The Gut Microbiome and Symptom Burden After Kidney Transplantation: An Overview and Research Opportunities.

Many kidney transplant recipients continue to experience high symptom burden despite restoration of kidney function. High symptom burden is a significant driver of quality of life. In the post-transplant setting, high symptom burden has been linked to negative outcomes including medication non-adherence, allograft rejection, graft loss, and even mortality. Symbiotic bacteria (microbiota) in the human gastrointestinal tract critically interact with the immune, endocrine, and neurological systems to maintain homeostasis of the host. The gut microbiome has been proposed as an underlying mechanism mediating symptoms in several chronic medical conditions including irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, and psychoneurological disorders via the gut-brain-microbiota axis, a bidirectional signaling pathway between the enteric and central nervous system. Post-transplant exposure to antibiotics, antivirals, and immunosuppressant medications results in significant alterations in gut microbiota community composition and function, which in turn alter these commensal microorganisms' protective effects. This overview will discuss the current state of the science on the effects of the gut microbiome on symptom burden in kidney transplantation and future directions to guide this field of study.

Feasibility Study to Compare Oxytocin Function Between Body Mass Index Groups at Term Labor Induction.

OBJECTIVE: To determine the feasibility of a protocol to examine the association between oxytocin system function and birth outcomes in women with and without obesity before induction of labor. DESIGN: Prospective descriptive. SETTING: Academic medical center in the U.S. Midwest. PARTICIPANTS: Pregnant women scheduled for induction of labor at 40 weeks of gestation or greater (n = 15 normal weight; n = 15 obese). METHODS: We collected blood samples and abstracted data by chart review. We used percentages to examine adherence to protocol. We used t tests and chi-square tests to describe differences in sample characteristics, oxytocin system function variables, and birth outcomes between the body mass index groups. RESULTS: The recruitment rate was 85.7%, protocol adherence was 97.1%, and questionnaire completion was 80.0%. Mean plasma oxytocin concentration was higher in the obese group (M = 2774.4 pg/ml, SD = 797.4) than in the normal weight group (M = 2193.5 pg/ml, SD = 469.8). Oxytocin receptor DNA percentage methylation (CpG -934) was higher in the obese group than in the normal weight group. CONCLUSION: Our protocol was feasible and can serve as a foundation for estimating sample sizes in forthcoming studies investigating the diversity in oxytocin system measurements and childbirth outcomes among pregnant women in different body mass index categories.

Factors associated with mental health among undergraduate nursing students early in the COVID-19 pandemic: an integrative review.

OBJECTIVES: We aimed to synthesize research findings identifying factors associated with mental health in undergraduate nursing students early in the COVID-19 pandemic. METHODS: Seven electronic databases were searched using key terms and subject headings. JBI Critical Appraisal Checklists were used to evaluate research report quality. RESULTS: Among 23 reports (19 quantitative and four qualitative) meeting inclusion criteria, negative emotional responses to COVID-19 (fear of infection, perceived risk, uncertainty about care/future), negative behavioral responses to COVID-19 (eating behaviors, problematic internet use, insomnia), and negative coping strategies were associated with more adverse mental health symptoms. Conversely, social support, professional identity, preventive behaviors, sufficient personal protective equipment (PPE), and positive coping strategies were related to fewer symptoms. CONCLUSIONS: During a pandemic, undergraduate nursing students require educational support to promote their ability to avoid severe mental health disorders. Also, educators should strengthen students' professional identity, provide infection prevention knowledge and skills, and supply sufficient PPE.

Shift work domains and their interactions with empty calorie food/beverage consumption: A 14-day intensive longitudinal study.

BACKGROUND/OBJECTIVES: Shift work has been linked to unhealthy eating behaviors such as imbalanced diet, or increased empty calorie food/beverage consumption. However, most research has focused on the impact of shift timing. The concept of shift work is complex, and it contains several domains such as shift timing, intensity, and speed. Previous studies have suggested that greater shift intensity and quicker shift speed may contribute to adverse health effects. However, evidence regarding associations between other domains of shift work and empty calorie food/beverage consumption has been relatively lacking. Therefore, the purpose of this study was to evaluate how other shift work domains related to empty calorie food/beverage consumption and whether different shift work domains interacted to influence the intake of foods or beverages. DESIGN: A 14-day intensive longitudinal study employing ecological momentary assessment. SETTINGS AND PARTICIPANTS: Eighty registered nurses working in 24 accredited Taiwanese hospitals (i.e., 9 medical centers, 12 regional hospitals, and 3 district hospitals) were recruited. METHODS: During the study period, a convenience sample of 77 participants completed 2444 momentary surveys about empty calorie food/beverage consumption on a smartphone. Three shift work domains (shift timing, intensity, and speed) were evaluated based on registry-based work schedules. To study how these shift work domains influenced empty calorie food/beverage consumption, we employed three-level mixed-effects regression models for data analyses. RESULTS: Findings suggested that greater night shift intensity increased the likelihood of sugar-sweetened beverage intake (odds ratio = 1.64, 95% confidence interval [1.01, 2.68]). The impacts of work shift intensity and shift timing on sugar-sweetened beverage consumption varied by shift speed. Among participants assigned a schedule with either medium or rapid shift speed, higher work shift intensity was associated with a higher probability of sugar-sweetened beverage consumption. Compared to day shifts, those who were assigned a quicker shift speed on evening shifts were more likely to consume sugar-sweetened beverages. However, associations between night shift intensity and sugar-sweetened beverage intake did not change by shift speed. Furthermore, shift intensity and shift timing did not interact to affect empty calorie food/beverage consumption. CONCLUSIONS: This study demonstrated assignments of shift schedules (i.e., high night shift intensity, more changes in shift timings) might influence workers' consumption of empty calorie foods/beverages. Therefore, identifying and mitigating hazardous shift schedules may help to improve shift workers' eating behaviors and benefit their overall health.

Decision Delay Is a Significant Contributor to Prehospital Delay for Stroke Symptoms.

Prehospital delay after stroke symptom onset is a primary barrier to eligibility for reperfusion therapies. Decision delay is an understudied contributor to prehospital delay. We aimed to explore decision delay as a component of prehospital delay. For this correlational study, 170 Thai acute stroke patients were interviewed to explore their treatment-seeking decision factors: prior stroke knowledge, onset context, and cognitive, emotional, and behavioral factors. Participants' mean age was 61.2 years, and 46% were women. Median decision delay and prehospital delay times were 120 and 372 minutes. Decision delay represented 49% of prehospital delays. Factors shortening decision delay were atrial fibrillation, prior stroke knowledge, perceived cause of symptoms as stroke, perceived severity of symptoms, and advice from bystanders to seek treatment. In contrast, seeking support from others and self-treatment affected prolonged decision delay. Shortening decision delay, often under the patient or bystander control, can reduce overall prehospital delay.

Pain Interference in End Stage Kidney Disease is Associated with Changes in Gut Microbiome Features Before and After Kidney Transplantation.

BACKGROUND: Pain, a common debilitating symptom among kidney transplant recipients (KTRs), is among the most common and undertreated symptoms after kidney transplantation. AIMS: Characterize associations between gut microbiome features and pain interference before and after kidney transplantation. DESIGN: Longitudinal, repeated measures study, collecting fecal specimens and pain interference data pretransplant and 3 months posttransplant. SETTING: Participants were recruited at the kidney transplant clinic at the University of Illinois Hospital & Health Sciences System. PARTICIPANTS/SUBJECTS: 19 living donor kidney transplant recipients. METHODS: We assessed fecal microbial community structure with shotgun metagenomic sequencing; we used pain interference scores derived from the Patient-Reported Outcomes Measurement Information System-57. RESULTS: We measured a reduction in the Shannon diversity index in both groups after transplantation but observed no significant differences between groups at either time point. We did observe significant differences in fecal microbial Bray-Curtis similarity index among those reporting pain interference pre- transplant versus no pain interference at 3-months posttransplant (R = .306, p = .022), and between pain interference groups at posttransplant (R = .249, p = .041). Pairwise models showed significant differences between groups posttransplant in relative abundances of several taxa, including a 5-fold reduction.ßin Akkermansia among those with pain interference and a higher relative abundance of taxa associated with chronic inflammation in those with pain interference posttransplant. Functional gene analysis identified two features that were significantly enriched in those with pain interference, including a peptide transport system gene. CONCLUSIONS: Gut microbiota community structure differs between groups with and without pain interference at 3 months after kidney transplantation. Several taxa involved in intestinal barrier integrity and chronic inflammation were associated with posttransplant pain.

Associations between sleep variability and cardiometabolic health: A systematic review.

This review explored the associations between sleep variability and cardiometabolic health. It was performed following PRISMA guidelines. We identified 63 studies. Forty-one studies examined the association between sleep variability and body composition, with 29 examined body mass index (BMI). Thirteen studies used social jet lag (SJL), n = 30,519, with nine reporting a null association. Eight studies used variability in sleep duration (n = 33,029), with five reporting a correlation with BMI. Fourteen studies (n = 133,403) focused on overweight/obesity; significant associations with sleep variability were found in 11 (n = 120,168). Sleep variability was associated with weight gain (seven studies; n = 79,522). Twenty-three studies examined glucose outcomes. The association with hemoglobin A1c (16 studies, n = 11,755) differed depending on populations, while associations with diabetes or glucose were mixed, and none were seen with insulin resistance (five studies; n = 6416). Sixteen studies examined cardiovascular-related outcomes, with inconsistent results. Overall significant associations were found in five studies focusing on metabolic syndrome (n = 7413). In summary, sleep variability was likely associated with obesity, weight gain, and metabolic syndrome. It might be associated with hemoglobin A1c in people with type 1 diabetes. The associations with other outcomes were mixed. This review highlighted the possible association between sleep variability and cardiometabolic health.

Psychometric properties of the Insomnia Severity Index for people with chronic obstructive pulmonary disease.

OBJECTIVE/BACKGROUND: Insomnia is one of the most commonly reported symptoms among people with chronic obstructive pulmonary disease (COPD). Prior research evaluated the psychometric properties of the Insomnia Severity Index (ISI) with various populations, but no studies have examined the measurement properties of the instrument in the COPD population. This study aimed to determine the reliability and validity of the ISI for the COPD population. PATIENTS/METHODS: This study included 96 people with COPD and insomnia. As psychometric properties, the ISI's internal consistency, factor structure, and criterion validity were examined with this sample. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to evaluate construct validity. Correlations between scores for the ISI and for measures of depression, anxiety, fatigue, and dyspnea were examined to determine criterion validity. RESULTS: The Cronbach's alpha value for the ISI was 0.79, indicating good internal consistency. In the EFA, a single ISI factor with an eigenvalue of 3.19 accounted for 45.6% of the variance. CFA indicated adequate construct validity, and interference of sleep problems with daytime functioning and level of distress caused by sleep difficulties showed the highest factor loadings (both 0.78). Criterion validity was supported by significant, weak to moderate correlations between scores for the ISI and for measures of depression, anxiety, fatigue, and dyspnea. CONCLUSIONS: The results provide evidence that the ISI has good reliability and validity for measuring insomnia severity in the COPD population.

Feasibility of sleep extension and its effect on cardiometabolic parameters in free-living settings: a systematic review and meta-analysis of experimental studies.

AIMS: Inadequate sleep is a global health issue and has been associated with an increased risk for cardiovascular diseases. As a part of sleep hygiene, intentional lengthening of night-time sleep duration (i.e. sleep extension) might be a behavioural intervention to improve cardiometabolic health. To examine the feasibility of sleep extension and its effects on cardiometabolic parameters in free-living settings. METHODS AND RESULTS: This review was registered in PROSPERO (CRD42019146174). Five databases were searched. Only experimental studies conducted in adults without a diagnosis of sleep disorder were included. The pooled mean difference was calculated by the inverse variance method. Narrative summaries were also used. Thirteen studies from 11 trials were included. The intervention ranged from 3 days to 6 weeks. Sleep extension increased total sleep time by 51 min [95% confidence interval (CI) 39-63]. Overall, sleep extension did not result in significant changes in blood pressure. However, sub-group analysis revealed that when 24 h mean blood pressure was obtained among those with pre-hypertension or Stage 1 hypertension, sleep extension reduced systolic (weighted mean difference = -7.8 mm/Hg; 95% CI -10.6 to -4.9), and diastolic blood pressure (weighted mean difference = -4.2 mm/Hg; 95% CI -6.7 to -1.8). The pooled effects on fasting glucose and insulin resistance were not significant. The effect of sleep extension on other parameters (e.g. heart rate) was not consistent. CONCLUSION: Sleep extension is feasible and could increase sleep in free-living settings. Sleep extension shows promise for reducing 24 h mean blood pressure among those with pre-hypertension or hypertension. More large-scale studies are needed to examine its long-term effects.

Relating three-dimensional airway measurements to the apnea-hypopnea index in pediatric sleep apnea patients.

OBJECTIVES: (a) To evaluate three-dimensional radiographic airway analysis as it relates to the pre-test probability for sleep apnea in pediatric patients, and (b) to develop cut-off values for measurements showing promising results. SETTING AND SAMPLE POPULATION: A consecutive series of pediatric patients between the ages of 7 and 17 years, referred for a sleep study were recruited. Cone beam computed tomography (CBCT) scans were acquired for 103 subjects within one month following the sleep study. METHODS: Three-dimensional airway analysis was performed including volumetric, area and linear measurements. Correlations with the apnea-hypopnea index (AHI) and receiver operating characteristic (ROC) curves were constructed. Sensitivity and specificity were calculated for prediction of AHI ≥ 5 and AHI ≥ 10. RESULTS: 99 CBCT scans were included (median age = 11 years). The nasopharyngeal volume (NPV) significantly correlated with AHI (rho≈-0.4, P < .05). In subjects aged 7-11 years, proposed cut-off values for NPV are 2400mm3 and 1600mm3 for AHI ≥ 5 and AHI ≥ 10, respectively. In subjects aged 12-17 years, proposed cut-off values for NPV are 3500mm3 and 2700mm3 for AHI ≥ 5 and AHI ≥ 10, respectively. Oropharyngeal cross-sectional area (OCSA) demonstrated significant predictive value in ROC curve analysis, and cut-off values for this airway measure are also proposed. CONCLUSIONS: Contrary to findings in adults, the NPV shows promise when screening for sleep apnea in children when CBCT scans are available. The OCSA might also be of value when screening for sleep apnea especially in older children.

Skeletal Muscle Mass Loss During Cancer Treatment: Differences by Race and Cancer Site.

OBJECTIVES: To examine skeletal muscle mass change in a racially diverse sample of patients undergoing cancer treatment, determine significant predictors of muscle mass loss, and explore the interaction of race and cancer site. SAMPLE & SETTING: A retrospective analysis was conducted for 212 patients seeking treatment at a university hospital clinic. METHODS & VARIABLES: Skeletal muscle mass index (SMI) was determined by computed tomography at the time of cancer diagnosis and with cancer treatment. RESULTS: One hundred thirty-four patients (63%) had SMI loss with cancer treatment. Race and cancer site were found to be significant predictors of SMI loss. Compared to other racial groups, non-Hispanic Black (NHB) patients had the greatest SMI loss (p < 0.001) with cancer treatment. NHB patients with rectal cancer experienced the greatest SMI loss compared to patients of other races and cancer types. IMPLICATIONS FOR NURSING: To improve survivorship care for patients with cancer, it is essential to develop strategies for assessing and managing skeletal muscle mass loss throughout treatment, particularly for NHB patients with rectal cancer.

Sex Differences in Prehospital Delay in Patients With Acute Stroke: A Systematic Review.

BACKGROUND: In 2009, the window from symptom onset to administration of tissue plasminogen activator for acute ischemic stroke was extended from 3 to 4.5 hours. Yet no systematic review has addressed prehospital delay by sex for stroke symptoms since this change. PURPOSE: We aimed to (1) compare prehospital delay times-the time from symptom onset to hospital arrival-between women and men with acute stroke or transient ischemic attack and (2) summarize factors influencing prehospital delay by sex. METHODS: The CINAHL, MEDLINE, PubMed, Scopus, and PsycINFO databases were searched using PRISMA guidelines. Inclusion criteria were as follows: (1) quantitative research articles published between May 2008 and April 2019, (2) investigation of prehospital delay among women and men 15 years or older who were given a diagnosis of acute stroke or transient ischemic attack, and (3) English-language publications. The Crowe Critical Appraisal Tool was used to evaluate the quality of studies. RESULTS: Fifteen publications (n = 162 856) met inclusion criteria. Most studies (n = 11) showed no sex differences in prehospital delay. Four studies from Asian-Pacific countries and the United States showed that women had significantly longer prehospital delay compared with men. Older age, minority race/ethnicity (black and Mexican American), and underuse of emergency medical services were associated with prolonged prehospital delay in women. CONCLUSIONS: Most study authors found no differences in prehospital delay between women and men; however, women delayed longer in some Asian-Pacific and American studies. Findings of sex differences were inconclusive.

Fatigue and Sleep Quality Predict Eating Behavior Among People With Type 2 Diabetes.

BACKGROUND: People with Type 2 diabetes frequently report increased fatigue and sleep disturbance. These symptoms might put them at a higher risk for unhealthy eating behavior-detrimental to diabetes control. OBJECTIVES: The aim of the study was to examine the effect of fatigue and sleep on eating behavior in people with Type 2 diabetes by using a daily diary approach. METHODS: Data from 56 patients were collected during a baseline interview and an 8-day ambulatory assessment period in the free-living setting. Each day, participants completed one diary upon awakening to assess their sleep duration and sleep quality during the previous night and morning fatigue. They also completed one diary before going to bed to assess their eating behavior during the day (e.g., uncontrolled eating, cognitive restraint, emotional eating, and snacking). Data from 7 days were analyzed using generalized estimating equations. RESULTS: During the 7 days, controlling for age, gender, and body mass index, between-person fatigue was a significant predictor of uncontrolled eating, emotional eating, and snacking. Similarly, controlling for the covariates, between-person sleep quality was a significant predictor of uncontrolled eating and emotional eating. No associations were found between sleep duration and eating behavior. DISCUSSIONS: At the between-person level, reporting higher fatigue or poorer sleep quality was associated with higher levels of unhealthy eating behavior. Patients with Type 2 diabetes with high fatigue or poor sleep quality may require additional attention to support their healthy eating.

Maternal and system characteristics, oxytocin administration practices, and cesarean birth rate.

BACKGROUND: The cesarean birth rate in the United States is 32%, and there is discussion about the cause of high surgical birth rates. Our purpose was to determine whether mode of birth is influenced by maternal, nurse, and system factors. METHODS: Secondary analysis of a data set of 163 women having postdates labor induction with oxytocin. Kaplan-Meier survival curves were calculated to compare the time for patients to reach an infusion rate of 6 mU/min, consistent with endogenous oxytocin levels in active labor. We used the log-rank test to evaluate survival curve differences. Multiple logistic regression and Cox proportional hazards models were conducted and included covariates that had statistically significant bivariate relationships with the time variable, or were clinically meaningful. RESULTS: The mean time to reach 6 mU/min was longer for women who birthed by cesarean (172.5 minutes) than for women who had vaginal birth (125.0 minutes, P = .024). The mean time to reach 6 mU/min was also longer for women admitted on night shift (147.0 minutes) than day shift (110.2 minutes, P = .018). No maternal characteristics were significantly related to the time to reach a rate of 6 mU/min. CONCLUSIONS: Even during the initial hours of labor induction, it is important that the oxytocin infusion is titrated appropriately to aid women in achieving timely vaginal birth. Intrapartum nurses should receive education about the pharmacokinetics of intravenous oxytocin to understand proper administration of this high-alert medication.

Impact of an integrated mother-preterm infant intervention on birth hospitalization charges.

OBJECTIVE: To examine whether the H-HOPE (Hospital to Home: Optimizing the Preterm Infant's Environment) intervention reduced birth hospitalization charges yielding net savings after adjusting for intervention costs. STUDY DESIGN: One hundred and twenty-one mother-preterm infant dyads randomized to H-HOPE or a control group had birth hospitalization data. Neonatal intensive care unit costs were based on billing charges. Linear regression, propensity scoring and regression analyses were used to describe charge differences. RESULTS: Mean H-HOPE charges were $10,185 lower than controls (p = 0.012). Propensity score matching showed the largest savings of $14,656 (p = 0.003) for H-HOPE infants, and quantile regression showed a savings of $13,222 at the 75th percentile (p = 0.015) for H-HOPE infants. Cost savings increased as hospital charges increased. The mean intervention cost was $680 per infant. CONCLUSIONS: Lower birth hospitalization charges and the net cost savings of H-HOPE infants support implementation of H-HOPE as the standard of care for preterm infants.

Sleep quality and gestational diabetes in pregnant women: a systematic review and meta-analysis.

Poor sleep quality is very common among pregnant women. Gestational diabetes mellitus (GDM) has been related to various adverse maternal and neonatal outcomes. The aim of this systematic review was to examine the association between poor sleep quality and gestational diabetes risk. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in five electronic databases from inception to February 2019. Studies that examined the relationship between sleep quality and glucose in pregnant women were screened for eligibility. Pooled odds ratio (OR) with 95% confidence interval (CI) was calculated from aggregate data using a fixed-effect model. Thirteen non-experimental studies (n = 21,194 women) were eligible for inclusion. Poor sleep quality was measured using subjective questionnaires in nine studies and objective methods (actigraphy or polysomnography) in four studies. GDM was typically diagnosed following standard guidelines. Eight studies were included in the meta-analysis for GDM. Overall, self-reported poor sleep quality was a significant risk factor for GDM (pooled OR = 1.43, 95%CI: 1.16,1.77, p = 0.001). Three studies examined the association between objective sleep quality and GDM, but no significant relationship was observed. Subjective poor sleep quality was related to an increased risk for GDM, while objectively measured sleep quality was not. This review was limited by the assessment of sleep quality. Future larger studies are warranted to examine the effects of sleep quality on glucose metabolism in pregnancy. Ideally, these studies should measure sleep quality using both validated questionnaires and objective methods. These will provide further directions for improving sleep during pregnancy and exploring its effects on glucose metabolism.

Enriching the quality of cross-cultural instrument development through cognitive interviewing: Implications for nursing research.

AIM: During cross-cultural instrument development, a gap commonly exists between the intended meaning of questionnaire items and the extent to which the participant understands that meaning. Because cognitive interviewing can provide such a powerful means for ensuring an accurate interpretation of items, the purpose of this report is to provide a practical guide to encourage its use in nursing research. METHODS: This report provides in-depth information describing: (a) advantages of cognitive interviewing, particularly for cross-cultural instrument development; (b) specific problems it can identify and solve; (c) strategies for performing cognitive interviews, including the four-step model of the question-and-answer process; (d) practical guidance for conducting successful cognitive interviews. RESULTS: To achieve linguistic validity as well as cultural relevance, a variety of factors need to be considered in addition to language, such as cultural interpretations, attitudes, and values. Examples of health-related studies are presented, demonstrating the advantages of cognitive interviewing for instrument development and cross-cultural research. These examples show how cognitive interviewing can be productively used to verify question clarity, patient comprehension, and patients' ease of response and judgment while also helping to establish content validity based on patients' perspectives. CONCLUSIONS: Cognitive interviewing can help nurse researchers discover potential instrument flaws and correct them in advance, subsequently avoiding collection of inaccurate data. Thus, cognitive interviewing should be considered an effective pretesting method for development of accurate instruments, particularly in cross-cultural nursing research.

Nurses' roles and challenges in providing end-of-life care in neonatal intensive care units in South Korea.

BACKGROUND: Neonatal Intensive Care Unit (NICU) nurses in Korea often experience challenges in providing care for dying infants and their families. However, there is limited understanding about what contributes to the challenges related to end-of-life care. PURPOSE: To describe NICU nurses' perceived roles and challenges faced while providing end-of-life care in South Korea. METHODS: A qualitative descriptive study was conducted with 20 NICU nurses in South Korea using semi-structured interviews. Participants were recruited from two NICUs in Seoul, where infant mortality is the highest in South Korea. Transcribed interviews were coded by two research personnel, and subsequently, a developed coding book was translated by three research personnel. The codes developed were categorized and peer-reviewed to develop themes using conventional content analysis. RESULTS: Nurses' roles during end-of-life care were grouped into four categories: providing information and support, enhancing attachment between the parents and infants, providing direct care to the infant, and completing documentation. Nurses' perceived challenges during end-of-life care included providing end-of-life care without adequate experience and knowledge, environmental constraints on end-of-life care, and conflicted situations during end-of-life care. CONCLUSION: Although the nurses provided the best care they could, their end-of-life care practice was hindered for various reasons. To enhance NICU nurses' ability to provide and make them more capable of providing high quality EOL care, hospitals need to support nurse education and improve staffing level, and create in NICUs an environment that is favorable for providing EOL care.

Factors Influencing Surveillance Mammography Adherence Among Breast Cancer Survivors.

PROBLEM IDENTIFICATION: Many breast cancer survivors fail to engage in surveillance mammography to detect new and recurrent cancers. This review identifies factors promoting or inhibiting breast cancer survivors' participation in recommended surveillance mammography. LITERATURE SEARCH: This integrative review included all English-language studies published from 2000 to 2017, identified in CINAHL®, PsycINFO®, Embase®, and MEDLINE® via PubMed®. DATA EVALUATION: 23 studies met the inclusion criteria and were analyzed and synthesized. SYNTHESIS: 19 factors influencing mammography adherence were identified and organized into a conceptual model with two major categories. IMPLICATIONS FOR RESEARCH: The new model of predictors of mammography adherence can provide guidance for identifying individuals at greatest risk for nonadherence, as well as development of new interventions to address barriers to regular mammography screening, to promote early detection of new and recurrent cancers and improved survival rates.

Associations between fatigue, sleep disturbance and eating style in adults with type 2 diabetes: A correlational study.

AIMS AND OBJECTIVES: To test the hypothesis that fatigue and sleep disturbance account for a significant amount of variation in eating styles among people with type 2 diabetes (T2D). BACKGROUND: Healthy eating is an important component of diabetes self-care but remains a major challenge. In people with T2D, symptoms of fatigue and sleep disturbance are pervasive. However, there is limited understanding of whether fatigue and sleep disturbance are associated with eating style in people with T2D. DESIGN: Correlational design. METHODS: This study was reported following the STROBE checklist. Data were collected between February 2017 and January 2018. A convenience sample of 64 T2D adults completed the Three-Factor Eating Questionnaire-R18V2 to measure eating style (e.g., emotional eating, cognitive restraint and uncontrolled eating). Diabetes distress, fatigue and sleep disturbance were measured using validated questionnaires. Hierarchical regression analyses were performed. RESULTS: Only age was a significant predictor (ß = -0.344) of cognitive restraint. Participant demographics, psychological factor and health-related factors contribute significantly to the model predicting emotional eating, but only diabetes distress was a significant predictor (ß = 0.433). Introducing fatigue and poor sleep quality explained an additional 12.0% of the variation in emotional eating. The final model explained 24.9% of the variation in emotional eating; both diabetes distress (ß = 0.294) and fatigue (ß = 0.360) were significant predictors. CONCLUSION: There is a strong, independent relationship of fatigue and diabetes distress with emotional eating T2D patients. The effect of improving fatigue and diabetes distress on eating style should be explored. RELEVANCE TO CLINICAL PRACTICE: In clinical practice, nurses are recommended to include a detailed assessment of fatigue and distress in patients with diabetes. Additional to the conventional nutrition therapy focusing on diet advice, eating style should also be incorporated in diet education by diabetes nurses.