Publications

Abstract

Objective To describe maternity nurses' perspectives on how they contribute to safety during labour and birth at two urban academic medical centres in the United States. Design Grounded theory: data were collected using semistructured, open-ended interviews and participant observations with registered nurses (RNs) in two inpatient maternity settings. Data were analysed simultaneously using constant comparison, and dimensional and situational analysis. Participants Purposive sample of 12 RNs working in the two maternity units. Findings Safety was broadly conceptualised by RNs as protecting the physical, psychological and emotional wellbeing of a woman and her family. During labour and birth, safety was maintained by RNs through "skilful anticipation" of situational potential. This required integration of medical and technical knowledge and skill with intimate knowledge of the woman and the operational context of care to achieve accurate situation awareness and appropriate future planning. Conditions and processes promoting skilful anticipation included being prepared, knowing, and envisioning the whole picture. Conclusions In the two settings, maternity RNs made active contributions to safe birth in the context of constrained resources through preparing the environment, anticipating potential problems and trapping errors before they reached the patient. The contributions of maternity nurses to team situation awareness and to creating safety need to be appreciated and administratively supported. Continued research with RNs may reveal previously unrecognised opportunities for safety improvements.

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This study investigated a potential independent association between hypovitaminosis D and suspected nonalcoholic fatty liver disease (NAFLD) in a nationally representative sample of the US adolescents. Data from 1630 subjects 12-19 years of age were examined using the National Health and Nutrition Examination Survey, 2001-2004. The vitamin D status of subjects was categorized into quartiles of serum 25-hydroxyvitamin D. Subjects with serum ALT>30 U/L were classified as having suspected NAFLD. Data regarding age, sex, race, BMI, and poverty level were also analyzed in bivariate and multivariate analyses using SAS and SUDAAN software. Suspected NAFLD was identified in 12.1% of adolescents in the lowest quartile compared to 6.9% of adolescents in the second quartile, 8.0% in the third quartile, and 13.17% in the highest quartile of serum 25(OH)D concentrations (P=.05). In analyses utilizing vitamin D as a continuous variable, no independent association was found between Vitamin D levels and rates of elevated ALT levels. In multivariate analyses, higher risks for suspected NAFLD were observed in males and overweight adolescents; however, vitamin D status was not found to be independently associated with suspected NAFLD after adjusting for obesity.

Abstract

Purpose: Aging is associated with losses in hearing and vision. The objective of this study was to assess whether aging also is associated with less ability to detect and interpret afferent physiological information.Design: A cross-sectional mixed methods study was conducted with 29 persons with a confirmed diagnosis of chronic heart failure of at least 6 months duration. The sample was divided at the median to compare younger (<73 years) versus older (≥73 years) patients in the ability to detect and interpret their heart failure symptoms.Methods: Shortness of breath was stimulated using a 6-minute walk test (6MWT) and used to assess the ability of heart failure patients to detect shortness of breath using the Borg measure of perceived exertion compared with gold standard ratings of each person's shortness of breath by trained registered nurse research assistants (inter-rater congruence 0.91). Accuracy of ratings by older patients was compared with those of younger patients. In-depth interviews were used to assess symptom interpretation ability.Findings: Integrated quantitative and qualitative data confirmed that older patients had more difficulty in detecting and interpreting shortness of breath than younger patients. Older patients were twice as likely as younger to report a different level of shortness of breath than that noted by the registered nurse research assistants immediately after the 6MWT.Conclusions: These results support our theory of an age-related decline in the ability to attend to internal physical symptoms. This decline may be a cause of poor early symptom detection.Clinical Relevance: The results of this study suggest that there is a need to develop interventions that focus on the symptom experience to help patients-particularly older ones-in somatic awareness and symptom interpretation. It may be useful to explore patients' statements about how they feel: " Compared to what? How do you feel today compared to yesterday?"

Abstract

BACKGROUND: Data on the quality of life (QOL) of children with non-alcoholic fatty liver disease (NAFLD) are needed to estimate the true burden of illness in children with NAFLD.AIM: To characterize QOL and symptoms of children with NAFLD and to compare QOL in children with NAFLD with that in a sample of healthy children.METHODS: Quality of life and symptoms were assessed in children with biopsy-proven NAFLD enrolled in the NASH Clinical Research Network. PedsQL scores were compared with scores from healthy children. For children with NAFLD, between-group comparisons were made to test associations of demography, histological severity, symptoms and QOL.RESULTS: A total of 239 children (mean age 12.6 years) were studied. Children with NAFLD had worse total (72.8 vs. 83.8, P < 0.01), physical (77.2 vs. 87.5, P < 0.01) and psychosocial health (70.4 vs. 81.9, P < 0.01) scores compared with healthy children. QOL scores did not significantly differ by histological severity of NAFLD. Fatigue, trouble sleeping and sadness accounted for almost half of the variance in QOL scores. Impaired QOL was present in 39% of children with NAFLD.CONCLUSIONS: Children with NAFLD have a decrement in QOL. Symptoms were a major determinant of this impairment. Interventions are needed to restore and optimize QOL in children with NAFLD.

Abstract

Conducting qualitative interviews with seriously ill individuals about end-of-life issues is challenging for interviewers seeking to understand the problems, processes, and experiences individuals undergo when faced with death and dying. Although all qualitative interviewers face issues of building trust and obtaining answers to their research questions, these issues are exacerbated for interviewers of end-of-life issues due to the challenges of debilitated participants, sensitive subject matter, and heightened emotionalism. The purpose of this article is to offer field-tested techniques to tailor basic interviewing practices for discussions of end-of-life issues with seriously ill individuals. Use of tailored techniques facilitates the comfort of both interviewer and participant and enhances the probability of obtaining complete and accurate data, which in turn can improve the effectiveness of subsequent programs, policies, and clinical practice based on research findings.

Abstract

Objectives: The bidirectional relationship between periodontitis and diabetes suggests that the dental visit may offer a largely untapped opportunity to screen for undiagnosed diabetes. To better examine this potential opportunity, data from the National Health and Nutrition Examination Survey (NHANES) 2003-2004 were used to determine if a larger proportion of patients with periodontal disease as compared with those without periodontitis would be recommended for screening according to American Diabetes Association (ADA) guidelines. The data were also used to determine whether at-risk individuals with periodontitis visited a dental professional recently, so that they could avail themselves of this opportunity for screening, if offered. Methods: Data to perform these analyses were collected from 2,923 subjects aged 20 and older who reported that they were never told that they had diabetes, had a periodontal examination, and had sufficient data to compute body mass index. Descriptive statistics, t-tests, and chi-square analyses that compared those with and without periodontitis were extrapolated to the US population. Results: A total of 62.9 percent of those without periodontitis and 93.4 percent of those with periodontal disease met ADA guidelines for diabetes screening. Of those at-risk with periodontal disease, 33.9 percent had seen a dentist in the past 6 months, 50 percent in the past year, and 60.4 percent in the past 2 years. Conclusions: As almost all individuals with periodontitis would have been recommended for diabetes screening, and many at-risk persons with periodontal disease recently visited a dentist, our data suggest that the dental visit provides an important potential venue for this screening.

Abstract

An 11-week culturally relevant group diabetes self-management training (DSMT), coping skills training (CST), and diabetes care intervention was compared to a 10-week usual diabetes education and diabetes care intervention on physiological and psychosocial outcomes in 109 Black women (aged 48 ± 10 years) with type 2 diabetes in primary care (PC). Strong time effects for hemoglobin A1c improvement were seen in both groups from baseline to 3 months and remained similar at 12 and 24 months (p <. 0001). Systolic blood pressure (p = .01) and low-density lipoprotein cholesterol levels (p = .05) improved in both groups from baseline to 24 months. Baseline quality of life ([QOL]; Medical Outcome Study Short Form-36) was low. Social function, role-emotional, and mental health domains increased initially in both groups then declined slightly, with less decline for the experimental group at 12 months. At 24 months, experimental group scores increased. General health (p = .002), vitality (p = .01), role-physical, and bodily pain (p = .02) domains increased in both groups over time. Perceived provider support for diet (p = .0001) and exercise (p = .0001) increased in both groups over time. Diabetes-related emotional distress decreased in the experimental compared to the control group (group × time, p = .01). Findings suggest that both methods of diabetes education combined with care can improve metabolic control, QOL, and perceptions of provider care. CST may further assist in long-term improvements in health outcomes. Behavioral interventions are needed in addition to routine diabetes care, particularly in PC.

Abstract

Objective: To describe prenatal weight gain and postpartum loss patterns among Hispanic women receiving prenatal care at an urban community health center by language preference. Methods: Data were abstracted from medical records of prenatal patients seen from 2000-2008. Included were self-identified Hispanic women, English- or Spanish-speaking, aged 16-40 years, with weight measured at ≤13 and at >37 weeks gestation. Women with preexisting diabetes, hypertension, gestational diabetes, pre-eclampsia, multiple gestation, or pretermdelivery were excluded. Bivariate (t-test, chi-square) and multivariate regression (linear, polychotomous logistic) statistics were used in the analysis. Results: Of 259 women who met eligibility criteria, 52 (20.1%) were primarily Spanish speakers. Overall, 43.6% exceeded prenatal weight gain recommendations; 30.8% of Spanish speakers vs 46.9% of English speakers (P=.07). Among normal-weight women, Spanish speakers gained below and English speakers gained above that recommended (P=.03). At late postpartum, 22.9% overall returned to their baseline body mass index (BMI ±0.5 kg/m2); Spanish speakers retained 1.21 vs 1.53 kg/m2 among English speakers, which was not statistically significant. Adjusting for baseline BMI, age, and smoking status, language preference was not associated with prenatal weight gain or postpartum weight retention. In adjusted models, being overweight at baseline was predictive of excessive prenatal weight gain (OR 2.12, 95%CI .99, 4.53; P=.05); older age was protective for postpartum weight retention (OR .90; 95% CI .82, .98; P=.02). Conclusions: Adherence to prenatal weight gain guidelines was poor and few women returned to their baseline weight at late postpartum, regardless of language preference.

Abstract

Background. Despite recent advances in breast cancer treatment, breast cancer related lymphedema (BCRL) continues to be a significant problem for many survivors. Some BCRL risk factors may be largely unavoidable, such as mastectomy, axillary lymph node dissection (ALND), or radiation therapy. Potentially avoidable risk factors unrelated to breast cancer treatment include minor upper extremity infections, injury or trauma to the arm, overuse of the limb, and air travel. This study investigates how providing information about BCRL affects the cognitive and symptomatic outcome of breast cancer survivors. Methods. Data were collected from 136 breast cancer survivors using a Demographic and Medical Information interview instrument, a Lymphedema Education Status interview instrument, a Knowledge Test for cognitive outcome, and the Lymphedema and Breast Cancer Questionnaire for symptom outcome. Data analysis included descriptive statistics, t tests, chi-square (χ2) tests, and regression. Results. BCRL information was given to 57% of subjects during treatment. The mean number of lymphedema-related symptoms was 3 symptoms. Patients who received information reported significantly fewer symptoms and scored significantly higher in the knowledge test. After controlling for confounding factors, patient education remains an additional predictor of BCRL outcome. Significantly fewer women who received information about BCRL reported swelling, heaviness, impaired shoulder mobility, seroma formation, and breast swelling. Conclusions. Breast cancer survivors who received information about BCRL had significantly reduced symptoms and increased knowledge about BCRL. In clinical practice, breast cancer survivors should be engaged in supportive dialogues so they can be educated about ways to reduce their risk of developing BCRL.

Abstract

Introduction: We studied the relationship between registered nurses' extended work duration with adverse events and errors, including needlestick injuries, work-related injuries, patient falls with injury, nosocomial infections, and medication errors. Method: Using bivariate and multivariate logistic regression, this secondary analysis of 11,516 registered nurses examined nurse characteristics, work hours, and adverse events and errors. Results: All of the adverse event and error variables were significantly related to working more than 40 hours in the average week. Medication errors and needlestick injuries had the strongest and most consistent relationships with the work hour and voluntary overtime variables. Discussion: This study confirms prior findings that increased work hours raise the likelihood of adverse events and errors in healthcare, and further found the same relationship with voluntary overtime. Impact on Industry: Legislation has focused on mandatory overtime; however, this study demonstrated that voluntary overtime could also negatively impact nurse and patient safety.

Abstract

Overview: Inpatient palliative care teams' (PCT) contribution to improved quality of life and patient satisfaction as well as decreased utilization and costs has been well established. Yet few studies have examined the specific effect of an inpatient PCT on discharge disposition, despite evidence of an association between hospice enrollment, decreased rehospitalization, and improved resource utilization. Methods: Patients admitted to a large nonprofit multisite hospital between June 2004 and December 2007 and seen by the PCT were matched to usual care (UC) patients on age, mortality risk, prior year hospitalized days, and disease severity. Discharge disposition and demographic factors were abstracted from hospital administrative claims; mortality data was collected from the social security death index. Analyses were performed using Wilcoxon's test, χ2 analysis, and multinomial logit regression. Results: Three hundred sixty-one matched pairs were available for analysis. Compared to UC, patients who received a PCT consultation were 3.24 times more likely to be discharged to hospice (p< 0.0001), 1.52 times more likely to be discharged to a nursing facility, and 1.59 times more likely to be discharged home with services (p< 0.001), controlling for patient demographics and disease severity. PCT patients were also referred to hospice earlier in their disease trajectory, rather than in the last few weeks of life. Conclusion: Patients receiving an inpatient PCT consultation are more likely to receive follow-up services upon discharge from the hospital. These services likely contribute to better quality of care and financial benefits, and warrants further study, especially considering the current focus on health care efficiency and quality.

Abstract

Purpose: This ethnography was done to explore the meaning of illness in Korean Americans with chronic hepatitis B. Methods: The participants were 6 patients with chronic hepatitis B and 6 general informants who could provide relevant data. Data were collected from iterative fieldwork with ethnographic interviews within Korean communities in two cities in the United States. Data were analyzed using causal chain analysis developed by Wolcott. Results: The analyses revealed three meanings for the illness: hidden disease, intentionally hidden disease, and inevitably hidden disease. The contexts of meaning of illness included characteristics of the illness, social stigma, structure of health care system and communication patterns and discourse between health care providers and clients. Conclusion: The meaning of illness was based on folk illness concepts and constructed in the sociocultural context. Folk etiology, pathology and interpretation of one's symptoms were factors influencing illness behavior. These findings could be a cornerstone for culture specific care for Korean Americans with chronic hepatitis B.

Abstract

The Sustainability Budgeting Model (SBM) is presented in the context of a department of nursing of a major hospital. If successfully incorporated in the department of nursing, the SBM can easily be moved into the larger hospital context. The SBM was designed recognizing the three necessary components underlying all budgeting models. The SBM incorporates the inherent variability of the resource inflows and outflows and in that sense is robust; it is recommended these resource flows be calibrated for the various time horizons using the standard Present Value model so as to provide comparability across projects. Most importantly, the SBM focuses on financial sustainability considering all the relevant costs - variable and fixed - and so speaks to longterm coordinated planning and continuation of desired patient services.

Abstract

From 2005 to 2008, the Bienvenidos Project trained Puerto Rican patients of New York City and New Jersey Methadone Maintenance Treatment Programs to conduct peer-based community outreach to migrant Puerto Rican drug users to reduce migrants' HIV risk behaviors. Ethnographic research, including focus groups, individual interviews, and observations, was conducted with a subset of the patients trained as peers (n 49; 67 male; mean age 40.3 years) to evaluate the self-perceived effects of the intervention. Results of the ethnographic component of this study are summarized. The role of ethnographic methods in implementing and evaluating this kind of intervention is also discussed.

Abstract

Background: Fatigue is a significant problem associated with radiation therapy (RT). Objective: This study examined how evening and morning fatigue changed from the time of simulation to 4 months after the completion of RT and investigated whether specific demographic and disease characteristics and baseline severity of symptoms predicted the initial levels of fatigue and characteristics of the trajectories of fatigue. Methods: Seventy-three women with breast cancer completed questionnaires that assessed sleep disturbance, depression, anxiety, and pain prior to the initiation of RT and the Lee Fatigue Scale, over 6 months. Descriptive statistics and hierarchical linear modeling were used for data analysis. Results: Large amounts of interindividual variability were found in the trajectories of fatigue. Evening fatigue at baseline was negatively influenced by having children at home and depression. The trajectory of evening fatigue was worse for women who were employed. Morning fatigue at baseline was influenced by younger age, lower body mass index, and the degree of sleep disturbance and trait anxiety. Trajectories of morning fatigue were worse for patients with a higher disease stage and more medical comorbidities. Conclusion: Interindividual and diurnal variability in fatigue found in women with breast cancer is similar to that found in men with prostate cancer. However, the predictors of interindividual variability in fatigue between these 2 cohorts were different. Implications for Practice: Diurnal variability and different predictors for morning and evening fatigue suggest different underlying mechanisms. The various predictors of fatigue need to be considered in the design of future intervention studies.

Abstract

Objective: The objective of this study was to test the hypothesis that sexual risk behavior would increase following initiation of antiretroviral therapy (ART) in Kenyan female sex workers (FSWs). Design: Prospective cohort study. Setting: FSW cohort in Mombasa, Kenya, 1993-2008. Subjects: Eight hundred and ninety-eight women contributed HIV-1-seropositive follow-up visits, of whom 129 initiated ART. Intervention: Beginning in March 2004, ART was provided to women qualifying for treatment according to Kenyan National Guidelines. Participants received sexual risk reduction education and free condoms at every visit. Main Outcome Measures: Main outcome measures included unprotected intercourse, abstinence, 100% condom use, number of sexual partners, and frequency of sex. Outcomes were evaluated at monthly follow-up visits using a 1-week recall interval. Results: Compared with non-ART-exposed follow-up, visits following ART initiation were not associated with an increase in unprotected sex [adjusted odds ratio (AOR) 0.86, 95% confidence interval (CI) 0.62-1.19, P = 0.4]. There was a nonsignificant decrease in abstinence (AOR 0.81, 95% CI 0.65-1.01, P = 0.07), which was offset by a substantial increase in 100% condom use (AOR 1.54, 95% CI 1.07-2.20, P = 0.02). Numbers of sex partners and frequency of sex were similar before versus after starting ART. A trend for decreased sexually transmitted infections following ART initiation provides additional support for the validity of the self-reported behavioral outcomes (AOR 0.67, 95% CI 0.44-1.02, P = 0.06). Conclusion: In the setting of ongoing risk reduction education and provision of free condoms, initiation of ART was not associated with increased sexual risk behavior in this cohort of Kenyan FSWs.

Abstract

BACKGROUND: Whether triglyceride-mediated pathways are causally relevant to coronary heart disease is uncertain. We studied a genetic variant that regulates triglyceride concentration to help judge likelihood of causality.METHODS: We assessed the -1131T>C (rs662799) promoter polymorphism of the apolipoprotein A5 (APOA5) gene in relation to triglyceride concentration, several other risk factors, and risk of coronary heart disease. We compared disease risk for genetically-raised triglyceride concentration (20,842 patients with coronary heart disease, 35,206 controls) with that recorded for equivalent differences in circulating triglyceride concentration in prospective studies (302 430 participants with no history of cardiovascular disease; 12,785 incident cases of coronary heart disease during 2.79 million person-years at risk). We analysed -1131T>C in 1795 people without a history of cardiovascular disease who had information about lipoprotein concentration and diameter obtained by nuclear magnetic resonance spectroscopy.FINDINGS: The minor allele frequency of -1131T>C was 8% (95% CI 7-9). -1131T>C was not significantly associated with several non-lipid risk factors or LDL cholesterol, and it was modestly associated with lower HDL cholesterol (mean difference per C allele 3.5% [95% CI 2.6-4.6]; 0.053 mmol/L [0.039-0.068]), lower apolipoprotein AI (1.3% [0.3-2.3]; 0.023 g/L [0.005-0.041]), and higher apolipoprotein B (3.2% [1.3-5.1]; 0.027 g/L [0.011-0.043]). By contrast, for every C allele inherited, mean triglyceride concentration was 16.0% (95% CI 12.9-18.7), or 0.25 mmol/L (0.20-0.29), higher (p=4.4x10(-24)). The odds ratio for coronary heart disease was 1.18 (95% CI 1.11-1.26; p=2.6x10(-7)) per C allele, which was concordant with the hazard ratio of 1.10 (95% CI 1.08-1.12) per 16% higher triglyceride concentration recorded in prospective studies. -1131T>C was significantly associated with higher VLDL particle concentration (mean difference per C allele 12.2 nmol/L [95% CI 7.7-16.7]; p=9.3x10(-8)) and smaller HDL particle size (0.14 nm [0.08-0.20]; p=7.0x10(-5)), factors that could mediate the effects of triglyceride.INTERPRETATION: These data are consistent with a causal association between triglyceride-mediated pathways and coronary heart disease.FUNDING: British Heart Foundation, UK Medical Research Council, Novartis.

Abstract

Background. Antiretroviral scale-up is increasing in resource-constrained settings. To date, few studies have explored the barriers and facilitators of adherence to ART in these settings. Facilitators and barriers of antiretroviral adherence in Peru are not completely understood. Methods. At two clinics that serve a large number of HIV-positive individuals in Lima, Peru, 31 in-depth interviews were carried out in 2006 with adult HIV-positive individuals receiving ART. Purposive sampling was used to recruit the participants. Interviews were transcribed and coded using two Spanish-speaking researchers and a content analysis approach to identify themes in the data. Results. Among the participants, 28/31 (90%) were male, 25/31 (81%) were self-identified as mestizo, and 19/31 (61%) had an education above high school. The most frequently discussed barriers to adherence included side effects, simply forgetting, inconvenience, dietary requirements, being away from home, and fear of disclosure/stigma. The most frequently discussed facilitators to adherence included having a fixed routine, understanding the need for compliance, seeing positive results, treatment knowledge, and faith in treatment. Conclusions. Overall, these findings were similar to the facilitators and challenges experienced by individuals on ART in other resource constrained settings. Further treatment support tools and networks should be developed to decrease the challenges of ART adherence for HIV-positive individuals in Lima, Peru.