Publications

Abstract

BACKGROUND: Maintaining adherence to antiretroviral therapy (ART) is a significant challenge for human immunodeficiency virus (HIV)-infected racial and ethnic minority adolescents and young adults (youth). Given the consequences of suboptimal ART adherence, there is a pressing need for an expanded understanding of adherence behavior in this cohort. OBJECTIVES: As part of an exploratory sequential, mixed-methods study, we used qualitative inquiry to explore adherence information, motivation, and behavioral skills among HIV-infected racial and ethnic minority youth. Our secondary aim was to gain an understanding of the contextual factors surrounding adherence behavior. METHODS: The information-motivation-behavioral skills model (IMB model) was applied to identify the conceptual determinants of adherence behavior in our target population, along with attention to emergent themes. In-depth, individual, semistructured interviews, including open-ended questions with probes, were conducted with a convenience sample of HIV-infected racial and ethnic minority youth (ages 16-29 years), receiving ART and with evidence of virologic failure (i.e., detectable HIV viral load). New participants were interviewed until information redundancy was reached. Qualitative interviews were digitally recorded, transcribed verbatim, and analyzed using Atlas.ti (v8). Directed content analysis was performed to generate categories and broad themes. Coding was initially conceptually driven (IMB model) and shifted to a data-driven approach, allowing for the discovery of key contextual factors that influence adherence behavior in this population. Methodological rigor was ensured by member checks, an audit trail, thick descriptive data, and triangulation of data sources. RESULTS: Twenty racial and ethnic minority participants (mean age = 24.3 years, 55.0% male) completed interviews. We found adherence information was understood in relation to HIV biomarkers; adherence motivation and behavioral skills were influenced by stigma and social context. We identified five primary themes regarding ART self-management: (a) emerging adulthood with a chronic illness, (b) stigma and disclosure concerns, (c) support systems and support deficits, (d) mental and behavioral health risks and challenges, and (e) mode of HIV transmission and perceptions of power and control. DISCUSSION: Key constructs of the IMB model were applicable to participating HIV-infected youth yet did not fully explain the essence of adherence behavior. As such, we recommend expansion of current adherence models and frameworks to include known contextual factors associated with ART self-management among HIV-infected racial and ethnic minority youth.

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Objective  The aim of this study was to evaluate rates of preterm birth (PTB) and obstetric complication with maternal serum analytes > 2.5 multiples of the median (MoM) by degree of elevation. Study Design  Retrospective cohort study of singleton live-births participating in the California Prenatal Screening Program (2005-2011) examining PTB and obstetric complication for α-fetoprotein (AFP), human chorionic gonadotropin (hCG), unconjugated estriol (uE3), and inhibin A (INH) by analyte subgroup (2.5 to < 6.0, 6.0 to < 10.0, and ≥ 10.0 MoM vs. < 2.5 MoM). Results  The risk of obstetric complication increased with increasing hCG, AFP, and INH MoM, and were greatest for AFP and INH of 6.0 to <10.0 MoM. The greatest risk of any adverse outcome was seen for hCG MoM ≥ 10.0, with relative risk (RR) of PTB < 34 weeks of 40.8 (95% confidence interval [CI]: 21.7-77.0) and 13.8 (95% CI: 8.2-23.1) for obstetric complication. Conclusions  In euploid, structurally normal fetuses, all analyte elevations > 2.5 MoM confer an increased risk of PTB and, except for uE3, obstetric complication, and risks for each are not uniformly linear. These data can help guide patient counseling and antenatal management.

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Background: Susceptibility to metabolic diseases may be influenced by mitochondrial genetic variability among people living with human immunodeficiency virus (HIV; PLWH), but remains unexplored in populations with African ancestry. We investigated the association between mitochondrial DNA (mtDNA) haplogroups and the homeostatic model assessments of β-cell function (HOMA-B) and insulin resistance (HOMA-IR), as well as incident diabetes mellitus (DM), among Black women living with or at risk for HIV. Methods: Women without DM who had fasting glucose (FG) and insulin (FI) data for ≥2 visits were included. Haplogroups were inferred from genotyping data using HaploGrep. HOMA-B and HOMA-IR were calculated using FG and FI data. Incident DM was defined by a combination of FG ≥ 126 mg/dL, the use of DM medication, a DM diagnosis, or hemoglobin A1c ≥ 6.5%. We compared HOMA-B, HOMA-IR, and incident DM by haplogroups and assessed the associations between HOMA-B and HOMA-IR and DM by haplogroup. Results: Of 1288 women (933 living with HIV and 355 living without HIV), PLWH had higher initial HOMA-B and HOMA-IR than people living without HIV. PLWH with haplogroup L2 had a slower decline in HOMA-B per year (Pinteraction =. 02) and a lower risk of incident DM (hazard ratio [HR], 0.51; 95% confidence interval [CI],. 32-.82) than PLWH with other haplogroups after adjustments for age, body mass index, combination antiretroviral therapy use, CD4 cell counts, and HIV RNA. The impact of HOMA-IR on incident DM was less significant in those with haplogroup L2, compared to non-L2 (HR, 1.28 [95% CI,. 70-2.38] vs 4.13 [95% CI, 3.28-5.22], respectively; Pinteraction <. 01), among PLWH. Conclusions: Mitochondrial genetic variation is associated with β-cell functions and incident DM in non-Hispanic, Black women with HIV and alters the relationship between insulin resistance and DM.

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The new nurse manager survival guide, part III.

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Objective: Seriously ill adults with multiple chronic conditions (MCC) who receive palliative care may benefit from improved symptom burden, health care utilization and cost, caregiver stress, and quality of life. To guide research involving serious illness and MCC, palliative care can be integrated into a conceptual model to develop future research studies to improve care strategies and outcomes in this population. Methods: The adapted conceptual model was developed based on a thorough review of the literature, in which current evidence and conceptual models related to serious illness, MCC, and palliative care were appraised. Factors contributing to patients’ needs, services received, and service-related variables were identified. Relevant patient outcomes and evidence gaps are also highlighted. Results: Fifty-eight articles were synthesized to inform the development of an adapted conceptual model including serious illness, MCC, and palliative care. Concepts were organized into 4 main conceptual groups, including Factors Affecting Needs (sociodemographic and social determinants of health), Factors Affecting Services Received (health system; research, evidence base, dissemination, and health policy; community resources), Service-Related Variables (patient visits, service mix, quality of care, patient information, experience), and Outcomes (symptom burden, quality of life, function, advance care planning, goal-concordant care, utilization, cost, death, site of death, satisfaction). Discussion: The adapted conceptual model integrates palliative care with serious illness and multiple chronic conditions. The model is intended to guide the development of research studies involving seriously ill adults with MCC and aid researchers in addressing relevant evidence gaps.

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AIM The aim of the integrative review was to examine the prebriefing phase of simulation as the foundation for the learning experience of nursing students and to determine effective prebriefing activities to enhance learning. BACKGROUND There are currently no frameworks or specific time allotments for prebriefing comparable to those implemented for debriefing. METHOD Eight electronic databases were searched for the period 2012 to 2019. Six studies were selected based on relevance and inclusion. Whittemore and Knafl's integrative review framework was used for data analysis. RESULTS The studies reviewed answer how to effectively prepare students for simulation to enhance their learning and have a positive effect on clinical judgment and self-confidence; yet, prebriefing is not considered the foundation of the simulation experience. CONCLUSION A well-designed prebriefing process is essential to high-quality simulation experiences. Standardization of this process has yet to be established.

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Chest pain is a common and high-risk chief complaint in the emergency department. There is an array of cardiac and non–cardiac-related conditions that could lead to this symptom. It is impor- tant for the clinician to have a broad perspective when treating patients complaining of chest pain so that dangerous and potentially life-threatening conditions are not overlooked. Here, we present one such cause of chest pain that can be detrimental if the clinician fails to correctly identify the underlying condition. A brief review of hypertriglyceridemia-induced acute pancreatitis is pro- vided, and challenges faced by the treatment team are discussed.

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A growing body of literature found that anxiety about aging is related to health and well-being of older adults. However, very few studies have been conducted on Chinese older adults residing in different countries and examined the role of resilience. Using the Pearlin's Stress Process Model, this study aims to fill in this gap by examining the relationship between anxiety about aging as the stressor and health status among Chinese older adults living in Honolulu, the United States (N = 292) and Wuhan, China (N = 532). The survey data were collected through June 2017 to September 2018, using snowball and convenience sampling strategy. The moderating role of resilience on the focal relationship is also explored. Results showed that for both samples, the negative relationship between anxiety about aging and self-rated health was significantly moderated by resilience (18 % and 13 %, respectively), implying the stress-buffering role of resilience. Although both mean levels of resilience and anxiety about aging were lower for the Honolulu sample, the moderating effect appeared to be stronger, implying that older adults in the Honolulu sample might rely more on psychological resources such as resilience in coping with stressors, compared with their counterparts in Wuhan. However, the moderating effect of resilience did not work for the association between anxiety about aging and number of chronic conditions for both samples. Our findings suggest that future research needs to take into account both social and psychological resources when examining anxiety about aging and health status among Chinese older adults residing in different cultural contexts.

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OBJECTIVES: To determine whether depression and anxiety are associated with advance care planning (ACP) engagement or values concerning future medical care. DESIGN: Cross-sectional. PARTICIPANTS: English- and Spanish-speaking patients, aged 55 years and older, from a San Francisco, CA, county hospital. MEASURES: Depression was measured by the Patient Health Questionnaire 8-item scale, and anxiety was measured by the Generalized Anxiety Disorder 7-item scale, using standardized cutoffs of 10 or more for moderate-to-severe symptoms. ACP engagement was measured using validated surveys of ACP behavior change (e.g., self-efficacy and readiness; mean five-point Likert score) and ACP actions (e.g., ask, discuss, and document wishes; 0- to 25-point scale), with higher scores representing higher engagement. In addition, we asked a question about valuing life extension (“some health situations would make life not worth living”). We used adjusted linear and logistic regression. RESULTS: Mean age of 986 participants was 63 years, 81% were non-White, 39% had limited health literacy, 45% were Spanish speaking, 13% had depression, and 10% had anxiety. After adjustment for demographic and health status variables, participants who were depressed versus not depressed had higher ACP behavior change scores (0.2 points; 95% confidence interval (CI) = 0.06–0.38; P =.007), higher ACP action scores (1.5 points; 95% CI = 0.51–2.57; P =.003), and higher odds of not valuing life extension (odds ratio (OR) = 2.5; 95% CI = 1.5–4.3; P <.001). Results were similar in participants with versus without anxiety (ACP behavior change: 0.2 points; 95% CI = 0.05–0.40; P =.01; ACP action scores: 1.2 points; 95% CI = 0.14–2.32; P =.028; odds of not valuing life extension: OR = 2.3; 95% CI = 1.3–3.9; P =.004). CONCLUSION: Depression and anxiety were associated with greater ACP engagement and not valuing life extension. Although the direction of association between ACP engagement and values with anxiety and depression cannot be determined in this cross-sectional study, these conditions may influence ACP preferences. Future studies should assess whether changes in anxiety or depression affect ACP preferences over time.

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Background: Hypertension is increasingly prevalent in Uganda and its clinical management remains subop-timal across the country. Prior research has elucidated some of the factors contributing to poor control, but little is known about providers’ approaches to hypertension management and perceptions of barriers to care. This is particularly true in private health care settings – despite the fact that the private sector provides a substantial and growing portion of health care in Uganda. Objective: Our exploratory, pragmatic qualitative study aimed to examine the factors affecting the quality of hypertension care from the perspective of providers working in an urban, private hospital in Uganda. We focused on the organizational and system-level factors influencing providers’ approaches to management in the outpatient setting. Methods: We conducted interviews with 19 health care providers working in the outpatient setting of a 110-bed, private urban hospital in Kampala, Uganda. We then coded the interviews for thematic analysis, using an inductive approach to generate the study’s findings. Findings: Several themes emerged around perceived barriers and facilitators to care. Providers cited patient beliefs and behaviors, driven in part by cultural norms, as key challenges to hypertension control; however, most felt their own approach to hypertension treatment aligned with international guidelines. Providers struggled to collaborate with colleagues in coordinating the joint management of patients. Furthermore, they cited the high cost and limited availability of medication as barriers. Conclusions: These findings offer important strategic direction for intervention development specific to this Ugandan context: for example, regarding culturally-adapted patient education initiatives, or programs to improve access to essential medications. Other settings facing similar challenges scaling up management of hypertension may find the results useful for informing intervention development as well.

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Distal sensory peripheral neuropathy (HIV-DSP) affects upwards of 50% of people living with HIV. Causing often debilitating symptoms of tingling, numbness and burning, HIV-DSP can result in disability, unemployment and low quality of life. Comorbidities further complicate nursing care, heightening risk of polypharmacy and symptom exacerbation. Therefore, a neurological sensory assessment, combined with the patient's self-report of symptoms, can help nurse practitioners visualize, quantify and understand symptoms. Common pharmacological interventions include antiepileptics, antidepressants, analgesics and medical marijuana. The complexity of care for individuals with HIV-DSP merits a comprehensive approach. Implications for practice include interdisciplinary management with neurologists, podiatrists, mental health providers, and nurse-led counseling inclusive of patient safety teaching.

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Background: Cognitive decline is common after stroke. The influence of early cognitive impairment on midterm functional outcomes among Chinese acute ischemic stroke (AIS) patients has not been fully studied. The aim of the study was to assess the association between early cognitive impairment and midterm functional outcomes among Chinese AIS patients. Methods: A longitudinal survey focusing on Chinese AIS patients was conducted in three stroke centers in Shanghai, China (July to December 2016). A total of 185 eligible patients were interviewed at acute stage and at 1, 3, and 6 months after onset. Patients' functional outcomes were measured by modified Rankin Scale (mRS) and Barthel Index (BI) at each time point. Cognitive function was assessed using Montreal Cognitive Assessment, Changsha version (MoCA-CS), within 7 days after stroke onset. Covariates included patient's demographic characteristics, socioeconomic status, clinical characteristics of stroke, vascular risk factors, receiving rehabilitation after discharge from acute hospital, and recurrence. Generalized linear mixed models and general linear mixed models were applied. Results: The prevalence of cognitive impairment at acute stage of stroke among these patients was 88.1%. The risk of disability (mRS 2–5) of all patients after stroke decreased over time (OR = 0.491, 95% CI = 0.401–0.603). The risk of disability among those with cognitive impairment increased compared with those with normal cognition (OR = 7.384, 95% CI = 1.041–52.407). The BI score of all patients increased over time after controlling for covariates (β = 1.51, p < 0.01). The BI score of those with cognitive impairment was lower than that with normal cognition over the follow-up period after controlling for other covariates (β = −8.11, p < 0.05). Conclusions: This study showed that early cognitive impairment was associated with higher risk of disability and poor activity of daily living (ADL) among Chinese AIS patients. Further studies are needed to examine the linkage between multi-domain cognitive impairment and long-term disability and ADL among stroke survivors by using neuropsychological test batteries.

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BACKGROUND: Global immune activation and HLA alleles are each associated with the pathogenesis of human immunodeficiency virus (HIV) and hepatitis C virus .METHODS: We evaluated the relationship between 44 HLA class I and 28 class II alleles and percentages of activated CD8 (CD8+CD38+DR+) and CD4 (CD4+CD38+DR+) T cells in 586 women who were naive to highly active antiretroviral therapy. We used linear generalized estimating equation regression models, adjusting for race/ethnicity, age, HIV load, and hepatitis C virus infection and controlling for multiplicity using a false discovery rate threshold of 0.10.RESULTS: Ten HLA alleles were associated with CD8 and/or CD4 T-cell activation. Lower percentages of activated CD8 and/or CD4 T cells were associated with protective alleles B*57:03 (CD8 T cells, -6.6% [P = .002]; CD4 T cells, -2.7% [P = .007]), C*18:01 (CD8 T cells, -6.6%; P < .0008) and DRB1*13:01 (CD4 T cells, -2.7%; P < .0004), and higher percentages were found with B*18:01 (CD8 T cells, 6.2%; P < .0003), a detrimental allele. Other alleles/allele groups associated with activation included C*12:03, group DQA1*01:00, DQB1*03:01, DQB1*03:02, DQB1*06:02, and DQB1*06:03.CONCLUSION: These findings suggest that a person's HLA type may play a role in modulating T-cell activation independent of viral load and sheds light on the relationship between HLA, T-cell activation, immune control, and HIV pathogenesis.

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Objective: To explore attitudes toward immigrants and refugees living in Ecuador. Design and Measures: A transnationalism framework informed this qualitative study, which utilized a semi-structured interview guide to elicit responses from participants about their attitudes toward immigrants and refugees. Interviews were conducted in Spanish, audio-taped, transcribed, coded, and analyzed in Spanish to identify emergent themes. Demographic data were analyzed using SPSS. Sample: Participants (n = 50) were recruited from five sectors that interact with refugees: health care, the press, the police, nongovernmental organizations, and education. Fifty interviews were conducted with adults in Quito, Ecuador, in 2017. Results: Participants reported concerns about the health and well-being of immigrants and refugees, expressed a willingness to assist them, but within limits, noted discrimination and bias against refugees, and cited social policies and human rights as factors that influenced their attitudes. Conclusions: Our findings indicate that immigrants and refugees face challenges which impact their health and well-being, according to participants in the study. Social policies can influence attitudes, but are also affected by rapidly shifting immigration patterns. Migration flows in South America is an under-studied area of research, with opportunity for further public health nursing inquiry.

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Background: End-of-life care is provided in a variety of healthcare settings, not just palliative care hospitals. This is one reason why it is very important to assess all barriers to end-of-life care and to provide safe and quality services to patients. This study was aimed at describing nurses' attitudes in providing end-of-life care and exploring barriers and facilitating behaviors of nurses in multi-profile hospitals in Eastern Europe. Methods: A descriptive, correlational design was applied in this study, using a cross-sectional survey of 1320 registered nurses within 7 hospitals in Lithuania. Results: Registered nurses working in the three different profiles emphasized safe and effective care and the importance of meeting the patient's spiritual needs at the end of life. The main barriers assigned by nurses caring for patients at the end of life were angry family members, inadequate understanding of nursing care by the patient's relatives; lack of time to talk to patients, lack of nursing knowledge to deal with the bereaved patient's family, lack of evaluation of nurses' opinions, and the evasion by physicians to talk about the diagnosis and their over-optimistic view of the situation. The main facilitating behaviors to improve nursing care were end-of-life training, volunteering, and family involvement. Conclusions: Spiritual needs were identified by nurses as the primary needs of patients at the end of life. Family-related barriers remain one of the main barriers to end-of-life care. Also, the behavior of physicians and their relationship with nurses remains one of the most sensitive issues in end-of-life care.

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Objective: HealthyHearts NYC was a stepped wedge randomized control trial that tested the effectiveness of practice facilitation on the adoption of cardiovascular disease guidelines in small primary care practices. The objective of this study was to identify was to identify attributes of small practices that signaled they would perform well in a practice facilitation intervention implementation. Methods: A mixed methods multiple-case study design was used. Six small practices were selected representing 3 variations in meeting the practice-level benchmark of >70% of hypertensive patients having controlled blood pressure. Inductive and deductive approaches were used to identify themes and assign case ratings. Cross-case rating comparison was used to identify attributes of high performing practices. Results: Our first key finding is that the high-performing and improved practices in our study looked and acted similarly during the intervention implementation. The second key finding is that 3 attributes emerged in our analysis of determinants of high performance in small practices: (1) advanced use of the EHR; (2) dedicated resources and commitment to quality improvement; and (3) actively engaged lead clinician and office manager. Conclusions: These attributes may be important determinants of high performance, indicating not only a small practice’s capability to engage in an intervention but possibly also its readiness to change. We recommend developing tools to assess readiness to change, specifically for small primary care practices, which may help external agents, like practice facilitators, better translate intervention implementations to context.

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Introduction: Cervical cancer is the second leading cause of cancer death among women in the Dominican Republic, and high rates persist despite existing Pap smear screening programs. The purpose of this study was to explore Dominican women’s knowledge and attitudes regarding human papillomavirus (HPV) and cervical cancer, cervical cancer screening practices, and perceived barriers and facilitators to early detection of cervical cancer. Method: Six focus groups (N = 64) were conducted in Spanish in urban, suburban, and rural locations, in private and public school settings, community and workplace settings, in or near Santo Domingo, as part of a larger study on barriers and facilitators to HPV vaccine implementation. Audio recordings were transcribed verbatim and translated from Spanish to English. Qualitative data analysis used inductive and deductive approaches. Results: Knowledge regarding HPV and cervical cancer varied across groups, but all agreed there was significant stigma and fear regarding HPV. Most women reported having Pap screening at least yearly. Follow-up of abnormal Pap testing was less consistent, with cost and uncertainty about provider recommendations identified as barriers. Discussion: Broader examination of provider-level and health system barriers and facilitators to cervical cancer prevention in the Dominican Republic is essential, in order to inform interventions to improve the effectiveness of cervical cancer screening and treatment programs and reduce preventable deaths.

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Background:: evidence suggests a reciprocal relationship between cognitive function (CF) and oral health (OH), but no study has demonstrated this inter-relationship in a longitudinal population. Objective:: to investigate the bidirectional relationship between CF and OH in an ageing cohort. Design:: cohort study. Setting:: general community. Subjects:: participants from the English Longitudinal Study of Ageing. Methods:: OH, measured by teeth status, self-reported OH and OH-related quality of life (OHRQoL), and CFs were collected at three time points in 2006/07, 2010/11 and 2014/15. Cross-lagged structural equation models were used to investigate the association between CF and OH, adjusted for potential confounding factors. Results:: 5477 individuals (56.4% women) were included (mean age = 63.1 years at 2006/07, 67.2 at 2010/11 and 70.4 at 2014/15, SD = 8.9) in analyses. The average CF score was 46.5(SD = 12.3) at baseline and 41.2 (SD = 13.4) at follow-up. 3350 (61.2%) participants had natural teeth only and 622 (11.2%) were edentulous. In the fully adjusted model, better cognition at baseline was associated with better OH at follow-up (beta coefficient = 0.02, 95% CI: 0.01–0.03); conversely better OH at baseline predicted better cognition (beta coefficient = 0.12, 95% CI: 0.06–0.18). Similar magnitude and direction of the reciprocal association was evident between cognition and OHRQoL. Conclusions:: This is the first longitudinal study to demonstrate the positive reciprocal association between CF and OH. The findings suggest the importance of maintaining both good CF and OH in old age.

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Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation's ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14–S20, 2020.

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Abstract corporal punishment (CP) is associated with negative short-term and long-term children outcomes. However, many caregivers continue to administer spankings and other forms of CP. Pediatric nurse practitioners are in a unique position to affect change in parental behavior related to CP use and other parenting practices. This article will summarize the research on the dangers of CP and the corresponding benefits of positive parenting. It defines positive parenting and offers resources pediatric health care providers, including pediatric nurse practitioners, can use to educate both themselves and caregivers about specific discipline techniques appropriate to each developmental stage. Finally, it suggests practice strategies pediatric nurse practitioners can use to help caregivers replace CP and other harsh parenting practices with positive parenting to build a safe and healthy America.