Publications

Abstract

Background: In the United States (US), pregnancy-related mortality is 2–4 times higher for Black and Indigenous women irrespective of income and education. The integration of midwifery as a fundamental component of standard maternity services has been shown to improve health outcomes and service user satisfaction, including among underserved and minoritized groups. Nonetheless, there remains limited uptake of this model in the United States. In this study, we examine a series of interdependent factors that shape how midwifery care operates in historically disenfranchised communities within the Unites States. Methods: Using data collected from in-depth, semi-structured interviews, the purpose of this study was to examine the ways midwives recount, describe, and understand the relationships that drive their work in a publicly funded urban health care setting serving minoritized communities. Using a qualitative exploratory research design, guided by critical feminist theory, twenty full-scope midwives working in a large public health care network participated. Data were thematically analyzed using Braun & Clarke's inductive thematic analysis to interpret data and inductively identify patterns in participants’ experiences. Findings: The overarching theme “Kairos care in a Chronos World” captures the process of providing health-promoting, individualized care in a system that centers measurement, efficiency, and pathology. Five subthemes support the central theme: (1) the politics of progress, (2) normalizing pathologies, (3) cherished connections, (4) protecting the experience, and (5) caring for the social body. Midwives used relationships to sustain their unique care model, despite the conflicting demands of dominant (and dominating) medical models. Conclusion: This study offers important insight into how midwives use a Kairos approach to maternity care to enhance quality and safety. In order to realize equitable access to optimal outcomes, health systems seeking to provide robust services to historically disenfranchised communities should consider integration of relationship-based strategies, including midwifery care.

Abstract

Objective: Global migration and linguistic diversity are at record highs, making healthcare language barriers more prevalent. Nurses, often the first contact with patients in the healthcare system, can improve outcomes including safety and satisfaction through how they manage language barriers. This review aimed to explore how research has examined the nursing workforce with respect to language barriers. Methods: A systematic scoping review of the literature was conducted using four databases. An iterative coding approach was used for data analysis. Study quality was appraised using the CASP checklists. Results: 48 studies representing 16 countries were included. Diverse healthcare settings were represented, with the inpatient setting most commonly studied. The majority of studies were qualitative. Coding produced 4 themes: (1) Interpreter Use/Misuse, (2) Barriers to and Facilitators of Quality Care, (3) Cultural Competence, and (4) Interventions. Conclusion: Generally, nurses noted like experiences and applied similar strategies regardless of setting, country, or language. Language barriers complicated care delivery while increasing stress and workload. Practice Implications: This review identified gaps which future research can investigate to better support nurses working through language barriers. Similarly, healthcare and government leaders have opportunities to enact policies which address bilingual proficiency, workload, and interpreter use.

Abstract

Background: Serious illness is characterized by high symptom burden that negatively affects quality of life (QOL). Although palliative care research has highlighted symptom burden in seriously ill adults with cancer, symptom burden among those with noncancer serious illness and multiple chronic conditions has been understudied. Latent class analysis is a statistical method that can be used to better understand the relationship between severity of symptom burden and covariates, such as the presence of multiple chronic conditions. Although latent class analysis has been used to highlight subgroups of seriously ill adults with cancer based on symptom clusters, none have incorporated multiple chronic conditions. Objectives: The objectives of this study were to (a) describe the demographic and baseline characteristics of seriously ill adults at the end of life in a palliative care cohort, (b) identify latent subgroups of seriously ill individuals based on severity of symptom burden, and (c) examine variables associated with latent subgroup membership, such as QOL, functional status, and the presence of multiple chronic conditions. Methods: A secondary data analysis of a palliative care clinical trial was conducted. The latent class analysis was based on the Edmonton Symptom Assessment System, which measures nine symptoms on a scale of 0–10 (e.g., pain, fatigue, nausea, depression, anxiousness, drowsiness, appetite, well-being, and shortness of breath). Clinically significant cut-points for symptom severity were used to categorize each symptom item in addition to a categorized total score. Results: Three latent subgroups were identified (e.g., low, moderate, and high symptom burden). Lower overall QOL was associated with membership in the moderate and high symptom burden subgroups. Multiple chronic conditions were associated with statistically significant membership in the high symptom burden latent subgroup. Older adults between 65 and 74 years had a lower likelihood of moderate or high symptom burden subgroup membership compared to the low symptom burden class. Discussion: Lower QOL was associated with high symptom burden. Multiple chronic conditions were associated with high symptom burden, which underlines the clinical complexity of serious illness. Palliative care at the end of life for seriously ill adults with high symptom burden must account for the presence of multiple chronic conditions.

Abstract

This chapter addresses the rise of lifestyle medicine. The impact of chronic diseases on health and quality of life are well-known within the medical community. Preventive medicine has only been partially successful in addressing these problems. For physicians to advocate healthy lifestyle choices for their patients, they must first understand what a healthy lifestyle entails. The Six Pillars of Lifestyle Medicine outline the six main lifestyle changes—healthful eating, increasing physical activity, improving sleep, managing stress, avoiding risky substances, forming and maintaining relationships—that physicians should promote to their patients. The global public health burden of diabetes, obesity, and other lifestyle diseases is increasing at an astounding rate. However, very few training programs have robust educational offerings for physicians on nonpharmacological treatment of obesity and diabetes.

Abstract

Background: Breast cancer-related lymphedema (BCRL) limits the movements of patients' limbs, which leads to a diminished ability to achieve essential activities of daily living (ADLs). The purpose of this study was to examine the associations between limb volume changes from the baseline before breast cancer surgery and self-reported difficulty in performing ADLs at 12 months following cancer surgery. We hypothesized that a positive association existed between limb volume changes from the baseline and self-reported difficulty in performing ADLs at 12 months following breast cancer surgery. Methods and Results: The data of the present study were part of a larger study with 140 breast cancer patients recruited before breast cancer surgery and followed up during their first year of treatment. Patients with more than 10% limb volume increase reported more frequent distress in performing 13 ADL items, compared with patients whose limb volume increased by 5%-10%. Regression analysis showed a significant increase in the odds ratio of reporting difficulty in ADLs compared with the group with less than 5% limb volume increase. Conclusion: Overall, patients with a greater limb volume increase underwent more difficulty performing ADLs. Patients reported more difficulty in performing ADLs even with 5%-10% limb volume increase. Currently, there is no standardized guideline to diagnose BCRL, although previous evidence suggests a limb volume increase greater than 10% as a criterion for BCRL. The findings from the present study suggest a more precise and clinically meaningful criteria for diagnosing BCRL to accommodate those with 5%-10% increase in limb volume.

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China has experienced a substantial increase in the number of older adults with dementia and milder forms of cognitive impairment. Being spouses of Persons with cognitive impairment (PWCI) and living with them for several decades does not necessarily mean that it is easier for them to provide person-centered care and maintain a valued and healthy relationship. The current study explored how elements of PCC, as operationalized by the Senses Framework, operate or fail to operate in the dyadic experiences of PWCI and their spousal care partners within the socio-cultural context of China. Our findings suggest that PWCI and their spouses experience the six senses through the person-centeredness in their daily interactions with each other. It also indicated successes and challenges to being person-centered early in the disease and identified their unmet needs as well as barriers and facilitators to improve their well-being.

Abstract

BACKGROUND/OBJECTIVES: To better understand the role of sensory loss as a potentially modifiable risk factor for cognitive decline, this study examined cognitive decline in relation to single modality hearing or vision loss and dual sensory loss. DESIGN: Longitudinal secondary data analysis. SETTING: The Health and Retirement Study (HRS) and its supplement: The Aging, Demographics, and Memory Study (ADAMS). PARTICIPANTS: Individuals aged 73 and older (N = 295). MEASUREMENTS: Hearing loss was defined by an inability to hear sounds of 25 dB at frequencies between 0.5 and 4.0 kHz in either ear. Vision loss was defined as having corrected binocular vision worse than 20/40. Dual sensory loss was defined as having both hearing and vision loss. We used one time point of hearing and vision data objectively measured in ADAMS Wave C (June 2006–May 2008) and five waves of cognitive function data measured by the HRS version of the Telephone Interview for Cognitive Status in HRS (2006–2014). Multilevel mixed models were used. RESULTS: Among the participants, 271 completed a hearing assessment and 120 had hearing loss; 292 completed a vision assessment and 115 had vision loss; 52 had dual sensory loss. Older adults with hearing loss had a significantly faster rate of cognitive decline as they aged compared to those with normal hearing (β = −0.16, P <.05). No significant association was found between vision loss and the rate of cognitive decline (β = −0.06, P =.41). Older adults who had dual sensory loss likewise had a significantly faster rate of cognitive decline as they age (β = −0.23, P <.05) compared to those with no sensory loss. CONCLUSION: Older adults with hearing loss and dual sensory loss have faster rates of cognitive decline than those with normal sensory function.

Abstract

Existing studies addressing alcohol consumption have not captured the multidimensionality of drinking patterns, including drinking frequency, binge drinking, beverage preference and changes in these measures across the adult life course. We examined longitudinal trends in drinking patterns and their association with diet over four decades in ageing US adults from the Framingham Offspring Study (n 4956; baseline mean age 36·2 years). Alcohol intake (drinks/week, drinking frequency, beverage-specific consumption, drinks/occasion) was assessed quadrennially from examinations 1 to 8. Participants were classified as binge drinkers, moderate drinkers or heavy drinkers (4+ and 5+ drinks/occasion; ≤1 and ≤2 drinks/d and >7 and >14 drinks/week for women and men, respectively). Dietary data were collected by a FFQ from examinations 5 to 8 (1991-2008). We evaluated trends in drinking patterns using linear mixed effect models and compared dietary intake across drinking patterns using heterogeneous variance models. Alcohol consumption decreased from 1971 to 2008 (3·7 v. 2·2 oz/week; P < 0·05). The proportion of moderate (66 v. 59·3 %), heavy (18·4 v. 10·5 %) and binge drinkers (40·0 v. 12·3 %) declined (P < 0·05). While average wine consumption increased (1·4 v. 2·2 drinks/week), beer (3·4 v. 1·5 drinks/week) and cocktail intake (2·8 v. 1·2 drinks/week) decreased. Non-binge drinkers consumed less sugary drinks and more whole grains than binge drinkers, and the latter consumed more total fat across all examinations (P < 0·05). There was a significant difference in consumption trends of total grains by drinking level (P < 0·05). In conclusion, alcohol drinking patterns are unstable throughout adulthood. Higher intakes were generally associated with poorer diets. These analyses support the nuanced characterisation of alcohol consumption in epidemiological studies.

Abstract

The physician’s role is continually changing and is sure to undergo significant changes in the near future. Among many other disruptive forces, healthcare continues to become more team- and technology-based. The COVID-19 pandemic is likely to be an important turning point for the medical profession. One current issue in healthcare is physicians experiencing moral distress due to conflicts between their duty as employees and their ultimate duty to patients. Other imminent changes are coming due to incorporation of technology, in particular, artificial intelligence and telehealth. These changes can be met through the process of lifelong learning, which entails a commitment to continually improve our knowledge and skills to deliver a high standard of care.

Abstract

Background: Although many adults with diabetes are productive members of the workforce, loss of work productivity has been associated with diabetes. The purpose of this study was to explore the interrelationship between work-related factors and current work ability in adults with type 1 diabetes (T1D) and type 2 diabetes (T2D). Methods: This study used a convergent mixed-method design. We assessed the relationship between work-related factors and work ability using bivariate statistics and logistic regression. Work ability was measured using the Work Ability Index and Karasek’s Job Content Questionnaire (JCQ) was employed to measure job demands. Qualitative interviews (n = 30) explored the relationship between diabetes and work. Findings: The sample (n =101) was mostly female (65%) and White (74%). Most worked full-time (65%), had T2D (87%), an elevated glycated hemoglobin A1c ≥ 7% (56%), and were overweight (22%) or obese (68%). Only 33% of subjects self-reported their work ability as excellent. Four of the JCQ subscales (skill discretion, psychological demands, supervisor support, and coworker support), and work–life balance were significantly associated with work ability (all p <.05). In adjusted models, better coworker support (OR = 1.4; 95% CI = [1.04, 1.9]) and better work–life balance (OR = 1.3; 95% CI = [1.1, 1.5]) were associated with excellent work ability. Many stated their diabetes impacted them at work and spoke of the effects of stress. Few engaged in workplace wellness programs. Conclusion/Application to Practice: Social support and work–life balance were associated with excellent work ability. Engaging workers with diabetes in workplace educational programs may take strategic efforts by occupational health staff.

Abstract

Over a decade following the nationwide push to implement electronic health records (EHRs), the focus has shifted to addressing the cognitive burden associated with their use. Most research and discourse about the EHR's impact on clinicians' cognitive work has focused on physicians rather than on nursing-specific issues. Labor and delivery nurses may encounter unique challenges when using EHRs because they also interact with an electronic fetal monitoring system, continuously managing and synthesizing both maternal and fetal data. This grounded theory study explored labor and delivery nurses' perceptions of the EHR's impact on their cognitive work. Data were individual interviews and participant observations with twenty-one nurses from two labor and delivery units in the western U.S. and were analyzed using dimensional analysis. Nurses managed the tension between caring and charting using various strategies to integrate the EHR into their dynamic, high-acuity, specialty practice environment while using EHRs that were not designed for perinatal patients. Use of the EHR and associated technologies disrupted nurses' ability to locate and synthesize information, maintain an overview of the patient's status, and connect with patients and families. Individual-, group-, and environmental-level factors facilitated or constrained nurses' integration of the EHR. These findings represent critical safety failures requiring comprehensive changes to EHR designs and better processes for responding to end-user experiences. More research is needed to develop EHRs that support the dynamic and relationship-based nature of nurses' work and to align with specialty practice environments.

Abstract

Objective: Examine the risk of adverse perinatal outcomes among the United States (US)-born and foreign-born Black women in California. Study design: The study comprised all singleton live births to Black women in California between 2011 and 2017. We defined maternal nativity as US-born or foreign-born. Using Poisson regression, we computed risk ratios (RR) and 95% confidence intervals (CI) for three adverse perinatal outcomes: preterm birth, small for gestational age deliveries, and infant mortality. Results: Rates of adverse perinatal outcomes were significantly higher among US-born Black women. In adjusted models, US-born Black women experienced an increased risk of preterm birth (RR 1.51, 95% CI 1.39, 1.65) and small for gestational age deliveries (RR 1.52, 95% CI 1.41, 1.64), compared to foreign-born Black women. Conclusions: Future studies should consider experiences of racism across the life course when exploring heterogeneity in the risk of adverse perinatal outcomes by nativity among Black women in the US.

Abstract

This study examines mental health symptoms among Black adolescents who were currently in mental health treatment and those who were not in treatment. The study uses a sample of Black adolescents (N= 154) and logistic regression was performed to determine which psychological factors were associated with exhibiting mental health symptoms. Both groups experienced high amounts of trauma exposure history, recent suicidality, substance use, and depressive symptoms. Nearly one in four adolescents in the out of treatment group met diagnostic criteria for anxiety disorders. Implications include better screening for mental health symptoms to ensure Black adolescent have access to mental health treatment.

Abstract

Critical appraisal of randomized controlled trials (RCTs) determines rigor, quality, and whether the findings are applicable to the populations served in clinical practices. The authors conducted a rigorous analysis using the RCT Critical Appraisal Skills Programme (CASP) Checklist for the two RCTs Pfizer (New York, NY) and Moderna (Cambridge, MA) conducted and the reporting of these RCTs using the Consolidated Standards of Reporting Trials checklist. The goals for this analysis were twofold: (1) enable health care providers to understand the methods and outcomes of these RCTs, and (2) enable health care providers and community leaders to become champions for the vaccines to reduce vaccine hesitancy among all populations. The analysis is presented using each of the 11 questions on the CASP tool while comparing the methodology and results for each vaccine. Most CASP tool items were positive or yes for both the Pfizer and Moderna RCTs. Items that were not scored as yes are discussed. The analysis outcomes revealed that both RCTs were rigorously conducted and provide an assurance to all health care providers and the public of the safety and efficacy of both vaccines to impact the astounding morbidity and mortality of COVID-19 disease. The authors believed that the analysis was an essential component of the distribution process to develop plans and communication strategies to reduce potential vaccine hesitancy and resistance.

Abstract

PURPOSE OF REVIEW: To review existing mHealth-based interventions and examine their efficacy in reducing cardiovascular disease (CVD) risk factors.RECENT FINDINGS: A total of 50 articles are included in this review. The majority of the mHealth interventions targeted a specific CVD risk factor, while 4 addressed 2 or more CVD risk factors. Of the 9 mHealth-supported weight loss intervention trials, 4 resulted in significant weight loss. Four out of 7 RCTs targeting improvement in physical activity reported significant improvement, while 4 of the 8 mHealth-supported smoking cessation intervention trials resulted in smoking abstinence. Of the 10 mHealth-based diabetes intervention trials, 5 reported significant reductions in HbA1c; however, only 3 out of the 9 antihypertension interventions resulted in significant reductions in blood pressure. There is a growing body of literature focused on mHealth interventions that address CVD risk factors. Despite the immense potential of mHealth interventions, evidence of their efficacy in mitigating cardiovascular risk is heterogeneous.

Abstract

Purpose of the Study: More than 50% of breast cancer survivors without a diagnosis of lymphedema suffer daily from numerous and co-occurring lymphedema symptoms. This study aimed to identify lymphedema symptom patterns and the association of such patterns with phenotypic characteristics and biomarkers using latent class analysis (LCA). A prospective, descriptive, and repeated-measure design was used to enroll 140 women and collect data. Recent Findings: LCA identified three distinct lymphedema symptom classes at 8 weeks and 12 months post-surgery: low, moderate, and severe symptom classes and associated phenotypic characteristics. Participants were more likely to be in the severe symptom classes at 12 months post-surgery if they had lower education level, cording, an axillary syndrome at 8 weeks post-surgery, neoadjuvant chemotherapy, and radiation. Summary: Pre-surgery level of IL1-a, IL-6, IL-8, and VEGF was associated with the severe symptom class at 8 weeks post-surgery, suggesting that such biomarkers may be used to predict risk for lymphedema symptoms.

Abstract

Pediatric bipolar, now more commonly referred to as disruptive mood dysregulation disorder (DMDD), is estimated to impact between 0.8% and 4.3% of youth. This chapter describes the symptoms, etiology, and management of mood dysregulation in children and adolescents with a focus on depression, DMDD, persistent depressive disorder, and persistent mood disorder. Additionally, the NIMH researched severe mood dysregulation disorder descriptors are presented. Associated risk factors, screening and assessment tools for use in primary care, evidence-based management strategies, roles for the advanced practice registered nurse (APRN), consequences of untreated mood dysregulation disorders, and implications for conducting and using nursing research in practice with this population are also presented. The chapter differentiates between the roles and responsibilities of primary care practitioners and child and adolescent psychiatric-mental health APRNs in managing the range of mood dysregulation disorders in children and adolescents.

Abstract

Objective: To investigate the trends of 1-year mortality and neonatal morbidities in preterm infants with serious congenital heart disease (CHD). Study design: This cohort study used a population-based administrative dataset of all liveborn infants of 26-36 weeks gestational age with serious CHD born in California between 2011 and 2017. We assessed 1-year mortality and major neonatal morbidities (ie, retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis, intraventricular hemorrhage grade >2, and periventricular leukomalacia) across the study period and compared these outcomes with those in infants without CHD. Results: We identified 1921 preterm infants with serious CHD. The relative risk (RR) of death decreased by 10.6% for each year of the study period (RR, 0.89; 95% CI, 0.84-0.95), and the RR of major neonatal morbidity increased by 8.3% for each year (RR, 1.08; 95% CI, 1.02-1.15). Compared with preterm neonates without any CHD (n = 234 522), the adjusted risk difference (ARD) for mortality was highest at 32 weeks of gestational age (9.7%; 95% CI, 8.3%-11.2%), that for major neonatal morbidity was highest at 28 weeks (21.9%; 95% CI, 17.0%-26.9%), and that for the combined outcome was highest at 30 weeks (26.7%; 95% CI, 23.3%-30.1%). Conclusions: Mortality in preterm neonates with serious CHD decreased over the last decade, whereas major neonatal morbidities increased. Preterm infants with a gestational age of 28-32 weeks have the highest mortality or morbidity compared with their peers without CHD. These results support the need for specialized and focused medical neonatal care in preterm neonates with serious CHD.

Abstract

Limited opportunities exist for university premedical students to gain exposure to the realities of clinical practice through physician shadowing or through a formal curriculum. Medical Professionalism and Observership utilizes didactics, reflective writing, small- and large- group discussions, and clinical observerships to enhance the process of professional identity formation during a critical developmental window of late- adolescence. The pilot semester included a sample of 135 students, all in their sophomore, junior, or senior years of study at Rice University. Students were selected through an application process and paired with physicians at Houston Methodist Hospital based on specialty preference and availability. Students were required to participate in biweekly lectures and discussions and to submit a weekly reflection on topics discussed in the course and their shadowing experiences. Student evaluations were administered to survey changes in students’ knowledge and perceptions of the curriculum. Selected reflections were read for evidence of professional identity formation. Lectures increased students’ exposure to core competencies within the medical profession and influenced their desire to become physicians. Reflective writings demonstrated integration of these core competencies into the professional identity of students. Structured reflection and didactics, when coupled with physician shadowing, appear to promote integration of the values, beliefs, and attitudes of medical professionalism. Future studies should seek to demonstrate how such a curriculum affects professional identity formation through established measures, and to assess whether such a curriculum may influence students’ preparedness for medical training and practice as they progress along their careers.

Abstract

Background: Identifying preterm infants at risk for mortality or major morbidity traditionally relies on gestational age, birth weight, and other clinical characteristics that offer underwhelming utility. We sought to determine whether a newborn metabolic vulnerability profile at birth can be used to evaluate risk for neonatal mortality and major morbidity in preterm infants. Methods: This was a population-based retrospective cohort study of preterm infants born between 2005 and 2011 in California. We created a newborn metabolic vulnerability profile wherein maternal/infant characteristics along with routine newborn screening metabolites were evaluated for their association with neonatal mortality or major morbidity. Results: Nine thousand six hundred and thirty-nine (9.2%) preterm infants experienced mortality or at least one complication. Six characteristics and 19 metabolites were included in the final metabolic vulnerability model. The model demonstrated exceptional performance for the composite outcome of mortality or any major morbidity (AUC 0.923 (95% CI: 0.917–0.929). Performance was maintained across mortality and morbidity subgroups (AUCs 0.893–0.979). Conclusions: Metabolites measured as part of routine newborn screening can be used to create a metabolic vulnerability profile. These findings lay the foundation for targeted clinical monitoring and further investigation of biological pathways that may increase the risk of neonatal death or major complications in infants born preterm. Impact: We built a newborn metabolic vulnerability profile that could identify preterm infants at risk for major morbidity and mortality.Identifying high-risk infants by this method is novel to the field and outperforms models currently in use that rely primarily on infant characteristics.Utilizing the newborn metabolic vulnerability profile for precision clinical monitoring and targeted investigation of etiologic pathways could lead to reductions in the incidence and severity of major morbidities associated with preterm birth.