Publications

Abstract

Familial combined hyperlipidemia (FCH) is a common genetic lipid disorder with a frequency of 1-2% in the population. In addition to the hypercholesterolemia and/or hypertriglyceridemia that affected individuals exhibit, small, dense LDL particles and decreased HDL-cholesterol levels are traits frequently associated with FCH. Recently, we reported that families with FCH and families enriched for coronary artery disease (CAD) share genetic determinants for the atherogenic lipoprotein phenotype (ALP), a profile presenting with small, dense LDL particles, decreased HDL-cholesterol levels, and increased triglyceride levels. Other studies in normolipidemic populations have shown that the hepatic lipase (HL) gene is linked to HDL- cholesterol levels and that a polymorphism within the HL promoter (-514C→T) is associated with increased HDL-cholesterol levels as well as larger, more buoyant LDL particles. In the present study, we tested whether the HL, gene locus also contributes to ALP in a series of Dutch FCH families using nonparametric sibpair linkage analysis and association analysis. Evidence for linkage of LDL particle size (P < 0.019), HDL-cholesterol (P < 0.003), and triglyceride levels (P < 0.026) to the HL gene locus was observed. A genome scan in a subset of these families exhibited evidence for linkage of PPD (LOD = 2.2) and HDL-cholesterol levels (LOD = 1.2) to the HL gene locus as well. The -514C→T promoter polymorphism was significantly associated (P < 0.0001) with higher HDL-cholesterol levels in the unrelated males of this population, but not in unrelated females. No association was observed between the polymorphism and LDL particle size or triglyceride levels. Our results provide support that ALP is a multigenic trait and suggest that the relationship between small, dense LDL particles, HDL-cholesterol, and triglyceride levels in FCH families is due, in part, to common genetic factors.

Abstract

Communication about health issues such as HIV/AIDS is essential for people, especially women, to obtain the social support they need either to prevent illness or manage it. This article compares the kinds of HIV-related issues that HIV positive and HIV negative substance-abusing women (N=211) in New York City talk about with various types of supporters. Despite the stigma associated with AIDS and their unconventional lifestyles, both groups of women talked to a broad spectrum of supporters about a variety of HIV-related issues, though this was more the case for HIV positive women. Although the main topic that both groups discussed with their supporters was their HIV status, the women also talked about risk reduction, their supporters' HIV status, HIV testing, how to live with AIDS, information about H/V/AIDS, and the emotional impact of AIDS (e.g., fear of infection, reactions to learning test results, and the impact of knowing others who have died from the disease).

Abstract

The experts concluded that current data show that the average nurse staffing levels (for RNs, LVN/LPNs, and NAs) in nursing homes are too low in some facilities to provide high quality of care. Caregiving, the central feature of a nursing home, needs to be improved to ensure high quality of care to residents. Because detailed time studies have not been conducted on the amount of time that is required to provide high quality of care to residents, expert opinion is currently the best approach to addressing the problem of inadequate staffing. Increases in the education level and training of nursing staff are also strongly recommended as a step to improving quality of care and reducing turnover rates in nursing homes. These recommendations are designed for consideration by Congress, HCFA regulators, policymakers, nursing home administrators, and nurses. Ideally, Congress would pass legislation establishing these recommendations as minimum standards for all nursing homes or direct HCFA to establish detailed minimum nurse staffing standards to ensure that staffing levels take into account the number and the case-mix of the residents. Alternatively, HCFA could introduce minimum staffing standards through the regulatory process. In 1999 there were a number of efforts at the state level to increase minimum staffing levels. Mohler (1999) surveyed selected states and found that 21 states had either proposed new legislation or were considering proposals for new legislation or new regulations. In California, for example, in 1999 the state budget approved $31 million in new state funds (to be matched with $31 million in federal Medicaid dollars) to increase nursing home staffing minimum requirements from 2.8 to 3.2 hr per resident day and to increase wage rates. Overall, nursing facilities need to be held accountable by HCFA for providing adequate levels and types of staffing to meet the needs of their residents, especially because government is paying for 61% of the expenditures. Adopting these minimum standards will have an important impact on improving the quality of the nation's nursing home care. Additional research is needed to determine appropriate levels and types of staff to provide high quality of care to residents. These studies could test the proposed staffing standards against existing staffing levels to examine the impacts on quality. As new data become available on staffing levels, revisions of staffing standards should be made if necessary to ensure that high standards are maintained.

Abstract

A descriptive design with repeated measures was used to describe patterns of fatigue, emotional stress, and left ventricular (LV) function among 22 patients with myocardial infarction (MI) from day 5 postadmission to day 21 postadmission for the MI. The severity of fatigue in patients with MI during the subacute period ranged from 32 to 44 on the 100-mm Visual Analogue Scale for Fatigue. Severity of fatigue and depression remained the same; however, LV function improved (p < .01) and patients experienced more energy (p < .01) and less anxiety (p < .01) in the third week following MI. Researchers observed five different fatigue patterns: decreasing fatigue, increasing fatigue, unchanged low fatigue, unchanged-high fatigue, and a curvilinear fatigue pattern. The finding of five different fatigue patterns after an MI suggests that all patients with MI should not be treated as a uniform group assumed to have decreasing fatigue with the passage of time.

Abstract

OBJECTIVE: To search for novel genes contributing to adiposity in familial combined hyperlipidemia (FCH), a disorder characterized by abdominal obesity, hyperlipidemia and insulin resistance, using a 10 cM genome-wide scan. DESIGN: Plasma leptin and soluble tumor necrosis factor receptor superfamily members 1A and 1B (sTNFRSF1A and sTNFRSF1B, also known as sTNFR1 and sTNFR2) were analyzed as unadjusted and adjusted quantitative phenotypes of adiposity, in addition to body mass index (BMI), in multipoint and single-point analyses. In the second stage of analysis, an important chromosome 1 positional candidate gene, the leptin receptor (LEPR), was studied. SUBJECTS: Eighteen Dutch pedigrees with familial combined hyperlipidemia (FCH) (n=198) were analyzed to search for chromosomal regions harboring genes contributing to adiposity. RESULTS: Multipoint analysis of the genome scan data identified linkage (log of odds, LOD, 3.4) of leptin levels to a chromosomal region defined by D1S3728 and D1S1665, flanking the leptin receptor (LEPR) gene by approximately 9 and 3 cM, respectively. The LOD score decreased to 1.8 with age- and gender-adjusted leptin levels. Notably, BMI also mapped to this region with an LOD score of 1.2 (adjusted BMI: LOD 0.5). Two polymorphic DNA markers in LEPR and their haplotypes revealed linkage to unadjusted and adjusted BMI and leptin, and an association with leptin levels was found as well. In addition, the marker D8S1110 showed linkage (LOD 2.8) with unadjusted plasma concentrations of soluble TNFRSF1A. BMI gave a LOD score of 0.6. Moreover, a chromosome 10q-ter locus, AFM198ZB, showed linkage with adjusted BMI (LOD 3.3). CONCLUSION: These data provide evidence that a human chromosome 1 locus, harboring the LEPR gene, contributes to plasma leptin concentrations, adiposity and body weight in humans affected with this insulin resistant dyslipidemic syndrome. Novel loci on chromosome 8 and 10qter need further study.

Abstract

During the past two decades, the drive to rein in rising health care costs has shifted some of the power in health care policy making from professional groups, government agencies, and not-for-profit health care organizations to large for-profit corporations (1-4). This has been a worldwide phenomenon, as the provision and financing of health care services is shifted from governments to private health care organizations (5,6). In the United States, the shift in power is manifested in profound ways. Market competition and bottom-line economics have permeated the health care system, creating powerful new incentives for mergers, other corporate restructuring, and the shift to for-profit status by formerly not-for-profit insurance companies and providers. Private sector health care is now increasingly influenced by for-profit organizations (3). Moreover, the health insurance industry has been transformed as traditional indemnity insurance is replaced by versions of managed care. The role of government, or the public sector, in setting parameters for health care financing and standards for the delivery of health care services is increasingly outpaced in cost cutting by organizations that directly face the bottom line. In addition, private foundations, many of which are under the auspices of managed care organizations, now fund a large proportion of health care research and demonstration projects, a task once largely within the realm of the government. Through education and experience, nurses have developed political sophistication and understanding of policy making in the public sector (7). The challenge now is to educate nurses to adapt their political and policy strategies to the new health care milieu. This challenge is particularly crucial for advanced practice nurses, who must survive in a managed care environment.

Abstract

PURPOSE The purpose of this study was to assess the health-promoting practices of young black women at risk for type 2 diabetes. METHODS The sample consisted of 30 black women from an urban area who had a history of gestational diabetes and/or a first-degree relative with diabetes. Participants completed the Health-Promoting Lifestyle Profile II Survey and an interview. Both were used to categorize health-promoting practices, exercise, diet, knowledge of diabetes prevention, and general health. RESULTS Demographic information and interview revealed a propensity towards obesity, despite education and income levels. The results for the Lifestyle II Survey showed a higher average total score for healthy nutrition than physical activity, which were inconsistent with the qualitative data obtained by interview. Fifty percent stated that they exercised as a general health-promoting behavior. Self-reported daily caloric, fiber, and fat intake was high to moderate; 60% reported initiating diet modifications secondary to a desire to lose weight or for medical problems; and 26% reported receiving information on diabetes prevention from a healthcare provider. CONCLUSIONS A systematic approach of planning and actively incorporating health-promoting activities into one's lifestyle as a young adult may protect or delay the onset of diabetes and prevent complications.

Abstract

Hildegard Peplau is remembered by nurses worldwide as the mother of psychiatric nursing. Her scope of influence transcended her psychiatric nursing specialty and had a profound effect on the nursing profession, nursing science, and nursing practice. Peplau played a leadership role by influencing and emphasizing the advancement of professional, educational, and practice standards, and the importance of professional self-regulation through credentialing. She made a major contribution to nursing science, professional nursing, and, of course, to the psychiatric nursing specialty through development of the Interpersonal Relations paradigm, a mid-range theory that has influenced the importance ivith ivhich the nurse-patient relationship is regarded. The essential nature of the nursepatient relationship and its significance as a therapeutic modality operationalizes Peplau's scholarship and provides the basis for both the art and science of nursing practice. Peplau would challenge psychiatric nurses to thrive in the new millennium through continued commitment to the importance of the nurse-patient relationship, engagement in evidence-based practice, support of competence in information technology, and provision of leadership in influencing, the health care paradigm shift to com-munity-based health care delivery.

Abstract

Background: This study reflects an attempt to identify the causes of diarrheal illness in hospitalized HIV patients in light of therapeutic advancements in HIV management. Methods: The study identifies the various etiologies associated with diarrhea among HIV patients hospitalized in New York State in 1998. Data for this study were extracted from the New York State Department of Health Statewide Planning and Research Cooperative System. Pathogens recognized to cause diarrhea in persons with HIV and general codes identifying diarrhea were examined by using the principal and all secondary diagnoses based on the International Classification of Diseases 9th Revision Clinical Modification codes. Results: Based on the Statewide Planning and Research Cooperative System data set, more than 15,000 patients with HIV were hospitalized in 1998. Among the HIV patients hospitalized, 2.8% were admitted with a diarrheal diagnosis. The following diagnoses occurred the most frequently among HIV patients hospitalized with a diarrheal illness: Clostridium difficile (51.3%), other protozoal diseases (18.1%), and other organisms, not elsewhere specified (11.7%). Conclusions: In the era of highly active antiretroviral therapy, diarrhea is still an occurring symptom in HIV patients. Despite the relatively small percentage of hospitalizations attributed to diarrhea, clinicians must remember that even 'mild' to 'moderate' diarrhea can have a debilitating impact among persons with the symptom.

Abstract

The past decade has witnessed pronounced changes in the organization of United States hospitals, many the direct result of restructuring and re-engineering initiatives intended to decrease costs and increase productivity. Little is known about how these initiatives have affected clinical care and patient outcomes. Using data from a variety of sources, the authors describe initiatives that hospitals undertook during this period, discuss how nurse staffing changed relative to the case mix of patients receiving care, and examine changes in nursing practice environments from 1986 to 1998.

Abstract

Familial combined hyperlipidemia (FCHL) is the most commonly inherited hyperlipidemia in man, with a frequency of ±1% in the general population and ~10% in myocardial infarction survivors. A genomic scan in 18 Dutch FCHL families resulted in the identification of several loci with evidence for linkage. One of these regions, 1p36.2, contains TNFRSF1B which encodes one of the tumor necrosis factor receptors. An intron 4 polymorphic CA-repeat was used to confirm linkage to FCHL. Linear regression analysis using 79 independent sib pairs showed linkage with a quantitative FCHL discriminant function (P = 0.032), and, borderline, with apolipoprotein B levels (P = 0.064). Furthermore, in a case-control study, association was demonstrated since the overall CA-repeat genotype distribution was significantly different among 40 unrelated FCHL patients and 48 unrelated healthy spouse controls (P=0.029). This difference was due to a significant increase in allele CA271 homozygotes in the FCHL patients (P = 0.019). Mutation analysis of exon 6 in 73 FCHL family members demonstrated the presence of a single nucleotide polymorphism with two alleles, coding for methionine (196M) and arginine (196R). Complete linkage disequilibrium between CA267, CA271 and CA273 and this polymorphism was detected. In 85 hyperlipidemic FCHL subjects, an association was demonstrated between soluble TNFRSF1B plasma concentrations and the CA271-196M haplotype. In conclusion, TNFRSF1B was found to be associated with susceptibility to FCHL. Our data suggest that an as yet unknown disease-associated mutation, linked to alleles 196M and CA271, plays a role in the pathophysiology of FCHL.

Abstract

Objectives To examine in-hospital mortality after acute myocardial infarction in patients with diabetes mellitus. Methods All patients in an 800-bed teaching hospital who had a discharge diagnosis of myocardial infarction, verified by creatine kinase levels at admission, between 1991 and 1993 made up the study population. All 118 such patients who died during this period made up the case group. Two control subjects (n = 236), survivors of the hospitalisation, matched by sex, age, and length of hospitalization, were selected randomly for each case. Information on the presence of diabetes mellitus, medical history, and data related to myocardial infarction were obtained through retrospective chart review. Results The mean age of all subjects in the study was 76 years. Thirty-three percent of the patients in the case group and 31% of the control subjects had a history of diabetes mellitus (odds ratio = 1.04; 95% CI, 0.64-1.70), indicating that diabetes mellitus was not associated with an increased risk of in-hospital death. The adjusted odds ratio was 1.10 (95% CI, 0.48-2.51) in patients with non-insulin-treated diabetes mellitus and 0.80 (95% CI, 0.34-1.86) in insulin-treated patients. Multivariate analysis, with conditional logistic regression, confirmed that known prognostic factors for myocardial infarction, rather than diabetic status, are predictive of in-hospital mortality. Conclusions Once the effects of age are accounted for, the risk of in-hospital mortality is not greater in patients with diabetes mellitus than in patients without diabetes; however, diabetes mellitus may be an important factor for long-term survival.

Abstract

Objectives: This study employs a sample population of older workers to estimate an empirical model of leisure exercise activity. Alternative theories relating work and leisure attitudes relevant for understanding the exercise behavior of older workers are tested empirically. Methods: Responses of 6,433 full-time older workers (51 to 61 years old) from the 1992 Health and Retirement Study (HRS) are grouped into two white-collar and blue-collar worker categories and are analyzed to test whether self-reported levels of regular physical activity are associated with the physical demands and stress associated with one's job. Results: Although the white-collar workers, whose jobs involve more physical efforts, are more likely to do light physical activity, the blue-collar workers, whose jobs are more physically demanding, tend to engage in more vigorous exercise. Discussion: The empirical results are most supportive of the generalization theory, and they also illustrate the complexity of relationships between work and leisure physical activity.

Abstract

This study evaluates the effectiveness of two strategies - communication and condom skills training - for increasing condom protected sex in a sample of 510 high-risk women ages 17 to 61. Baseline and 3- and 6-month postintervention interview data were gathered in three cities participating in a randomized trial of a six-session, group skill-building intervention. This analysis was conducted for the entire sample and for six subgroups categorized by age, single or multiple partners, and history of childhood sexual abuse. The dependent variable was the odds ratio of protected sex acts at each follow-up. Structural equation modeling was used to estimate effects for two intervention pathways. The pathway through condom skills increased the odds of protected sex for the intervention group (χ2 difference = 35, df = 2, p < .05) as well as for all subgroups. The pathways through communication were significant for the intervention group (χ2 difference = 23, df = 3, p < .05) but fully effective only for participants under 30 and participants who reported childhood sexual abuse. The effectiveness of both pathways diminished at 6 months. WINGS demonstrates that condom skills training can increase protected sex for a heterogeneous group of women. Further research needs to examine how such skill training translates into use of condoms by male partners. To increase the duration of intervention effects, booster sessions may need to be incorporated.

Abstract

The resource-based relative value scale is used to quantify work for reimbursement of services in the Medicare Fee Schedule. This pilot study explored use of the resource-based relative value scale for services provided by nurse practitioners. Estimation of relative work values for office visits by nurse practitioners was consistent with the Medicare Fee Schedule. Content analysis revealed that nurse practitioners provide additional services including comprehensive patient evaluation and education and attendance to social factors. Future research is needed to examine systems that identify and reimburse nurse practitioners for their services.