Publications

Abstract

Background: Metabolic syndrome is a combination of risk factors for cardiovascular disease and diabetes, It has been reported to be increased in human immunodeficiency virus (HIV)-infected individuals. Methods: In a cohort of HIV-infected adults we examined parameters that contribute to defining the metabolic syndrome and to estimating the 10-year risk of coronary heart disease (CHD). The study group consisted of 296 participants (217 men and 79 women) of mixed ethnicity with a mean age of 45.3 years. Results: There was an appreciable prevalence of metabolic syndrome (30.0%), with the frequency increasing to 42.5% in those over 50 years of age. Those with the metabolic syndrome had a lower viral load. More women had abdominal obesity (59.5%) than men (20.7%, P < 0.001). The frequency of elevated plasma glucose was higher in females (37.2%) compared to males (16.9%, P = 0.004). High frequencies of decreased high-density lipoprotein cholesterol (HDL-C) and elevated blood pressure were seen in both sexes. Hypertriglyceridemia was less prevalent in African Americans. In those under 50 years of age, the 10-year CHD risk score for men was double that for women (6.2% vs 2.7%, P < 0.001). In older participants, the risk was similar between the sexes, with a third having scores over 10%. Conclusions: The prevalence of metabolic syndrome was higher than in most other HIV cohorts. Those with the syndrome had significantly lower viral loads. Mean 10-year Framingham Cardiovascular Risk (FCR) scores were nearly doubled for those with metabolic syndrome. Both researchers and clinicians should consider age as well as sex when assessing patients with HIV infection for risks associated with metabolic syndrome.

Abstract

This article describes the work experience of a national cohort of 229 RNs who participated in a survey on work environment at two different time periods. Survey results of the RNs’ experience within two and a half years of their initial RN licensure (time period two) are described in detail, and comparisons are made to their experiences one year earlier (time period one). Using Krippendorff’s technique for content analysis, six inter-related themes emerged at time period two. Findings indicate that the working environment of RNs impacts both nurses’ satisfaction and their dissatisfaction. Factors associated with dissatisfaction center on the lack of nurse manager leadership, persistent verbal abuse, high patient-to-nurse ratios, and the physical demands of bedside nursing that result in injuries. Suggestions from the nurses themselves are used to guide strategies to improve the work environment and retain nurses.

Abstract

Background: Quality improvement (QI) is a focus of hospital managers and policymakers. The role of registered nurses (RNs) in QI in hospitals is vital because most hospital-based RNs provide direct care to patients. QI skills are necessary to identify gaps between current care and best practice and to design, implement, test, and evaluate changes and are essential for R.N.s to participate effectively in QI. Newly licensed registered nurses' (new nurses') positions as direct caregivers could have an impact on QI if nurses lack sufficient knowledge, concepts, and tools required for QI. Methods: Data came from the 436 respondents (69.4% response rate) to a 2008 eight-page mailed survey to participants in a nationally representative panel survey of new nurses who graduated between August 1, 2004, and July 31, 2005. Results: Overall, 159 (38.6%) of new nurses thought that they were "poorly" or "very poorly" prepared about or had "never heard of" QI. Their perceptions of preparation varied widely by the specific topic. Baccalaureate (B.S.) graduates reported significantly higher levels of preparation than associate degree (A.D.) graduates in evidence-based practice; assessing gaps in practice, teamwork, and collaboration; and many of the research-type skills such as data collection, analysis, measurement, and measuring resulting changes. Discussion: Registered-nurse educational programs need to improve education about and application of QI concepts and to consider focusing QI content into a separate course to have some confidence that faculty will teach it. Despite the strong focus on QI in hospitals, new nurses do not see the connection between QI education and successfully performing their hospital jobs. Both nursing programs and hospitals should help new nurses make the connection.

Abstract

The purpose of this article was to describe the next-of-kin's perspective of the end-of-life (EOL) experiences associated with the death of a family member or close friend. The quality of EOL care from the next-of-kin's perspective given to their loved one needs further study in the context of a community setting focus. A secondary analysis of data from a survey of a random sample of dying experiences in the community setting included qualitative descriptive analysis of open-ended survey data and content analysis used to count the number of positive, negative, mixed, and not applicable responses. Qualitative content analysis of 186 next-of-kin responses revealed two themes: (1) communication and (2) family values and preferences including three subthemes of having a supportive environment to secure a peaceful death with dignity and respect, the desire to be present at the time of death, and attending to the needs and wishes of the dying individual and family. The need for palliative care services in institutionalized settings, continuity of provider care (physician and nurse), family presence, and support for caregiver and financial concerns with hospice services was identified. Communication remains an essential component in all aspects of EOL care with further examination involving the loved one's perspectives.

Abstract

Background: Surveillance studies have noted intravenous injection of promethazine hydrochloride (PHC) among populations that use heroin in south and southeast Asia. However, little is known about onset and initiation of PHC use and its relationship to habitual heroin use. Methods: As part of a longitudinal study of heroin initiation, a sample of 179 new heroin users, aged 15-27 years, were interviewed between October 2005 and December 2006 in Hanoi, Vietnam. Cox proportional hazard regression analysis was used to characterize age at promethazine initiation and its association with relevant covariates. Results: 76% reported lifetime use of PHC. Mean age of PHC initiation was 21.3 years, on average 6 months following onset of heroin injection. In multivariate analysis, lifetime use of diazepam [HR = 1.69 (1.17, 2.44); p-value = .01] and injecting heroin for more than 1.58 years [HR = 1.46 (1.04, 2.06); p-value = .03] were associated with PHC initiation. Conclusion: Intravenous injection of PHC is a relatively common practice among young injection heroin users in Hanoi, Vietnam who use it on a situational basis to substitute for heroin (when heroin is not available or when heroin is too costly) or to augment the effects of an inadequate heroin dosing (delaying onset of heroin withdraw). Existing drug prevention strategies in Vietnam are focused primarily on heroin and most new heroin users initiate PHC use without prior knowledge of its high risk for serious vein damage. Future research is needed on the PHC use among heroin users, including long-term medical consequences of PHC exposure.

Abstract

We explored the relationship between nurse burnout and ratings of quality of care in 53,846 nurses from six countries. In this secondary analysis, we used data from the International Hospital Outcomes Study; data were collected from 1998 to 2005. The Maslach Burnout Inventory and a single-item reflecting nurse-rated quality of care were used in multiple logistic regression modeling to investigate the association between nurse burnout and nurse-rated quality of care. Across countries, higher levels of burnout were associated with lower ratings of the quality of care independent of nurses' ratings of practice environments. These findings suggest that reducing nurse burnout may be an effective strategy for improving nurse-rated quality of care in hospitals. 2010 Wiley Periodicals, Inc.

Abstract

Aim: This paper is a report of a study of the relationship between work environment characteristics and neonatal intensive care unit nurses' perceptions of care rationing, job outcomes, and quality of care. Background: International evidence suggests that attention to work environments might improve nurse recruitment and retention, and the quality of care. However, comparatively little attention has been given to neonatal care, a specialty where patient and nurse outcomes are potentially quite sensitive to problems with staffing and work environments. Methods: Over a 6-month period in 2007-2008, a questionnaire containing measures of work environment characteristics, nursing care rationing, job satisfaction, burnout and quality of care was distributed to 553 nurses in all neonatal intensive care units in the province of Quebec (Canada). Results: A total of 339 nurses (61·3%) completed questionnaires. Overall, 18·6% were dissatisfied with their job, 35·7% showed high emotional exhaustion, and 19·2% rated the quality of care on their unit as fair or poor. Care activities most frequently rationed because of insufficient time were discharge planning, parental support and teaching, and comfort care. In multivariate analyses, higher work environment ratings were related to lower likelihood of reporting rationing and burnout, and better ratings of quality of care and job satisfaction. Conclusion: Additional research on the determinants of nurse outcomes, the quality of patient care, and the impact of rationing of nursing care on patient outcomes in neonatal intensive care units is required. The Neonatal Extent of Work Rationing Instrument appears to be a useful tool for monitoring the extent of rationing of nursing care in neonatal units.

Abstract

Background: Previous studies suggest that obesity is associated with higher prostate cancer progression and mortality despite an association with lower prostate cancer incidence. This study aims to better understand these apparently inconsistent relationships among obese men by combining evidence from 3 nationally representative cross-sectional surveys. Methods: We evaluated relationships between obesity and 1) testosterone concentrations in the Third National Health and Nutrition Examination Survey (NHANES III; n = 845); 2) prostate-specific antigen (PSA) in NHANES 2001-2004 (n = 2458); and 3) prostate biopsy rates in the National Health Interview Survey (NHIS 2000; n = 4789) population. Mean testosterone, PSA concentrations, and biopsy rates were computed for Body Mass Index (BMI) categories. Results: Testosterone concentrations were inversely associated with obesity (P-trend <.0001) in NHANES III. In NHANES 2001-2004, obese (BMI >35) versus lean (BMI <25) men were less likely to have PSA concentrations that reached the biopsy threshold of >4 ng/mL (3% vs 8%; P <.0001). Among NHIS participants, all BMI groups had similar rates of PSA testing (P = .24). However, among men who had PSA tests, 11% of men with BMI >30 versus 16% with BMI <25, achieved a PSA threshold of 4 ng/mL; P = .01. Furthermore, biopsy rates were lower among men with BMI >30 versus BMI <25 in NHIS participants (4.6% vs 5.8%; P = .05). Conclusions: Obesity was associated with lower PSA-driven biopsy rates. These data support further studies to test the hypothesis that obesity affects prostate cancer detection independent of prostate cancer risk by decreasing the PSA-driven biopsy rates.

Abstract

This discussion focuses on the difference between educational objectives and outcomes. Both terms are used in nursing education, many times for the same purpose, yet they are expressions of different educational paradigms. A historical view of the development of objectives and outcomes is provided as well as a description of each.The discussion concludes with a demonstration of formats for developing educational outcomes.

Abstract

This review offers an analysis of practice overlap between physicians and registered nurses (RNs) who are not advanced practice nurses. Additionally, it spotlights opportunities for expanding traditional professional boundaries to establish novel care delivery models. The examples of RN role expansion offer a beginning for discussion regarding how the health professionals' knowledge and skills can be best used in designing an effective and efficient health care system. Although limited data exist on cost effectiveness and workload implications of the novel care delivery models, policy makers can use the findings of this review to begin to inform U.S. health care reform.

Abstract

This qualitative study explored partner selection in a sample ofimmigrant Latino men who have sex with men (MSM). In-depth interviews were conducted with men living in the greater New York metropolitanarea who had been born in Brazil (n = 10), Colombia (n = 14), or the Dominican Republic (n = 9). One focus group was conducted with MSM from each of the three countries (9 Brazilian, 11 Colombian, and 5 Dominican participants). A grounded theory approach revealed three main themes relating to partner selection. The first concerned stereotypes of how Latino and Anglo-American men tendtobehaveintheir sexualencounters and relationships. The participants perceived Latinos to be more affectionate and passionate, whereas they saw Anglo-American men as more independent and practical. These cultural discrepancies sometimes resulted in a preference for Latino partners. A second theme concerned stereotypes of the national groups, including expectations that Brazilians would be sexy and sensual and that Dominicans would have large penises. As found in other research on MSM of color, ethnic and national stereotypes were associated with experiences of sexual objectification. The third theme addressed the importance of masculine characteristics in sexual attraction and partner selection. Negative feelings towards effeminate men who did not conform to normative male physical or behavioral presentation reflect a stigma found inside and outside of the gay community. These findings suggest that gender and ethnic stereotypes play an important role in shaping partner choice and have implications for sexual risk and relationship formation.

Abstract

Communication and teamwork problems are leading causes of documented preventable adverse outcomes in perinatal care. An essential component of perinatal safety is the organizational culture in which clinicians work. Clinicians' individual and collective authority to question the plan of care and take action to change the direction of a clinical situation in the patient's best interest can be viewed as their "agency for safety." However, collective agency for safety and commitment to support nurses in their role of advocacy is missing in many perinatal care settings. This article draws from Organizational Accident Theory, High Reliability Theory, and Symbolic Interactionism to describe the nurse's role in maintaining safety during labor and birth in acute care settings and suggests actions for supporting the perinatal nurse at individual, group, and systems levels to achieve maximum safety in perinatal care.

Abstract

BACKGROUND: The impact of personal, organizational, and economic factors on nurses' job satisfaction have been studied extensively, but few studies exist in which the effects of physical work environment-including perceptions of architectural, interior design, and ambient features on job satisfaction-are examined. OBJECTIVES: The purpose of this study was to examine the effect of perceived physical work environment on job satisfaction, adjusting for multiple personal, organizational, and economic determinants of job satisfaction. METHODS: A cross-sectional, predictive design and a Web-based survey instrument were used to collect data from staff registered nurses in a large metropolitan hospital. The survey included 34 questions about multiple job satisfaction determinants, including 18 Likert-type measures with established good validity (comparative fit index = .97, Tucker-Lewis index = .98, root mean square error of approximation = .06) and reliability (r ≥ .70). RESULTS: A response rate of 48.5% resulted in a sample of 362, with 80% power to detect a medium effect of perceived physical environment on job satisfaction. On average, nurses had negative perceptions of physical work environment (M = 2.9, SD = 2.2). Although physical environment was related positively to job satisfaction (r =.256, p = .01) in bivariate analysis, in ordered probit regression, no effect of physical work environment on job satisfaction was found. DISCUSSION: In future studies, this relationship should be examined in larger and more representative samples of nurses. Qualitative methods should be used to explore how negatively perceived physical work environment impacts nurses. Rebuilding of U.S. hospitals, with a planned investment of $200 billion without considering how physical environment contributes to nurse work outcomes, threatens to exacerbate organizational nurse turnover.

Abstract

Purpose/Objectives: To examine how attentional fatigue changed from the time of simulation to four months after the completion of radiation therapy and to investigate whether specific variables predicted initial levels and trajectories of attentional fatigue. Design: Descriptive, longitudinal study. Setting: Two radiation therapy departments. Sample: 73 women with breast cancer who received primary or adjuvant radiation therapy. Methods: Participants completed questionnaires prior to, during, and after radiation therapy. Descriptive statistics and hierarchical linear modeling were used for data analysis. Main Research Variables: Attentional fatigue; demographic, clinical, and symptom characteristics. Findings: Large amounts of interindividual variability were found in the trajectories of attentional fatigue. At baseline, higher levels of attentional fatigue were associated with younger age, not working, a higher number of comorbidities, and higher levels of trait anxiety. The trajectory of attentional fatigue improved over time for women with higher body mass index at baseline. Conclusions: This study is the first to identify predictors of interindividual variability in attentional fatigue in women with breast cancer undergoing radiation therapy. The predictors should be considered in the design of future correlational and interventional studies. Implications for Nursing: Nurses could use knowledge of the predictors to identify patients at risk for higher levels of attentional fatigue. In addition, nurses could use the information to educate patients about how attentional fatigue may change during and following radiation therapy for breast cancer.

Abstract

Context: Fatigue and sleep disturbance are common problems in oncology patients and their family caregivers (FCs). However, little is known about factors that contribute to interindividual variability in these symptoms or to their underlying biologic mechanisms. Objectives: An evaluation was done on whether genetic variation in a prominent proinflammatory cytokine, interleukin-6 (IL-6 c.-6101A>T [rs4719714]), was associated with mean ratings of evening fatigue, morning fatigue, and sleep disturbance, as well as with the trajectories of these symptoms. Methods: Over six months, participants completed standardized measures of fatigue and sleep disturbance. Linear regression was used to assess the effect of the IL-6 genotype and other covariates on mean fatigue and sleep disturbance scores. Hierarchical linear modeling was used to determine the effect of the IL-6 genotype on symptom trajectories. Results: Common allele homozygotes reported higher levels of evening fatigue (P = 0.003), morning fatigue (P = 0.09), and sleep disturbance (P = 0.003) than minor allele carriers. Predictors of baseline level and trajectories of evening fatigue included age, gender, and genotype (intercepts) and baseline level of evening fatigue (slope). Predictors of baseline level and trajectories of morning fatigue included age and genotype (intercept) and age and baseline level of morning fatigue (slope). Predictors of baseline level and trajectories of sleep disturbance included age and genotype (intercept) and baseline level of sleep disturbance (slope). Conclusions: Findings provide preliminary evidence of a genetic association between a functional promoter polymorphism in the IL-6 gene and severity of evening fatigue, morning fatigue, and sleep disturbance in oncology patients and their FCs.

Abstract

HCV infection continues to spread at an alarming rate among IDU populations. The available evidence suggests that HCV is acquired relatively quickly following onset of injection. However, there are few prospective studies of HCV acquisition, particularly among IDU populations in resource-poor settings. A sample of young male heroin injectors with recent onset of injection (<4 years) was recruited in Hanoi, Vietnam for a prospective assessment of the early course of injection (n=179). Both behavioral and biological assessments (including detailed retrospective assessment of injection initiation) were conducted at baseline and repeated at 6-month intervals for a period of 16 months. Variables associated with HCV infection (p value<0.05) in bivariate analyses were considered for inclusion in logistic regression models to identify risk factors independently associated with HCV infection. HCV incidence was calculated by using the incidence density approach and was expressed in terms of person-years of observation. The baseline of prevalence of HCV was 46%. HCV significantly increased in relation to time since first injection, from 30% in subjects with ≤10 months of injection risk to 70% in subjects with ≥30 months injection risk (p value=0.0005). In multivariate logistic regression analysis, increasing age, incarceration in a drug detention facility (OR=2.54; 95%CI 1.05, 6.15), and time since first injection remained significantly associated with HCV infection. Use of injection as primary mode of administration (OR=2.56; 95%CI 0.98, 6.69) achieved marginal significance. After 16 months of follow-up, the incidence rate of HCV was 23.35 per 100 person-years and the mean time between first injection and first positive HCV test was 1.2 years. HCV is acquired much more rapidly among new injector populations than previously recognized, demonstrating the need for early behavioral intervention among new heroin-user populations. Particularly critical are interventions that target new heroin user populations, including interventions that improve understanding of viral transmission dynamics, that promote alternative strategies for drug sharing, and that delay initiation of injection.

Abstract

Aims/hypothesis: The aim of this study was to define the prevalence of the metabolic syndrome and its component risk factors among individuals of South Asian origin living in the United States. Methods: We analyzed baseline data from 1,445 participants enrolled in a cohort study investigating risk factors for cardiovascular disease in South Asians. We defined the metabolic syndrome using the International Diabetes Federation criteria for waist circumference (>90cm for men; >80cm, women), triglycerides (>150mg/dL), high-density lipoprotein cholesterol (HDL-C) (<40mg/dL (men), <45mg/dL (women)), blood pressure (>135/80mmHg), and fasting glucose (>100mg/dL). Results: The mean age was 43±10 years, and 30% of participants were women. The prevalence of metabolic syndrome was 27% (31% men vs. 17% women, P<0.05). Fifty-nine percent of the cohort had high waist circumference (58% men vs. 62% women, P = not significant [N.S.]), 47% had low HDL-C [46% men vs. 48% women (NS)], 19% had elevated triglycerides (23% men vs. 8% women, P<0.05), 14% had hypertension (16% men vs. 9% women, P< 0.05), and 13% had elevated fasting glucose (18% men vs. 11% women, P<0.05). The most common metabolic syndrome phenotype is low HDL-C with elevated triglycerides. Conclusions: Although the prevalence of the metabolic syndrome is lower than previous reports of South Asians, the prevalence is still unacceptably high despite the presence of protective demographic factors.

Abstract

Purpose of the Study: To examine the effects of the present on admission (POA) indicator on the prevalence of and factors associated with postsurgical adverse events in older patients. Design and Methods: This is a secondary data analysis of 82,898 surgical patients aged 65 years or older in 252 acute care hospitals in California in 2004. Four adverse events were counted using the Agency for Healthcare Research and Quality's Patient Safety Indicator (PSI) definitions with and without using the POA indicator. We also examined the effects of the POA indicator on the relationships between patient- and hospital-level factors and adverse events, using generalized linear mixed models. Results: The use of the POA indicator resulted in a marked reduction in the estimated rates of all 4 adverse event rates. Adjustment for POA conditions also influenced factors associated with adverse events. Compared with those with newly occurring adverse events only, admissions with only POA conditions were more likely to be admitted through the emergency department, be unplanned, and belong to patients with one or more preceding admissions or those with multiple admissions within the same year. Implications: Adverse event rates estimated from discharge abstracts using PSI methodology could be overstated when the POA indicator was not used. The POA indicator could influence predictors of adverse events. Studies on geriatric safety and outcomes using large administrative data sets should consider using the POA indicator. Further studies are needed on how to determine POA conditions.

Abstract

Age-related macular degeneration (AMD) is the leading cause of blindness among Americans. Local inflammation is implied in the pathophysiology of AMD that may cause photoreceptor destruction and blindness. Vitamin D may prevent AMD progression via its anti-inflammatory and antiangiogenic properties. Scientific evidence is discussed for the associations of vitamin D (serum, diet, and sunlight) and AMD. Evidence suggests inverse associations between serum vitamin D and its sources (specifically fish), and AMD. Associations with sunlight, hypothesized to increase risk for AMD, have been inconsistent possibly due to protection from vitamin D. Vitamin D may be a new protective factor against AMD.

Abstract

Chronic hepatitis B virus (HBV) infection is the leading cause of cirrhosis, liver failure, and liver cancer, and an estimated 620,000 persons die annually from HBV-related liver disease (Goldstein et al., 2005; World Health Organization, 2000). Immunization with the HBV vaccine is the most effective means of preventing HBV infection and its consequent acute and chronic liver diseases such as cirrhosis and hepatocellular carcinoma. The HBV vaccine has been used against HBV in the United States since 1982 (Centers for Disease Control and Prevention, 1982); during the last 25 years, HBV vaccine policy continued to evolve in response to public health issues and epidemiologic data. Although the number of newly acquired HBV infections has substantially declined as a result of implementation of a national immunization program, the prevalence of chronic HBV infection remains high. The purpose of this article is to review the epidemiology of HBV, provide a historical review of health policies for HBV immunization, and summarize the recent evidence-based public health guidelines for management of HBV infection in the United States.