 2010). Setting: Academic medical centre with a well established MET system. Measurements: The characteristics of patients before, during and after transport to radiology were extracted from medical records and administrative databases. These characteristics were compared between patients with good and poor outcomes. Main results: The majority of patients who experience MET-RD calls had a Charlson Comorbidity Index ≥4 and were from non-intensive care units (60%). Almost half (43%) of MET-RD calls occurred during patients'first day in hospital. Patients commonly arrived with nasal cannula oxygen (38%), recent tachypnoea (28%) and tachycardia (34%). A minority (16%) fulfilled MET call criteria in the 12 h before the MET-RD. MET-RD etiologies were cardiac (41%), respiratory (29%) or neurological (25%), and occurred most frequently during CT (44%) and MRI (22%) testing. Post METRD, the majority of patients (70%) required a higher level of care. Death before discharge (25%) was associated with need for cardiovascular support prior to RD transport (p=0.02), need for RD monitoring (p=0.02) and need for heightened RD surveillance (p=0.04). Conclusions: The majority of patients who experienced MET-RD calls came from non-intensive care units, with comorbidities and vital sign alterations prior to arrival at the RD. Risk appeared to be increased for those requiring CT and MRI. These findings suggest that prior identification of a subset of patients at risk of instability in the RD may be possible.

Abstract

Vitamin E was recently shown to improve hepatic histology in a randomized controlled trial of pioglitazone or vitamin E for nonalcoholic steatohepatitis (PIVENS). The current study utilized samples collected in the PIVENS trial to identify: (1) baseline metabolomic profiles that could identify who would respond to vitamin E treatment and (2) end of treatment metabolomic profiles reflective of histologic improvement. A comprehensive analysis of metabolomics profiles (n = 547) quantified by mass spectrometry was performed in vitamin E responders (n = 16), vitamin E non-responders (n = 15), and placebo responders (n = 15). At baseline, phenyl-propionic acid (Odds ratio: 29.4, p<0.01), indole-propionic acid levels (Odds ratio: 16.2, p<0.01) were directly associated with a subsequent histologic response to vitamin E treatment whereas γ-carboxyethylhydroxychroman (CEHC) levels were inversely related to histologic response. Adjusting for baseline values by analysis of covariance, the end of treatment levels of gamma-glutamyl leucine (Fold change: 0.82, p<0.02) and gamma-glutamyl valine (Fold change: 0.8, p<0.03) were significantly lower in vitamin E responders compared to non-responders. The levels of gamma-glutamyl transpeptidase were not significantly different across the two groups. Subjects receiving placebo who demonstrated a histologic improvement also demonstrated lower levels of gamma-glutamylated amino acids (leucine, valine and isoleucine) compared to vitamin E non-responders. These data provide exploratory proof that there are measurable differences in the metabolic profile of subjects who are likely (vs unlikely) to respond to vitamin E treatment for NASH and in those experiencing histologic improvement (vs no improvement) on treatment and support further studies to validate these biomarkers.

Abstract

Qualitative data was collected from Mexican-American (MA) and Puerto Rican (PR) breast cancer survivors to gain their perspectives on the relevant issues surrounding breast cancer survivorship and exercise. Six focus groups, a total of 31 participants were convened (three in Puerto Rico and three in Texas). Responses were analyzed and compared between the MA and PR groups. Follow-up sessions were conducted at the sites to review the initial results and to validate a culturally adapted exercise intervention trial. A total of 900 responses were catalogued into 27 codes. Both groups had similar descriptions of exercise and barriers to exercise. Both groups expressed lack of information regarding their exercise capabilities. The groups differed in their responses to perceived safety in their community and how to deliver a culturally adapted exercise intervention in their community. We found important cultural differences and similarities in relevant factors of exercise and breast cancer survivorship.

Abstract

Introduction. Circumcision among adult men has been widely promoted as a strategy to reduce human immunodeficiency virus (HIV) transmission risk. However, much of the available data derive from studies conducted in Africa, and there is as yet little research in the Caribbean region where sexual transmission is also a primary contributor to rapidly escalating HIV incidence. Aim. In an effort to fill the void of data from the Caribbean, the objective of this article is to compare history of sexually transmitted infections (STI) and HIV diagnosis in relation to circumcision status in a clinic-based sample of men in Puerto Rico. Methods. Data derive from an ongoing epidemiological study being conducted in a large STI/HIV prevention and treatment center in San Juan in which 660 men were randomly selected from the clinic's waiting room. Main Outcome Measures. We assessed the association between circumcision status and self-reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit. Results. Almost a third (32.4%) of the men were circumcised (CM). Compared with uncircumcised (UC) men, CM have accumulated larger numbers of STI in their lifetime (CM=73.4% vs. UC=65.7%; P=0.048), have higher rates of previous diagnosis of warts (CM=18.8% vs. UC=12.2%; P=0.024), and were more likely to have HIV infection (CM=43.0% vs. UC=33.9%; P=0.023). Results indicate that being CM predicted the likelihood of HIV infection (P value=0.027). Conclusions. These analyses represent the first assessment of the association between circumcision and STI/HIV among men in the Caribbean. While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection. Findings suggest the need to apply caution in the use of circumcision as an HIV prevention strategy, particularly in settings where more effective combinations of interventions have yet to be fully implemented.

Abstract

Hereditary haemorrhagic telangiectasia (HTT) is a vascular dysplasia syndrome caused by mutations in transforming growth factor-β/bone morphogenetic protein pathway genes, ENG and ACVRL1. HTT shows considerable variation in clinical manifestations, suggesting environmental and/or genetic modifier effects. Strain-specific penetrance of the vascular phenotypes of Eng+/- and Tgfb1-/- mice provides further support for genetic modification of transforming growth factor-β pathway deficits. We previously identified variant genomic loci, including Tgfbm2, which suppress prenatal vascular lethality of Tgfb1-/- mice. Here we show that human polymorphic variants of PTPN14 within the orthologous TGFBM2 locus influence clinical severity of HTT, as assessed by development of pulmonary arteriovenous malformation. We also show that PTPN14, ACVRL1 and EFNB2, encoding EphrinB2, show interdependent expression in primary arterial endothelial cells in vitro. This suggests an involvement of PTPN14 in angiogenesis and/or arteriovenous fate, acting via EphrinB2 and ACVRL1/activin receptor-like kinase 1. These findings contribute to a deeper understanding of the molecular pathology of HTT in particular and to angiogenesis in general.

Abstract

An important domain that emerged from the interpretation of 91 nurse manager (NM) narratives was achieving the right relationship between a NM and a recalcitrant staff member. This article depicts the qualitative distinctions in 2 stages of NM practice to show the importance of reflection on experiential learning in the development of expertise. This work confirms that NM development is more complex than teaching a curriculum of business and management theory and should include teaching for mastery of the skilled know-how of clinical leadership practice and formation of the person as manager.

Abstract

Background: This pilot study examines whether a novel diabetes screening approach using gingival crevicular blood (GCB) could be used to test for hemoglobin A1c (HbA1c) during periodontal visits. Methods: Finger-stick blood (FSB) samples from 120 patients and GCB samples from those patients with adequate bleeding on probing (BOP) were collected on special blood collection cards and analyzed for HbA1c levels in a laboratory. The Pearson correlation coefficient was used to measure correlation between FSB and GCB HbA1c values for 75 paired FSB and GCB samples. A receiver-operator characteristic curve (ROC) analysis was performed to determine an optimal GCB HbA1c criterion value for a positive diabetes screen. Results: For the 75 paired samples, the Pearson correlation coefficient was 0.842. The ROC analysis identified a criterion value of 6.3% for the GCB HbA1c test with high sensitivity (0.933) and high specificity (0.900), corresponding to FSB HbA1c values ≥6.5% (in the diabetes range). Using this GCB HbA1c criterion value for 27 additional paired samples, in which there was an unidentified component observed to coelute within the elution window of GCB HbA1c in the laboratory, there was agreement between FSB and GCB values for 24 of the pairs according to whether both were within or outside of the diabetes range. Conclusion: Using a criterion value of 6.3%, GCB samples are acceptable for HbA1c testing to screen for diabetes in most persons with BOP at the GCB collection site.