Publications

Abstract

Growing discourse around maternity care during the pandemic offers an opportunity to reflect on how this crisis has amplified inequities in health care. We argue that policies upholding the rights of birthing people, and policies decreasing the risk of COVID-19 transmission are not mutually exclusive. The explicit lack of standardization of evidence-based maternity care, whether expressed in clinical protocols or institutional policy, has disproportionately impacted marginalized communities. If these factors remain unexamined, then it would seem that equity is not the priority, but retaining power and control is. We advocate for a comprehensive understanding of how this pandemic has revealed our deepest failures.

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This paper aims to analyze the regulatory structure of nursing in Mexico through its legislation and perspectives of participant stakeholders. A case study was undertaken using qualitative and quantitative data sources, as well as from the review of official documents. The analysis included data from the sources according to the four realms proposed by the Moran & Wood (1993) model. The more advanced realm was the market entry since the state regulates entry through a license of practice. The regulation of competition is weak, showing very reduced areas of autonomous practice. The labor market is offering a wide variety of entry options with clear signs of deterioration. The dominant payment mechanism is salary, showing a structure that incorporates a component that does not impact on pensions at the end of the labor cycle. The regulation of nursing is a component of its professionalization, and as such, it is understood as a multidimensional consolidating process, particularly realms related to the regulation of competition, market structure, and payment mechanisms, in which nursing representatives should play a more active role in the future.

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BACKGROUND: Psychological state, stress level, and gastrointestinal function are intricately related and relevant to symptom exacerbation in patients with irritable bowel syndrome (IBS), but genetic contributors to this brain-gut connection are not fully understood. The purpose of this exploratory study was to compare gene expression in participants with IBS to that of healthy controls (HC) and to examine patterns of expression in participants with IBS by sex and IBS subtype.METHOD: Participants were recruited to an ongoing protocol at the National Institutes of Health. Differences in demographic and clinical characteristics were assessed using descriptive statistics and Mann-Whitney U tests. Expression levels of 84 genes were evaluated in peripheral whole blood using Custom RT2 Profiler polymerase chain reaction (PCR) Arrays, and data analysis was performed through GeneGlobe Data Analysis Center.RESULTS: Participants with IBS (n = 27) reported greater levels of perceived stress (p = .037) and differed in expression values of ±2 for the genes ADIPOR1, ADIPOR2, CNR2, COMT, OXTR, and PPARA compared to HC (n = 43). Further analyses by sex and IBS subtype revealed differential patterns of gene expression related to the endocannabinoid system, cytokines, stress, and sex steroid hormones.CONCLUSIONS: Diverse yet interconnected processes such as metabolism, inflammation, immunity, social behavior, and pain are associated with differences in gene expression between participants with IBS and HC. These findings lend support for genomic associations with the brain-gut connection in patients with IBS and highlight the relevance of sex and IBS subtype in performing such analyses.

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Background and Objectives: Pain and functional limitations can severely impede older adults' quality of life. In Chinese residential care facilities, limited research suggests that residents potentially have significant unmet care needs with pain and related functional limitations. Therefore, we aimed to explore residents' challenges and self-management strategies in these two areas. This knowledge is essential to developing care interventions to improve quality of care and quality of life in Chinese residential care facilities. Research Design and Methods: We conducted semi-structured open-ended interviews with residents (n = 21) in two facilities in eastern and central China and assessed their pain and functional status using self-report measures from Minimum Data Set 3.0. We applied descriptive statistics to the self-reported data and analyzed the interview data using thematic analysis by drawing on the Adaptive Leadership Framework. This framework proposes that individuals living with chronic conditions need to engage in work to address their complex health concerns and that they need support from the environment to facilitate problem-solving. Results: Residents described significant unmet care needs with pain and functional limitations. To address these care needs, they adopted a substantial number of self-management strategies. While doing so, they faced significant barriers, including service gaps and inadequate direct care. Discussion and Implications: The findings suggest further research to explore long-term care policy change that is needed to provide comprehensive health and medical services and adequate direct care in these facilities. The importance of establishing various types of long-term care facilities is also highlighted.

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Patients in home health care (HHC), a rapidly growing healthcare sector, are at high risk for infections. This study aimed to identify risk factors for infections among HHC patients using the Outcome and Assessment Information Set (OASIS) data. We used a 5% random sample of the 2013 national OASIS data. Infections were identified if records indicated that patients were hospitalized or received emergency care for one of three types of infections (respiratory, wound site, and urinary tract infection). Multivariate logistic regression models were used to identify risk factors for each individual infection type. The final analysis included 128,163 patients from 8,255 HHC agencies nationwide. Approximately 3.2% of the patients developed infections during their HHC stay that led to hospitalization or emergency care treatment. We found that associations between demographics and infection risk are specific to the type of infection. In general, a history of multiple hospitalizations in past 6 months, comorbidity, having a severe condition at HHC admission, and impaired physical functioning increased HHC patients' risk of infections. We also identified that HHC patients with caregivers who needed training in providing medical procedure or treatment are at higher risk for wound-site infections. Our findings suggest that patients with underlying medical conditions and limited physical function status are more likely to develop infection. The caregiver's lack of training in providing needed care at home also places HHC patients at high risk for infection. Education for patients and caregivers should be tailored based on their health literacy level to ensure complete understanding.

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Introduction: A large body of literature exists on self-management of type 2 diabetes (T2D) in a variety of populations. However, research is limited on how Haitian immigrants self-manage their T2D despite a prevalence of 6.9% in Haiti. The purpose of this study was to explore and describe the lived experience of adult Haitian immigrants managing T2D living in the United States. Methodology: Moustakas’s phenomenological approach guided this qualitative study. Adult Haitian immigrants diagnosed with T2D for at least 1 year were interviewed. Individual interviews were audio-recorded, transcribed verbatim, uploaded into NVivo, and analyzed using Moustakas’s existential data analysis process. Results: We interviewed 16 participants (mean age 56;12 females; an average of 11 years living in the United States; mean hemoglobin A1c 8.1%). Four themes emerged: self-reliance, spirituality, nostalgia for home, and a desire for positive patient–provider relationships. Cultural influences and health beliefs may affect individual self-management of T2D in this population. Conclusions: These results may assist clinicians in identifying factors that contribute to suboptimal self-management in Haitian immigrants and help patients reach glycemic control. Culturally competent assessment and interventions for Haitian immigrants with T2D may not be provided without considering these four themes.

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The current article highlights an interprofessional, older adult oral health community program, created through an Accelerating Interprofessional Community-Based Education and Practice grant from the National Center for Interprofessional Practice and Education, designed to address the gap between older adult health education and care delivery. This project developed an advanced practice, nurse-led partnership among The Hartford Institute for Geriatric Nursing and the Oral Health Nursing Education and Practice Program (both located at New York University Rory Meyers College of Nursing), New York University College of Dentistry, and Regional Aid for Interim Needs (RAIN), a community service organization for older adults in the Bronx. Teams of nursing (n = 26), nurse practitioner (n = 16), and dental (n = 64) students provided oral health education and oral hygiene instruction using Tooth Wisdom® educational materials to older adults, home health aides (HHAs), and volunteers in nine RAIN senior centers. Students demonstrated increases in their self-reported interprofessional competencies based on the Interprofessional Collaborative Competency Attainment Survey. Results also revealed that older adults (n = 500), HHAs (n = 142), and volunteers (n = 21) at the RAIN senior centers who attended the Tooth Wisdom presentation demonstrated an increase in oral health knowledge.

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Delta-9-tetrahydrocannabinol (THC) is known to modulate immune response in peripheral blood cells. The mechanisms of THC’s effects on gene expression in human immune cells remains poorly understood. Combining a within-subject design with single cell transcriptome mapping, we report that THC acutely alters gene expression in 15,973 blood cells. We identified 294 transcriptome-wide significant genes among eight cell types including 69 common genes and 225 cell-type-specific genes affected by THC administration, including those genes involving in immune response, cytokine production, cell proliferation and apoptosis. We revealed distinct transcriptomic sub-clusters affected by THC in major immune cell types where THC perturbed cell-type-specific intracellular gene expression correlations. Gene set enrichment analysis further supports the findings of THC’s common and cell-type-specific effects on immune response and cell toxicity. This comprehensive single-cell transcriptomic profiling provides important insights into THC’s acute effects on immune function that may have important medical implications.

Abstract

We are experiencing a historical moment with an unprecedented challenge of the COVID-19 global pandemic. The outbreak of COVID-19 will have a long-term and profound impact on older adults' health and well-being. Social isolation and loneliness are likely to be one of the most affected health outcomes. Social isolation and loneliness are major risk factors that have been linked with poor physical and mental health status. This paper discusses several approaches that may address the issues of social isolation and loneliness. These approaches include promoting social connection as public health messaging, mobilizing the resources from family members, community-based networks and resources, developing innovative technology-based interventions to improve social connections, and engaging the health care system to begin the process of developing methods to identify social isolation and loneliness in health care settings.

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Longer life expectancy means that chronological age is no longer a useful indicator of defining old age. This study included 6,452 participants aged 60 years and older from the 2014 China Longitudinal Aging Social Survey to investigate the relationships between different types of social participation and self-perception of being old in China. Ordinary least square regression was applied. Results show that respondents who engaged in political participation or community participation reported higher self-perception of being old than those who did not engage in these social participations. Respondents who provided more care for grandchildren reported self-perception of being old at younger age. In the context of delaying retirement in China, obligatory participation was associated with an earlier start of the self-perception of being old. Elimination of mandatory retirement and separating that from pension eligibility may be good choices for promoting active aging.

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Insufficient research has explored whether sociodemographic differences in self-reported, individual-level diet quality are similarly reflected by grocery purchase quality. This cross-sectional analysis of n = 3961 U.S. households from the nationally representative Food Acquisition and Purchase Survey (FoodAPS) compared Healthy Eating Index (HEI)-2015 scores from 1 week of food-at-home acquisitions across self-reported demographic factors (race/ethnicity, Supplemental Nutrition Assistance Program (SNAP) participation, food security, and household-level obesity status). Multivariable-adjusted, survey-weighted regression models compared household HEI-2015 scores across sociodemographic groups. Respondents were primarily White and female, with a mean age of 50.6 years, 14.0% were food insecure, and 12.7% were SNAP-participating. Mean HEI-2015 scores were 54.7; scores differed across all sociodemographic exposures (p < 0.05). Interactions (p < 0.1) were detected between SNAP participation and (1) food insecurity and (2) household-level obesity, and race/ethnicity and (1) household-level obesity. HEI-2015 scores were higher among food secure, non-SNAP households than among food insecure, SNAP-participating households (53.9 ± 0.5 vs. 50.3 ± 0.7, p = 0.007); non-SNAP households without obesity had significantly higher HEI-2015 scores than other households. Household-level obesity was associated with lower HEI-2015 scores in White (50.8 ± 0.5 vs. 52.5 ± 0.7, p = 0.046) and Black (48.8 ± 1.5 vs. 53.1 ± 1.4, p = 0.018) but not Hispanic households (54.4 ± 1.0 vs. 52.2 ± 1.2, p = 0.21). Sociodemographic disparities in household HEI-2015 scores were consistent with previous research on individual-level diet quality.

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Disparities in rates of sexually transmitted infections (STIs) and HIV between Black/African American and Hispanic/Latino adolescents and their white counterparts are well documented. Researchers may encounter notable challenges recruiting Black/African American and Hispanic/Latino adolescents for sexual risk reduction studies. In this article, we present information to assist with planning, implementing, and evaluating recruitment and retention strategies. We also provide practical examples of challenges and solutions from three STI/HIV epidemiologic or prevention intervention studies with different study purposes and populations. Researchers can use this information to aid proposal development, create or refine a recruitment/retention protocol before implementation, and troubleshoot challenges during implementation.

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Background: In many countries, healthcare-associated infections (HAIs) are problematic in long-term aged care living facilities. In the United States (US), HAIs occur frequently in nursing homes (NHs). Identifying effective practices for state Departments of Health (DOHs) to help NHs improve infection prevention and control and reduce HAIs is necessary. Aim: As a first step, the objective was to systematically examine and catalogue the variations in state intentions and activities related to HAI prevention in NHs. Methods: An environmental scan of state DOH websites, HAI plans, and HAI state infographics was conducted. Data were collected on 16 items across three domains: (1) intentions to reduce HAIs in NHs, (2) actions to reduce HAIs in NHs, and (3) website usability. Findings: State infection control support for NHs varied widely. Most states (92%) mentioned NHs in their HAI plans and 76% included NHs in their infographic. Half has an HAI prevention advisory council, while one-third had a state HAI prevention collaborative. Only 57% of HAI plans that mentioned NHs included training materials on HAI reduction. The most common training available was on antibiotic stewardship. Conclusion: Many US states have room for improvement in the support they provide NHs regarding infection prevention and control. Specific areas of improvement include: (1) increased provision of training materials on HAI reduction, (2) focusing training materials on common HAIs, and (3) NH engagement in collaboratives aimed at HAI reduction. More research is needed linking DOH activities to resident outcomes.

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Introduction: Malignant fungating wounds (MFWs), non-healing wounds caused by aggressive proliferation of malignant tumors, afflict 5%-14.5% of patients with advanced cancer. We conducted an integrative review to evaluate the level of evidence of peer-reviewed literature published from 2000 to 2019 on symptoms of MFWs, and the impact of the symptoms on functional performance among patients with advanced cancer. Methods: Four electronic databases were searched and 1506 articles were retrieved. A total of 1056 abstracts were screened for relevance and a full review of the 26 articles was performed. A total of 12 articles met inclusion criteria. An established quality assessment tool was used to rate the quality of the included studies. Results: The overall quality of the included 12 studies was adequate. This integrative review of the literature provided strong evidence that patients with MFWs suffered multiple symptoms, including pain, odor, exudate, bleeding, pruritus, perceived wound status, perceived bulk effect and lymphedema. Quantitative research was not able to capture the occurrence and characteristics of all the identified symptoms. There was a lack of quantitative research on the impact of MFWs and symptoms on patients' functional performance. Yet, qualitative studies provided vivid description of how the symptoms negatively affected patients' functional performance. Future research should develop a clinical tool that enables the comprehensive assessment of symptoms of MFWs. Well-designed quantitative research is needed to delineate the impact of symptoms of MFWs on patients' functional performance to ensure quality palliative care.

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Metastasis reduces survival in oral cancer patients and pain is their greatest complaint. We have shown previously that oral cancer metastasis and pain are controlled by the endothelin axis, which is a pathway comprised of the endothelin A and B receptors (ETAR and ETBR). In this study we focus on individual genes of the pathway, demonstrating that the endothelin axis genes are methylated and dysregulated in cancer tissue. Based on these findings in patients, we hypothesize that ETAR and ETBR play dichotomous roles in oral carcinogenesis and pain, such that ETAR activation and silenced ETBR expression result in increased carcinogenesis and pain. We test a treatment strategy that targets the dichotomous functions of the two receptors by inhibiting ETAR with macitentan, an ETAR antagonist approved for treatment of pulmonary hypertension, and re-expressing the ETBR gene with adenovirus transduction, and determine the treatment effect on cancer invasion (i.e., metastasis), proliferation and pain in vitro and in vivo. We demonstrate that combination treatment of macitentan and ETBR gene therapy inhibits invasion, but not proliferation, in cell culture and in a mouse model of tongue cancer. Furthermore, the treatment combination produces an antinociceptive effect through inhibition of endothelin-1 mediated neuronal activation, revealing the analgesic potential of macitentan. Our treatment approach targets a pathway shown to be dysregulated in oral cancer patients, using gene therapy and repurposing an available drug to effectively treat both oral cancer metastasis and pain in a preclinical model.

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simulation of an initial telemedicine visit

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Objective To explore the impact of an adapted goals-of-care communications skills workshop created for ED physicians from the physicians’ perspective. Methods Semi-structured, one-on-one audio-recorded interviews lasting 30–60 min were conducted with twelve physicians who had completed the training workshop. Interviews explored the experience of undertaking the workshop, its impact on their clinical practice and their ability to teach new skills to other clinicians using learnt techniques. Descriptive content analysis was performed on interview transcripts. Results Participants reported positive experiences of the workshop. The analysis identified four main themes and ten subthemes dealing with workshop content and its impact on subsequent ED-based clinical practice. There were: 1) value and future improvements for the course; 2) value of the course to practice; 3) value of the course for teaching residents and 4) barriers to application of learning. Specifically recommended components include the use of mnemonics, mechanisms to introduce difficult conversations and a positive feedback environment. Participant-recommended refinements to the workshop included emphasising urgency, replicating the chaotic ED environment and expanding content to include more ED-focused goals-of-care discussions. Conclusion A short, focused training workshop directed at improving palliative care communication skills among ED clinicians appears to be welcomed and useful.