Publications

Abstract

Objective: To determine whether selected genes and plasma markers involved in energy homeostasis are associated with sleep disruption or duration in adults with HIV/AIDS. Methods: A sample of 289 adults with HIV/AIDS wore a wrist actigraph for 72 h to estimate total sleep time (TST) and wake after sleep onset (WASO). Twenty-three single nucleotide polymorphisms (SNP) spanning 5 energy homeostasis genes (adiponectin [ADIPOQ], ghrelin [GHRL], leptin [LEP], peroxisome proliferator-activated receptor-alpha [PPARA], and -gamma [PPARG]) were genotyped using a custom array. Plasma markers of energy homeostasis (adiponectin, ghrelin, leptin) were measured by commercial multiplex assay. Results: After adjusting for demographic and clinical characteristics (race/ethnicity, gender, CD4 cell count, waist circumference, medications), both WASO and TST were associated with SNPs in ADIPOQ (rs182052), LEP (rs10244329, rs3828942), PPARA (rs135551, rs4253655), and PPARG (rs709151). Additional SNPs in ADIPOQ were associated with WASO (rs1501299, rs3821799, rs6773957) and TST (rs2241766). TST was also associated with SNPs in GHRL (rs26802), LEP (rs11760956), PPARA (rs135547, rs8138102, rs4253776), and PPARG (rs12490265, rs796313). Many covariate-adjusted associations involved a significant interaction with markers of HIV (viral load, years since diagnosis). Among plasma markers, higher adiponectin was associated with less WASO, higher ghrelin and glucose levels with shorter TST, and higher leptin with longer TST. Conclusions: Replication of SNPs in all five genes and three plasma markers of energy homeostasis were associated with objective sleep measures. HIV disease influenced many of the associations. Findings strengthen evidence for associations between energy homeostasis genetics and poor sleep, and provide direction for pharmacological intervention research.

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Background: Arterial stiffness and increased blood pressure variability (BPV) are important subclinical cardiovascular diseases (CVDs). Evidence is accumulating that poor sleep is associated with subclinical CVDs. The purpose of our study was to investigate how sleep was related to arterial stiffness and BPV. We also explored whether sleep moderated the association between arterial stiffness and BPV. Methods: We conducted a cross-sectional study including 78 healthy adults aged between 35 and 64 years. Variables of interest were: 1) objective seep characteristics, assessed with a wrist actigraphy for two consecutive nights; 2) arterial stiffness, measured by carotid-femoral pulse wave velocity (cfPWV); and 3) BPV, measured using an ambulatory blood pressure monitor over 24 h and estimated by average real variability. Results: Lower sleep efficiency was an independent predictor of higher cfPWV and higher systolic BPV, while longer wake after sleep onset (WASO) was an independent predictor of higher cfPWV only. In addition, cfPWV showed a positive relationship with systolic BPV, and this relationship was moderated by sleep efficiency and WASO, respectively. The relationship between cfPWV and systolic BPV became stronger among individuals who had a level of sleep efficiency lower than 84% and who had WASO higher than 67 min, respectively. Conclusion: Our study showed that poor sleep not only directly linked with arterial stiffness and BPV but also moderated the relationship between these two subclinical CVDs. These findings suggest that improving sleep quality could be a target intervention to promote cardiovascular health in clinical practice.

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Middle-aged and older persons living with HIV (PLWH) suffer from sleep distress and cognitive disorders due to HIV infection and aging. We aim to explore the relationship between sleep satisfaction and cognitive complaints, and the mediating role of anxiety and fatigue in this relationship among middle-aged and older PLWH. We used data from a multicenter cross-sectional study in China (Shanghai, Kunming, Nanning, Hengyang, and Changning) conducted in 2017. The data analysis included 435 PLWH aged 45 years and over. Multiple linear regression models showed that worse sleep satisfaction was significantly associated with lower cognitive complaints after controlling for anxiety, fatigue, demographic variables, and clinical variables (β = −0.246, p < 0.01). Both anxiety and fatigue were significant partial mediators in the relationship between sleep satisfaction and cognitive complaints. The serial multiple mediation models of sleep satisfaction–anxiety (M1)–fatigue (M2)–cognitive complaints were supported and the alternative model of sleep satisfaction–fatigue (M2)–anxiety (M1)–cognitive complaints were both supported. Our study indicates that it is important to improve sleep quality to promote cognitive function among Chinese middle-aged and older PLWH. Prevention and treatment programs for sleep satisfaction and cognitive function should include the assessment and reduction of fatigue and anxiety.

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Introduction: Sixty million Latinxs make up 26.4% of all COVID-19 cases in the United States. It is uncertain whether behaviors and beliefs of immunizations among Latinxs is influenced by social determinants of health. The purpose of this study was to examine how social determinants of health predict COVID-19 behaviors and beliefs toward immunization among Latinxs. Methods: In this exploratory study, 11 chapters from the National Association of Hispanic Nurses collaborated to recruit participants. The CDC National 2009 H1N1 Flu Survey was adapted to measure behaviors and beliefs about immunizations of COVID-19. The Health Access Survey was used to measure social determinants of health. Instruments were available in both Spanish and English. Results: Participants (n=228) with higher education and health insurance tended to have less worry about taking the vaccine. Access to resources and practicing COVID-19 protective factors was positively associated. Alternative medicine and use of COVID-19 protective factors were negatively associated. Exposure to drugs and violence was associated with a decrease in likelihood to pursue a vaccine. Conclusions: Latinx need education about COVID-19 and vaccinations. Access to health care services must be available. Results highlight the importance of careful measurement when assessing social determinants of health among Latinx.

Abstract

Sixty million Latinxs make up 26.4% of all COVID-19 cases in the United States. It is uncertain whether behaviors and beliefs of immunizations among Latinxs is influenced by social determinants of health. The purpose of this study was to examine how social determinants of health predict COVID-19 behaviors and beliefs toward immunization among Latinxs.

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OBJECTIVE: "Diminishing returns" of socioeconomic status (SES) suggests that higher SES may not confer equivalent health benefits for ethnic minority individuals as compared to White individuals. Little research has tested whether diminishing returns also affects Native Americans. The objective of this study was to determine whether higher SES is associated with lower diabetes risk and longer gestational length in both Native American and White women, and whether SES predicts gestational length indirectly via diabetes risk. METHOD: A sample of 674,014 Native American and White women was drawn from a population-based California cohort of singleton births (2007-2012). Education, public health insurance status, gestational length, and diabetes diagnosis were extracted from a state-maintained birth cohort database. Covariates were age, health behaviors, pregnancy variables, residence rurality, and prepregnancy body mass index. RESULTS: In logistic regression models, the race by SES interaction (both education and insurance status) was associated with diabetes risk. Compared to high-SES White women, high- and low-SES Native American women had highest and equivalent diabetes risk. In path analyses, the race by SES interaction indirectly predicted gestational length through diabetes, ps < .001. For White women, an indirect effect of diabetes was detected, ps < .001, such that higher SES was associated with reduced risk for diabetes and thus longer gestational length. For Native American women, no indirect effect was detected, ps > .067. CONCLUSIONS: Among Native American women, higher SES did not confer protection against diabetes or shorter gestational length. These findings are consistent with the diminishing returns of SES phenomenon. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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As a humanistic, patient-centered approach to medicine becomes more accepted, physicians are moving from a purely objective, systematic approach to medicine toward a more holistic approach adapted to individual patients and their values and beliefs. While doctors are often uncomfortable discussing religion and spirituality with patients, some patients may actually benefit from the integration of these beliefs into the treatment process. While the terms are often used interchangeably, “religion” and “spirituality” have different meanings; religion refers to an organized system of beliefs, while spirituality relates to how individuals seek and express meaning in life through their connections to the self, others, nature, and the sacred. Religion or spirituality can improve treatment outcomes by providing patients with a more positive perspective, a greater sense of purpose, and healthier coping strategies. Prayer and meditation can inspire the relaxation response, which can improve many health indicators. The HOPE Questions for Spiritual Assessment and the FICA Spiritual History Tool are two methods that can be used to assess patients’ attitude toward the spiritual and how treatment should acknowledge these beliefs. Medical humanism encompasses many of these practices, because it is based on the idea that the physician should focus on the whole patient, including patients’ religious or spiritual beliefs.

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Excessive and prolonged stress can result in physician burnout. Burnout can compromise a physician’s ability to effectively meet the needs of patients, while also having adverse effects on personal health and well-being. Physicians are exposed to a tremendous number of stressors that arise from factors such as time and resource constraints, the complex hierarchy among medical professionals, malpractice claims, and “difficult” patients and treatments. Although burnout is currently considered to be mostly due to external causes, protective mechanisms that physicians can employ to shield themselves are explored. Hans Selye’s model of the general adaptation syndrome is one means that individuals cope with stress, along with Richard Lazarus’s transactional model of stress. Other coping strategies include problem-based coping, the ABC technique, and meditation and mindfulness. Several maladaptive responses may temporarily offer relief but can in the long run prove to be damaging. Finally, online and other digital stress-reduction programs are explored.

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Background: The Republic of Liberia has had major disruptions to the education of its health care cadres. Post Ebola, the Resilient and Responsive Health Systems (RRHS) initiative began a new era of capacity building with the support of PEPFAR and HRSA. Nursing and Midwifery serve as the largest healthcare cadres in Liberia. The national nursing and midwifery curricula were overdue for the regulated review and revisions.Methods: The Science of Improvement was used as the framework to accomplish this multilateral activity. The Institute for Healthcare Improvement's (IHI) stages of improvement included: 1) Forming the team, 2) Setting the aims, 3) Establishing measures, 4) Selecting measures, 5) Testing changes, 6) Implementing changes, and 7) Spreading changes. These stages served as the blueprint for the structures and processes put into place to accomplish this national activity.Findings: The RN, Bridging, and BScM curricula all had redundant content that did not reflect teaching pedagogy and health priorities in Liberia. Courses were eliminated or reconfigured and new courses were created. Development of Nursing and Midwifery Curricular Taskforces were not as successful as was hoped. Two large stakeholder meetings ensured that this was the curricula of the Liberian faculty, deans and directors, and clinical partners. Monitoring and evaluation tools have been adopted by the Liberian Board for Nursing and Midwifery to serve as another improvement to check that the new curricula are being implemented and to identify gaps that may require future cycles of change for continued quality and improvement.Conclusions: Developing trust among the multilateral partners was critical to the success of this activity. Networks have been expanded, and a proposed pilot with the Ghana Board of Nursing and Midwifery and the US academic partner will examine the feasibility of implementing electronic licensing examinations for nurses and midwives.

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Patient safety is jeopardized when healthcare services are provided by physicians who suffer from substance use disorders (SUDs). When focusing on the problem of substance abuse and dependence among physicians, certain factors inherent in the medical field, such as long hours, the high-stress nature of the work, and the ease of access to drugs, make physicians more susceptible to abusing or becoming dependent on prescription drugs and alcohol. SUDs may differ in severity. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (Washington, DC: American Psychiatric Association, 2013) provides three severity specifiers: mild, moderate, and severe. Severe SUDs are also known as addictive disorders. To make matters worse, a culture of silence exists among colleagues, who often seek to protect the compromised physician from the legal consequences of abusing drugs. Luckily, the compromised physician can be provided with an intense and individualized treatment regime through physician health programs that aim for rehabilitation over termination of employment.

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Background: Young adult cancer survivors have significant work-related challenges, including interruptions to education and employment milestones, which may affect work-related goals (WRGs). The study purpose was to explore posttreatment perspectives of WRGs in a sample of young adult hematologic cancer survivors. Methods: This qualitative descriptive study used social media to recruit eligible cancer survivors (young adults working or in school at the time of cancer diagnosis). Data were collected through telephone semi-structured interviews and analyzed using directed content analysis, followed by thematic content analysis to identify themes. Findings: The sample (N = 40) were mostly female (63.5%), White (75%), and diagnosed with Hodgkin lymphoma (57.5%); most worked in professional (40%) or health care (23%) roles. The overarching theme, “Survivors’ Dilemma,” highlights a changed perspective on work-related fulfillment and financial obligations, capturing survivors’ decision-making process regarding work. Three subthemes illustrated questions that participants contemplated as they examined how their WRGs had changed: (a) Self-identity: Do I want to do this work? (b) Perceived health and work ability: Can I do this work? and (c) Financial toxicity: Can I afford to/not to do this work? Conclusions/Application to Practice: Participants experienced a state of dilemma around their WRGs, weighing areas around self-identity, perceived health and work ability, and financial toxicity. Findings suggest occupational health nurses should be aware of challenges surrounding WRGs, including how goals may change following a cancer diagnosis and treatment, and the potential stressors involved in the Survivors’ Dilemma. Occupational health nurses should assess for these issues and refer young survivors to employee and financial assistance programs, as necessary.

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To effectively diagnose and treat patients, physicians must often cooperate, coordinate, and problem-solve with other healthcare workers. Successful teams in medicine define and work toward shared goals, employ the pertinent and appropriate qualifications of each member, and establish trust in other team members. Task-shifting passes certain roles onto other team members so that physicians can focus on their key areas of responsibility. A number of medical schools have adopted interprofessional education to train today’s physicians, but there are other strategies that are also being explored. Training modules such as Crew Resource Management and TeamSTEPPSTM are being adapted to the needs of the healthcare field. High-fidelity patient simulations are being used to replicate common situations encountered by healthcare workers. Also, many medical schools are using problem-based or team-based learning practices through which students work with one another to tackle and reason through clinical scenarios.

Abstract

Objectives: Telemedicine and telehealth are increasingly used in nursing homes (NHs). Their use was accelerated further by the COVID-19 pandemic, but their impact on patients and outcomes has not been adequately investigated. These technologies offer promising avenues to detect clinical deterioration early, increasing clinician's ability to treat patients in place. A review of literature was executed to further explore the modalities' ability to maximize access to specialty care, modernize care models, and improve patient outcomes. Design: Whittemore and Knafl's integrative review methodology was used to analyze quantitative and qualitative studies. Setting and Participants: Primary research conducted in NH settings or focused on NH residents was included. Participants included clinicians, NH residents, subacute patients, and families. Methods: PubMed, Web of Science, CINAHL, Embase, PsycNET, and JSTOR were searched, yielding 16 studies exploring telemedicine and telehealth in NH settings between 2014 and 2020. Results: Measurable impacts such as reduced emergency and hospital admissions, financial savings, reduced physical restraints, and improved vital signs were found along with process improvements, such as expedient access to specialists. Clinician, resident, and family perspectives were also discovered to be roundly positive. Studies showed wide methodologic heterogeneity and low generalizability owing to small sample sizes and incomplete study designs. Conclusions and Implications: Preliminary evidence was found to support geriatrician, psychiatric, and palliative care consults through telemedicine. Financial and clinical incentives such as Medicare savings and reduced admissions to hospitals were also supported. NHs are met with increased challenges as a result of the COVID-19 pandemic, which telemedicine and telehealth may help to mitigate. Additional research is needed to explore resident and family opinions of telemedicine and telehealth use in nursing homes, as well as remote monitoring costs and workflow changes incurred with its use.

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After decades of working in the medical field, physicians have gathered an extensive knowledge of human pathology as well as effective courses of treatment for illnesses. However, aging may also bring about cognitive deterioration, which may compromise the quality of care physicians provide to their patients. In 2015, 23 percent of physicians were above the age of 65. An estimated 25,000 to 50,000 active physicians are expected to suffer from mild cognitive impairment and up to 25,000 from dementia. Currently, physicians are not held to a mandatory retirement age and are not subject to oversight of their cognitive abilities and physical health as they age. However, the current system of self-regulation for cognitive impairment is insufficient for protecting patient safety; on the other hand, mandatory retirement or screening of aging physicians may be ethically or legally problematic. An optimal solution would balance the safety of patients and the dignity of aging physicians. It is likely to be multipronged and multifactorial, involving multiple screening steps and continued development to assess the quality of validation. Adoption of healthy lifestyle practices and financial literacy, as well as providing opportunities for retired physicians to stay involved with the medical profession, may encourage successful aging among physicians and ease the transition to retirement.

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BACKGROUND: While mental health conditions such as postpartum depression are common, little is known about how mental healthcare utilization varies after term versus preterm delivery. OBJECTIVE: This study aimed to determine whether preterm birth is associated with postpartum inpatient and emergency mental healthcare utilization. STUDY DESIGN: The study sample was obtained from a database of live-born neonates delivered in California between the years of 2011 and 2017. The sample included all people giving birth to singleton infants between the gestational age of 20 and 44 weeks. Preterm birth was defined as <37 weeks’ gestation. Emergency department visits and hospitalizations with a mental health diagnosis within 1 year after birth were identified using International Classification of Diseases codes. Logistic regression was used to compare relative risks of healthcare utilization among people giving birth to preterm infants vs term infants, adjusting for the following covariates: age, race or ethnicity, parity, previous preterm birth, body mass index, tobacco use, alcohol or drug use, hypertension, diabetes mellitus, adequacy of prenatal care, education, insurance payer, and the presence of a mental health diagnosis before birth. Results were then stratified by mental health diagnosis before birth to determine whether associations varied based on mental health history. RESULTS: Of our sample of 3,067,069 births, 6.7% were preterm. In fully adjusted models, compared with people giving birth to term infants, people giving birth to preterm infants had a 1.5 times (relative risk; 95% confidence interval, 1.4–1.7) and 1.3 times (relative risk; 95% confidence interval, 1.2–1.4) increased risk of being hospitalized with a mental health diagnosis within 3 months and 1 year after delivery, respectively. People giving birth to preterm infants also had 1.4 times (95% confidence interval, 1.3–1.5) and 1.3 times (95% confidence interval, 1.2–1.4) increased risk of visiting the emergency department for a mental health diagnosis within 3 months and 1 year after birth, respectively. Stratifying by preexisting mental health diagnosis, preterm birth was associated with an elevated risk of mental healthcare utilization for people with and without a previous mental health diagnosis. CONCLUSION: We found that preterm birth is an independent risk factor for postpartum mental healthcare utilization. Our findings suggest that screening for and providing mental health resources to birthing people after delivery are crucial, particularly among people giving birth to preterm infants, regardless of mental health history.

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Introduction: Our understanding of the association between coronavirus disease 19 (COVID-19) and preterm or early term birth among racially and ethnically diverse populations and people with chronic medical conditions is limited. Methods: We determined the association between COVID-19 and preterm (PTB) birth among live births documented by California Vital Statistics birth certificates between July 2020 and January 2021 (n=240,147). We used best obstetric estimate of gestational age to classify births as very preterm (VPTB, <32 weeks), PTB (< 37 weeks), early term (37 and 38 weeks), and term (39-44 weeks), as each confer independent risks to infant health and development. Separately, we calculated the joint effects of COVID-19 diagnosis, hypertension, diabetes, and obesity on PTB and VPTB. Findings: COVID-19 diagnoses on birth certificates increased for all racial/ethnic groups between July 2020 and January 2021 and were highest for American Indian/Alaska Native (12.9%), Native Hawaiian/Pacific Islander (11.4%), and Latinx (10.3%) birthing people. COVID-19 diagnosis was associated with an increased risk of VPTB (aRR 1.6, 95% CI [1.4, 1.9]), PTB (aRR 1.4, 95% CI [1.3, 1.4]), and early term birth (aRR 1.1, 95% CI [1.1, 1.2]). There was no effect modification of the overall association by race/ethnicity or insurance status. COVID-19 diagnosis was associated with elevated risk of PTB in people with hypertension, diabetes, and/or obesity. Interpretation: In a large population-based study, COVID-19 diagnosis increased the risk of VPTB, PTB, and early term birth, particularly among people with medical comorbidities. Considering increased circulation of COVID-19 variants, preventative measures, including vaccination, should be prioritized for birthing persons. Funding: UCSF-Kaiser Department of Research Building Interdisciplinary Research Careers in Women's Health Program (BIRCWH) National Institute of Child Health and Human Development (NICHD) and the Office of Research on Women's Health (ORWH) [K12 HD052163] and the California Preterm Birth Initiative, funded by Marc and Lynn Benioff.

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Objectives: To explore the compliance of end-of-life (EOL) care preferences, and the facilitators and barriers of promoting quality of EOL care among older adults. Design: A scoping review was used to identify key themes in the compliance of EOL care preferences among older adults. Setting and participants: Studies published between 2009 and 2020 were identified from the Medline and Cochrane libraries. Eligible articles containing components related to the compliance of EOL care preferences among older adults were selected. Measures: The eligible articles were thematically synthesized. Factors that affected the compliance of EOL care preferences among older adults were identified from the key components. Results: In total, 35 articles were included to identify the key components in the compliance of EOL care preferences: (1) supportive policy, (2) supportive environment, (3) cultural characteristics, (4) advance care planning (ACP), (5) the concordance of EOL care preferences between patients and surrogate decision makers, (6) prognosis awareness, and (7) patient's health status and the type of disease. Facilitators for the compliance of EOL care preferences included enactment of relevant policy, sufficient care institutions, the utilization of ACP, and poor health status. Barriers included lack of supportive policy, different culture, and low utilization of ACP. Conclusions/Implications: The compliance of EOL care preferences was low among older adults. The compliance of EOL care preferences can be improved through relevant policy development and the utilization of ACP.

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Persons living with HIV (PLWH) continuously experience symptom burdens. Their symptom prevalence and severity are also quite different. Mobile health (mHealth) applications (apps) offer exceptional opportunities for using personalized interventions when and where PLWH are needed. This study aimed to demonstrate the development process of the symptom management (SM) app and the structure and content of it. Our research team systematically searched for evidence-based resources and summarized up-to-date evidence for symptom management and health education. Our multidisciplinary research team that included physicians, nurses, software engineers, and nursing professors, evaluated the structure and content of the drafted app. Both quantitative data and qualitative results were collected at a group discussion meeting. Quantitative data were scores of sufficient evidence, situational suitability, practicability, cost-effectiveness, and understandability (ranged from one to four) for 119 items of the app contents, including the health tracking module, the self-assessment module, coping strategies for 18 symptoms (80 items), medication management, complementary therapy, diet management, exercise, relaxation techniques, and the obtaining support module. The SM app was comprised of eight modules and provided several personalized symptom management functions, including assessing symptoms and receiving different symptom management strategies, tracking health indicators, and communicating with medical staff. The SM app was a promising and flexible tool for HIV symptom management. It provided PLWH with personalized symptom management strategies and facilitated the case management for medical staff. Future studies are needed to further test the app’s usability among PLWH users and its effects on symptom management.

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Background: Multiple sclerosis (MS) is an autoimmune disease leading to physical, emotional and cognitive disability. High body mass index (BMI) may impact cognitive function and brain volume in MS. Yet, there is paucity of evidence addressing the impact of BMI on cognitive function and brain volume in MS. Objectives: The purpose of this study was to examine the effects of BMI on normal appearing brain volume and cognitive function in patients with relapsing–remitting MS. Methods: A secondary data analysis of the NIH CombiRx study was conducted. Multivariate regression and mixed model analyses were executed to analyze the effect of BMI on brain volume and cognitive function. Results: The mean baseline age of the 768 participants was 38.2(SD = 9.4) years. 73% were female and 88.8% were Caucasian. The mean BMI was 28.8 kg/m2(SD = 6.7). The multivariate regression and mixed model analyses failed to show a clinical effect of BMI on brain volume and cognitive function. Conclusion: BMI did not show an effect on cognitive function and brain volume among MS patients. Although there is increased interest in the effects of modifiable factors on the course of MS, the effects of BMI on brain volume and cognitive function are debatable and warrant further research. ClinicalTrials.gov

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BACKGROUND: Transitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission. OBJECTIVES: To develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events. DESIGN, SETTING, AND PARTICIPANTS: Two-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO). INTERVENTIONS: Multicomponent intervention in the 30 days following hospitalization, including inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient “discharge advocate” and a primary care “responsible outpatient clinician,” postdischarge phone calls, and postdischarge primary care visit. MAIN OUTCOMES AND MEASURES: The primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission. RESULTS: Among patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates. CONCLUSION: A multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.

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Abstract: BackgroundLymphatic pain and swelling due to lymph fluid accumulation are the most common and debilitating long-term adverse effects of cancer treatment. This study aimed to quantify the effects of obesity on lymphatic pain, arm, and truncal swelling. Methods: A sample of 554 breast cancer patients were enrolled in the study. Body mass index (BMI), body fat percentage, and body fat mass were measured using a bioimpedance device. Obesity was defined as a BMI ≥ 30 kg/m2 . The Breast Cancer and Lymphedema Symptom Experience Index was used to measure lymphatic pain, arm, and truncal swelling. Multivariable logistic regression models were used to estimate the odds ratio (OR) with 95% confidence interval (CI) to quantify the effects of obesity. Results: Controlling for clinical and demographic characteristics as well as body fat percentage, obesity had the greatest effects on lymphatic pain (OR 3.49, 95% CI 1.87–6.50; p < 0.001) and arm swelling (OR 3.98, 95% CI 1.82–4.43; p < 0.001). Conclusions: Obesity is a significant risk factor for lymphatic pain and arm swelling in breast cancer patients. Obesity, lymphatic pain, and swelling are inflammatory conditions. Future study should explore the inflammatory pathways and understand the molecular mechanisms to find a cure.