Publications

Abstract

Hepatitis C virus (HCV) is the most prevalent blood-borne infectious disease in the United States, especially among drug users, and coinfection with HIV is common. Because drug users are often medically underserved, drug treatment units are important sites of opportunity for providing services for these infectious diseases. Given the commonalities in the routes of transmission of HIV and HCV, and the fact that many drug treatment units have established an infrastructure to provide HIV services, some have suggested integrating HCV services into those already established for HIV. Using data collected in a telephone survey with 89 drug treatment units throughout the United States, this paper examines the extent to which drug treatment units have expanded their HIV services to include those for HCV, and the extent to which this expansion was facilitated by having HIV services in place. Overall, a greater proportion of methadone maintenance than drug-free treatment units provided services for HIV and HCV. The majority of units in both modalities that provided HIV- and HCV-related services expanded their HIV service delivery to include similar HCV services, and one third expanded all of their HIV services. A large number of these units, however, indicated that having an HIV service infrastructure did not facilitate this expansion, often because the units wanted to emphasize differences in the two viral infections. Policy makers and individual treatment units need to develop strategies that capitalize on existing infrastructures while maintaining the distinction between HIV and HCV primary and secondary prevention efforts.

Abstract

More than 24,000 women in the United States are diagnosed with ovarian cancer every year, and half of these women die from their disease. Stage 1 ovarian cancer is curable in 95% of cases; however, due to inadequate screening tools and lack of symptoms in early disease, ovarian cancer is generally at Stage 3 or 4 when finally diagnosed. CA125 is a tumor antigen used to monitor the progression and regression of epithelial ovarian cancer. When its levels are elevated postsurgery (hysterectomy/salpingo-oophorectomy with or without peritoneal washings and lymph node biopsy) and postchemotherapy, it is suggestive of recurrent disease. Due to its similarly elevated levels in some nonmalignant conditions, however, it is not specific enough to be used for population screening. The CA125 molecule is considered a very large glycoprotein because of its molecular weight, and it has three domains: the carboxy terminal domain, the extracellular domain, and the amino terminal domain. MUC16 is the gene that encodes the peptide moiety of the CA125 molecule. MUC16 domains provide novel opportunities to develop newassays and refine current tools to improve the sensitivity and specificity of CA125 for population-based screening guidelines.

Abstract

Over the course of addiction, a substantial proportion of drug users enter drug abuse treatment programs. Data from a cross-sectional survey of drug abuse treatment programs in the United States were analyzed to describe the scope of the medical examination performed at admission to such programs. All of the methadone programs (n = 95) and 50% of drug-free programs (80 of 161) required a medical examination at entry. Most examinations included screening for signs and symptoms of liver disease and liver function testing. Nearly all methadone programs (97%) provided referral to medical care or support for patients with test results positive for antibody to hepatitis C virus (HCV), compared with 75% of drug-free programs (P < .01). Drug-free programs requiring medical examinations provided education about HCV and testing for HCV to a larger proportion of their patients (P < .05). With high dropout rates in the early stages of treatment for drug addiction, these medical visits may be an important opportunity for further monitoring and care for HCV infection and other conditions.

Abstract

Aims. To examine factors associated with metabolic control, self-management (diet and exercise behaviour), and psychosocial adjustment (diabetes-related distress) in women with type 2 diabetes. Design. Cross-sectional design using baseline data of women with type 2 diabetes enrolled to participate in a pilot study of a nurse coaching intervention (n = 53). Ethical issues. Appropriate ethical review and approval was completed. Informed consent from participants was obtained. Outcome measures. Physiological measures included body mass index and glycosylated haemoglobin (HbA1c). Self-management measures included the Dietary Subscale of the Summary of Diabetes Self-Care Activities Questionnaire and a modified Paffenbarger Physical Activity Questionnaire. Psychosocial measures included the Problem Areas in Diabetes Survey (diabetes-related distress), the Diabetes Questionnaire, the Diabetes Self-Management Assessment Tool Support and Confidence Subscale, and the Social Functioning Scale. Descriptive, bivariate, and multivariate analyses were completed. Results. The most consistent predictor of metabolic control, dietary self-management, and diabetes-related distress was support and confidence in living with diabetes. Additionally, women had difficulty meeting optimal goals for exercise, yet reported higher levels of other physical activity. Limitations. This study was an exploratory analysis with a homogeneous sample of women with type 2 diabetes enrolled in an intervention study and measurements included multiple self-report instruments. Conclusions. Interventions to increase women's perceived self-confidence and support may contribute to positive health outcomes in women with type 2 diabetes. Relevance to clinical practice. Assessment of social support and self-confidence in diabetes self-management in women with type 2 diabetes may assist in determining individualized goals and strategies. Enhanced social support and self-confidence in diabetes self-management may subsequently improve metabolic control, self-management and psychosocial adjustment to diabetes.

Abstract

• BACKGROUND: Although nurses are ideally situated to facilitate communication about prognosis and hospice referral among patients, patients' family members, and hospital staff, nurses do not always assume this task. • OBJECTIVE: To identify common obstacles to nurses' discussions of prognosis and referral to hospice care with terminally ill patients in the hospital setting. • METHODS: Data from a previous study were analyzed. In that study, a total of 174 experienced staff nurses working full-time in hospital practice areas where terminally ill patients routinely receive care at 6 randomly selected community hospitals in Connecticut participated. Each nurse completed a self-administered, cross-sectional survey. In this study, the open-ended responses of the nurses were examined by using content analysis and descriptive analysis. • RESULTS: The most common obstacles were unwillingness of a patient or the patient's family to accept the prognosis and/or hospice, sudden death or noncommunicative status of the patient, belief of physicians' hesitance, nurses' discomfort, and nurses' desire to maintain hope among patients and patients' families. • CONCLUSIONS: The reasons for noncommunication of prognosis and referral to hospice care by nurses are complex. Because limited discussion between clinicians and patients about prognosis and treatment options can reduce the likelihood of referral to hospice care, improved communication skills may result in more referrals and a smoother transition to hospice.

Abstract

Wound care, a form of palliative care, supports the health care needs of dying patients by focusing on alleviating symptoms. Although wound care can be both healing and palliative, it can impair the quality of the end of life for the dying if it is done without proper consideration of the patient's wishes and best interests. Wound care may be optional for dying patients. This article will discuss the ethical responsibilities and challenges of providing wound care for surgical wounds, pressure ulcers, and wounds associated with cancer as well as wound care in home health compared to end of life.

Abstract

Little is known about the contribution of advanced practice nurses (APNs) to the mental health care of older adults. This study describes mental health services to older adults by APNs compared with primary care physicians, psychiatrists, psychologists, and social workers. The study uses a retrospective, cross-sectional design with a 5% national sample of 1999 Medicare outpatient claims. Bivariate statistics and multinomial logit models were used to determine differences among these mental health providers. A small proportion of the nationally available providers (10.4%) submitted claims for mental health services rendered to older adults. APNs, psychiatrists, and primary care physicians care for a disproportionate number of rural and poor older adults with complex medical/psychiatric needs compared with psychiatrists, psychologists, and social workers. APNs seem to be an untapped resource for providing mental health services to older adults. Health policy reform is needed to remove barriers to meet mental health care needs.

Abstract

Some of the highest rates of curable sexually transmitted diseases in the USA are found among adolescents. Routine, comprehensive health care that includes a sexual history may contribute to alleviating this problem. We designed and ran a three-session small-group workshop for adolescents, using local community organizations as intervention sites, with peers (typically 2-3 years older) helping facilitate the interactive sessions. Outcomes are summarized elsewhere: in this paper, we present an examination of theoretically based psychological mediating factors that we sought to influence during the intervention, Adolescents' health care-seeking beliefs, general attitudes to seeking care, and intentions to do so all changed such that they held more positive beliefs, evaluated health care more favorably, and developed stronger intentions to seek care. Furthermore, relationships among these constructs were strengthened according to theoretical precepts. Adolescents' self-efficacy and their perceptions of social norms pertaining to health care-seeking, however, were unaffected by the intervention. We explored gender differences in mediating factors, finding no interaction, although females did score higher on post-intervention attitude and intention measures.

Abstract

Migrant populations have been found to be at risk of HIV/AIDS. The growth in immigrant and migrant Hispanic populations in the United States increases the need to enhance understanding of influences on their HIV-risk behaviors. Four challenges to conducting research among these populations were identified: (1) the need to use multilevel theoretical frameworks; (2) the need to differentiate between Hispanic subgroups; (3) challenges to recruitment and data collection; and (4) ethical issues. This article describes how two studies of Hispanic immigrants and migrants in the New York area addressed these challenges. One study focused on new immigrants from Mexico, the Dominican Republic, El Salvador, Honduras and Guatemala, and a second study focused on Puerto Rican drug users. Both studies incorporated qualitative and quantitative methods to study these hard-to-reach populations. Continued study of the sociocultural and contextual factors affecting HIV risk for mobile populations, and addressing the research challenges, is crucial to developing effective intervention programs.

Abstract

Hepatitis C virus (HCV) infection is highly prevalent among drug users. While there are antiviral medications available to combat the virus, the medication regimen is quite arduous, presenting special issues for drug users. We examined the challenges and benefits of using residential substance user treatment programs as venues for clients to undergo HCV medication regimens. Analyses of qualitative data collected from clients and staff in 2003 at four residential substance user treatment programs in the U.S. indicate that challenges primarily include issues involving the medications' side effects, and both financial and communication concerns. Benefits especially involve clients' feelings that they are being proactive in addressing health issues in an environment that provides much-needed support. Findings illuminate the complex issues involved for both clients and the programs, and some steps that programs can take to better support HCV-infected clients regarding HCV medication concerns.

Abstract

Individual and maternal characteristics as potential risk factors for having severe mental retardation (SMR) occurring with and without cerebral palsy (CP), epilepsy, or a pervasive developmental disorder (PDD) were explored among a cohort of 119,404 children without Down syndrome born in the California Central Valley in 1992 and 1993. Unadjusted and adjusted relative risks (RRs) and their 95% confidence intervals (CIs) based on the Poisson distribution were used to estimate the risks associated with each individual and maternal factor studied for each SMR diagnostic category. The most notable increased risks for SMR occurring in isolation or with CP or epilepsy was for children born low-birth-weight or preterm who were at a substantially increased risk (RRs 2.6-9.9). In contrast, the risk of SMR occurring with a PDD was the greatest among males compared to females (RR = 3.4, 95% CI 1.5, 7.9), Blacks compared to Whites (RR = 5.1, 95% CI 1.7, 15.5), and Asians compared to Whites (RR = 3.9, 95% CI 1.3, 12.0). Etiologic heterogeneity when SMR occurs with a PDD was suggested.

Abstract

Homelessness has been associated with levels of stress beyond the normal strain of living in poverty. For mothers who are homeless, support from their social networks may provide a buffer from some of the stresses associated with being homeless. To better understand the relationship between social support and female-headed homeless families, an integrative review was conducted of 12 research articles that compare social support among low-income housed mothers and homeless mothers, using guidelines set forth by Ganong. The included studies revealed four significant attributes of social support among housed and homeless mothers: size of the social support network; composition of the social support network; contacts with members of the social support network; and perceived support from members of the social support network. Nurses who work with homeless families are in a position to help develop ways for these families to cultivate and maintain their social support networks while homeless. Nurses can be available to offer support, including the necessary mental health services or referrals.

Abstract

Medication administration is an essential component of quality child care, and nurses play a central role in assuring high-quality training of child care providers. Through key informant interviews and review of public documents, this case study explored the development of state statutes and regulations for medication administration training of child care providers in the state of Connecticut, nursing liability issues related to the definition of this activity, and the role of the Connecticut State Board of Examiners for Nursing. This article also examines the interpretation of the nursing role within this context as delegation versus professional activity and the impact of such designation on nursing practice, child care providers’ access to medication administration training by nurses, and children’s health status in child care settings. As a result of this case study, the Connecticut State Board of Examiners for Nursing revised its policies, demonstrating an exemplar linkage among research, practice, and policy.

Abstract

Background. "Telephone tag" for questions about postoperative symptoms and other concerns often engenders dissatisfaction. E-mail use may improve communication between patients and clinicians. This study aimed to describe surgeons' and nurses' use of E-mail with patients and their caregivers after head and neck cancer surgery. Methods. We conducted a cross-sectional national survey of head and neck nurses and surgeons. Results. Ninety-six percent of surgeon and 87% of nurse respondents used E-mail, but only 40% and 25%, respectively, used it with patients. More than 50% of both clinician groups that used E-mail with patients have done so for 2 to 5 years and began this practice at the request of patients. Surgeons not using E-mail with patients were twice as likely as nurses to cite privacy and liability issues, as well as time management and miscommunication concerns. Conclusions. Some clinicians use E-mail with patients, most often by patient request. Medicolegal and clinical ramifications require further study.

Abstract

Academic exchanges between the U.S. and other countries around the world are increasing and teaching students abroad is part of this trend. China is in its initial stage of developing gerontology education and is in great need of new concepts and ideas for dealing with its rapidly aging population. This paper discusses the challenges and rewards of teaching gerontology to health care professionals in China. To achieve the desired learning outcomes in another country requires culturally appropriate course materials and teaching methods; drawing on students' knowledge and expertise by using an interactive format and gaining students' respect.

Abstract

The objective of this study was to determine the direct cost of HIV adherence support programmes participating in a cross-site evaluation in the US. Data on the frequency, type, and setting of adherence encounters; providers' professions; and adherence tools provided were collected for 1,122 patients enrolled in 13 interventions at 9 sites. The site staff estimated the average duration of each type of encounter and national wage rates were used for labour costs. The median (range) adherence encounters/year among interventions was 16.5 (4.3-104.6) per patient; encounters lasted 24.6 (8.9-40.9) minutes. Intervention direct cost was correlated with the average frequency of encounters (r = 0.57), but not with encounter duration or providers' professions. The median direct cost/month was $35 ($5-$58) per patient, and included direct provider costs (66%); incentives (17%); reminders and other tools (8%); and direct administrative time, provider transportation, training, and home delivery (9%). The median direct cost/month from a societal perspective, which includes patient time and travel costs, was $47 ($24-$114) per patient. Adherence interventions with moderate efficacy costing ≤$100/month have been estimated to meet a cost-effectiveness threshold that is generally accepted in the US. Payers should consider enhanced reimbursement for adherence support services.