Exploring Preventive Health Care Utilization Among Black/African American Men

Black/African American (BAA) men have the lowest life expectancy among other major demographic groups in the United States, with BAA male mortality rates 40% higher than their White male counterparts. Despite known benefits of preventive health care utilization, BAA men are 43% more likely to use the emergency department for usual care. Many intersecting factors like medical mistrust and religion have been identified as common barriers BAA men face in health care utilization with few studies exploring factors that impact their current preventive health care utilization. In addition, BAA men's perceptions of health and ability to identify or seek help have always been disproportionately lower than other racial groups despite higher rates of preventable diseases. Using the tenets of the Andersen Healthcare Utilization Model, this cross-sectional study of 176 BAA men explores BAA men's current preventive health care practices while examining the intersection of predisposing, enabling, and need factors on BAA men's preventive health care utilization. While it is well known that higher income levels and higher education positively influence health care utilization, the intersection of religious affiliation and higher levels of medical mistrust was associated with BAA men's decreased engagement with health care as religion posed as a buffer to health care utilization. This study demonstrated that BAA men's perception of health differed by sexual orientation, educational status, and income. However, across all groups the participants' perspective of their health was not in alignment with their current health outcomes. Future studies should evaluate the impact of masculine norms as potential enabling factors on BAA men's preventive health care utilization.

Correction: OjiNjideka Hemphill et al. Feasibility Study of Lactobacillus Plantarum 299v Probiotic Supplementation in an Urban Academic Facility among Diverse Pregnant Individuals. Nutrients 2023, 15, 875

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Symptom Cluster Experiences of Patients Operated for Oral Cancer: A Mixed Methods Study

OBJECTIVE

This convergent mixed methods study aimed to obtain a comprehensive understanding of symptom cluster experiences in patients with oral cancer. Survey and phenomenological interviews were conducted in parallel to identify distinct patient subgroups based on symptom cluster experiences along with their predictors and explore experiences of living with symptom clusters, respectively.

DATA SOURCES

A convenience sample of 300 patients with oral cancer who had completed surgery provided the quantitative data, and a maximum variation purposive subsample of 20 participants, drawn from the survey sample, provided the qualitative data. Agglomerative hierarchical cluster analysis was used to identify subgroups, multivariate analyses were done to identify predictors, and thematic analysis was used for patient narratives.

CONCLUSION

Almost 94% of the survey participants had two or more co-occurring symptoms. The four most severe and prevalent symptoms were dysphagia, problems with teeth or gums, speech difficulty, and dry mouth. A distinct subgroup consisting of 61% of patients reported severe dysphagia and teeth problems, which was associated with age, oral cancer stage and site. Interviews revealed the causes and the context influencing the perception and response to these symptoms. Thus, the quantitative data provided information on severity and patient subgroups based on symptom cluster experiences, while the qualitative data validated these conclusions and additionally provided in-depth details and meaningful insight on perceived causes and contextual influences of their experiences. This comprehensive picture of symptom cluster experiences can aid in the development of patient-centered interventions for people with oral cancer.

IMPLICATIONS FOR NURSING PRACTICE

An interdisciplinary approach to targeting concurrent symptoms incorporating psychological and physical interventions is necessary. Older patients treated for Stage IV cancers and for buccal mucosa tumors are at high-risk of having severe dysphagia postoperatively, and these patients should be targeted for dysphagia interventions. The contextual factors play an important role in developing patient-centered interventions.

Use of drug-induced sleep endoscopy in Germany-an analysis based on claims data

Background

Drug-induced sleep endoscopy (DISE) has recently gained relevance as a diagnostic tool for obstructive sleep apnea (OSA). However, it is unclear to what extent and in which patient cohorts DISE is used in Germany. With introduction of specific coding for this method in 2021 (Operationen- und Prozedurenschluessel, OPS code), usage can now be analyzed based on diagnosis-related groups (DRG) claims data.

Methods

Aggregated data from all inpatient DISE procedures conducted in German hospitals in 2021 were obtained from the publicly available Institut fuer das Entgeltsystem im Krankenhaus (InEK) database. Patient-relevant information as well as data on hospitals providing the examinations were exported and analyzed.

Results

Between January and December 2021, a total of 2765 DISE procedures were conducted and documented using the newly introduced specific code (1-611.01). Most patients were male (75.6%), in the age categories 30-39 (15.2%) and 40-49 years (17.2%), and presented with the lowest patient clinical complexity level (PCCL; class 0 = 81.88%). Pediatric use was rare (1.8%). Leading main diagnoses of patients were G47.31 (OSA) and J34.2 (deviation of nasal septum). The most common procedures conducted together with DISE were nasal surgery, and the examination was mostly provided in large public hospitals with more than 800 beds.

Conclusion

Though the OSA prevalence in Germany is high, use of DISE as a diagnostic tool is low and represented only 4.4% of cases with a main diagnosis of OSA in 2021. Since specific coding was only introduced in January 2021, trends cannot yet be identified. Noticeable is the frequent combination of DISE with nasal surgery, which is not obviously related to a diagnosis of OSA. Limitations of the study are mainly related to the underlying data, which are available for the inpatient sector only, and due to potentially limited use of the OPS code, which was introduced recently and might not be known to all hospitals.

Feasibility Study of Lactobacillus Plantarum 299v Probiotic Supplementation in an Urban Academic Facility among Diverse Pregnant Individuals

(1) Background: Despite iron intake recommendations, over a quarter of pregnant individuals have iron deficiency. Lactobacillus plantarum 299v (Lp299v®) enhances iron absorption in non-pregnant populations and may have positive effects in pregnancy among those with sufficient iron stores; however, no studies have evaluated the effect of Lp299v® on maternal and neonatal iron status among individuals at risk for iron deficiency anemia in pregnancy. Thus, this study aims to assess the feasibility and preliminary efficacy of daily oral Lp299v® maternal supplementation among diverse pregnant individuals. (2) Methods: In this double-blind placebo-controlled randomized supplementation feasibility study, participants were randomized to probiotic Lp299v® + prenatal vitamin with iron or placebo + prenatal vitamin with iron from 15-20 weeks of gestation through delivery. (3) Results: Of the 20 enrolled and randomized participants, 58% (7/12) from the Lp299v® group and 75% (6/8) from the placebo group were retained. Adherence to supplementation was 72% for Lp299v®/placebo and 73% for the prenatal vitamin. A slower decline in maternal hematological and iron parameters across pregnancy was observed in the Lp299v® group compared to placebo. (4) Conclusions: Lp299v® may be a tolerable therapy during pregnancy and has the potential to affect maternal and neonatal hematological and iron status.

On a pathway to resigned acceptance: Patients' experiences of living with symptom clusters in oral cancer

PURPOSE

Patients treated for oral cancer experience multiple concurrent symptoms. A larger mixed-methods study was conducted among patients who were treated with surgery alone or in combination with other modalities. The aim of the qualitative strand was to explore the experiences of living with symptom clusters.

METHODS

A phenomenological design was used to explore the lived experiences. Participants were recruited for the larger study from two outpatient units of a tertiary teaching hospital (N = 300). After completion of a survey, a maximum variation purposive subsample of 20 participants was drawn from the larger sample and were interviewed in-depth about their experiences. Thematic analysis was conducted.

FINDINGS

All participants experienced multiple concurrent symptoms, commonly including chewing difficulties + dry mouth + speech difficulties; chewing difficulties + dry mouth + diminished taste; and chewing difficulties + dry mouth + speech difficulties + trismus. Analysis of their experiences of living with these symptom clusters revealed six themes: Acknowledged Disruptions, Inner Dialogue, Shifting Expectations, Floods of Emotions, Exercising Control over Life, and Resigned Acceptance. These themes portrayed that time and living with symptom clusters lead to what we describe as a pathway to resigned acceptance. This pathway is intermingled with disruptions, self-reflections on 'why me' and karma, negative emotions, and failed expectations regarding symptom recovery. Attempts to exercise control over their lives were also revealed through coping strategies, watchful living, future planning, and being health advocates. On realizing with time that further symptom alleviation is unlikely, and considering symptom-cluster experiences as being written in their fate, they move towards a state of resigned acceptance. However, unlike passive acceptance, their belief in fate was accompanied with resilience, evidenced by their ongoing efforts to explore pragmatic ways to live with symptom clusters.

CONCLUSIONS

Findings provide key insights into patient perspectives which most often remain unexpressed in clinical settings. Further research is required to explore watchful living, fate as a coping strategy, and intertwining of faith, fate, and karma.

Sleep-Opt-In: A Randomized Controlled Pilot Study to Improve Sleep and Glycemic Variability in Adults With Type 1 Diabetes

PURPOSE

The purpose of this study was to evaluate the feasibility and acceptability of a technology-assisted behavioral sleep intervention (Sleep-Opt-In) and to examine the effects of Sleep-Opt-In on sleep duration and regularity, glucose indices, and patient-reported outcomes. Short sleep duration and irregular sleep schedules are associated with reduced glycemic control and greater glycemic variability.

METHODS

A randomized controlled parallel-arm pilot study was employed. Adults with type 1 diabetes (n = 14) were recruited from the Midwest and randomized 3:2 to the sleep-optimization (Sleep-Opt-In) or Healthy Living attention control group. Sleep-Opt-In was an 8-week, remotely delivered intervention consisting of digital lessons, sleep tracker, and weekly coaching phone calls by a trained sleep coach. Assessments of sleep (actigraphy), glucose (A1C, continuous glucose monitoring), and patient-reported outcomes (questionnaires for daytime sleepiness, fatigue, diabetes distress, and depressive mood) were completed at baseline and at completion of the intervention.

RESULTS

Sleep-Opt-In was feasible and acceptable. Those in Sleep-Opt-In with objectively confirmed short or irregular sleep demonstrated an improvement in sleep regularity (25 minutes), reduced glycemic variability (3.2%), and improved time in range (6.9%) compared to the Healthy Living attention control group. Patient-reported outcomes improved only for the Sleep-Opt-In group. Fatigue and depressive mood improved compared to the control.

CONCLUSIONS

Sleep-Opt-In is feasible, acceptable, and promising for further evaluation as a means to improve sleep duration or regularity in the population of people with type 1 diabetes.

Therapy for insomnia with chronic obstructive pulmonary disease: a randomized trial of components

STUDY OBJECTIVES

To determine efficacy and mechanisms of cognitive behavioral therapy for insomnia (CBT-I) and chronic obstructive pulmonary disease (COPD) education (COPD-ED) on clinical outcomes in adults with concurrent COPD and insomnia.

METHODS

We conducted a 2 × 2 factorial study to test the impact of CBT-I and COPD-ED delivered alone or in combination on severity of insomnia and fatigue, sleep, and dyspnea. Participants were randomized to 1 of 4 groups-group 1: CBT-I + attention control (AC; health videos, n = 27); group 2: COPD-ED + AC, n = 28; group 3: CBT-I + COPD-ED, n = 27; and group 4, AC only, n = 27. Participants received six 75-minute weekly sessions. Dependent variables included insomnia severity, sleep by actigraphy, fatigue, and dyspnea measured at baseline, immediately postintervention, and at 3 months postintervention. Presumed mediators of intervention effects included beliefs and attitudes about sleep, self-efficacy for sleep and COPD, and emotional function.

RESULTS

COPD patients (percent predicted forced expiratory volume in 1 second [FEV1pp] 67% ± 24% [mean ± standard deviation]), aged 65 ± 8 years, with insomnia participated in the study. Insomnia and sleep improved more in patients who received CBT-I than in those who did not, an effect that was sustained at 3 months postintervention and mediated by beliefs and attitudes about sleep. CBT-I was associated with clinically important improvements in fatigue and dyspnea. When CBT-I and COPD-ED were concurrently administered, effects on insomnia, fatigue, and dyspnea were attenuated.

CONCLUSIONS

CBT-I produced significant and sustained decreases in insomnia improved sleep and clinically important improvement in fatigue, and dyspnea. The combination of CBT-I and COPD-ED reduced CBT-I's effectiveness. Further research is needed to understand the mechanisms associated with effects of insomnia therapy on multiple symptoms in COPD.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: A Behavioral Therapy for Insomnia Co-existing with COPD; URL: https://clinicaltrials.gov/ct2/show/NCT01973647; Identifier: NCT01973647.

CITATION

Kapella M, Steffen A, Prasad B, et al. Therapy for insomnia with chronic obstructive pulmonary disease: a randomized trial of components. J Clin Sleep Med. 2022;18(12):2763-2774.

Discharge planning practice for patients with colorectal cancer in Thailand

Background & Aim: Nurses play a vital role in discharge planning, especially for patients with colorectal cancer who require complex post-treatment care. However, there is a limited understanding of nurses' discharge planning practice in oncology settings. This study aimed to examine current discharge planning practices for patients with colorectal cancer among oncology nurses in Thailand and associated factors. Methods & Materials: A cross-sectional survey study was conducted between October and November 2020. Oncology nurses involved in colorectal cancer care were recruited across Thailand via Facebook and the Line application. A convenience and snowball sample of 206 nurses completed the online survey. Descriptive statistics, t-test, and one-way ANOVA were used for data analysis. Results: The discharge planning activity with the lowest mean score was related to sharing discharge planning summaries and/or care plans with other healthcare facilities (M = 3.00, SD= 1.32), followed by providing information about returning to work (M= 3.06, SD= 1.28), financial resources (M= 3.12, SD= 1.26), and disease (M= 3.13, SD= 1.25). Factors significantly associated with discharge planning practice included nursing education levels, specialty training in cancer care, and experience in colorectal cancer care. Conclusion: Despite the availability of discharge planning guidelines, Thai oncology nurses did not perform the full scope of discharge planning activities required for patients with colorectal cancer. Additional strategies, resources, and support systems should be established to facilitate nurses' performance of the full scope of their discharge planning practice in oncology settings. Moreover, our results suggest the need for additional education and training in the form of enhanced curriculums and continuing education seminars addressing cancer care to advance nurses' discharge planning for patients with colorectal cancer.

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Thai oncology nurses' perspectives toward survivorship care plan components and implementation for colorectal cancer survivors

PURPOSE

To describe oncology nurses' perspectives regarding survivorship care plan (SCP) components and implementation for colorectal cancer (CRC) survivors in Thailand.

METHODS

A cross-sectional, descriptive online study was conducted between October and November 2020. Thai oncology nurses were recruited using Facebook and the Line application. Study participants (n = 160) rated the usefulness of four standard SCP components (treatment summaries, surveillance, late/long-term effects, and health promotion and psychosocial needs; n = 23 items) and gave input on the implementation of SCPs in clinical practice (n = 11 items). Data were analyzed using descriptive statistics.

RESULTS

Most oncology nurses supported providing CRC survivors with SCPs (93.2%) and felt that SCPs were an important part of their practice (93.7%). Nurses rated all four SCP components as "very useful," including treatment summaries (76.4%), surveillance (81.9%), late/long-term effects (85.7%), and health behavior and psychosocial concerns (80.2%). In terms of implementation, most nurses indicated that oncologists should prepare (84.4%) and provide SCPs (95%), but 61.9% and 69.4% of nurses, respectively, also believed that they should perform these tasks. In addition, most nurses indicated that they should play a significant role in the ongoing management of CRC survivors (95.7%) and that evidence-based surveillance guidelines are needed (96.2%).

CONCLUSION

Oncology nurses believed that the four SCP components were helpful to the long-term management of CRC survivors, supported SCP provision, and expressed their perceived responsibilities for preparing and delivering SCPs. The findings suggested opportunities for oncology nurses to play a significant role in developing and implementing SCPs. However, additional efforts are needed to expand nurses' roles in survivorship care and establish practice guidelines that will facilitate integration of SCPs into nursing practice.

A Study Protocol for Increasing Access to Smoking Cessation Treatments for Low-Income Minority Smokers

Background: Smoking rates among low-income patients are double those of the general population. Access to health care is an essential social determinant of health. Federally qualified health care centers (FQHC) are government-supported and community-based centers to increase access to health care for non-insured and underinsured patients. However, barriers to implementation impact adherence and sustainability of evidence-based smoking cessation within FQHC settings. To address this implementation barrier, our multi-disciplinary team proposes Mi QUIT CARE (Mile Square QUIT Community-Access-Referral-Expansion) to establish the acceptability, feasibility, and capacity of an FQHC system to deliver an evidence-based and multi-level intervention to increase patient engagement with a state tobacco quitline. Methods: A mixed-method approach, rooted in an implementation science framework of RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), will be used in this hybrid effectiveness-implementation design. We aim to evaluate the efficacy of a novel delivery system (patient portal) for increasing access to smoking cessation treatment. In preparation for a future randomized clinical trial of Mi QUIT CARE, we will conduct the following developmental research: (1) Examine the burden of tobacco among patient populations served by our partner FQHC, (2) Evaluate among FQHC patients and health care providers, knowledge, attitudes, barriers, and facilitators related to smoking cessation and our intervention components, (3) Evaluate the use of tailored communication strategies and patient navigation to increase patient portal uptake among patients, and (4) To test the acceptability, feasibility, and capacity of the partner FQHC to deliver Mi QUIT CARE. Discussion: This study provides a model for developing and implementing smoking and other health promotion interventions for low-income patients delivered via patient health portals. If successful, the intervention has important implications for addressing a critical social determinant of cancer and other tobacco-related morbidities. Trial Registration: U.S. National Institutes of Health Clinical Trials, NCT04827420, https://clinicaltrials.gov/ct2/show/NCT04827420.

Use of Complementary and Integrative Health Therapies Prior to Intensive Functional Restoration in Active Duty Service Members with Chronic Pain

OBJECTIVE

Psychosocial factors are known to predict chronic pain, and the use of complementary and integrative health (CIH) therapies to address pain is emerging among military population. However, conflicting results on pain outcomes warrant additional research. This study aimed to (1) evaluate the benefit of adding a CIH pain management program to standard rehabilitative care (SRC), as compared to SRC alone, as precursor to an intensive functional restoration (FR) program; (2) identify factors that predict improvement in pain outcomes following treatment; and (3) determine the proportion of participants who experience clinically meaningful response.

DESIGN

Pragmatic randomized controlled clinical trial. Participants were randomized to a 3-week course of either SRC alone or SRC+CIH (stage 1), followed by a 3- to 6-week course of FR (stage 2).

SETTING AND SUBJECTS

Active duty service members with chronic pain.

METHODS

Participants completed either SRC alone or SRC+CIH (stage 1), followed by a course of FR (stage 2). Patient-reported and provider-determined outcomes were collected at baseline, after stage 1, and after stage 2. A covariance pattern model with unstructured residual covariance matrix was used to compare treatment arms while accounting for dependency due to repeated measurements.

RESULTS

A total of 210 service members participated. Most were Army (82%) and male (84%). Participants randomized to the SRC+CIH intervention had greater improvement in the pain impact score than those in the SRC alone group. Predictors of outcomes were baseline impact score, anger, depression, and educational status.

CONCLUSIONS

This study found that military service members with the highest pain impact benefit the most from interdisciplinary pain care.

The Influence of Sedentary Behavior on the Relationship Between Cognitive Function and Vascular Function in Older Adults with and without Chronic Kidney Disease

Cognitive impairment and vascular dysfunction are common in older adults with and without chronic kidney disease (CKD). Older adults with and without CKD are also sedentary - a behavior associated with cognitive and vascular function. The objective of this study was to explore whether sedentary behavior influenced the relationship between cognitive and vascular function in older adults with preclinical cognitive impairment with and without CKD. In our study, 48 older adults underwent assessment of cognition, vascular compliance, and sedentary behavior, and relationships were explored with regression moderation analysis. Sedentary time and breaks did not moderate the relationship between vascular and cognitive function. Although significant moderation was not found, cognition, vascular function, and sedentary behavior are important to assess when evaluating older adults with and without CKD.

Perspectives and practices regarding colorectal cancer survivorship care: Online survey results from oncology nurses in Thailand

PURPOSE

Limited research has highlighted disparities in survivorship care in low- and middle-income countries. However, such care for colorectal cancer (CRC) survivors remains unexplored, especially in Thailand. This study examined Thai oncology nurses' perceptions of responsibility, confidence levels, and frequency of survivorship care practice for CRC survivors and identified factors impeding such care.

METHODS

A cross-sectional study utilizing an online survey approach was conducted between October and November 2020. Thai oncology nurses (N = 155) completed the survey's demographic questionnaire, 29-item survivorship care scale, and 16-item impeding factor scale.

RESULTS

Oncology nurses had high levels of perceived responsibility (mean = 73.37, SD = 12.12) and confidence (mean = 65.09, SD = 14.89) for providing CRC survivorship care. However, they reported less frequency of practice (mean = 47.60, SD = 21.03), especially concerning sexual, fertility, employment, and financial issues. Nurses with higher education had significantly higher responsibility perceptions, confidence levels, and frequency of practice (all p < .05). Also, nurses with specialty training in cancer care reported higher frequency of practice (p = .013). Common factors impeding survivorship care were lack of physical facilities (60.4%), knowledge/skills (57.4%), and educational resources for family members (52.3%) and survivors (51.6%).

CONCLUSIONS

This study revealed inconsistencies between oncology nurses' responsibility perceptions, confidence levels, and frequency of survivorship care practice. The results can guide nurse researchers, educators, leaders, and policymakers in enhancing the quality of CRC survivorship care in low- and middle-income countries such as Thailand. Future efforts should focus on developing educational resources and training programs for survivorship care for oncology nurses and addressing factors impeding such care during healthcare service planning.

Symptom Clusters in Head and Neck Cancer: A Systematic Review and Conceptual Model

OBJECTIVE

The two approaches to symptom-cluster research include grouping symptoms and grouping patients. The objective of this systematic review was to examine the conceptual approaches and methodologies used in symptom-cluster research in patients with head and neck cancer.

DATA SOURCES

Articles were retrieved from electronic databases (CINAHL, MEDLINE via Ovid, APA PsycINFO, Scopus, Embase, and Cochrane Central Register of Controlled Trials-CENTRAL), five grey literature portals, and Google Scholar. Seventeen studies met the eligibility criteria. Eight studies grouped symptoms to identify symptom clusters, of which two used qualitative methods. The number of symptom clusters ranged from two to five, and the number of symptoms in a cluster ranged from 2 to 11. Nine studies grouped patients based on their experiences with multiple symptoms. Cluster analysis and factor analysis were most commonly used. Despite variable names and composition of symptom clusters, synthesis revealed three prominent symptom clusters: general, head and neck cancer-specific, and gastrointestinal. Being female and quality of life were significantly associated with high symptom group or cluster severity. Biological mechanisms were sparsely examined.

CONCLUSION

Symptom cluster research in head and neck cancer is emerging. Consensus on nomenclature of a symptom cluster will facilitate deduction of core clinically relevant symptom clusters in head and neck cancer. Further research is required on understanding patients' subjective experiences, identifying predictors and outcomes, and underlying mechanisms for symptom clusters.

IMPLICATIONS FOR NURSING PRACTICE

Identification of clinically relevant symptom clusters would enable targeted symptom assessment and management strategies, thus improving treatment efficiencies and patient outcomes.

The influence of minority stress on indicators of suicidality among lesbian, gay, bisexual and transgender adults in Thailand

WHAT IS KNOWN ON THE SUBJECT?: Established research from the United States and other Western countries has found that lesbian, gay, bisexual and transgender (LGBT) populations are at an elevated risk for suicide. Suicidality among LGBT individuals is understudied in Thailand and other Asian countries, warranting additional research to better understand risk factors and to create effective treatment and suicide prevention interventions. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The study examined rates and predictors of suicidality in Thai LGBT adults. Study findings suggest that general (e.g. stress and loneliness) and minority stressors (e.g. discrimination and victimization) played important roles in predicting lifetime and past-year suicidal ideation, while socio-demographic and health-related factors (e.g. living in high poverty area and having chronic diseases) were associated with suicide attempts among LGBT individuals. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Changes in the nursing curriculum and continuing education resources are needed to improve knowledge and core competencies in the mental health and treatment needs of LGBT individuals in Thailand. Among LGBT serving practitioners, routine assessment of suicidality is needed to increase the early identification and treatment of individual at risk for suicidal behaviours. Standardized measures of sexual orientation and gender identity should be included in all patient intake forms. In conducting research on strategies to improve mental health outcomes among LGBT populations, standardized measures of sexual orientation/gender identity and minority-specific stressors should be used. Suicide prevention interventions aimed at reducing general and minority stress among LGBT populations should be a priority in mental health nursing.

ABSTRACT

INTRODUCTION: A large and rigorous body of research in the United States has demonstrated that lesbian, gay, bisexual and transgender (LGBT) populations are at an elevated risk for suicide. However, scant research aimed at understanding the rates and predictors for suicidality among Thai LGBT individuals exists.

AIM

To examine rates and predictors of suicidality among Thai LGBT adults (N = 411).

METHOD

Data collection was conducted via online and in-person surveys. Guided by the Minority Stress Model, standardized measures of demographics, health-related factors, general and minority-specific stressors and suicidality were completed.

RESULTS

Thirty-nine per cent of participants reported lifetime suicidal ideation, 19.0% past 12-month suicidal ideation and 13.1% lifetime suicide attempts. Lifetime suicidal ideation was associated with higher levels of social discrimination, stress, loneliness and chronic disease (OR = 1.12, 1.16, 2.75, and 1.46, p ≤ .05, R² = 0.327). Past-year suicidal ideation was associated with victimization, stress, loneliness and being a former smoker (OR = 1.52, 1.20, 2.34, and 4.89, p < .05, R²  = 0.345). Suicide attempts were associated with internalized homophobia, poverty, chronic disease, alcohol use and physical health (OR = 1.44, 1.06, 1.59, 1.45 and 0.95, p ≤ 0.05, R²  = 0.187).

DISCUSSION

General and minority-specific stressors negatively impacted suicidality among LGBT participants.

IMPLICATION FOR PRACTICE

Study findings have implications for nursing education, practice and research. Nursing education should include information about the influence of sexual orientation and gender identity on mental health outcomes. Further, systematic screening for suicidality should be conducted by LGBT serving psychiatric and mental health nurses. Finally, research is needed to determine best practices for interventions aimed at reducing suicidality risk among LGBT individuals.

Exploring data management content in doctoral nursing handbooks

Objective:

While data management (DM) is an increasing responsibility of doctorally prepared nurses, little is understood about how DM education and expectations are reflected within student handbooks. The purpose of this study was to assess the inclusion of DM content within doctoral nursing student handbooks.

Methods:

A list of 346 doctoral programs was obtained from the American Association of Colleges of Nursing (AACN). Program websites were searched to locate program handbooks, which were downloaded for analysis. A textual review of 261 handbooks from 215 institutions was conducted to determine whether DM was mentioned and, if so, where the DM content was located. Statistical analysis was performed to compare the presence of DM guidance by type of institution, Carnegie Classification, and the type of doctoral program handbook.

Results:

A total of 1,382 codes were identified across data life cycle stages, most commonly in the handbooks’ project requirements section. The most frequent mention of DM was in relation to collecting and analyzing data; the least frequent related to publishing and sharing data and preservation. Significant differences in the frequency and location of codes were identified by program type and Carnegie Classification.

Conclusions:

Nursing doctoral program handbooks primarily address collecting and analyzing data during student projects. Findings suggest limited education about, and inclusion of, DM life cycle content, especially within DNP programs. Collaboration between nursing faculty and librarians and nursing and library professional organizations is needed to advance the adoption of DM best practices for preparing students in their future roles as clinicians and scholars.

Cognitive and vascular function in older adults with and without CKD

BACKGROUND

Cognitive impairment is a common complication of aging that is also associated with chronic kidney disease (CKD). Vascular dysfunction has been implicated as a potential cause of cognitive impairment in older adults, with particular deficits noted in those with CKD.

AIMS

To determine the differences in cognitive function and vascular compliance in older adults with and without CKD with preclinical cognitive impairment and the relationship between these factors.

METHODS

Utilizing a cross-sectional approach, 48 older adults with preclinical cognitive impairment (24 with and 24 without CKD) were evaluated for performance on a test of global cognition and executive function, and vascular compliance via tonometry and ultrasound.

RESULTS

Cognitive function and some indicators of vascular function were significantly different in older adults with and without CKD. Global cognition was correlated with carotid-femoral pulse wave velocity (r = - 0.36, p = 0.02) in the entire sample. Vascular function was not correlated with executive function.

DISCUSSION

Older adults with preclinical cognitive impairment and CKD had different cognitive and vascular function than those without CKD, and an indicator of vascular function may have a relationship with cognitive function in older adults.

CONCLUSIONS

The findings of this study support the assessment of cognitive and vascular function in older adults with and without CKD with preclinical cognitive impairment.

Advance Care Planning for African American Caregivers of Relatives With Dementias: Cluster Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

African-American family caregivers may have insufficient knowledge to make informed end-of-life (EOL) decisions for relatives with dementias. Advance Care Treatment Plan (ACT-Plan) is a community-based education intervention to enhance knowledge of dementia and associated EOL medical treatments, self-efficacy, intentions, and behavior (written EOL care plan). This study evaluated efficacy of the intervention compared to attention control.

RESEARCH DESIGN AND METHODS

In a theoretically based, 2-group, cluster randomized controlled trial, 4 similar Midwestern urban megachurches were randomized to experimental or control conditions. Each church recruited African-American caregivers, enrolling concurrent waves of 5 to 9 participants in 4 weekly 1-hour sessions (358 total: ACT-Plan n = 173, control n = 185). Dementia, cardiopulmonary resuscitation (CPR), mechanical ventilation (MV), and tube feeding (TF) treatments were discussed in ACT-Plan classes. Participants completed assessments before the initial class, after the final class (week 4), and at week 20. Repeated measures models were used to test the intervention effect on changes in outcomes across time, adjusting for covariates as needed.

RESULTS

Knowledge of CPR, MV, TF, and self-efficacy to make EOL treatment decisions increased significantly more in the ACT-Plan group at weeks 4 and 20. Knowledge of dementia also increased more in the ACT-Plan group at both points, reaching statistical significance only at week 20. Intentions to make EOL treatment decisions and actually an advance care plan were similar between treatment arms.

DISCUSSION AND IMPLICATIONS

Findings demonstrate promise for ACT-Plan to increase informed EOL treatment decisions for African American caregivers of individuals with dementias.

Exploring HIV stigma among future healthcare providers in Indonesia

Future healthcare professionals are an important group for interventions to eliminate HIV stigma in the health workforce. Researchers examined HIV stigma and its relationship with healthcare discipline, HIV knowledge, and religiosity among nursing, medical, and midwifery students (N = 505) in three regions of Indonesia. In a multivariable linear model, higher HIV stigma was associated with male sex, lower levels of income and HIV knowledge, and higher levels of religiosity. An interaction of healthcare discipline and province was also significant. Medical students in Jakarta had higher predicted stigma scores compared to nursing students in Jakarta and compared to medical students in other provinces. Nursing students in Papua had lower predicted stigma scores compared to medical and midwifery students in Papua and compared to nursing students elsewhere. Strategies to reduce HIV stigma in the Indonesian health workforce should include a strong focus on pre-clinical educational settings and consider public nursing institutions as providing possible best practice models.

Pain Management Telementoring, Long-term Opioid Prescribing, and Patient-Reported Outcomes

OBJECTIVE

Benefits of primary care provider (PCP) participation in pain management telementoring have been reported; however, no studies have examined within-patient changes in dose or discontinuation of long-term opioid therapy (LOT). The objectives of this nonrandomized study were to evaluate the relationship between telementoring participation and 1) LOT dose reduction and 2) LOT discontinuation and to 3) explore the relationship between LOT dose changes and patient-reported outcomes.

METHODS

PCPs were recruited from a US Army medical center. Intervention group PCPs (N = 12) attended telementoring sessions; control group providers (N = 13) did not. Morphine equivalent daily doses (MEDD) for patients of study providers (N = 396) were extracted from the study site's opioid database. The intervention group was subdivided based on number of sessions attended (i.e., active and low participation). Intent-to-treat and as-treated analyses were conducted using generalized estimating equations. Separate analyses evaluated the association between within-patient changes in MEDD and pain impact, depression, and anxiety (N = 40).

RESULTS

Intent-to-treat analysis revealed no significant difference in MEDD reduction; however, a higher proportion of patients of intervention PCPs discontinued LOT (25% ± 3.6%) compared with control PCPs (16% ± 3.6%, P < 0.05). As-treated analyses revealed differences in MEDD reduction between active (13.2 ± 3.0) and low-participating (2.6 ± 3.0) PCPs (P < 0.01). Further, a higher proportion of patients of actively participating PCPs discontinued LOT (29% ± 4.9%) compared with control PCPs (16% ± 3.6%, P = 0.01). We found no evidence that decreased MEDD was associated with poorer self-reported outcomes within patients.

CONCLUSIONS

Pain management telementoring supports PCPs' efforts to reduce reliance on LOT for chronic pain management and highlights the need for actively engaged PCP pain champions.

Diagnosis and treatment of isolated snoring-open questions and areas for future research

STUDY OBJECTIVES

Snoring is a common phenomenon which is generated by vibration of soft tissue of the upper airway during sleep. Due to the high incidence of isolated snoring and the substantial burden for the patient and the bed partner, a thorough examination and appropriate therapy are required. Many recommendations for the treatment of isolated snoring are either not evidence-based or are derived from recommendations for the management of obstructive sleep apnea. Therefore, the aim of this study is the identification and description of open questions in the diagnosis and treatment of isolated snoring and the illustration of areas for further research.

METHODS

In the context of the development of the new version of the German guideline "Diagnosis and treatment of isolated snoring in adults," a multidisciplinary team of experts performed a systematic literature search on the relevant medical data and rated the current evidence regarding the key diagnostic and therapeutic measures for snoring.

RESULTS

The systematic literature review identified 2293 articles. As a major inclusion criterion, only studies on primary snoring based on objective sleep medical assessment were selected. After screening and evaluation, 33 full-text articles remained for further analysis. Based on these articles, open questions and areas for future research were identified for this review.

CONCLUSION

Several major gaps in the literature on the diagnosis and treatment of isolated snoring were identified. For the majority of diagnostic and therapeutic measures for snoring, high-level scientific evidence is still lacking.

Prepregnancy Obesity Is Not Associated with Iron Utilization during the Third Trimester

BACKGROUND

An adequate maternal iron supply is crucial for maternal red blood cell (RBC) expansion, placental and fetal growth, and fetal brain development. Obese women may be at risk for poor iron status in pregnancy due to proinflammatory-driven overexpression of hepcidin leading to decreased iron bioavailability.

OBJECTIVE

The objective of this study was to determine the impact of prepregnancy (PP) obesity on third-trimester maternal iron utilization.

DESIGN

Using the stable isotope 57Fe, we measured iron utilization in the third trimester in PP obese [BMI (in kg/m2): ≥30] and nonobese (BMI: 18.5-29.9) women. We also assessed iron status, hepcidin, inflammation, erythropoietin, dietary iron intake, and gestational weight gain. Descriptive and inferential statistical tests (e.g., Student t test, Pearson correlation) were used for data analysis.

RESULTS

Fifty pregnant women (21 PP obese, 29 PP nonobese) were included. Mean age was 27.6 ± 6.8 y and mean gestational age at time of 57Fe administration was 32.7 ± 0.7 wk. Anemia (hemoglobin <11 g/dL for non-black and <10.2 g/dL for black women) affected 38% of women (43% PP obese compared with 35% PP nonobese; P = 0.55). Women with PP obesity had significantly higher C-reactive protein (8.5 compared with 3.4 mg/L, P = 0.0007) and total body iron corrected for inflammation (6.0 compared with 4.3 mg/kg, P = 0.04) compared with the nonobese women. There was no difference in serum hepcidin or iron utilization between the PP BMI groups.

CONCLUSION

This is the first study to assess the impact of PP obesity on maternal iron utilization. We found no difference in iron utilization in the third trimester of pregnancy in women with and without PP obesity. Despite higher frequency of anemia, women with PP obesity had less depleted body iron stores, suggesting some degree of iron sequestration. This finding should be followed up and extended to understand effects on fetal iron bioavailability.

Relationships between objective sleep parameters and inflammatory biomarkers in pregnancy

We examined the relationships between sleep and inflammatory biomarkers during late pregnancy. Seventy-four women underwent an overnight sleep assessment by polysomnography. Blood samples were collected before bedtime and again within 1 h upon awakening to measure C-reactive protein (CRP), interleukin (IL)-6, and IL-6 soluble receptor. Sleep parameters included variables characterizing sleep architecture and sleep continuity. The participants were 32.2 (SD = 4.1) years old, and the average gestational age was 32.8 (3.5) weeks. Controlling for covariates, evening CRP was negatively associated with N3 sleep (β = -0.30, P = 0.010). N3 sleep was also negatively associated with morning CRP (β = -0.26, P = 0.036), with a higher percentage of N3 sleep associated with a lower level of morning CRP. Contrarily, there was a tendency for a positive association between stage N2 sleep and morning CRP (β = 0.23, P = 0.065). Stage N1 sleep was associated with morning IL-6 (β = 0.28, P = 0.021), with a higher percentage of N1 sleep associated with a higher morning IL-6. No significant associations were found between morning inflammatory biomarkers and sleep continuity parameters. In conclusion, increased light sleep was associated with increased inflammatory biomarkers, whereas more deep sleep was associated with decreased inflammatory biomarkers. These findings further support the interactions between sleep and the immune system during late pregnancy.

0869 Slow Wave Sleep Is Associated With Decreased Risk Of Gestational Diabetes Mellitus

Introduction

Pregnancy is associated with disrupted slow-wave sleep (SWS) and a high prevalence of sleep disordered breathing (SDB), which may further exacerbate the decrease of deep sleep. Reduced slow wave sleep may impair glucose homeostasis, contributing to Gestational Diabetes Mellitus (GDM). Studies investigating EEG markers of deep and light sleep, and their associations with SDB and GDM are lacking. In this study, we measured associations of EEG Delta-power with objective SDB measures assessed in late-pregnancy to determine if changes in these bands are associated with GDM risk.

Methods

74 women (24-36 weeks pregnancy) underwent overnight polysomnography. Spectral profiles for Delta relative power were created for NREM and REM sleep after removing epochs with movements or muscle artifacts. The association of Delta power with SDB, assessed by the Apnea Hypopnea-Index (AHI) and AHI-based SDB severity (none, mild, moderate, severe) was tested by multivariate linear regression including demographic variables with bivariate correlations (p&lt;0.2) versus Delta-power. Conditional-regression was used to explore relationships between Delta-power and GDM, controlling for covariates.

Results

Obstructive Sleep Apnea (OSA, AHI&gt;5) was present in 14% of subjects (8 GDM-cases and 3 controls). In bivariate analyses, AHI, AHI-severity categories and OSA were associated with Delta-power in NREM (all p&lt;0.2) and AHI was associated with Delta relative-power in REM (p=0.18). However, these associations did not remain significant after adjusting for covariates. Delta relative-power in NREM was significantly associated with decreased risk of GDM (OR:0.50, 95%CI-0.25,0.91), but, in REM sleep, was not associated with GDM risk (OR:1.25, 95%CI-0.79,1.97).

Conclusion

These analyses failed to demonstrate an association between OSA or OSA severity and EEG Delta power. However, lower levels of SWS, characterized by low Delta power were associated with increased GDM risk.

Support

NIH-R00-NR013187

0529 Behavioral Therapy Components for Insomnia and Fatigue in COPD

Introduction

Insomnia contributes to fatigue, a common symptom in COPD. Our study aims were: (1) to determine the efficacy of a) cognitive behavioral therapy for insomnia (CBT-I) and b) COPD education (COPD-ED) on insomnia and fatigue, and (2) to define potential mechanistic contributors to pre/post intervention change in insomnia and fatigue in patients with COPD and insomnia.

Methods

A randomized 2x2 factorial design was used with factors representing CBT-I (yes/no) and COPD-ED (yes/no). Attention control (health videos) were used in the absence of CBT-I or COPD-ED. All patients received 6, 75-minute weekly sessions. Dependent variables included insomnia severity (Sleep Impairment Index (SII), range 0-28) and fatigue (Chronic Respiratory Disease Questionnaire (CRQ) range 1-7) measured at baseline, just post-intervention, and at 3-months post-intervention.

Results

One hundred nine patients (FEV1% predicted 67 ± 24% (mean ± SD), age 65 ± 8 years, SII 15.9 ± 8, CRQ 3.7 ± 1.1) participated in the study. After 6 sessions, insomnia decreased more in patients who received CBT-I (-5.8) than those who did not (-2.2; p=0.0002). This effect was sustained at the 3-month follow-up (p=0.0003). Fatigue showed no significant differences for CBT-I at 6-weeks (p=.27) but at 3-months patients receiving CBT-I showed marginally better improvement (.75, a clinically important difference) compared to those who did not receive CBT-I (.43; p=.09). COPD-ED showed no effect on insomnia or fatigue. Two main effects suggest mechanisms for the pre-post efficacy of CBT-I: improved sleep beliefs (p=0.0257) and self-efficacy for sleep (p=0.0619) after 6 sessions which were sustained at 3 months (p=0.0184 and p=0.0431 respectively).

Conclusion

CBT-I produced sustained decreases in insomnia in patients with COPD. Results suggest that changes in beliefs about sleep and improved self-efficacy for managing sleep may mediate CBT-I associated decreases in insomnia.

Support

This research was supported by the National Institute of Nursing Research of the National Institutes of Health R01NR013937.

0674 Association Between Lateral Wall Collapse On Drug-induced Sleep Endoscopy And MRI Findings In Hypoglossal Nerve Stimulator Patients

Introduction

Hypoglossal nerve stimulator (HNS) is an effective and safe alternative therapy for obstructive sleep apnea (OSA) in selected patients. Emerging evidence demonstrates that the outcome of HNS is variable, especially for patients with lateral wall collapse on drug-induced sleep endoscopy (DISE). Awake magnetic resonance imaging (MRI) offers detailed visualization of soft tissue. The aim of this study was to determine whether lateral wall collapse on DISE is associated with awake MRI findings in prospective HNS patients.

Methods

Patients from the ADHERE Registry, an international outcomes study for UAS were used for this study. At baseline, awake, supine MRI scans of each subject’s head and neck region were collected. The distance between the lateral walls was measured at the level of the hard palate, located by the appearance of the posterior nasal spine, using axial T2 turbo spin echo MRI. DISE assessments of the upper airway were recorded using the VOTE classification. All statistical analyses were performed using SPSS IBM 19.0 software program. Kendall’s Tau-b was performed to compare the association between VOTE scoring and MRI findings.

Results

Twenty-seven patients (N = 3 female, AHI = 28.8±10.5, BMI = 28.8 ±3.8 kg/m2, age = 53±9.9 years) were included in this study. The mean overall VOTE score and lateral wall score was 5.6±1.1 and 0.5±0.5, respectively. The mean lateral wall distance was 18.8±3.2 mm. A significant, inverse association was found between MRI lateral wall measurement and oropharyngeal lateral wall scoring on DISE (T=-.332,p=0.042) but not other anatomic subsites on DISE.

Conclusion

In our study, greater lateral wall collapse on DISE corresponded to narrower lateral airway distance on MRI. The utility of static imaging modalities such as MRI as patient selection tools for HNS warrants further study.

Support

Drs. Dedhia and Schwab receive related support for this project from the National Institutes of Health (NHBLI R01HL144859)

Sleep disturbance, associated symptoms, and quality of life in adults living with HIV in Jakarta, Indonesia

Adverse symptom experiences, including sleep disturbances, are important negative predictors of quality of life (QoL), but few studies conducted in low-income countries have examined the impact of poor sleep and its associated symptoms on QoL among people living with HIV (PLWH). To this end, 200 PLWH who were receiving treatment with antiretroviral therapy (ART) were recruited through a community nongovernment organization in Jakarta, Indonesia. Validated instruments measured QoL, sleep disturbance, fatigue, pain, ART adherence, substance use, drug use severity, and methadone treatment. Descriptive statistics, bivariate correlations, and multivariate linear regression were conducted to identify independent correlates of QoL. Overall, participants perceived their QoL as being good to very good (mean = 105.70, standard deviation = 14.7) and higher among women than men (p < 0.05). After adjusting for sex, education, drug-use severity, and ART adherence, QoL was negatively associated with fatigue, insomnia, and pharmacological treatment with methadone. Along with other known symptoms of HIV, sleep problems and their complications are important to clinically address and research more fully to assure satisfying QoL among PLWH.

A systematic review of illness representation clusters in chronic conditions

A person's beliefs about their chronic condition (illness representations) influence health and treatment outcomes. Recently, researchers have used clustering approaches to identify subgroups with different patterns of beliefs about their illness, with some subgroups having more favorable health outcomes than others. To date, these findings have not been synthesized. The purpose of this systematic review of the literature was to synthesize results of studies that used clustering approaches to analyze illness representation in chronic disease populations, in order to characterize the clusters and their relationship to health outcomes. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines we searched CINAHL, PsycInfo, and PubMed. To be included, studies had to be (a) peer reviewed, (b) in English, (c) performing a cluster analysis (CA), latent class analysis (LCA), or latent profile analysis (LPA), (d) using only illness representation (IR) subscales to form clusters, (e) measuring illness representation with the Illness Perception Questionnaire (IPQ-R), (f) in a chronic condition sample, and (g) measuring health-related outcomes. Twelve studies were included. Across studies, the number of clusters found ranged from two to three. In all studies, an association was found between illness representation group and at least one of their health outcomes. Illness representation clusters associated with favorable outcomes usually included lower disease-related consequences, fewer symptoms, less negative emotion, and a more stable disease pattern. The results of this review indicate that the relationship between the patterns of the illness representation profiles and health outcomes transcend diseases. Additionally, some dimensions of illness representation may be more important drivers of group membership than others.

Sedentary Time and White Matter Hyperintensity Volume in Older Adults

PURPOSE

Cerebrovascular disease in the form of white matter hyperintensities (WMH) increases with age and is associated separately with sedentary time and reduced kidney function. A better understanding of the relationships among these variables would help clarify whether sedentary time should be considered more closely in older adults at particular levels of kidney function to reduce the risk of WMH.

METHODS

We analyzed information from 94 healthy community-dwelling older adults to determine the association of sedentary time and WMH in nondemented, nondepressed older adults, and whether level of kidney function was an effect modifier of the relationship between sedentary time and WMH. Sedentary behavior was measured using the Sedentary Behavior Questionnaire. White matter hyperintensity was assessed using whole-brain 3T magnetic resonance imaging T1- and T2-weighted images. Kidney function was calculated by the epi-chronic kidney disease formula for estimated glomerular filtration rate (eGFR). Exposures or predictors were sedentary time, age, sex, education in years, Framingham stroke risk 10-yr prediction score, and eGFR. The analytical approach was multiple linear regression.

RESULTS

Adjusting for age, sex, education in years, Framingham stroke risk 10-yr prediction score, greater sedentary time was associated with greater WMH but this effect was dependent on level of eGFR (sedentary time-eGFR interaction b = -0.0005, P = 0.022). At eGFR values of 69, 81, and 93 mL·min per 1.73 m (the 25th, 50th, and 75th percentiles), sedentary time b coefficients were b = 0.021 (95% confidence interval [CI], 0.011-0.031), b = 0.015 (95% CI, 0.008-0.022), and b = 0.009 (95% CI, 0.003-0.016). The effect weakened linearly as eGFR increased, with no significant association at eGFR ≥97 mL·min per 1.73 m.

CONCLUSIONS

Findings suggest that sedentary time is associated with WMH in persons with an eGFR ≤96 mL·min per 1.73 m and that this association is stronger with lower levels of kidney function.

[Upper Airway Stimulation for obstructive sleep apnea-Can radiological position monitoring predict tongue motion one year after implantation? German version]

BACKGROUND

Tongue motion patterns (TMP) can influence the outcome of upper airway stimulation (UAS) in the treatment of obstructive sleep apnea (OSA). As a postoperative control the cuff position of the stimulation lead is monitored via X‑ray imaging. A multidimensional X‑ray assessment system was established and the association between these positional assessments and TMP was investigated 1 year after implantation.

MATERIAL AND METHODS

The study on TMP and the X‑ray assessments were carried out at a German ear nose and throat clinic as an implantation center. The TMPs were assessed under bipolar electrode configuration and were categorized according to the currently available literature as right-sided protrusion (RP), left-sided protrusion (LP), bilateral protrusion (BP) and mixed activation (MA). The X‑ray assessment was carried out in five dimensions: the position relative to the mandible and hyoid, cuff steepness in the lateral view of the neck, the cuff position based on the single electrode and the lead connection to the cuff in the anterior-posterior view. The analyses were performed by three raters with different medical backgrounds and knowledge regarding TMP.

RESULTS

In approximately 60% of the patients the apnea-hypopnea index was reduced to below 15/h, 1 year after implantation. The most common TMPs were RP and BP (82.9%). The interrater variability of the X‑ray assessment was good except for one category. Furthermore, no relevant associations were found apart from the correlation between a favorable TMP and the cuff position with respect to the lateral position of the stimulation cable.

CONCLUSION

Despite good interrater variability and convenient usage of the suggested X‑ray assessment system, this approach did not enable the identification of any associations, by which a TM and therefore a possible straightforward or complicated treatment pathway could be predicted. Attention should possibly be paid to a rotation of the cuff during implantation with a lateral position of the stimulation lead.

The association between symptom onset characteristics and prehospital delay in women and men with acute coronary syndrome

BACKGROUND

A decision to delay seeking treatment for symptoms of acute coronary syndrome increases the risk of serious complications, disability, and death.

AIMS

The purpose of this study was to determine if there was an association between gradual vs abrupt symptom onset and prehospital delay for patients with acute coronary syndrome and to examine the relationship between activities at symptom onset and gradual vs abrupt symptom onset.

METHODS

This was a secondary analysis of a large prospective multi-center study. Altogether, 474 patients presenting to the emergency department with symptoms of acute coronary syndrome were included in the study. Symptom characteristics, activity at symptom onset, and prehospital delay were measured with the ACS Patient Questionnaire.

RESULTS

Median prehospital delay time was four hours. Being uninsured (β=0.120, p=0.031) and having a gradual onset of symptoms (β=0.138, p=0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (β=-0.205, p=0.001) and arrival by ambulance (β=-0.317, p<0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs gradual symptom onset (2.57 h vs 8 h, p<0.001). Among men with an abrupt onset of symptoms and a ST-elevation myocardial infarction diagnosis, 54% reported that symptoms were triggered by exertion (p=0.046).

CONCLUSION

Patients should be counselled that a gradual onset of symptoms for potential acute coronary syndrome is an emergency and that they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent acute coronary syndrome.

The Quality of Symptoms in Women and Men Presenting to the Emergency Department With Suspected Acute Coronary Syndrome

INTRODUCTION

More than 5.5 million patients present to emergency departments in the United States annually for potential acute coronary syndrome (ACS); however, diagnosing ACS remains a challenge in emergency departments. Our aim was to describe the quality of symptoms (chest discomfort/description of pain, location/radiation, and overall symptom distress) reported by women and men ruled-in and ruled-out for ACS in emergency departments.

METHODS

The sample consisted of 1,064 patients presenting to emergency departments with symptoms that triggered cardiac workups. Trained research staff obtained data using the ACS Patient Information Questionnaire upon patient presentation to emergency departments.

RESULTS

The sample (n = 1,064) included 474 (44.55%) patients ruled-in and 590 (55.45%) patients ruled-out for ACS. Symptom distress was significantly higher in patients ruled-in versus ruled-out for ACS (7.3 ± 2.6 vs. 6.8 ± 2.5; P = 0.002) and was a significant predictor for an ACS diagnosis in men (odds ratio [OR], 1.10; confidence interval [CI], 1.03-1.17; P = 0.003). Women also reported more chest pressure (51.75% vs. 44.65; P = 0.02) compared with men, and chest pressure was a significant predictor for a diagnosis of ACS (OR, 1.61; CI, 1.03-2.53; P = 0.02).

DISCUSSION

Higher levels of symptom distress may help ED personnel in making a decision to evaluate a patient for ACS, and the presence of chest pressure may aid in making a differential diagnosis of ACS.

A latent class analysis of prolonged mechanical ventilation patients at a long-term acute care hospital: Subtype differences in clinical outcomes

RATIONALE

Patients on prolonged mechanical ventilation (PMV) at Long-Term Acute Care Hospital's (LTACHs) are clinically heterogeneous making it difficult to manage care and predict clinical outcomes.

OBJECTIVES

Identify and describe subgroups of patients on PMV at LTACHs and examine for group differences.

METHODS

Latent class analysis was completed on data obtained during medical record review at Midwestern LTACH.

MAIN RESULTS

A three-class solution was identified. Class 1 contained young, obese patients with low clinical and co-morbid burden; Class 2 contained the oldest patients with low clinical burden but multiple co-morbid conditions; Class 3 contained patients with multiple clinical and co-morbid burdens. There were no differences in LTACH length of stay [F(2,246) = 2.243, p = 0.108] or number of ventilator days [F(2,246) = 0.641, p = 0.528]. Class 3 patients were less likely to wean from mechanical ventilation [χ²(2, N = 249) = 25.48, p < 0.001] and more likely to die [χ²(2, N = 249) = 23.68, p < 0.001].

CONCLUSION

Patient subgroups can be described that predict clinical outcomes. Class 3 patients are at higher risk for poor clinical outcomes when compared to patients in Class 1 or Class 2.

Depression and Victimization in a Community Sample of Bisexual and Lesbian Women: An Intersectional Approach

Mental health inequities among bisexual and lesbian women are well-documented. Compared to heterosexual women, both bisexual and lesbian women are more likely to report lifetime depressive disorders, with bisexual women often faring the worst on mental health outcomes. Risk factors for depression, such as victimization in childhood and adulthood, are also more prevalent among bisexual women. Less is known about the intersection of racial/ethnic and sexual minority identities, and how depression and victimization may differ across these multiple, co-occurring identities. Data were from Wave 3 of the Chicago Health and Life Experiences of Women study, an 18-year, community-based longitudinal study of sexual minority women's health. We constructed a six-category "intersection" variable based on sexual identity and race/ethnicity to examine group differences in lifetime depression and victimization. We tested childhood and adult victimization as moderators of lifetime depression (n = 600). A majority (58.2%) of the total sample met criteria for lifetime depression. When considering the intersection of race/ethnicity and sexual identity, Black bisexual and Black lesbian women had significantly lower odds of depression than White lesbian women, despite their higher reports of victimization. Latina bisexual and lesbian women did not differ from White lesbians on depression. Victimization did not moderate the association between the intersection variable and depression. More research is needed to better understand risk and protective factors for depression among racially/ethnically diverse sexual minority women (SWM). We highlight the need to deliberately oversample SWM of color to accomplish this goal.

Trends and regional variations in the administrative prevalence of attention-deficit/hyperactivity disorder among children and adolescents in Germany

There is a controversy regarding temporal trends in prevalence of attention-deficit/hyperactivity disorder (ADHD). Using nationwide claims data containing data for approximately six million statutory health insured children we aimed to examine a) trends of ADHD administrative prevalence during 2009-2016; b) regional variations in prevalence, and c) factors associated with an increased chance of ADHD diagnosis. The ICD-10 code 'F90-hyperkinetic disorder' was used to define an ADHD case. Global and Local Moran's I tests were used to examine the spatial autocorrelation and k-means-cluster analysis to examine the course of ADHD prevalence in administrative districts over years. Two-level logistic regression was applied to examine individual- and district-level factors associated with ADHD diagnosis. The administrative prevalence of ADHD was 4.33% (95% CI: 4.31-4.34%). We observed pronounced small-area differences on the district level with prevalences ranging between 1.6% and 9.7%. There was evidence of strong spatial autocorrelation (Global Moran's I: 0.46, p < 0.0001). The k-means-method identified six clusters of different size; all with a stagnating trend in the prevalence over the observation period of eight years. On the district level, a lower proportion of foreign citizens, and a higher density of paediatric psychiatrists and paediatricians were positively associated with ADHD with a more pronounced effect in urban districts.

Self-schema as a non-drinker: a protective resource against heavy drinking in Mexican-American college women

Alcohol use is considered less acceptable for women than men in the Mexican culture. However, recent studies of Mexican-American (MA) women show that prevalence and rates of alcohol use are escalating, particularly in those with high acculturation to Western standards. Building on recent studies that demonstrated that drinking-related identities (self-schemas) are important predictors of alcohol use in college populations, this secondary data analysis investigated the association between acculturation, MA cultural values, and acculturative stress, drinking-related self-schemas and heavy drinking over time in college-enrolled MA women. Data were drawn from a 12-month longitudinal study of self-schemas and health-risk behaviors in 477 college-enrolled MA women. Drinking-related self-schemas, acculturation, MA cultural values and acculturative stress were measured at baseline, and heavy drinking was measured at baseline, 3, 6, 9 and 12 months. Thirty-six percent of women had a non-drinker self-schema but only 3% had a drinker self-schema. Higher spirituality was protective against heavy drinking, and this effect can be partially explained by presence of a non-drinker self-schema. Interventions that emphasize the personal relevance of being a non-drinker and support the importance of spirituality may help to prevent heavy drinking in MA college women.

Illness Representation and Self-Care Ability in Older Adults with Chronic Disease

Chronic illness affects >50% of adults in the United States and accounts for >80% of healthcare spending. The purpose of this study was to determine whether beliefs about one’s chronic disease (illness representation) are associated with self-care activation, emergency department (ED) visits, or hospitalizations. Using a cross-sectional design, we recruited older adults with heart failure, chronic obstructive pulmonary disease (COPD), and chronic kidney disease. The Revised Illness Perception Questionnaire (IPQ-R) measured perceptions about disease. The Patient Activation Measure measured self-care activation. ED visits and hospitalizations were measured by self-report. IPQ-R scores were analyzed using latent profile analysis to identify subgroups. Participants included 187 adults (mean age 65 years, 54% female, 74% Black). We found three subgroups (stable, overwhelmed, and confident). Groups did not differ demographically or by disease. The stable group (few consequences, non-fluctuating pattern) had the fewest hospitalizations. The overwhelmed group (many consequences, fluctuating pattern, high negative emotion) had high hospitalizations and low self-care ability. The confident group (high disease control, well-understood) had the highest self-care ability, but also high hospitalizations. ED visits did not differ by group. We found three subgroups that differ in their illness representation and health outcomes. Findings suggest that assessing patients’ illness representations may have important implications for subgroup-specific interventions.

Demographic, Healthcare, and Contextual Factors Associated with Smoking Status Among Sexual Minority Women

PURPOSE

The study purpose was to examine demographic, healthcare, and contextual correlates of smoking among sexual minority women (SMW).

METHODS

Data were from the Chicago Health and Life Experiences of Women study (2010-2012, N = 726).

RESULTS

The rate of current smoking was 29.6%, with 29.5% and 40.9% former or nonsmokers, respectively. A history of ever smoking was associated with lower educational levels, having a partner who smokes, heavy drinking, illicit drug use, and a bisexual identity. Statistically significant correlates of former versus current smoker included higher education, having a nonsmoking partner, being from the newest recruited cohort, and less illicit drug use. A past-year quit attempt among current smokers was associated with higher levels of illicit drug use, longer time until first cigarette, and being from the original cohort.

CONCLUSION

The study results highlight key correlates of smoking behaviors among SMW and make an important contribution to the literature on smoking disparities. Additional research is needed to inform smoking cessation prevention and control efforts to reduce known and persistent smoking disparities among SMW.

Increasing chloride concentration causes retention of mercury in melted Arctic snow due to changes in photoreduction kinetics

Mercury (Hg) in the Arctic is a significant concern due to its bioaccumulative and neurotoxic properties, and the sensitivity of Arctic environments. Previous research has found high levels of Hg in snowpacks with high chloride (Cl^-) concentrations. We hypothesised that Cl^- would increase Hg retention by decreasing Hg photoreduction to Hg(0) in melted Arctic snow. To test this, changes in Hg photoreduction kinetics in melted Alert, NU snow were quantified with changing Cl^- concentration and UV intensity. Snow was collected and melted in Teflon bottles in May 2014, spiked with 0-10μg/g Cl^-, and irradiated with 3.52-5.78W·m^-2 UV (280-400nm) radiation in a LuzChem photoreactor. Photoreduction rate constants (k) (0.14-0.59hr^-1) had positive linear relationships with [Cl^-], while photoreduced Hg amounts (Hg(II)_red) had negative linear relationships with [Cl^-] (1287-64pg in 200g melted snow). Varying UV and [Cl^-] both altered Hg(II)_red amounts, with more efficient Hg stabilisation by Cl^- at higher UV intensity, while k can be predicted by Cl^- concentration and/or UV intensity, depending on experimental parameters. Overall, with future projections for greater snowpack Cl^- loading, our experimental results suggest that more Hg could be delivered to Arctic aquatic ecosystems by melted snow (smaller Hg(II)_red expected), but the Hg in the melted snow that is photoreduced may do so more quickly (larger k expected).

The assessment of cognitive function in older adult patients with chronic kidney disease: an integrative review

INTRODUCTION

Chronic kidney disease (CKD) is a common chronic condition in older adults that is associated with cognitive decline. However, the exact prevalence of cognitive impairment in older adults with CKD is unclear likely due to the variety of methods utilized to assess cognitive function. The purpose of this integrative review is to determine how cognitive function is most frequently assessed in older adult patients with CKD.

METHODS

Five electronic databases were searched to explore relevant literature related to cognitive function assessment in older adult patients with CKD. Inclusion and exclusion criteria were created to focus the search to the assessment of cognitive function with standardized cognitive tests in older adults with CKD, not on renal replacement therapy.

RESULTS

Through the search methods, 36 articles were found that fulfilled the purpose of the review. There were 36 different types of cognitive tests utilized in the included articles, with each study utilizing between one and 12 tests. The most commonly utilized cognitive test was the Mini Mental State Exam (MMSE), followed by tests of digit symbol substitution and verbal fluency. The most commonly assessed aspect of cognitive function was global cognition.

DISCUSSION

The assessment of cognitive function in older adults with CKD with standardized tests is completed in various ways. Unfortunately, the common methods of assessment of cognitive function may not be fully examining the domains of impairment commonly found in older adults with CKD. Further research is needed to identify the ideal cognitive test to best assess older adults with CKD for cognitive impairment.