Multimorbidity in Patients With Acute Coronary Syndrome Is Associated With Greater Mortality, Higher Readmission Rates, and Increased Length of Stay: A Systematic Review.

OBJECTIVE: The aims of this systematic review were to determine the magnitude and impact of multimorbidity (≥2 chronic conditions) on mortality, length of stay, and rates of coronary intervention in patients with acute coronary syndrome (ACS) and to compare the prevalence of cardiovascular versus noncardiovascular multimorbidities. METHODS: MEDLINE, PubMed, MedlinePlus, EMBASE, OVID, and CINAHL databases were searched for studies published between 2009 and 2019. Eight original studies enrolling patients with ACS and assessing cardiovascular and noncardiovascular comorbid conditions met the inclusion criteria. Study quality was evaluated using the Crowe Critical Appraisal Tool. RESULTS: The most frequently examined cardiovascular multimorbidities included hypertension, diabetes, heart failure, atrial fibrillation, stroke/transient ischemic attack, coronary heart disease, and peripheral vascular disease; the most frequently examined noncardiovascular multimorbidities included cancer, anemia, chronic obstructive pulmonary disease, renal disease, liver disease, and depression. The prevalence of multimorbidity in the population with ACS is high (25%-95%). Patients with multimorbidities receive fewer evidence-based treatments, including coronary intervention and high-dose statins. Patients with multimorbidities experience higher in-hospital mortality (5%-13.9% vs 2.6%-6.1%), greater average length of stay (5-9 vs 3-4 days), and lower rates of revascularization (9%-14% vs 39%-42%) than nonmultimorbid patients. Women, despite being the minority in all sample populations, exhibited greater levels of multimorbidity than men. CONCLUSIONS: Multimorbid patients with ACS are at a greater risk for worse outcomes than their nonmultimorbid counterparts. Lack of consistent measurement makes interpretation of the impact of multimorbidity challenging and emphasizes the need for more research on multimorbidity's effects on postdischarge healthcare utilization.

Possible selves, psychological well-being, and substance use in young men within 12 months post-incarceration.

OBJECTIVE: Community reentry post-incarceration is fraught with challenges. The investigators examined the influence of highly personalized goals (possible selves) on psychological well-being, drug use, and hazardous drinking in recently incarcerated young men returning to the community. DESIGN AND SAMPLE: In this cross-sectional study, 52 young men released from jail or prison within the past 12 months were recruited from community-based organizations and reentry events. MEASUREMENTS: Participants completed open-ended possible selves measure and psychological well-being and substance use questionnaires. RESULTS: Possible selves accounted for 19%-31% of the variance in sense of purpose, environmental mastery, and personal growth. Having a feared delinquent possible self was associated with lower sense of purpose. Having many feared possible selves was associated with lower environmental mastery. Having an expected possible self related to interpersonal relationships was associated with higher personal growth and environmental mastery. Men having a feared delinquent possible self or an expected possible self related to material/lifestyle were more likely to use marijuana than men who did not. CONCLUSION: The content and number of possible selves may be an important focus for assessment by public health nurses in correctional and community settings serving young men post-incarceration. Longitudinal studies with larger samples are needed.

Environmental and personal correlates of physical activity and sedentary behavior in African American women: An ecological momentary assessment study.

The authors of this study examined within-person associations of environmental factors (weather, built and social environmental barriers) and personal factors (daily hassles, affect) with moderate-to-vigorous physical activity (MVPA) and sedentary behavior (SB) in African American women aged 25-64 years living in metropolitan Chicago (n = 97). In 2012-13, for seven days, women wore an accelerometer and were signaled five times per day to complete a survey covering environmental and personal factors on a study-provided smartphone. Day-level measures of each were derived, and mixed regression models were used to test associations. Poor weather was associated with a 27.3% reduction in daily MVPA. Associations between built and social environmental barriers and daily MVPA or SB were generally not statistically significant. Negative affect at the first daily signal was associated with a 38.6% decrease in subsequent daily MVPA and a 33.2-minute increase in subsequent daily SB. Each one-minute increase in MVPA during the day was associated with a 2.2% higher likelihood of positive affect at the end of the day. SB during the day was associated with lower subsequent positive affect. Real-time interventions that address overcoming poor weather and negative affect may help African American women increase MVPA and/or decrease SB.

Prospective effects of possible selves on alcohol consumption in adolescents.

Possible selves, cognitions about the self that reflect hopes, fears, and expectations for the future, are reliable predictors of health risk behaviors but have not been explored as predictors of adolescents' alcohol use. In a secondary analysis of data from 137 adolescents, we examined the influence of possible selves assessed in eighth grade on alcohol consumption (yes/no and level of use) in ninth grade. Having a most important feared possible self related to academics in eighth grade predicted alcohol abstinence in ninth grade. Among those who reported alcohol use, having many hoped-for possible selves and a most important hoped-for possible self related to academics in eighth grade predicted lower level of alcohol consumption in ninth grade. Interventions that foster the personal relevance and importance of academics and lead to the development of hoped-for possible selves may reduce adolescents' alcohol consumption.

Expected Problem Drinker Possible Self: Predictor of Alcohol Problems and Tobacco Use in Adolescents.

BACKGROUND: Alcohol and tobacco use commonly co-occur in adolescents. According to the cross-substance facilitation of information processing hypothesis, cognitive structures related to one substance increase use of another related substance through enhanced cognitive processing. In this study, the authors test this hypothesis by determining whether a problem drinker "possible self" in 8th grade predicts alcohol and tobacco use in 9th grade. METHODS: A secondary data analysis of a 12-month longitudinal dataset was conducted. The outcome variables were alcohol consumption, alcohol problems, and tobacco use in 9th grade. The main predictor of interest was presence of an expected problem drinker possible self in 8th grade. Zero-inflated gamma regression, zero-inflated negative binomial regression, and logistic regression were used. RESULTS: Among 137 adolescents, controlling for known family, parent, and peer determinants, and corresponding 8th grade behavior, having an expected problem drinker possible self in 8th grade predicted alcohol problems, but not level of alcohol consumption in 9th grade. Moreover, the expected problem drinker possible self in 8th grade predicted tobacco use in 9th grade, controlling for known determinants and concurrent alcohol problems. CONCLUSIONS: Findings provide support for the cross-substance facilitation hypothesis, suggesting that interventions designed to modify the expected problem drinker possible self may reduce not only adolescent alcohol use but also tobacco use. Further studies are needed to determine whether smoking content is embedded in a drinking cognition or 2 separate but related drinking and smoking cognitions account for the association between alcohol and tobacco use.

Transitions in latent classes of sexual risk behavior among young injection drug users following HIV prevention intervention.

We analyzed data from a large randomized HIV/HCV prevention intervention trial with young injection drug users (IDUs). Using categorical latent variable analysis, we identified distinct classes of sexual behavior for men and women. We conducted a latent transition analysis to test the effect of the intervention on transitions from higher to lower risk classes. Men who were in a high-risk class at baseline who received the intervention were 86 % more likely to be in a low-risk class at follow-up compared to those in the control group (p = 0.025). High-risk intervention participants were significantly more likely to transition to the class characterized by unprotected sex with a main partner only, while low-risk intervention participants were significantly less likely to transition to that class. No intervention effect was detected on the sexual risk behavior of women, or of men who at baseline were having unprotected sex with a main partner only.

Job strain and psychological distress among employed pregnant Thai women: role of social support and coping strategies.

Most Thai women continue to work throughout their pregnancy; however, little is known about job strain and its relation to psychological distress. This study aimed to examine: (1) the direct effects of job strain, perceived workplace support, perceived family support, and coping strategies on psychological distress and (2) the moderating effect of perceived workplace support, perceived family support, and coping strategies on the relationship between job strain and psychological distress. Lazarus and Folkman's transactional model of stress and coping guided this cross-sectional study. Full-time employed pregnant women (N = 300) were recruited from three antenatal clinics in Thailand. Thai versions of the following instruments were used: the State-Anxiety Inventory and Center for Epidemiological Studies-Depression Scale (psychological distress), the Job Content Questionnaire (job strain and perceived workplace support), the Medical Outcome Study Social Support Survey (perceived family support), and the Ways of Coping Checklist-Revised (coping strategies). Job strain with other predictors explained 54% of the variance in psychological distress. In the separate hierarchical multiple linear regression models, two types of coping strategies, seeking social support and wishful thinking, moderated the effects of job strain on psychological distress. Perceived family support had a direct effect in reducing psychological distress. Job strain is a significant contributor to psychological distress. The average levels of seeking social support and wishful thinking were most beneficial in moderating the negative impact of job strain on psychological distress. Since perceived workplace and family support did not have moderating effects, stress management programs for decreasing the levels of job strain should be developed.

Peer-education intervention to reduce injection risk behaviors benefits high-risk young injection drug users: a latent transition analysis of the CIDUS 3/DUIT study.

We analyzed data from a large randomized HIV/HCV prevention intervention trial with young injection drug users (IDUs) conducted in five U.S. cities. The trial compared a peer education intervention (PEI) with a time-matched, attention control group. Applying categorical latent variable analysis (mixture modeling) to baseline injection risk behavior data, we identified four distinct classes of injection-related HIV/HCV risk: low risk, non-syringe equipment-sharing, moderate-risk syringe-sharing, and high-risk syringe-sharing. The trial participation rate did not vary across classes. We conducted a latent transition analysis using trial baseline and 6-month follow-up data, to test the effect of the intervention on transitions to the low-risk class at follow-up. Adjusting for gender, age, and race/ethnicity, a significant intervention effect was found only for the high-risk class. Young IDU who exhibited high-risk behavior at baseline were 90% more likely to be in the low-risk class at follow-up after the PEI intervention, compared to the control group.

Survivor profiles predict health behavior intent: the Childhood Cancer Survivor Study.

OBJECTIVES: To determine whether unique groups of adult childhood cancer survivors could be defined on the basis of modifiable cognitive, affective, and motivation indicators. Secondary objectives were to examine to what extent group membership co-varied with more static variables (e.g. demographics, disease, and treatment) and predicted intent for subsequent medical follow-up. METHODS: Using latent class analysis of data from 978 participants (ages, 18-52 years; mean, 31; and SD, 8) in the Childhood Cancer Survivor Study, we classified survivors according to their worries about health, perceived need for follow-up care, health motivation, and background variables. Intent to participate in medical follow-up, as a function of class membership, was tested using equality of proportions. RESULTS: The best-fitting model (BIC = 18 540.67, BLMRT = <0.001) was characterized by three distinctive survivor classes (worried, 19%; self-controlling, 26%; and collaborative, 55%) and three significant class covariates (gender, perceptions of health, and severity of late effects). A smaller proportion of survivors in the self-controlling group (81%) than in the worried (90%) (P = 0.015) and collaborative (88%) (P = 0.015) groups intended to obtain a routine medical checkup. A smaller proportion of survivors in the self-controlling group (32%) than in the collaborative (65%) (P = <0.001) and worried (86%) (P = <0.001) groups planned a cancer-related check-up. A smaller proportion of survivors in the collaborative group (65%) than in the worried group (86%) (P = <0.001) were likely to obtain a cancer-related check-up. CONCLUSIONS: Childhood cancer survivors can be classified according to the modifiable indicators. The classification is distinctive, predicts intent for future medical follow-up, and can inform tailored interventions.

Risk of breastfeeding cessation among low-income women, infants, and children: a discrete time survival analysis.

BACKGROUND: Women who receive services from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) often stop breastfeeding earlier than recommended. Little is known about maternal background and intrapersonal variables that predict the timing of breastfeeding cessation over the 12-month postpartum period. OBJECTIVES: The aim of this study was to identify the maternal background and intrapersonal predictors associated with the timing of breastfeeding cessation in WIC participants over the course of the 12-month postpartum period. METHOD: Existing longitudinal survey and administrative data from low-income breastfeeding WIC recipients (n = 309) were analyzed using discrete time survival analysis. Risk of breastfeeding cessation was the outcome, and self-reported items were used to derive predictor variables that corresponded to the background and intrapersonal variables of the Interaction Model of Client Health Behavior. RESULTS: Rates of breastfeeding were low (31% at 6 months and 6% at 12 months). In the best fitting discrete time survival analysis model, women who were older and of Mexican ethnicity, who had previous breastfeeding experience, and who had breastfeeding support from family or friends were at lowest risk for breastfeeding cessation at each monthly interval. DISCUSSION: Breastfeeding duration rates were lower than Healthy People 2020 benchmarks of 61% at 6 months and 34% at 12 months. Clinicians and researchers can use the findings from this study to develop interventions that are targeted to periods of greatest risk of premature breastfeeding cessation to prolong breastfeeding duration in this vulnerable population.

The McGill Pain Questionnaire as a multidimensional measure in people with cancer: an integrative review.

First published in 1975, the McGill Pain Questionnaire (MPQ) is an often-cited pain measure, but there have been no systematic reviews of the MPQ in cancer populations. Our objective was to evaluate the MPQ as a multidimensional measure of pain in people with cancer. A systematic search of research that used the MPQ in adults with cancer and published in English from 1975 to 2009 was conducted. Twenty-one articles retrieved through computerized searches and nine studies from manual searches met the criteria. Review of the 30 studies demonstrated that pain intensity (n = 29 studies) and pain quality (n = 27 studies) were measured more frequently than pain location, pattern, and behavior parameters. Measuring cancer pain using the MPQ provided insights about disease sites, magnitude of pain, and effectiveness of treatment and intervention. Additionally, the MPQ data informed speculations about pain mechanisms, emotional status, overall sensory pain experience, changes in pain over time, and alleviating and aggravating behaviors/factors. Findings supported the MPQ as an effective multidimensional measure with good stability, content, construct, and criterion validity and showed sensitivity to treatment or known-group effects. The MPQ is a valid, reliable, and sensitive multidimensional measure of cancer pain. Cancer pain is a subjective complex experience consisting of multiple dimensions, and measuring cancer pain with the MPQ may help clinicians to more fully understand whether those dimensions of cancer pain influence each other. As a result, clinicians can provide better and effective cancer pain management.

Strategies to Move Entry-Level Nurse Practitioner Education to the Doctor of Nursing Practice Degree by 2025.

BACKGROUND: The National Organization of Nurse Practitioner Faculties (NONPF) has made the commitment to move all entry-level nurse practitioner (NP) education to the Doctor of Nursing Practice (DNP) degree by 2025. PROBLEM: Although there are more than 250 DNP NP programs throughout the United States, many other NP programs have yet to transition to the doctoral level. APPROACH: Leaders representing licensure, accreditation, certification, education, and practice organizations attended a NONPF 2017 Summit to discuss the DNP degree as entry into NP practice. Summit participants strategized on building collective strengths and addressed barriers to implementation. A solution-oriented discussion with action items has been operationalized for the last 4 years. OUTCOMES: Four workgroups were created to address education, outcomes, capacity, and messaging related to moving all entry-level NP education to the DNP degree. CONCLUSION: Ongoing collaborative efforts are critical to facilitate advancing all NP education programs to the DNP degree by 2025.

Diagnostic reasoning: relationships among expertise, accuracy, and ways that nurse practitioner students self-explain.

OBJECTIVES: To improve diagnostic ability, educators should employ multifocal strategies. One promising strategy is self-explanation, the purposeful technique of generating self-directed explanations during problem-solving. Students self-explain information in ways that range from simple restatements to multidimensional thoughts. Successful problem-solvers frequently use specific, high-quality self-explanation types. In a previous phase of research, unique ways that family nurse practitioner (NP) students self-explain during diagnostic reasoning were identified and described. This study aims to (a) explore relationships between ways of self-explaining and diagnostic accuracy levels and (b) compare differences between students of varying expertise in terms of ways of self-explaining and diagnostic accuracy levels. Identifying high-quality diagnostic reasoning self-explanation types may facilitate development of more refined self-explanation educational strategies. METHODS: Thirty-seven family NP students enrolled in the Doctor of Nursing Practice program at a large, Midwestern university diagnosed three written case studies while self-explaining. During the quantitative phase of a content analysis, associational and comparative data analysis techniques were applied. RESULTS: Expert students voiced significantly more clinical and biological inference self-explanations than did novice students. Diagnostic accuracy scores were significantly associated with biological inference scores. Clinical and biological inference scores accounted for 27% of the variance in diagnostic accuracy scores, with biological inference scores significantly influencing diagnostic accuracy scores. CONCLUSIONS: Not only were biologically focused self-explanations associated with diagnostic accuracy, but also their spoken frequency influenced levels of diagnostic accuracy. Educational curricula should support students to view patient presentations in terms of underlying biology from the onset of their education.

Ways that nurse practitioner students self-explain during diagnostic reasoning.

OBJECTIVES: An important step in mitigating the burden of diagnostic errors is strengthening diagnostic reasoning among health care providers. A promising way forward is through self-explanation, the purposeful technique of generating self-directed explanations to process novel information while problem-solving. Self-explanation actively improves knowledge structures within learners' memories, facilitating problem-solving accuracy and acquisition of knowledge. When students self-explain, they make sense of information in a variety of unique ways, ranging from simple restatements to multidimensional thoughts. Successful problem-solvers frequently use specific, high-quality self-explanation types. The unique types of self-explanation present among nurse practitioner (NP) student diagnosticians have yet to be explored. This study explores the question: How do NP students self-explain during diagnostic reasoning? METHODS: Thirty-seven Family NP students enrolled in the Doctor of Nursing Practice program at a large, Midwestern U.S. university diagnosed three written case studies while self-explaining. Dual methodology content analyses facilitated both deductive and qualitative descriptive analysis. RESULTS: Categories emerged describing the unique ways that NP student diagnosticians self-explain. Nine categories of inference self-explanations included clinical and biological foci. Eight categories of non-inference self-explanations monitored students' understanding of clinical data and reflect shallow information processing. CONCLUSIONS: Findings extend the understanding of self-explanation use during diagnostic reasoning by affording a glimpse into fine-grained knowledge structures of NP students. NP students apply both clinical and biological knowledge, actively improving immature knowledge structures. Future research should examine relationships between categories of self-explanation and markers of diagnostic success, a step in developing prompted self-explanation learning interventions.

Multimorbidity phenotypes in patients presenting to the emergency department with possible acute coronary syndrome.

BACKGROUND: Multimorbidity (> 2 conditions) increases the risk of adverse outcomes and challenges health care systems for patients with acute coronary syndrome (ACS). These complications may be partially attributed to ACS clinical care which is driven by single-disease-based practice guidelines; current guidelines do not consider multimorbidity. OBJECTIVES: To identify multimorbidity phenotypes (combinations of conditions) with suspected ACS. We hypothesized that: 1) subgroups of patients with similar multimorbidity phenotypes could be identified, 2) classes would differ according to diagnosis, and 3) class membership would differ by sex, age, functional status, family history, and discharge diagnosis. METHODS: This was a secondary analysis of data from a large multi-site clinical study of patients with suspected ACS. Conditions were determined by items on the Charlson Comorbidity Index and the ACS Patient Information Questionnaire. Latent class analysis was used to identify phenotypes. RESULTS: The sample (n = 935) was predominantly male (68%) and middle-aged (mean= 59 years). Four multimorbidity phenotypes were identified: 1) high multimorbidity (Class 1) included hyperlipidemia, hypertension (HTN), obesity, diabetes, and respiratory disorders (COPD or asthma); 2) low multimorbidity (Class 2) included only obesity; 3) cardiovascular multimorbidity (Class 3) included HTN, hyperlipidemia, and coronary heart disease; and 4) cardio-oncology multimorbidity (Class 4) included HTN, hyperlipidemia, and cancer. Patients ruled-in for ACS primarily clustered in Classes 3 and 4 (OR 2.82, 95% CI 1.95-4.05, p = 0.001 and OR 1.76, 95% CI 1.13-2.74, p = 0.01). CONCLUSION: Identifying and understanding multimorbidity phenotypes may assist with risk-stratification and better triage of high-risk patients in the emergency department.

The Well Woman Program: a community-based randomized trial to prevent sexually transmitted infections in low-income African American women.

In this sexually transmitted infection (STI) prevention study, we compared the efficacy of the Well Woman Program (WWP), a nurse practitioner-directed, culturally specific, intensive intervention, to minimal intervention (MI), brief lecture, and referral to usual care, in a community-based randomized controlled trial. African American women having past STIs and residing in high-risk communities were randomly assigned to the two groups. STI outcome was measured at baseline and three later points. A random effects logistic longitudinal regression model showed that, at baseline, approximately 75% of participants tested positive for an STI, predominantly trichomoniasis. At month 15, the estimated probability of a WWP participant having an STI was 20% less than an MI participant. Better STI outcomes were due to the intensive individualized intervention.

Acute Coronary Syndrome Symptom Clusters: Illustration of Results Using Multiple Statistical Methods.

Researchers have employed various methods to identify symptom clusters in cardiovascular conditions, without identifying rationale. Here, we test clustering techniques and outcomes using a data set from patients with acute coronary syndrome. A total of 474 patients who presented to emergency departments in five United States regions were enrolled. Symptoms were assessed within 15 min of presentation using the validated 13-item ACS Symptom Checklist. Three variable-centered approaches resulted in four-factor solutions. Two of three person-centered approaches resulted in three-cluster solutions. K-means cluster analysis revealed a six-cluster solution but was reduced to three clusters following cluster plot analysis. The number of symptoms and patient characteristics varied within clusters. Based on our findings, we recommend using (a) a variable-centered approach if the research is exploratory, (b) a confirmatory factor analysis if there is a hypothesis about symptom clusters, and (c) a person-centered approach if the aim is to cluster symptoms by individual groups.

An Analysis and Evaluation of the Theory of Unpleasant Symptoms.

The Theory of Unpleasant Symptoms was developed to enhance understanding of relationships among multiple symptoms and symptom experiences. Although the theory has been used to guide research, no formal critique of the theory has been published since 2000. This article comprehensively analyzes and evaluates the theory using Fawcett and DeSanto-Madeya's framework. Although its semantic clarity, semantic and structural consistency, and parsimony could be improved, the theory demonstrates good social and theoretical significance, testability, and empirical and pragmatic adequacy. Understanding multiple patient symptoms is essential, and the theory demonstrates that nurses should focus on multiple rather than individual symptoms.

Cesarean Outcomes in US Birth Centers and Collaborating Hospitals: A Cohort Comparison.

INTRODUCTION: High rates of cesarean birth are a significant health care quality issue, and birth centers have shown potential to reduce rates of cesarean birth. Measuring this potential is complicated by lack of randomized trials and limited observational comparisons. Cesarean rates vary by provider type, setting, and clinical and nonclinical characteristics of women, but our understanding of these dynamics is incomplete. METHODS: We sought to isolate labor setting from other risk factors in order to assess the effect of birth centers on the odds of cesarean birth. We generated low-risk cohorts admitted in labor to hospitals (n = 2527) and birth centers (n = 8776) using secondary data obtained from the American Association of Birth Centers (AABC). All women received prenatal care in the birth center and midwifery care in labor, but some chose hospital admission for labor. Analysis was intent to treat according to site of admission in spontaneous labor. We used propensity score adjustment and multivariable logistic regression to control for cohort differences and measured effect sizes associated with setting. RESULTS: There was a 37% (adjusted odds ratio [OR], 0.63; 95% confidence interval [CI], 0.50-0.79) to 38% (adjusted OR, 0.62; 95% CI, 0.49-0.79) decreased odds of cesarean in the birth center cohort and a remarkably low overall cesarean rate of less than 5% in both cohorts. DISCUSSION: These findings suggest that low rates of cesarean in birth centers are not attributable to labor setting alone. The entire birth center care model, including prenatal preparation and relationship-based midwifery care, should be studied, promoted, and implemented by policy makers interested in achieving appropriate cesarean rates in the United States.