Full text for dissertations and theses included in this collection dates back to 2011. For older dissertations, check the library’s catalog CatalogUSMAI or Dissertations and Theses database.

Recent Submissions

  • Neuroimaging in Headache Patients: The Sensitivity of Computerized Tomography (CT) in Missed Stroke Diagnoses

    Heetderks, Elizabeth; Johantgen, Mary E. (2018)
    Background: Stroke is the leading cause of disability in the US, costing $34 billion a year and affecting 800,000 patients. Early detection and treatment is the best way to improve outcomes. Yet, 12.5% of strokes are discharged from the ED within the prior 30 days, with headache the most common diagnosis. Neuroimaging, ideally, would catch an impending stroke, but head CT has variable sensitivity based on onset of symptoms and there are both Federal and provider-led (including Choosing Wisely and the American College of Radiology Appropriateness Criteria (ACR-AC) initiatives to reduce overuse of imaging. Purpose: This study examined variation in ED treatment for patients presenting with a headache, particularly focusing on use of neuroimaging. Potential missed strokes were identified to determine if CT or MRI could have captured stroke. Methods: Using HCUP 2013 Maryland State Emergency Department Dataset, and State Inpatient Data, patients who were seen in the ED within 30 days of a stroke with a complaint of headache were identified. Generalized linear mixed modeling determined if neuroimaging predicted stroke bounce back while controlling for patient and hospital variables. Results: Of the 63,942 headache visits in Maryland EDs, 337 patients presented with a stroke within 30 days of ED discharge. Half (54%) were seen in the ED the day of their stroke and 72% were seen within 7 days. A large majority of the stroke patients (82%) underwent CT for their ED headache visit. Patients who underwent CT for their headache were 2.5 times more likely to return with ischemic stroke, and 7.7 times more likely to return with hemorrhagic. Patients who underwent MRI were 1.7 times more likely to return with any stroke, and 2.8 times more likely to return with ischemic stroke. Conclusions: Providers were concerned about pathology, given the large percentage of patients imaged; however, imaging did not catch active ischemia or bleeding. The negative predictive value of imaging for headache may need to be reconsidered. Patients with high suspicion of pathology should be placed in observation and have appropriate follow up testing. The ACR-AC should be incorporated into diagnostic pathways to optimize use.
  • Steps Towards an Intervention: Exploring Correlates and Measurement of Fatigue in Osteoarthritis

    Hackney, Alisha Jean; Klinedinst, N. Jennifer; 0000-0002-0928-0366 (2018)
    Background: Fatigue affects up to 90% of adults with osteoarthritis and contributes to disability and reduced quality of life. Treatment options are non-specific and limited to self-management. These limitations are due to least two gaps in current research: the lack of a standardized, reliable, and valid fatigue measure, and the lack of mechanistic insight. Purpose: To begin to address these limitations, the purposes of this three-manuscript dissertation were: 1) to examine standardized, valid, and reliable measures of osteoarthritis fatigue and 2) to explore correlates of fatigue to provide mechanistic insight. Methods: The first manuscript is a narrative literature review of osteoarthritis fatigue correlates. The second and third manuscripts analyze data from cross-sectional, retrospective studies. Analyzing pilot study data in SPSS and WINSTEPS, the second manuscript examines psychometrics of the standardized PROMIS Fatigue Short Forms 8a and 7a in osteoarthritis. The third manuscript uses data from the 2007-2010 National Health and Nutrition Examination Survey (NHANES) to examine fatigue correlates. Using SPSS complex samples analysis, adjusted logistic regression models were generated to predict odds of osteoarthritis fatigue as a function of a biological correlate (i.e., systemic inflammation: c-reactive protein [CRP] and white blood cell count [WBCC]). Results: Correlates of osteoarthritis fatigue include age, gender, medications, comorbidities, anxiety, depression, joint pain, physical activity, physical exercise, physical function, sleep quality, and systemic inflammation. The 8a and 7a were reliable (α =.86-.93) in adults with osteoarthritis. Differences existed in 8a, but not 7a, total scores, between adults with (N=20) and without osteoarthritis (t29=-2.8, p<.001; N=11). From the NHANES data, with every 1 mg/dL increase in CRP, adults with osteoarthritis had 3.19 times higher odds of fatigue (95% CI 1.11-9.19, p=.03) when controlling for age, pain, depression, sleep quantity, sleep disturbances, and body mass index. Conclusion: These findings have begun to fill the gaps that hindered development and testing of targeted interventions. Future research is necessary to gain more understanding of the use of the 7a and 8a in osteoarthritis and to delineate the relationship between other correlates, including additional systemic inflammatory markers, and fatigue in osteoarthritis. This will propel development and testing of targeted interventions.
  • The Association of Integrated Management of Childhood Illness' Asthma Management Protocol and Asthma Control in Omani Children 2-5 years Old

    Al Amri, Warda; Ogbolu, Yolanda; Johantgen, Mary E. (2018)
    Background: Oman had the highest asthma prevalence and severity in children among Eastern Mediterranean countries. Despite national implementation of Integrated Management of Childhood Illness (IMCI) asthma protocol, reports show no improvement in asthma-related hospital admissions among children aged 1-4 years. IMCI asthma treatment protocol implementation and factors affecting asthma control are understudied. Purpose: Describe characteristics of IMCI asthma management protocol implementation (medication, counselling, and specialist referral); explore multilevel factors associated with asthma control in children attending IMCI clinics; and analyze trends in acute care visits (emergency department [ED] and hospital admissions) by asthmatic children and their characteristics during one year follow-up. Methods: Retrospective cohort study of Omani children aged 2-5 years in Muscat was conducted using electronic health data (2012-2015). Asthma control was measured by number of exacerbations requiring visits to the health center, emergency care or hospitalization within one year of asthma index diagnosis. Generalized linear mixed-effects modelling was used to account for the clustering of children within health centers. Results: Mean age was 2.8 years, predominantly male (63.2%) and originally from Muscat (96.2%). On index diagnosis day, 61.2% were given reliever medications, and on discharge 47.1% were prescribed controller medications. Most (74%) children had well-controlled asthma that was highly associated with being treated in a health center with higher proportion of IMCI training (Adj. OR= 3.0; 95% CI =1.34, 6.73; p <0.01), and receiving short acting β2-agonists for acute management at index diagnosis (Adj. OR=2.4; 95% CI=1.38-4.09). There was limited data for specialist referrals and counselling. Majority of children with ED visits were infrequent attenders (94.1%), however, a small percentage had high acute care utilization (e.g. 21 visits/year). Conclusion: IMCI is designed to improve health outcomes of young children. A high proportion of children treated in IMCI clinics achieved well-controlled asthma. Training of physicians improved asthma outcomes, but specific components in the IMCI asthma management protocol need more reinforcement and further exploration. Utilizing prevention quality indicators to screen for implementation of IMCI components is recommend. Longitudinal investigation of multilevel factors (patient, family, practice, and health care system) associated with childhood asthma control in Oman is needed.
  • Promoting admission in active labor for childbirth: Triage dynamics and early labor lounge use

    Breman, Rachel Blankstein; Johantgen, Mary E. (2018)
    Background: Cesarean birth is the most common surgery amongst women of reproductive age and nearly one third of term pregnant women will birth via cesarean. All professional organizations involved in intrapartum care are advocating for reducing the rate. Overwhelming evidence supports admission in active labor as an effective strategy to promote vaginal birth. Yet, how this evidence translates into decision-making during triage is unknown. Use of an early labor lounge (ELL) as an alternative to hospital admission is one care innovation that has not been evaluated. Purpose: The study aims were to: 1) examine the dynamics of triage from the clinician perspective, and 2) explore the facilitators and barriers to use of an ELL by clinicians. Patient use of the ELL and satisfaction was also explored. Methods: A mixed methods approach was used. Semi-structured interviews of clinical staff were conducted using a qualitative descriptive approach to explore the triage and admission process. A framework analysis utilized the domains of the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to ELL use. Surveys examined the satisfaction of women after childbirth; for women using the ELL, their experience was also assessed. Results: Interviews revealed the decision-making triad among the pregnant woman, the provider, and the triage nurse that influences admission. The category that emerged is "Admission of Low-Risk Pregnant Women Depends on Many Factors." Four themes revealed were: 1) woman's expectation about birth, 2) woman's coping with labor, 3) variation in care management, and, 4) maternal and fetal safety. Several barriers and facilitators to ELL use were identified. A higher proportion of ELL users received their prenatal care from a midwife, were informed about the ELL during their prenatal visits, and experienced vaginal deliveries. Conclusion: Obstetrical triage is a complex process with multiple factors to be considered when deciding to admit a woman in labor. The decision making process and the use of an ELL must be further examined in a variety of settings to get a better understanding of context, birth outcomes and satisfaction with birth.
  • Diet Quality Among Pregnant Women Associated with Food Supplementation from the Women, Infants, and Children Program

    Zvenyach, Tracy; Regan, Mary J. (2018)
    Background: Dietary intake is known to influence human metabolism in ways that can affect health. The Special Supplemental Women, Infants, and Children program (WIC) is a population-based program aimed at improving nutrition and reducing health disparities among pregnant women and children. There is a paucity of research about diet quality in WIC that could optimize maternal and child health outcomes. Purpose: The purpose of this study was to describe diet quality of pregnant women receiving WIC food supplementation and estimate how much WIC food components contribute to quality of the diet. Methods: The study population was drawn from a large federally funded study examining the influence of diet on the vaginal microbiota and preterm birth (Birth, Eating and the Microbiota Study-BEAM: NR014826). A sub-group of 63 women enrolled in the WIC program formed the cohort for this study. An image-based dietary intake method called FoodFotoTM was used to capture nutritional intake. Diet quality was estimated using the healthy eating index (HEI-2010) representing conformance to Dietary Guidelines for Americans. Three-digit food codes aligned to the Food and Nutrient Database for Dietary Studies were used to quantify the density of WIC approved foods in participants diets. Results: The HEI scores for the sample ranged from 32.2 -71.3 (x50.8, SD=9.7). Food components scores for total vegetables, greens and beans, dairy, seafood plant protein and fatty acid ratio exceeded the 50th percentile. Inversely, low scores for sodium and refined grain scores demonstrated high consumption. Regression analysis showed that for every 1% increase in the proportion of WIC approved foods in the diet there was a corresponding increase of 0.65 points to the total HEI score (t=.6.86 (1, 61), P=.001). Conclusions: The mean HEI score for this study was consistent with other studies. The study findings support the hypothesis that the WIC food supplement significantly improves diet quality among the pregnant women enrolled in the program.
  • Influence of Social Observational Learning on Pain Perception

    Raghuraman, Nandini; Colloca, Luana (2018)
    Background: Placebo hypoalgesia is the reduction of pain purely by treatment context. Humans are social beings and learn about their environment by observing others. Research shows observational learning induces placebo hypoalgesia, but its neural underpinnings are not explored. Methods: During EEG acquisitions, twenty-six healthy participants observed a demonstrator experiencing pain on two inert creams on the forearm. He showed painful and neutral expression for each. They then received same creams and recorded their pain ratings. Results: We got 11 responders reporting lower pain (Placebo x = 12.8 ± 3.7, (F (1, 10) = 11.812, p = 0.006)) and 10 non-responders who showed opposite trend (Placebo x = -6.9±3.5, (F (1, 9) = 3.85, p = 0.081)). The peak alpha frequencies during eyes closed resting state did not correlate with placebo response. Conclusion: Social learning does induce placebo in certain people, and further EEG task analysis can help generate an electrophysiological marker for placebo.
  • Clinical Simulation in Pre-Licensure Nursing Students: Improving Learning Outcomes in Psychologically Safe Learning Environments

    Daniels, Amy Louise; Johantgen, Mary E. (2018)
    Background: Simulation-based education in pre-licensure nursing programs is increasing exponentially as alternative clinical teaching experiences. Implementing quality simulation experiences is resource intensive, cost limiting, with limited evidence of the impact on learning outcomes. Standards of Best Practice: SimulationSM identify formal training is essential for quality debriefing, including providing a psychologically safe learning environment. However, a recent nationwide survey of 150 nursing schools identified only 40% of programs formally train simulation facilitators. In addition, there are limited valid and reliable instruments measuring reflective thinking as a learning outcome and debriefing competence. Purpose: The first paper reviewed literature on psychological safety in nursing pre-licensure simulation and assessed alignment with Edmondson's work-team learning model. A second paper described reflective thinking measured by the Reflective Thinking Questionnaire (RTQ), and explored RTQ scores in relation to facilitator training length and Debriefing Assessment for Simulation in Healthcare Student Version (DASH-SV)© scores. A third paper explored the psychometric qualities of the RTQ. Methods: Using a quasi-experimental, cross-sectional, nonequivalent, two-group design, pre-licensure nursing students were surveyed using the RTQ and the DASH-SV (N=99). The six facilitators had varied experience and training. Descriptive and bivariate analyses examined RTQ subscales in relation to student characteristics and DASH-SV© scores in relation to student and facilitator characteristics. MPLUS was used for CFA of the RTQ to explore how well a hypothesized model based on pre-licensure nursing students fit sample data. Results: Simulation-based nursing education literature demonstrates alignment with Edmondson's work-team learning model, although only 10 articles met inclusion criteria. RTQ subscale scores did not differ across differing facilitator characteristics. Students rated 1-day trained facilitators higher in establishing psychological safety and provoking in-depth discussions compared to 5-day trained facilitators. Confirmatory factor analysis of the RTQ supported the hypothesized model from the literature, although model fit remains inadequate. Conclusions: No associations were found between 1-day and 5-day facilitator training and student reflective thinking. Although a small single-site study with limited measures, nursing schools should require 1-day training at a minimum. It is imperative to conduct more rigorous simulation studies to establish efficacy of simulation as a training methodology, development conceptual frameworks, and improve measures.
  • Social Stability as a Consistent Measure of Social Context in a Low-Income Social Network

    Moen, Marik; Johantgen, Mary E.; 0000-0001-8369-819X (2018)
    Background: Increasingly, studies of factors influencing health consider the importance of social contexts in which people are living. The selection of indicators to represent this social context in health research can seem arbitrary. This study examines the potential of social stability as a useful construct to represent social context in these studies. Purpose: This study applied a previous definition of social stability (SS) in a new population and examined its relationship to syndemic risk behaviors (sexual, substance use, and violence). Aim 1 examined whether SS (as measured by German, 2009) can identify distinct subgroups while describing SS prevalence and patterns. Aim 2 assessed whether measures of perceived or historical stability are related to SS status, and whether they influence latent SS classes. Aim 3 explored how SS level and subgroup are associated with risk behaviors, while examining the co-occurrence of these syndemic behaviors. Methods: A secondary analysis of data of heterosexuals at high-risk of HIV infection from the Baltimore site of National HIV Behavioral Surveillance Study was conducted. Descriptive and latent class analyses (LCA) were applied to characterize the prevalence and patterns of SS and risk behaviors and to identify SS subgroups. Logistic and latent class regression were applied to model the relationships of SS to risk behaviors and demographic covariates. Results: SS was more prevalent than expected, and co-occurrence of SS indicators was common in this population. LCA showed evidence for 3 sub-classes: high stability, residential instability, and income, employment instability. Perception or history of stability did not contribute to identifying latent classes. Education was an influential covariate in LCA. Co-occurrence and significant associations among risk behaviors are also common in the population. Ordinal and latent measurements of SS reliably predicted individual and combinations of sexual-substance use- and-violence risks. Relationships vary with the method of SS specification with stronger magnitude of odds of risk associated with the latent approach. Conclusion: Social stability well represented certain aspects of the social context in a new study population and demonstrated an influential relationship with syndemic risks. Consistent measures of SS should be considered for application in research including social conditions and health.
  • Factors Influencing the Use of Labor Management Interventions and Their Effect on Cesarean Birth

    Iobst, Stacey Elaine; Johantgen, Mary E.; 0000-0002-6954-2903 (2018)
    Background: The cesarean birth (CB) rate of 31.9% in the US is concerning because the procedure is associated with increased maternal mortality as well as increased maternal and neonatal morbidity. Women considered low-risk for CB are defined as nulliparous and pregnant with a term, singleton gestation in the vertex position (NTSV). Even among NTSV women, cesarean rates range from 2.4% to 36.5% across hospitals, suggesting that CB may be influenced by differences in practice patterns, including admission triage, the use of labor management interventions (e.g., amniotomy, epidural analgesia, and oxytocin augmentation), and availability of a laborist. Purpose: The following were examined in three manuscripts: (1) influence of cervical dilation at admission on labor management and CB, (2) influence of provider and hospital characteristics on labor management and CB, (3) influence of combinations of labor management interventions on likelihood of CB. Methods: All three manuscripts were cross-sectional, observational studies of NTSV women with spontaneous onset of labor whose births occurred from 2002-2007 at hospitals included in the National Institutes of Health Consortium on Safe Labor. Samples sizes varied due to missing data but ranged from 17,443 to 26,259. Generalized linear mixed modeling was used to account for the effects of hospital and provider clusters. Results: Greater dilation at admission (>6 cm) was associated with a lower likelihood of receiving all three interventions (RR 0.40, CI95 0.35-0.46) and a lower likelihood of CB (4-5 cm: RR 0.44, CI95 0.40-0.49; >6 cm: RR 0.20, CI95 0.17-0.24). Midwives were more likely to use no interventions compared to obstetrician/gynecologists (RR 1.81, CI95 1.50-2.19). Women delivering at hospitals with an as-needed laborist available had a greater likelihood of receiving no interventions (RR 4.27, CI95 1.43-12.70) compared to those at hospitals with a 24/7 laborist. Compared to no interventions, use of all three interventions was associated with an increased likelihood of CB (RR 1.84, CI95 1.53-2.21). Conclusion: Admitting women at more advanced cervical dilation may reduce the use of labor management interventions and CB. The combined use of labor management interventions should be considered carefully given the association with an increased likelihood of CB.
  • The Use of Text Messaging to Improve Adherence and Functioning in Psychiatric Patients

    Duarte, Ana Cecilia; Storr, Carla L.; 0000-0002-5294-9870 (2018)
    Background: Failure to attend psychiatric appointments can lead to poor medication adherence, relapse into crisis and/or re-hospitalization, or dropping out of treatment altogether. Changes are called for in the way clinicians and their practices can use technology to level the playing field in terms of health disparities, remove barriers to communication, decrease stigma, and assist in building self-efficacy and confidence in the treatment system. Purpose: To explore whether text messaging can improve adherence and function in the adult psychiatric outpatient population. Methods and Results: A literature review demonstrated that psychiatry, as a discipline, has not fully embraced all that technology has to offer despite a limited number of studies showing phone interventions improved health outcomes. A pilot randomized texting intervention of 89 adult psychiatric patients was conducted at a non-profit outpatient mental health clinic in a large urban Mid-Atlantic metropolitan area. The intent to treat group (n=47) received text message appointment reminders in addition to regular reminder calls from the clinic's Front Desk, while the treatment as usual group (n=42) received the reminder phone calls only. Implications: Though the main outcomes of appointment and medication adherence in response to the text reminder intervention of this study did not achieve significance, the results were still generally in line with the literature, which demonstrates support for the use of text messaging technology in this way. This would suggest there is value in using text appointment reminders in practice for psychiatry/mental health. Because appointment adherence is a problem that plagues every type of healthcare practice, those that avail themselves of technology that provides text reminder capability will likely benefit in terms of improved appointment adherence. Regular attendance at appointments improves the patient-provider relationship which plays an important role in patients' medication adherence and overall stability and good health. This cannot help but cascade into improved well-being.
  • Exploration of Toddler Sleep and Maternal Sleep/Mental Health in Low-income Families at Risk for Sleep Disparities

    Covington, Lauren Bentley; Rogers, Valerie E. (2018)
    Introduction: Sleep plays an important role in children's physical growth, behavior and development. The National Sleep Foundation recommends that toddlers get 11-14 hours of sleep in 24-hours and go to bed before 9 pm. Accurate sleep assessment is necessary to explore if toddlers are meeting these recommendations. Mothers play a primary role in toddler's sleep routines and duration. Conversely, toddler sleep is associated with maternal sleep quality. Poor maternal sleep has been linked to increased mental health symptoms. This reciprocal relationship requires investigation of the mother-toddler dyad, especially among low-income families in whom sleep deficiencies have previously been identified. Purpose: The purpose of this dissertation was to explore toddler sleep and maternal sleep/mental health in low-income families at risk for sleep disparities. Methods: Three cross-sectional studies were conducted. The first tested an integrated model to examine whether associations between perceived toddler sleep problems and maternal mental health varied by co-sleeping versus independent sleeping. The second identified differences between nightly versus non-nightly bedtime routine implementation based on maternal and demographic characteristics, and explored relationships between bedtime routines, awakenings and sleep duration. The final study compared sleep diary to actigraphy measurement of sleep. Results: Perceived toddler sleep problems were associated with an average decrease of 51 minutes in maternal sleep when co-sleeping. Maternal sleep duration mediated the relation between perceived toddler sleep problems and mental health symptoms for co-sleeping mothers. Presence of maternal depressive symptoms, housing insecurity, and food insecurity were associated with decreased likelihood of nightly bedtime routine implementation (all p<0.05); a practice that was found to be associated with long nighttime sleep duration through few nighttime awakenings (β = 22.93, 95% CI = 7.41 to 47.04). Compared to actigraphy, sleep diaries underestimated bedtime by an hour, overestimated nighttime sleep duration by 2.5 hours, and overestimated 24-hour sleep duration by 2.25 hours. Conclusions: The relation between maternal/toddler sleep and maternal mental health supports the necessary consideration of the mother-toddler dyad. Factors associated with low socioeconomic status may negatively impact the sleep environment and be related to poor sleep quality. Sleep diaries may not be an accurate sleep measure in this population.
  • A qualitative analysis of the implementation of a complex intervention: evaluating implementation of the Trauma Survivors Network

    Frey, Katherine Parris; Lipscomb, Jane (2017)
    Background: Annually, two million adults are admitted to US hospitals due to traumatic injury. The trauma recovery process often brings physical and psychological challenges. The Trauma Survivors Network (TSN) is a multimodal program designed to improve outcomes for this population. However, despite early efforts at dissemination, widespread adoption of the program remains low. Understanding barriers and facilitators to adoption and implementation is a common challenge in intervention development and dissemination generally, representing a knowledge gap in planning for the implementation of complex, behavior change interventions more specifically. Purpose: The purpose of this project was to qualitatively assess the implementation of the TSN at 6 trauma centers using a combination of prospective documentation and retrospective interviews. The implementation process at each of the participating centers was analyzed and compared to rate implementation strength. Specific barriers and facilitators to program implementation were identified. Methods: In this qualitative multiple case study, data sources included implementation logs (6), diary entries (147), and semi-structured interviews with key informants (37). Each of the centers was considered an analytic case. Data analysis followed a primarily deductive approach, using a coding framework based on the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Matrices of themes and cases were constructed, allowing the evaluation constructs at the case and study level. Results: The result of this research is the development of a model of program implementation proposing the factors most likely to result in successful implementation of the TSN. Implementation requires leaders at local centers to recognize the need for the program, and working with a dedicated coordinator and engaged opinion leaders, provide the time, support, and resources necessary to demonstrate program continuity and value to staff. This process is facilitated by external, national level support for the program, including the potential incorporation of the TSN into guidelines for trauma center verification, as well as the design of internal processes intended to integrate the program into the center, ensuring acceptance and longevity for the program. The results of this study can assist future adopters of the TSN, improving the likelihood of successful program implementation.
  • Nurse Fatigue Increases the Risk of Sickness Absence

    Sagherian, Knar; Geiger-Brown, Jeanne (2017)
    Introduction: Sickness absence (SA) is problematic in occupations requiring 24/7 coverage where one person's SA cascades into more work days, longer shift durations and elevated fatigued states for remaining workers. As part of this dissertation, a systematic literature review found strong evidence that fatigue increased the risk of SA in the workforce. Few studies examined this relationship in nurses, despite reported high fatigue and differences in shiftwork characteristics. Fatigue-risk scores generated from bio-mathematical fatigue models are popular in safety-sensitive industries and may be useful for assessing and monitoring fatigue on nursing units and predicting SA. Purpose: The purpose of this study was to explore prospective associations between work-related fatigue, bio-mathematically modeled fatigue-risk and SA in 12-hour shift hospital nurses. Methods: Two studies were conducted that used retrospective cohort design of hospital nurses representing four nursing units from a major pediatric hospital. Baseline data on work-related fatigue were from Fatigue Risk, Alertness Management Effectiveness (FRAME) study (n=40) using the self-reported Occupational Fatigue Exhaustion Recovery Scale. Data on fatigue-risk scores were generated from work-rest schedules of 197 nurses working 41,538 shifts using Fatigue Audit InterDyne (FAID) and Fatigue Risk Index (FRI) software programs. Work-related fatigue and fatigue-risk scores were then linked to SA data that were extracted from the hospital's attendance system. The statistical approach was generalized linear mixed models that account for non-independency of repeated measures. Results: The SA rate in both studies was ~5%. Among FRAME participants, for every 1SD increase in acute fatigue scores, nurses were 1.29 times more likely to be absent from work (OR=1.29, 95%CI=1.02-1.63). In the bio-mathematical model study, when FAID-scores were moderate (scores=41-79, OR=1.38, 95%CI=1.21-1.58) or high (scores=81-150, OR=1.67, 95%CI=1.42-1.95), nurses were more likely to take SA than nurses with lower (<41) scores. Similarly, when FRI-scores were >60, nurses were 1.58 times (95%CI=1.05-2.37) more likely to take SA compared to nurses with lower scores. Conclusion: Work-related acute fatigue and fatigue-risk modeled bio-mathematically significantly predicted nurses' SA. While surveys are instrumental in identifying the nature and severity of fatigue, bio-mathematical fatigue models may be more practical to monitor for day-to-day fatigue changes in the workplace.
  • Synthetic cannabinoid use and clinical correlates among youth in treatment for substance use disorders

    Selby, Victoria Lynn; Storr, Carla L. (2017)
    Statement of the problem: Little is known about synthetic cannabinoids (SC) use among adolescents and young adults admitted to residential substance use treatment programs. The purpose of this study is to explore the extent of SC use in this population, identify characteristics of those at greatest risk to use, and examine psychiatric comorbidities, as well as associated risk behavior unique to SC users that may complicate treatment and recovery. Methods: This is a case-control study using retrospective chart review of patients, ages 12-25. SC users (n = 227) were compared to a random sample of nonusers (n = 202). Relationships between SC use (lifetime, recency, and amount of use) and characteristics, psychiatric indicators, and risk behaviors were examined using chi-square comparisons and logistic regression models. Results: Nearly one-third (32.5%) of the youth entering treatment had lifetime SC use. SC use was more common among males (OR=1.64, CI=1.02, 2.63, p=0.04), Whites (OR=1.94, CI =1.18, 3.20, p=0.009), and LGBT identifying youth (OR=2.19, 95%, CI =1.06, 4.52, p=0.04); while it was less common among those preferring opioids (OR=0.49, CI=0.30, 0.80, p=0.004). Persistent use was more common than experimental use in youth with legal involvement (OR=2.17, CI=1.12, 4.27, p=0.02) and having two or more choice drugs (OR=2.80, CI=1.45, 5.42, p=0.002). Youth who reported lifetime SC use had over three times the odds of having a diagnosis of psychotic disorder (OR=3.38, CI=1.89, 9.61, p=0.02). Amount of use and recency of use was not significantly associated with psychotic disorders. Lifetime SC users were more likely to be prescribed an antipsychotic medication (OR=1.89, 95%, CI=1.18, 3.05, p=0.01). Lifetime hallucinogen use was a behavior associated with lifetime SC use (OR=1.68, 95%, CI=1.08, 2.62, p=0.03). Conclusions: SC use was fairly common among these patients. Recognizing personal characteristics and risk behaviors that are associated with SC use may help health care providers to recognize users and those at risk of using; however, it is important to screen all patients. Prevention strategies for youth are needed, especially for those with legal involvement and who identify as LGBT. Psychiatric morbidity such as psychosis is associated with SC, which may complicate treatment.
  • Impact of State Nurse Practitioner Practice Authority on Mental Health Service Delivery

    Yang, Bo Kyum; Trinkoff, Alison M. (2017)
    Background: The involvement of nurse practitioners (NPs) in mental healthcare has become increasingly important, given their expanded scope of practice and growing mental healthcare demand. Nonetheless, little is known about whether NP-independent practice authority (NP-IPA) influences the role of NPs in mental healthcare for underserved populations. Purpose: The major purpose of this study was 1) to determine if NP-IPA status was associated with the proportion of mental healthcare provided by NPs in US community health centers (CHCs) and 2) to characterize trends and patterns of psychotropic medication prescriptions by NPs compared to physicians for Medicaid insured youth. Methods: The study used two national surveys and a mid-Atlantic state Medicaid insurance claims dataset. Descriptive statistics were performed to describe trends and patterns of mental healthcare provided by NPs compared to physicians. The adjusted odds of mental health visits within CHCs provided by NPs in states with NP-IPA were compared to the odds in states without NP-IPA, using multiple logistic regression while accounting for the complex survey design. Results: From 2012 to 2014, there was a 3.7% proportional increase in psychotropic medication prescriptions by NPs, while physician-written prescriptions declined by 4.8% in Medicaid insured youth. Overall, a similar prescribing pattern was found between physicians and NPs by specialty, whereas there were notable differences in prescribing patterns by psychiatric versus non-psychiatric specialties. The odds of NP- versus physician-provided mental health visits were two times greater in states with NP-IPA than in comparison states between 2006 and 2011. Among all mental disorder-related visits, the odds of having NP visits with psychotropic medications were three times higher in states with NP-IPA than in comparison states. In contrast, there was no significant difference in non-mental health visits provided by NPs over time. Conclusion: Findings suggest that NP-IPA can expand NP contributions to mental health service delivery in CHCs. For Medicaid insured youth, NPs overall, and especially psychiatric NPs, played an increasing role in psychotropic medication prescribing from 2012 to 2014; these NPs exhibited similar prescribing patterns compared to physicians. Future studies evaluating the quality of NP-provided mental healthcare under NP-IPA could extend these findings.
  • Development of a New Animal Model and Treatment Strategies for Aromatase Inhibitor-Associated Arthralgia

    Yang, Gee Su; Renn, Cynthia L.; 0000-0002-9098-719X (2017)
    Background: Aromatase inhibitors (AIs) are widely used as the most effective adjuvant chemotherapy for postmenopausal women with breast cancer. Unfortunately, nearly half of women receiving AIs have reported AI-associated arthralgia (AIA), which may increase cancer-related mortality and non-adherence to the therapy. As of now, no clear biological mechanisms of AIA have been found partially due to a lack of relevant animal models, and consequently, few beneficial treatments have been developed for AIA. Purpose: The purpose of this dissertation is to establish a clinically relevant animal model of AIA, and to examine potential treatment strategies for attenuating AIA by focusing on anti-nociceptive properties of curcumin (turmeric) and physical exercise. Methods: To mimic the clinical condition of AIA, female immune-deficient mice underwent tumor transplantation on flanks, surgical removal of grown tumors (~300 mm3) and ovaries, and subcutaneous injections of letrozole (10µg/day for 8 weeks). Mice weekly received behavior assays of musculoskeletal pain and physical function at pre-tumor baseline, post-tumor removal, and during AI treatment. To test effects of curcumin or physical exercise on AIA, letrozole-treated mice were given either 45 mg/kg curcumin or peanut oil (vehicle) orally, or they were housed either in cages with free voluntary running wheels or cages with locked wheels for five weeks, respectively. Following the interventions, protein expression levels of brain-derived neurotrophic factor (BDNF), a critical molecular moderator of pain behavior, were evaluated in the spinal dorsal horn. Results: Eight weeks of letrozole injections significantly induced mechanical allodynia, thermal (cold) allodynia, joint hypersensitivity, decreased grip strength, worsened motor coordination, and anteroposterior weight shift. Curcumin administration improved almost all deteriorated nocifensive behavior and neuromuscular function except for mechanical allodynia. Physical exercise enhanced the deteriorated nocifensive behavior but did not rescue neuromuscular dysfunction. BDNF protein expression levels were down-regulated following curcumin administration and physical exercise. Conclusion: This animal model is clinically relevant to AIA with face validity. It will provide an important platform to better understand progression and characteristics of AIA and allow examination of factors that cause AIA symptoms. Curcumin and physical exercise could be considered as effective interventions to reduce AIA symptoms and warrant studies in humans.
  • Sarcopenia and PRAISEDD-2 Intervention's Impact on Diet, Physical Activity, and Body Composition

    Hammersla, Margaret; Resnick, Barbara (2017)
    Background: Older adults with a low socioeconomic status and African Americans are more sedentary than the general population. This contributes to the development of sarcopenia and has a negative impact on the health and function of these individuals. PRAISEDD-2 was a 24-month quasi-experimetnal study of low income adults living in senior housing. A focused 3-month intervention included education about stroke prevention and heart health through adherence to heart healthy diets, regular exercise, and prescribed medication combined with exercise classes that included verbal encouragement, blood pressure feedback, and role modeling. Classes continued to be offered in months 4-24 but only included a monthly motivational intervention. The impact of the PRAISEDD-2 intervention on diet (fat, sodium, and protein intake), time spent in physical activity, and body composition are examined in the study reported here. Design: Diet and body composition measures were collected at baseline, 3, 6, 12, and 24 months. Sample included 29 residents of a low-income senior housing complex in Baltimore, MD. Complete data was obtain from 13 participants. Generalized estimating equations (GEE) were used to examine change over the time periods. An intention-to-treat (ITT) paradigm was followed. Results: At 3 months, participants experienced a decrease in sodium (p<0.01) and fat intake (p<0.01), as well as in a decrease in percent body fat (p<.001). However, at 24 months, fat intake (p<0.001) and percent body fat (p<0.001) increased, although protein intake increased (p<.001). No significant change was noted in physical activity (p=.056) or sodium intake (p=0.69) at 24 months. Conclusions: The findings from this study provided some support for the feasibility and preliminary efficacy of the PRAISEDD-2 intervention. The changes that occurred in the early 3 month period were likely due to the intensive nature of the education and exercise classes. Future research should focus on building a stronger self-efficacy based motivational component into the exercise classes to strengthen long term adherence to the recommended dietary change and physical activity, essential to promote decrease in body fat and increases in muscle mass. Interventions may need to be sustained longer to achieve more permanent changes in diet and exercise.
  • The Use of Current Perception Threshold for the Assessment of Oxaliplatin-Induced Peripheral Neuropathy

    Akpadiaha, Israel Ndueso; Griffith, Kathleen A.; 0000-0003-3661-1148 (2016)
    Background: Colorectal cancer (CRC) is a common malignancy, and up to 80% of patients diagnosed receive chemotherapy. Oxaliplatin is the principal chemotherapy agent for the treatment of CRC, and yet the associated oxaliplatin-induced peripheral neuropathy (OIPN) affects sensory fibers and is a treatment-limiting factor. OIPN reduces quality of life (QoL) and is associated with neuropathic pain (NP). As no effective treatment is available, improved early assessment of OIPN is needed. Current perception threshold (CPT) is a promising approach that uses sine-wave current electrical stimulus delivered at specific frequencies to elicit responses from peripheral nerves and may aid in OIPN identification. Purpose: The purpose of this study was threefold: 1) to compare CPT with validated quantitative sensory testing (QST) clinical tests in assessing sensory fiber function; 2) to compare CPT with provider administered National Cancer Institute Common Toxicity Criteria for Adverse Events (NCI CTC-AE) for identification of OIPN; and 3) to describe the relationship between NP measured by Neuropathic Pain Scale (NPS) and QST and their differential impact on QoL (FACT-G). Methods: A correlational descriptive design was used and a secondary analysis conducted using data from the Genetic Correlates of OIPN study. A total of 19 participants were enrolled and assessed at baseline, following 500mg/m2 of oxaliplatin, and upon oxaliplatin completion. Bivariate linear mixed models were used to account for repeated assessments clustered within patients. Results: An association between certain QST measures and CPT 2000Hz was identified (Vibration: =-44.55, p=0.045; mechanical detection: =269.59, p=0.008). CPT 2000 Hz and 250 Hz were associated with warm detection threshold (=9.0, p=0.030 and =4.24, p=0.027, respectively). There was also a positive association between neuropathic pain severity (NPS) and QoL [FACT-G (=0.276, p<0.016)]. Conclusion: The association between CPT and currently documented methods of OIPN assessment was limited. Furthermore, the positive association between NP and QoL requires additional exploration as it contradicts published data. Larger studies are needed to explore further if CPT is useful for assessment of OIPN.
  • An Identification of Nursing Activities of Value in Assisting the Aphasic Patient to Develop Increased Self Dependency

    Kreider, Mildred Sherk, 1936-; Hosfeld, Carol M. (1968)
    The problem of this study was to identify the nursing activities of value in assisting aphasic patients to develop increased self dependency. Action research was utilized to collect the data. The nurse-investigator administered nursing care to two adult aphasic patients, attempting to direct care toward developing increased self dependency. Nursing activities were of value in assisting the patients to develop increased ability to care for their physical needs, to communicate, and to understand the implications of the disease process and plan of therapy. Activities of value in assisting the patient to increase communication included coordinating verbal communication with the use of objects and activities in the environment; reflecting the patient's attempts to verbalize; pronouncing words for the patient; encouraging expression of feelings; and verbalizing feelings which the nurse surmised the patient experienced. Activities which were of value in assisting the patient to care for her physical needs included the administration of immediate physical assistance; demonstration of activities; offering assistance to the patient; and suggesting an activity or approach to a problem. Activities which were of value in assisting patients to develop an increased understanding of the implications of the disease process and plan of therapy were providing the patient with factual information; offering assistance; and suggesting an activity.
  • Temporal Dynamics of Gastrointestinal Microbiota during Pregnancy

    Chung, SeonYoon; Regan, Mary J. (2016)
    Background: Research about the gastrointestinal (GI) microbiota has demonstrated that it plays a crucial role in maintaining human physiologic homeostasis. In particular, it regulates inflammatory pathways, glucose and energy metabolism, and vitamin production that have significant relevance during pregnancy. Purpose: To characterize the structure of GI microbiota during pregnancy and changes that occur over time. Methods: This study expanded the scope of a large prospective longitudinal study looking at the influence of diet on vaginal microbiota during pregnancy and preterm birth (Birth, Eating and the Microbiota - BEAM, R01-NR014826). A subset of 20 women from the parent study was included in the sample and stool was collected monthly from 20 weeks gestation to birth. The specimens were analyzed using culture-independent molecular sequencing-based techniques following 16SrRNA gene polymerase chain reaction amplification. Descriptive analytics and advanced statistical modeling techniques were used to characterize the structure and the temporal dynamics of the GI microbiota during pregnancy. Results: Three enterotypes were identified at all taxonomic ranks. Members of Firmicutes were dominant at all levels. Enterotypes changed at each time point within subjects, forming 17 temporal enterotype profiles that classified into three enterotypes categories. Significant associations were identified between race, body mass index, fiber, iron, fat, protein, carbohydrate and sweets in the diet and specific GI microbiota. The associations were more pronounced at lower taxonomic ranks. Discussion: The findings of the study are important because they identify specific relationships between the microbial composition of the GI microbiota and factors such as body mass index and diet quality that are known factors implicated in adverse pregnancy outcomes. More research using a larger sample size is needed to verify these findings.

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