Publications

Abstract

Although short- and long-term outcomes in individuals with DM following ACS, PCI, and CABG have improved over the past decade, CVD continues to be an important cause of morbidity and mortality in this population. Nursing has a critical role in the prevention of CVD, and in the early detection of symptomatic and asymptomatic CHD. Following ACS, PCI, or CABG, ongoing assessment for new ischemia, HF, or renal insufficiency, and specific complications of ACS or revascularization is crucial. Long-term prevention of recurrent ischemia, ACS, HF, and death necessitates multifactorial CHD risk factor reduction, along with aggressive glucose control, in all individuals with DM.

Abstract

Nurses and health care increasingly are embracing and guided by achievements and challenges of evidence-based practice and reflective practice. Nursing science advances have positioned nurses to move forward in the development of science. New directions for nursing knowledge need to emerge in several ways including the development of interdisciplinary knowledge, emphasis on the nursing care process, creation of new workforce patterns, and development of economic theories of nursing practice.

Abstract

Purpose: To discuss the pathophysiology and the current treatment approaches for the dysregulation of glucose metabolism in the context of human immunodeficiency virus (HIV) infection. Data sources: Selected research, clinical studies, clinical guidelines, and review articles. Conclusions: In HIV infection, multiple factors are associated with the pathogenesis of glucose dysregulation. Studies suggest that protease inhibitors, a class of antiretroviral agent, as well as viral factors, lipodystrophy, hepatitis C infection, injection drug use, and second-generation antipsychotics have been implicated in the development of glucose disorders and diabetes. Current treatment recommendations are based on extrapolated data from non-HIV diabetic patients. More research is needed to establish the most appropriate management for the disorders of glucose metabolism in the context of HIV infection. Implications for practice: If left untreated, patients are at increased risk for cardiovascular disease and complications associated with untreated diabetes.

Abstract

Hepatitis C virus (HCV) infection is the most common blood-borne infectious disease among drug users in the US. Drug treatment programs are ideally situated to assist their clients to obtain HCV medical and support services. Using data collected from 233 drug free and methadone maintenance treatment programs (MMTPs) throughout the US, this article examines the range of HCV services that treatment programs provide to their HCV positive clients. Findings indicate that MMTPs offer more comprehensive HCV services to more of their HCV positive clients than drug free programs, although drug free programs provide more individualized services. While 84% of the programs provided some HCV services, there are still serious gaps in the provision of these services (e.g., dealing with medical providers to obtain HCV medication and facilitating access to liver transplant lists). Drug treatment programs need increased funding and staff training to be able to provide comprehensive HCV services to their HCV positive clients.

Abstract

Objective: Associations between magnitude and timing of maternal pregnancy blood lead (Pb) levels (BLLs), birth weight, and total days of gestation were examined, as well as associations with related clinical diagnoses of low birth weight (LBW), preterm, and small-for-gestational-age (SGA) birth. Study Design: Among a sample of 262 mother-infant pairs studied retrospectively, one-way analysis of variance and regression statistics were used to measure the relationship between level of maternal pregnancy BLLs and birth outcomes while controlling for key maternal and newborn factors. Results: Women with maximum pregnancy BLLs (max-PBLLs) ≥10 μ/dl tended to give birth earlier and their babies were at substantially increased risk for preterm and SGA birth. By holding other explanatory factors constant, each unit increase in max-PBLL above 10≥ μ/dl was found to be associated with a decrease of -0.3 in total days of gestation. Compared to women with lower levels, women with max-PBLLs 10≥ μ/dl were at a threefold increased risk for preterm birth (adjusted OR = 3.2, 95% CI 1.2-7.4) and more than a fourfold increased risk for having an SGA infant (adjusted OR = 4.2, 1.3-13.9). Second trimester maximum BLLs 10≥ μ/dl were associated with a steep decrease in total days of gestation (a decrease of -1.0 days per each unit increase above 10≥ μ/dl). Conclusions: These data provide evidence of the adverse effects of maternal pregnancy BLLs, particularly when levels are 10≥ μ/dl. Prenatal Pb exposure at these levels was associated with significant decreases in total days of gestation and an increased risk of preterm and SGA birth.

Abstract

Objective: To evaluate the effects of protease inhibitors (PIs) as antiretroviral therapy in comparison with other antiretroviral (non-PI) medications on glucose tolerance, lipid metabolism, and body fat distribution in human immunodeficiency virus (HIV)-infected young patients. Methods: We conducted a cross-sectional clinical study in an outpatient HIV clinic. The study population consisted of 21 patients (15 female and 6 male) who had had at least 6 months of antiretroviral treatment. The mean age of the patients was 11.9 years (range, 6 to 16.5). Results: Fifteen patients treated with PIs and 6 patients treated with non-PIs were enrolled in the study. We found no significant differences in the lipid panel and insulin resistance, as determined by using the Quantitative Insulin Sensitivity Check Index formula, in the PI group in comparison with the non-PI group. Lipodystrophy was observed in 47% (7 of 15) of the PI group and 33% (2 of 6) of the non-PI group (P = 0.66). In the presence of lipodystrophy, serum triglyceride levels were higher in the PI group than in the non-PI group (P = 0.046). No such difference was found between the treatment groups when no lipodystrophy was present. There was no significant difference in insulin resistance between the treatment groups in the presence or absence of lipodystrophy. Conclusion: Our study found the presence of lipodystrophy in HIV-infected young patients regardless of whether they were taking PIs or not. In the patients who had lipodystrophy, those treated with PIs had higher serum triglyceride levels than those not treated with PIs.

Abstract

Even children who appear healthy can have dangerous levels of environmental toxins in their bodies. The health effects of environmental toxins, especially neurological effects, are particularly damaging to children. Environmental toxins have several similarities among them as most are neurotoxins and cannot be destroyed. Chemicals such as arsenic, PCBs, lead, and mercury will remain part of our environment for years to come. Pediatric nurse practitioners must become knowledgeable about environmental toxins and inform their families of ways to prevent exposures. Much of the information regarding environmental toxins is available via the World Wide Web. However, many Web sites for information regarding environmental toxins and other pediatric environmental health issues may not contain accurate information. Nurse practitioners should make themselves aware of Web sites for environmental toxins that contain accurate information that may be suggested to patients and their families. The Web sites for the EPA (www.epa.gov), the ATSDR (www.atsdr.cdc.gov), and the CDC (www.cdc.gov) contain accurate and current information regarding environmental toxins. These Web sites also link readers to other Web sites with reliable, valid information on environmental toxins.

Abstract

The incidence and prevalence of diabetes, particularly T2DM, is increasing both in the United States and worldwide. Identified risk factors, such as glucose intolerance, hypertension, and hyperlipidemia, often precede and accompany the diagnosis of T2DM. Further, all are associated physiologic alterations of obesity. Obesity that has grown in epidemic proportion, because of overconsumption of calories in the presence of decreased physical activity, affects greater numbers of persons including children and adolescents. National recommendations for screening and diagnosis of diabetes, hypertension, and dyslipidemia provide a basis for early detection, treatment, and intervention that may potentially decrease related complications, and personal and economic costs of the disease. Most important is that knowledge exists about who is at risk for diabetes by weight, family history of diabetes, ethnicity, and history of gestational diabetes that allows for the development and implementation of diabetes primary prevention programs. Multiple national health surveys and databases provide important information for health care providers, systems of care, and communities that can be used to guide such prevention, early screening, and disease detection and intervention programs aimed at decreasing the burden of diabetes.

Abstract

Computerized drug utilization review (DUR) can potentially reduce adverse drug events. We examined automated DUR for home healthcare patients with diabetes or hypertension. Sixty-eight percent of diabetes patients and 50.7% of hypertension patients triggered severe, moderate, or duplicative alerts. Among diabetes patients, 74.3% of duplicative alerts were trivial or inappropriate, compared with 3.9% among hypertension patients. Experts judged that 40.5% of high-risk diabetes patients and 53.6% of hypertension patients had alerts requiring nurse follow-up. Adequate follow-up was significantly lower for the former. The relationship between inappropriate alerts and poorer follow-up reinforces the need for more specific alert systems to focus clinicians' attention on clinically important alerts.

Abstract

Purpose: To examine the factors that influence the work satisfaction of a national sample of registered nurses in metropolitan statistical areas (MSAs). Design: A cross-sectional mailed survey design was used. The sample consisted of RNs randomly selected from 40 MSAs in 29 states; 1,907 RNs responded (48%). The sample of 1,538 RNs working in nursing was used for analysis. Methods: The questionnaire included measures of work attitudes and demographic characteristics. The data were analyzed using ordinary least-squares regression. Findings: More than 40% of the variance in satisfaction was explained by the various work attitudes: supervisor support, work-group cohesion, variety of work, autonomy, organizational constraint, promotional opportunities, work and family conflict, and distributive justice. RNs who were White, self-perceived as healthy, and working in nursing education were more satisfied. RNs that were more career oriented were more satisfied. Of the benefits options, only paid time off was related to satisfaction. Conclusions: Work-related factors were significantly related to RNs' work satisfaction.

Abstract

Objective. To analyze factors that are related to whether registered nurses (RNs) work (WK) or do not work (NW) in nursing; and if the RN works, whether she works full- (FT) or part-time (PT). Data Sources. Secondary data from National Sample Survey of Registered Nurses 2000 (NSSRN), the InterStudy Competitive Edge Part III Regional Market Analysis (2001), and the Area Resource File (2002). Study Design. Using a cross-sectional design we tested the relationship between WK or NW and FT or PT; and demographic, job-related, and metropolitan statistical area (MSA)-level variables. Data Collection/Extraction Methods. We combined the data sources noted above to produce the analytic sample of 25,471 female RNs. Principal Findings. Working in nursing is not independent of working FT or PT. Age (55 and older), other family income, and prior other work experience in health care are negatively related to working as an RN. The wage is not related to working as an RN, but negatively influences FT work. Age, children, minority status, student status, employment status, other income, and some job settings have a negative impact on working FT. Previous health care work has a positive effect on whether married RNs worked. Married RNs who are more dissatisfied are less likely to work FT. A greater number of market-level factors influence FT/PT than WK/NW behavior. Conclusions. An important contribution of this study is demonstrating that MSA-level variables influence RN work behavior. The market environment seems to have little effect on whether a nurse works, but is influential on how much the nurse works, and has differential effects on married versus single nurses.

Abstract

Nonalcoholic fatty liver disease (NAFLD) is a metabolic liver disease with widely variable phenotypes extending from simple steatosis, through nonalcoholic steatohepatitis (NASH) to cirrhosis and hepatocellular carcinoma. Inevitably, this reflects the interplay of well-recognized environmental factors and disease associations such as obesity and insulin resistance with host genetic factors, which are polygenic or complex in nature. Most of the observed phenotypic variability will probably be explained by variations in single nucleotide polymorphism frequency, although knowledge of the effect of most polymorphisms on biologic function is currently limited. Several observational studies of kindred with NASH suggest a genetic contribution. Most data characterizing genetic variation in different NAFLD phenotypes is derived from case-control association studies involving putative candidate genes. These candidate genes have been selected largely based upon the "two-hit hypothesis" of the pathogenesis of NAFLD, although other hypothesis-independent approaches can also be informative in gene selection. Thus far, candidate gene association studies have had significant limitations such as small cohort sizes and poor reproducibility. Rapid technologic developments are increasing the capability of detecting genetic variation. Identification of the genetic contribution to NAFLD will inform theories of disease pathogenesis and progression and ultimately improve management.

Abstract

Phospholipid transfer protein (PLTP) participates in key processes in lipoprotein metabolism, including interparticle phospholipid transfer, remodeling of HDL, cholesterol and phospholipid efflux from peripheral tissues, and the production of hepatic VLDL. The impact of PLTP on reverse cholesterol transport suggests that the gene may harbor sequence anomalies that contribute to disorders of HDL metabolism. The human PLTP gene was screened for sequence anomalies by DNA melting analysis in 276 subjects with hypoalphalipoproteinemia (HA) and 364 controls. The association with plasma lipid parameters was evaluated. We discovered 18 sequence variations, including four missense mutations and a novel polymorphism (c.-34G>C). In healthy controls, the c.-34G>C minor allele was associated with higher high density lipoprotein-cholesterol (HDL-C) and was depleted in subjects with HA. Linear regression models predict that possession of the rare allele decreases plasma triglyceride (TG) and TG/HDL-C and increases HDL-C independent of TG. Decreased PLTP activity was observed in one (p.R235W) of four (p.E72G, p.S119A, p.S124Y, and p.R235W) mutations in an in vitro activity assay. These findings indicate that PLTP gene variation is an important determinant of plasma lipoproteins and affects disorders of HDL metabolism.

Abstract

The most common form of von Willebrand disease (VWD) is reported to be type 1, accounting for as much as 80% of reported cases. With prevalence estimates as high as 1.6% in the general population, upwards of 4.5 million Americans may be affected. Unfortunately, VWD type 1 is also the most difficult type to diagnose. Despite the continuing progress in defining the genetic lesions responsible for VWD types 2 and 3, identification of the genetic determinants of VWD type 1 remains elusive. Herein the phenomenon known as VWD is summarized, the challenges associated with the diagnosis of type 1 VWD are described, and the role of genetic research in meeting these challenges is explored. The authors identify key gaps in the current genetics literature and suggest new avenues for future research. Lastly, they explore the role of nurses in this research and clinical endeavor. To the authors'knowledge, this review is the first to address these complex issues in nursing research.

Abstract

Purpose: The purpose of this descriptive study was to describe attainment of glucose and coronary heart disease (CHD) risk factor goals and to identify factors that were associated with successful goal achievement. Methods: A cross-sectional survey enrolled 110 subjects with type 2 diabetes undergoing screening for asymptomatic myocardial ischemia. Results: Many participants had HbA1c levels ≥7% (45%), and 46% to 79% were not meeting goals for CHD risk reduction. Individual factors of age, gender, and anxiety; the illness-related factor of lipid-lowering therapy; and the family-related factor of living alone were independently associated with 1 of the 7 outcomes under study. Illness-related factors of a longer duration of diabetes were strongly associated with glucose and blood pressure control, insulin use with glucose control and waist circumference, and antihypertensive use with blood pressure, triglycerides, and body mass index. Family-related factors of higher income were significantly associated with poorer glucose control and higher body mass index, while higher levels of perceived support by family and friends were associated with a lower risk of not meeting lipid goals. However, individual factors, represented by several aspects of personal model beliefs (exercising regularly, testing glucose, and checking one's feet) and physical activity, were consistently related to lipid and weight control. Conclusions: A variety of factors were associated with control of blood glucose and CHD risk factors, suggesting that a one-size-fits-all approach to multiple risk factor reduction efforts may not result in goal attainment.

Abstract

Objective: Older adults are less likely than other age groups to participate in clinical decision-making. To enhance participation, we sought to understand how older adults consider and discuss their life and health goals during the clinical encounter. Methods: We conducted six focus groups: four with community-dwelling older persons (n = 42), one with geriatricians and internists (n = 6), and one with rehabilitation nurses (n = 5). Participants were asked to discuss: patients' life and health goals; communication about goals, and perception of agreement about health goals. Group interactions were tape-recorded, transcribed, and analyzed using content analysis. Results: All participants were willing to discuss goals, but varied in the degree to which they did so. Reasons for non-discussion included that goal setting was not a priority given limited time, visits focused on symptoms, mutual perception of disinterest, and the presumption that all patients' goals were the same. Conclusion: Interventions to enhance goal setting need to address key barriers to promoting goals discussions. Participants recognized the benefits of goal setting, however, training and instruments are needed to integrate goal setting into medicine. Practice implications: Setting goals initially and reviewing them periodically may be a comprehensive, time-efficient way of integrating patients' goals into their care plans.

Abstract

Staff in drug treatment programs are in an optimal position to support the hepatitis C related needs of their patients. To do so effectively, however, staff need to have accurate information about the hepatitis C virus (HCV). This article examines the HCV knowledge of staff (N = 104) in two drug-free and two methadone maintenance treatment programs (MMTPs) in the New York metropolitan area. Five of 20 items on an HCV Knowledge Assessment were not answered correctly by the majority of the participating staff, and total scores on the Assessment averaged 70%, 71%, and 45% among the medically credentialed staff, non-medically credentialed staff in the MMTPs, and non-medically credentialed staff in the drug-free programs, respectively. The majority of those in the latter group had never participated in a training specifically devoted to HCV. Results suggest the need for effective HCV-related training for all staff in drug treatment programs.

Abstract

In recent years, CVD risk factors have been recognized among individuals living with HIV/AIDS (Dube et al., 2003) and have been associated with the medication regimen (HAART) used to manage the diseases. A specific class of HIV medication, protease inhibitors, has been implicated in elevating serum levels of triglyceride and cholesterol in treated individuals (Green, 2002; Penzak & Chuck, 2000). However, current treatments for hyperlipidemia in HIV are not always effective and can be dose-limited due to interactions with HAART regimens (Currier, 2002). Dietary guidelines by the NCEP have been recommended as the first-line approach to managing this condition. Well-controlled studies are needed to test the effectiveness of the NCEP diet on HIV-positive individuals. Published studies have focused primarily on dietary counseling and have lacked randomization, control groups, and adequate description of the counseling intervention. Because the mechanism associated with dyslipidemia and HAART is not fully understood, rigorously controlled dietary studies may provide the opportunity to investigate how diet metabolically affects lipid levels during HAART treatment.

Abstract

BACKGROUND: Changes in sexual risk behaviour may occur following HIV-1 infection. OBJECTIVE: To test the hypothesis that HIV-1 seroconversion and disease progression are associated with changes in risk behaviours, using data from a cohort of Kenyan female sex workers (FSWs). METHODS: HIV-1-seronegative FSWs were enrolled in a prospective cohort study of risk factors for HIV-1 acquisition. At monthly visits, standardized interviews were conducted to assess sexual risk behaviour and HIV-1 serologic testing was performed. Seroconverters were invited to continue with follow-up. Between 1993 and 2004 (when antiretroviral therapy was introduced in the cohort), 265 women seroconverted for HIV-1 (incidence 7.7/100 person-years) and were included in this analysis. RESULTS: Unprotected intercourse was reported at 546/2037 (27%) pre-seroconversion visits versus 557/3732 (15%) post-seroconversion visits (P < 0.001). These findings remained significant after adjustment for potential confounding factors [adjusted odds ratio (AOR) 0.69; 95% confidence interval (CI), 0.55-0.86]. Compared with HIV-1-seronegative women, there was a progressive stepwise decrease in unprotected intercourse among HIV-1-seropositive women with CD4 cell counts ≥ 500 (AOR, 0.93; 95% CI, 0.62-1.39), 200-499 (AOR, 0.58; 95% CI, 0.41-0.82) and < 200 cells/μl (AOR, 0.45; 95% CI, 0.25-0.82). Decreases in unprotected intercourse reflected increases in both abstinence and 100% condom use. Women also reported fewer partners and fewer episodes of intercourse after HIV-1 seroconversion. CONCLUSIONS: HIV-1 seroconversion and disease progression were associated with decreases in sexual risk behaviour among Kenyan FSWs.

Abstract

The purpose of this article was to synthesize the findings of six qualitative studies on homeless adolescent mothers. Metasynthesis was conducted using the meta-ethnographic approach of Noblit and Hare [Noblit, G., & Hare, R. (1988). Meta-ethnography: Synthesizing qualitative studies. Newbury Park, CA: Sage Publications]. Six reciprocal translations illuminating the experiences of homeless adolescent mothers emerged: being homeless, enduring abuse, lamenting lost years, searching for support, recreating self, and seeking a better life. The findings may be used by nurses working with this population as the basis for a framework of intervention strategies directed toward helping these mothers cope with their dual transitions into motherhood and adulthood while simultaneously being homeless.