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Over the past two decades, the management of severe asthma has shifted from relying on inhaled corticosteroids and bronchodilators to more precise, targeted approaches. Monoclonal antibodies (mAbs) designed to address specific molecular pathways in asthma have transformed care for patients with severe asthma. Since therapy targeting immunoglobulin E (IgE) became the first biologic developed for allergic asthma in 2003, monoclonal antibodies targeting interleukin (IL)-5, IL-5 receptor, IL-4/13 receptor, and thymic stromal lymphopoietin (TSLP) have been approved for treating difficult-to-treat asthma, improving symptoms, reducing exacerbations, and reducing oral corticosteroid dosing. Despite these advances, many patients continue to experience asthma exacerbations and symptoms, and fail to achieve remission. To address this, pharmaceutical companies and researchers are exploring novel therapies targeting different aspects of asthma pathophysiology, including cytokines, enzymes, and cellular pathways. Innovative treatments like inhaled biologics, ultra-long-acting biologics, and combination biologics are in development. New molecular targets, such as Bruton tyrosine kinase (BTK), Ox40 ligand, and Janus kinase (JAK), offer promise for addressing unmet needs in asthma care. While many therapies have failed to get approval for use due to lack of efficacy, trial design, or toxicity, these experiments still provide insights into asthma's underlying mechanisms. The future of asthma management looks promising, with emerging therapies aiming to improve patient outcomes. The challenge will lie in identifying the right therapy for each patient and developing personalized treatment strategies.
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Background: Telemedicine (TM) usage increased rapidly during the COVID-19 pandemic. This study is part of a larger mixed-methods study comparing TM and in-person visits of older adults with heart failure (HF) and describes patient's TM experiences during the pandemic. Methods: This study employed qualitative design using survey responses and individual interviews. Study eligibility requirements included >55 years old, HF diagnosis, and TM visit between September 1, 2020 and May 31, 2021, at one of two participating health systems in the southern United States. Results: Twenty-two TM recipients completed qualitative interviews, and 91 of 125 online survey respondents answered open-ended questions. Data were gathered, sorted, and revealed five themes. Discussion: Interview respondents identified benefits, e.g., convenience, inclusion, decreased exposure, and problems, e.g., connectivity issues, inadequate equipment, and medical conditions impacting use. Recommendations included allocating sufficient appointment time, tailoring visits, and increasing written communication. This study was part of a larger clinical trial registered at ClinicalTrials.gov: NCT04304833.
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Purpose of Review: Pneumocystis jirovecii pneumonia (PJP) is an opportunistic fungal infection that is increasingly seen in HIV-negative patients with immune compromise due to other etiologies. We lack comprehensive clinical recommendations for this population. Recent Findings: In non-HIV cases, PJP has a mortality rate of up to 50%, which is unacceptable despite the presence of safe and effective prophylaxis and therapy. Steroid use is one of the most common risk factors for disease development. New data suggests that lower doses of the preferred treatment regimen, TMP-SMX, may be equally effective for treatment while limiting side effects. While commonly used, the benefit of corticosteroids for the treatment of PJP has recently been called into question, with a recent multicenter cohort demonstrating no benefit among solid organ transplant recipients. Summary: A high suspicion of PJP in individuals with pneumonia during immunosuppressant use is crucial. Therapeutic options are evolving to decrease potential side effects while maintaining efficacy in this highly morbid disease.
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PURPOSE: To describe the experiences of registered nurses and certified nurse midwives who provided labor support and care in the early months of the COVID-19 pandemic. STUDY DESIGN AND METHODS: A descriptive, qualitative approach was used to explore nurses' and midwives' perceptions via in-depth interviews. Data were analyzed via thematic analysis. RESULTS: Thirteen nurses, four of whom were also midwives, participated in semi-structured interviews. All provided care during the first 9 months of the pandemic and represented seven states across the United States. The analysis revealed an overarching theme, A New World but still a Celebration. This overarching theme encompasses participants' accounts of trying to provide the same support, presence, and celebration while dealing with constant policy changes, the impact of limited family presence in labor, and their own fears and risks. Four sub-themes were identified: The Impact of Nursing during COVID-19; Challenges, Changes, and Consequences; Unexpected Benefits; and The Cost. CLINICAL IMPLICATIONS: The first year of the COVID-19 pandemic saw unprecedented challenges for nurses. Practice changes due to these changing policies had negative and positive effects. Negative practices affected family support, decreased interprofessional collaboration, and caused shorter hospital stays for new mothers. Some positive aspects of practice changes included additional time for mother-newborn bonding due to restrictive visitation policies, increased initiation of breastfeeding, and focused patient education. Nurses across the United States are still coping with practice changes from the pandemic. Our study highlights the need to support nurses in adapting care in the midst of practice changes.
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COVID-19 , Pesquisa Qualitativa , Humanos , COVID-19/epidemiologia , Estados Unidos/epidemiologia , Feminino , Gravidez , Adulto , SARS-CoV-2 , Pandemias , Enfermeiros Obstétricos/psicologia , Trabalho de Parto/psicologia , Entrevistas como Assunto/métodos , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Poor sleep quality is often reported by individuals with asthma, particularly by those who have poor asthma control overall. However, there is little understanding of how underlying sleep disorders such as insomnia may impact asthma control. Furthermore, given the frequent overlap of depression and insomnia, the incremental impact of mood disorders and insomnia on asthma control remains unclear. METHODS: We conducted a retrospective analysis of patients at a large asthma center to further elucidate connections between these disease processes. Asthma patients with and without a diagnosis of insomnia were matched by age, sex, Charlson comorbidity index, and biologic therapy. We evaluated the presence of concurrent obstructive sleep disorder, mood disorders, exacerbation frequency, and asthma control test (ACT) scores. RESULTS: From a cohort of 659 patients with an asthma diagnosis, 89 subjects with insomnia (13.5%) were matched 1:1 to patients without insomnia. Compared to those without insomnia, patients with insomnia were more likely to have a concurrent diagnosis of obstructive sleep apnea (57.3% vs. 18%, p < 0.001) and to have a diagnosis of depression or anxiety (68.5% vs. 11.4%, p < 0.001). Among insomnia patients, there was an average of 0.93 asthma exacerbations per year, compared to 0.59 exacerbations per year for those without insomnia (p = 0.039). CONCLUSION: Our data reveal a considerable interaction between insomnia, depression, and obstructive sleep apnea in individuals with asthma. The increased exacerbation rate suggests that underlying sleep and mood disorders negatively affect asthma control.
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Asma , Depressão , Distúrbios do Início e da Manutenção do Sono , Humanos , Asma/psicologia , Asma/epidemiologia , Asma/complicações , Distúrbios do Início e da Manutenção do Sono/epidemiologia , Distúrbios do Início e da Manutenção do Sono/psicologia , Feminino , Masculino , Estudos Retrospectivos , Pessoa de Meia-Idade , Depressão/epidemiologia , Adulto , Idoso , Comorbidade , Apneia Obstrutiva do Sono/epidemiologia , Apneia Obstrutiva do Sono/psicologia , Ansiedade/epidemiologiaRESUMO
BACKGROUND: Arterial punctures are a common procedure used to obtain blood samples for lab tests that guide treatment of neonatal patients. These punctures can be painful and have associated risks, emphasizing the importance of keeping attempts to a minimum. PURPOSE: The purpose of this quality improvement initiative was to determine whether using transillumination to visualize arteries before and while obtaining a blood sample would improve outcomes in neonatal patients. METHODS: Quantitative data were collected pre- and postimplementation of education for the use of a transillumination device for arterial punctures on neonates in a level III neonatal intensive care unit (NICU). Outcomes followed included the success rate, average time to obtain a blood sample, and the average number of sticks to obtain a blood sample. Data were collected on 47 blood draw attempts in the control group (preimplementation) and 19 blood draw attempts in the experimental group (postimplementation). RESULTS: A statistical analysis concluded that the use of the studied transillumination device does positively affect the incidence of successful blood draws, particularly for the novice NICU nurse. In addition, the average number of sticks to obtain a blood sample significantly decreased in the experimental group. Finally, the average time to obtain a blood sample using the device was not impacted in this study. IMPLICATIONS FOR PRACTICE AND RESEARCH: Use of a transillumination device does appear to result in improved outcomes for arterial punctures in neonatal patients. More research is needed to confirm these findings due to the small sample size of the study.
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Punções , Transiluminação , Recém-Nascido , Humanos , Punções/efeitos adversos , Dor/etiologia , Unidades de Terapia Intensiva Neonatal , Melhoria de QualidadeRESUMO
A delay in detecting acute hypertensive crisis in postpartum mothers can exacerbate complications in the mother. Neonatal nurses are uniquely qualified to identify postpartum warning signs in mothers while they are in the NICU with their infants. Few research studies have explored the use of neonatal nurse screenings for acute hypertensive crisis in postpartum mothers. NICU nurses screening mothers for postpartum depression has yielded success in improving outcomes, and this model could be translated into screening for acute hypertensive crisis. Further education should be implemented for NICU nurses that include a review of adult blood pressure monitoring, early warning signs, and symptoms of preeclampsia that the mother should report. This article discusses the importance of the neonatal nurse's role in identifying early warning signs of maternal postpartum hypertensive crisis.
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Depressão Pós-Parto , Enfermeiros Neonatologistas , Adulto , Lactente , Recém-Nascido , Feminino , Gravidez , Humanos , Mães , Período Pós-Parto , Triagem NeonatalRESUMO
While smoking prevalence has decreased among the general population, the use of electronic cigarettes (E- cigarettes) has risen significantly and can cause significant lung injury. We sought to determine if persons with cystic fibrosis (PwCF) have similar rates of E-cigarette use as compared with age-matched peers, and to understand perceptions of E-cigarette safety through a survey-based study. A total of 29 PwCF and 26 age-matched control patients participated in this study. There was no significant difference between PwCF and control patients regarding perceptions of the negative impact of E-cigarette use on one's health. Overall, both PwCF and control patients reported a good quality of life. PwCF were equally likely to identify E-cigarettes as harmful to one's lung health as healthy controls but were significantly more likely to have heard of EVALI. While small, our study has demonstrated the need for further education of both PwCF and healthy young adults.
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Fibrose Cística , Sistemas Eletrônicos de Liberação de Nicotina , Vaping , Humanos , Adulto Jovem , Fibrose Cística/epidemiologia , Qualidade de Vida , Fumar/epidemiologia , Vaping/efeitos adversos , Vaping/epidemiologiaRESUMO
Rationale: Family members of critically ill patients with coronavirus disease (COVID-19) have described increased symptoms of posttraumatic stress disorder (PTSD). Little is known about how these symptoms may change over time. Objectives: We studied changes in PTSD symptoms in family members of critically ill patients with COVID-19 over 12 months. Methods: This prospective, multisite observational cohort study recruited participants at 12 hospitals in five states. Calls were made to participants at 3-4 months, 6 months, and 12 months after patient admission to the intensive care unit. Results: There were 955 eligible family members, of whom 330 (53.3% of those reached) consented to participate. Complete longitudinal data was acquired for 115 individuals (34.8% consented). PTSD symptoms were measured by the IES-6 (Impact of Events Scale-6), with a score of at least 10 identifying significant symptoms. At 3 months, the mean IES-6 score was 11.9 ± 6.1, with 63.6% having significant symptoms, decreasing to 32.9% at 1 year (mean IES-6 score, 7.6 ± 5.0). Three clusters of symptom evolution emerged over time: persistent symptoms (34.8%, n = 40), recovered symptoms (33.0%, n = 38), and nondevelopment of symptoms (32.2%, n = 37). Although participants identifying as Hispanic demonstrated initially higher adjusted IES-6 scores (2.57 points higher [95% confidence interval (CI), 1.1-4.1; P < 0.001]), they also demonstrated a more dramatic improvement in adjusted scores over time (4.7 greater decrease at 12 months [95% CI, 3.2-6.3; P < 0.001]). Conclusions: One year later, some family members of patients with COVID-19 continue to experience significant symptoms of PTSD. Further studies are needed to better understand how various differences contribute to increased risk for these symptoms.
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COVID-19 , Transtornos de Estresse Pós-Traumáticos , Humanos , Transtornos de Estresse Pós-Traumáticos/etiologia , Estudos Prospectivos , Estado Terminal , COVID-19/complicações , FamíliaRESUMO
BACKGROUND: The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life; however, a lack of access to breastfeeding resources influences breastfeeding initiation and continuation. Tele-lactation services may reduce some of these barriers to access. RESEARCH AIMS: To identify facilitators and barriers of two modes of tele-health service utilization and to compare the differences between two modes of providing tele-lactation services on breastfeeding knowledge, breastfeeding intention, perceived social support, and 3-month breastfeeding continuation behavior. METHODS: We conducted a mixed method, longitudinal pilot study utilizing prospective convenience sampling and random assignment of postpartum women recruited from two medical centers in Little Rock, Arkansas. Participants (N = 43) were randomized into telephone-only (n = 23) or audio-visual (n = 20) intervention groups. Participants completed a self-administered pre- and post-intervention survey, as well as a semi-structured qualitative phone interview at 4-6 weeks post-discharge. RESULTS: No significant difference in demographic characteristics across groups was found. At 3 months after discharge, both groups reported continued breastfeeding (telephone-only: n = 17, 81%; audio-visual: n = 18, 90%) with no significant difference between the two groups (p = .663). Additionally, no group differences were found for breastfeeding knowledge or perceived social support. Overall, participants reported positive experiences with tele-lactation, emphasizing the convenience, accessibility, education, and support provided. CONCLUSION: We found that both telephone-only and audio-visual delivery of tele-lactation services were equally effective. Both methods of tele-lactation services should be considered by health care providers to encourage and sustain breastfeeding behavior in mothers.
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Assistência ao Convalescente , Aleitamento Materno , Humanos , Feminino , Criança , Estudos Prospectivos , Projetos Piloto , Alta do Paciente , Lactação , Mães , Encaminhamento e ConsultaRESUMO
Background: Increasing awareness of the emotional impact of an Intensive Care Unit (ICU) hospitalization on patients and their families has led to a rise in studies seeking to mitigate Post Intensive Care Syndrome (PICS) for both groups. In efforts to decrease symptoms of anxiety and depression, ICUs have implemented a variety of programs to reduce family distress. Methods: We conducted a systematic review of experimental studies which aimed to reduce stress related disorders in family members after the experience of having a patient admitted to the ICU. Multiple databases were searched for randomized controlled trials or nonrandomized comparative trials which targeted family members or surrogate decision makers. A total of 17 studies were identified for inclusion in the review representing 3471 participants. Results: We describe those interventions which we qualitatively assigned as "not passive," or those which actively engaged the family to express themselves, as more likely to be successful in both the available pediatric and adult literature than interventions which we identified as "passive." Studies which described active engagement of family members demonstrated comparative improvements in symptoms of depression, anxiety, and PTSD, as well as reduced hospital costs in the case of two studies. Discussion: This review may serve to aid in the development of future interventions targeted at reducing family stress and PICS following an ICU hospitalization.
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BACKGROUND: Health educators are called on to dismantle health care inequities as they train future health care clinicians to deliver care that promotes equity, improves access to care, and actively addresses antiracism. METHOD: Through an Advanced Nursing Workforce grant by the Health Resources and Services Administration, a partnership was established with the Institute for Perinatal Quality Improvement to provide training for health care clinicians and students on ways to SPEAK UP against implicit and explicit bias with an emphasis on maternal health. RESULTS: Dismantling racism is a continuous process. Activities included self-reflection, small group meetings, antiracism and bias training, and community engagement. CONCLUSION: Acknowledging that racism and health inequities exist and directly contribute to the rise in maternal and infant mortality is only the beginning. Rethinking nursing education, curriculum, and clinical care to train culturally responsive health care clinicians is required to address systemic and structural racism in health care. [J Nurs Educ. 2022;61(8):493-496.].
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Educação em Enfermagem , Equidade em Saúde , Racismo , Currículo , Atenção à Saúde , Feminino , Humanos , Lactente , Gravidez , Grupos RaciaisRESUMO
Importance: The psychological symptoms associated with having a family member admitted to the intensive care unit (ICU) during the COVID-19 pandemic are not well defined. Objective: To examine the prevalence of symptoms of stress-related disorders, primarily posttraumatic stress disorder (PTSD), in family members of patients admitted to the ICU with COVID-19 approximately 90 days after admission. Design, Setting, and Participants: This prospective, multisite, mixed-methods observational cohort study assessed 330 family members of patients admitted to the ICU (except in New York City, which had a random sample of 25% of all admitted patients per month) between February 1 and July 31, 2020, at 8 academic-affiliated and 4 community-based hospitals in 5 US states. Exposure: Having a family member in the ICU with COVID-19. Main Outcomes and Measures: Symptoms of PTSD at 3 months, as defined by a score of 10 or higher on the Impact of Events Scale 6 (IES-6). Results: A total of 330 participants (mean [SD] age, 51.2 [15.1] years; 228 [69.1%] women; 150 [52.8%] White; 92 [29.8%] Hispanic) were surveyed at the 3-month time point. Most individuals were the patients' child (129 [40.6%]) or spouse or partner (81 [25.5%]). The mean (SD) IES-6 score at 3 months was 11.9 (6.1), with 201 of 316 respondents (63.6%) having scores of 10 or higher, indicating significant symptoms of PTSD. Female participants had an adjusted mean IES-6 score of 2.6 points higher (95% CI, 1.4-3.8; P < .001) than male participants, whereas Hispanic participants scored a mean of 2.7 points higher compared with non-Hispanic participants (95% CI, 1.0-4.3; P = .002). Those with graduate school experience had an adjusted mean score of 3.3 points lower (95% CI, 1.5-5.1; P < .001) compared with those with up to a high school degree or equivalent. Qualitative analyses found no substantive differences in the emotional or communication-related experiences between those with high vs low PTSD scores, but those with higher scores exhibited more distrust of practitioners. Conclusions and Relevance: In this cohort study, symptoms of PTSD among family members of ICU patients with COVID-19 were high. Hispanic ethnicity and female gender were associated with higher symptoms. Those with higher scores reported more distrust of practitioners.
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COVID-19 , Transtornos de Estresse Pós-Traumáticos , COVID-19/epidemiologia , Criança , Estudos de Coortes , Família/psicologia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Prospectivos , Transtornos de Estresse Pós-Traumáticos/psicologiaRESUMO
OBJECTIVE: To determine the level of agreement between the advice given to an obstetric patient calling an obstetric call center and the advice given by health care providers with varying degrees of knowledge and experience. STUDY DESIGN: This is a retrospective quality improvement project which evaluates the level of agreement between advice from nurses at an obstetric call center using software with obstetric triage protocols compared with advice given by women's health advanced practice nurse (APN), a fourth year obstetrics and gynecology (OB-GYN) resident, and a maternal fetal medicine (MFM) specialist on the same call scenarios. RESULTS: The call center nurses advised emergency care more frequently (51.7%) than the MFM (44%) and the APN (31.9%) but less frequently than the OB-GYN resident (57.1%). The levels of agreement between the call center nurse and the MFM were good (κ = 0.71; 95% CI: 0.57-0.85). The levels of agreement between the call center nurses and the resident and APN were considered moderate with κ = 0.60 (95% CI: 0.42-0.77) and κ = 0.60 (95% CI: 0.45-0.76). CONCLUSION: Advice given by nurses at an obstetric call center was highly consistent with the most skilled specialist (MFM) followed closely by OB-GYN resident or an APN.
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Call Centers , Obstetrícia , Feminino , Pessoal de Saúde , Humanos , Gravidez , Estudos Retrospectivos , Triagem/métodosAssuntos
COVID-19 , Fibrose Cística , Adulto , Fibrose Cística/epidemiologia , Humanos , Pandemias , SARS-CoV-2 , Inquéritos e QuestionáriosRESUMO
Substantial racial disparities accounted for 66% of non-Hispanic Black mothers initiating breastfeeding in 2015 compared with 83% of non-Hispanic white mothers and 87% of Hispanic mothers in Tennessee. Created in 2015, Breastfeeding Sisters That Are Receiving Support (BSTARS) uses key partnerships at monthly meetings that promote supportive environments with topics around breastfeeding education, support, and women's health issues. The BSTARS group helps rebuild the culture surrounding the health equity of Black women and women of color and their families by offering informational and emotional support, facilitate positive changes, and heal historical trauma. BSTARS addresses barriers to breastfeeding support for Black women and women of color, including lack of support from the mother's partner, family, or health care provider, generational myths, unawareness of public health programs to support breastfeeding, educational gaps, and embarrassment. This program incorporates critical partnerships, including health care providers, birth workers, and other supporters, into the organization to offer comprehensive support for the mother's continuity of care. The environment and educational support for breastfeeding and women's health issues are addressed under the lens of health equity and eliminating barriers experienced by the mother's color, or socioeconomic status. A mother's socioeconomic status often unjustly hinders her from receiving the lactation and social support needed for healthier outcomes. In 2019, the breastfeeding initiation rate in Tennessee increased to 71.3% among non-Hispanic Blacks. BSTARS has reached >500 families since its inception. BSTARS focuses their specific intervention on all facets of the family dyad, through teaching the importance of breastfeeding and breast milk now and sustainable for the future.
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Aleitamento Materno , Pigmentação da Pele , Aconselhamento , Feminino , Humanos , Leite Humano , Mães , Apoio SocialRESUMO
Many rural residents do not receive genetic counseling or testing when needed because of health care access barriers, such as lack of providers in rural areas and the requirement for rural residents to travel to larger cities for these services. Telehealth technology can reduce these barriers by allowing rural residents to receive genetic counseling through a two-way interactive audio/video secure connection in a local clinic setting or in their homes. Telegenetics is a satisfactory solution for both patient and provider and provides benefits for rural patients despite ethical, legal, and reimbursement considerations.