Comparison of the Skindex-Teen and the Skindex-29 quality of life survey instruments in a predominantly American Indian adolescent population.

BACKGROUND/OBJECTIVES: The Skindex-29 and Skindex-Teen assess dermatology-related quality of life among adults and adolescents, respectively. This study directly compared the same adolescents' responses to the Skindex-29 relative to Skindex-Teen in a predominantly American Indian and/or Alaska Native population. This population is underrepresented in medical research. Although skin-related quality-of-life issues are widespread, American Indian and/or Alaska Native adolescents are not well-represented in related studies. METHODS: Data were collected in-person by self-report survey at two regional powwows in Denver, Colorado in 2021 and 2022. Respondents completed the full Skindex-29 and Skindex-Teen (40 unique items total). RESULTS: Eighty-six adolescents, 12-17 years old, completed the survey. The majority (70.9%, 61/86) of respondents self-identified as American Indian and/or Alaska Native. Analyses were conducted with all respondent survey data. Nearly two-thirds (64.0%, 55/86) of our respondents had a Skindex-29 score that revealed their quality of life was impaired at least mildly by skin disease. The Skindex-29 and Skindex-Teen demonstrated good reliability; there was substantial concordance between responses to the two measures (r values ranged from 0.88 to 0.97 for similar subscales). Compared to younger adolescents (aged 12-14), older adolescents (aged 15-17) reported worse dermatology-related quality of life and emotional toll based on higher Skindex-29 total, Skindex-Teen total, Skindex-29 Emotional subscale, and Skindex-Teen Psychosocial Functioning subscale scores. CONCLUSIONS: American Indian and/or Alaska Native adolescents suffer from skin-related quality-of-life issues. The Skindex-Teen and Skindex-29 generated similar information regarding quality of life in young patients with skin disease. While the Skindex-Teen may be slightly more relevant to adolescents, these surveys were highly concordant. Both the Skindex-Teen and Skindex-29 exhibited frequent "never" responses to questions about impact of skin conditions on relationships with others and tendencies to stay home. Thus, careful attention should be paid to such questions to ensure their relevance to adolescents.

Pilot randomized trial of an acceptance-based telehealth intervention for women with ovarian cancer and PARP inhibitor-related fatigue.

OBJECTIVE: Poly(ADP-ribose) polymerase inhibitors (PARPi) have dramatically changed treatment for advanced ovarian cancer, but nearly half of patients experience significant fatigue. We conducted a two-site pilot randomized trial to evaluate the feasibility, acceptability, and preliminary efficacy of a brief, acceptance-based telehealth intervention (REVITALIZE) designed to reduce fatigue interference in patients on PARPi. METHODS: From June 2021 to April 2022, 44 participants were randomized 1:1 to REVITALIZE (6 weekly one-on-one sessions+booster) or enhanced usual care. Feasibility was defined as: ≥50% approach-to-consent among potentially eligible patients and ≥70% completion of 12-week follow-up assessment; acceptance was <20% participants reporting burden and <20% study withdrawal. Fatigue, anxiety, depression, and quality of life were assessed at baseline, 4-, 8- and 12-weeks. RESULTS: Among 44 participants (mean age = 62.5 years, 81.8% stage III/IV disease), the study was feasible (56.4% approach-to-consent ratio, 86.3% completion of 12-week assessment) and acceptable (0% reporting burden, 11.3% study withdrawal). At 12-week follow-up, REVITALIZE significantly reduced fatigue interference (Cohen's d = 0.94, p = .008) and fatigue severity (d = 0.54, p = .049), and improved fatigue levels (d = 0.62, p = .04) relative to enhanced usual care. REVITALIZE also showed promise for improved fatigue self-efficacy, fatigue catastrophizing, anxiety, depression, and quality of life (ds = 0.60-0.86, p ≥ .05). Compared with enhanced usual care, REVITALIZE participants had fewer PARPi dose reductions (6.7% vs. 19.0%), and dose delays (6.7% vs. 23.8%). CONCLUSIONS: Among fatigued adults with ovarian cancer on PARPi, a brief, acceptance-based telehealth intervention was feasible, acceptable, and demonstrated preliminary efficacy in improving fatigue interference, severity, and levels. REVITALIZE is a novel, scalable telehealth intervention worthy of further investigation.

Integration of Person-Centered Narratives Into the Electronic Health Record.

BACKGROUND: Care delivery that is not person-centered has been called discordant care . There has been a shift to incorporate more of a person's narrative into their individual healthcare treatment plan to reduce discordant care. Aligning with this shift in healthcare delivery, we developed a person-centered narrative intervention (PCNI) to address existing gaps in delivery of person-centered care. OBJECTIVES: This study aimed to evaluate the feasibility of conducting a randomized study and describe the outcomes of PCNI to usual care on the following person (patient)-reported outcomes: perceptions of the quality of communication with their nurses and their psychosocial and existential well-being. METHODS: This study's design was an Obesity-Related Behavioral Intervention Trials model Phase II proof-of-concept randomized study. The participants were people admitted to an acute care hospital diagnosed with heart failure and/or end-stage renal disease. RESULTS: Despite COVID-19 challenges, the PCNI was feasible in an acute care setting; it showed a moderate positive difference between conditions in the person's perception of their quality of communication and a small positive difference in their perception of feeling heard and understood. For our secondary outcomes of anxiety, depression, and psychosocial illness effect, there were small or no effects in the acute care setting. DISCUSSION: Using a person-centered narrative, such as the PCNI, can help inform delivery of care that incorporates a person's (patient's) beliefs, values, and preferences into their healthcare. This study used a pragmatic approach to evaluate the PCNI in real time in an acute care setting to assess patient-reported outcomes. These positive results in a small sample indicate the need for continued testing of the PCNI. These promising effects require further testing in a Phase III efficacy study within a larger randomized controlled clinical trial.

Retrospective chart review of patient socioeconomic status and language preference associated with live video telehealth in a pediatric dermatology practice.

Pediatric teledermatology rapidly expanded with the COVID-19 pandemic, and the impacts of this expansion on patients' access to care have not yet been entirely defined. In this retrospective study of 3027 patients in an academic pediatric dermatology practice, patients who identified as having a primary language other than English were less likely to access pediatric dermatology care during the COVID lockdown. This study did not identify a significant or meaningful difference in age, geography, socioeconomic status, ethnicity, or race between patients who were offered pediatric dermatology care that was either in-person or via synchronous telehealth. These findings are overall reassuring that there were not major disparities in telehealth utilization during the COVID shelter-in-place mandate, although highlight the need for institutions to ensure systems are in place to enhance telehealth access for patients with non-English primary language.

Longitudinal Assessment of Multimorbidity Medication Patterns among Smokers in the COPDGene Cohort.

Background and objectives: Chronic obstructive pulmonary disease (COPD) is usually comorbid with other chronic diseases. We aimed to assess the multimorbidity medication patterns and explore if the patterns are similar for phase 1 (P1) and 5-year follow-up phase 2 (P2) in the COPDGene cohort. Materials and Methods: A total of 5564 out of 10,198 smokers from the COPDGene cohort who completed 2 visits, P1 and P2 visits, with complete medication use history were included in the study. We conducted latent class analysis (LCA) among the 27 categories of chronic disease medications, excluding COPD treatments and cancer medications at P1 and P2 separately. The best number of LCA classes was determined through both statistical fit and interpretation of the patterns. Results: We found four classes of medication patterns at both phases. LCA showed that both phases shared similar characteristics in their medication patterns: LC0: low medication; LC1: hypertension (HTN) or cardiovascular disease (CVD)+high cholesterol (Hychol) medication predominant; LC2: HTN/CVD+type 2 diabetes (T2D) +Hychol medication predominant; LC3: Hychol medication predominant. Conclusions: We found similar multimorbidity medication patterns among smokers at P1 and P2 in the COPDGene cohort, which provides an understanding of how multimorbidity medication clustered and how different chronic diseases combine in smokers.

Cancer survivors' cancellations of healthcare appointments during the COVID-19 pandemic: Associations with anxiety and depression.

OBJECTIVE: Though it is well-documented that cancer survivors experienced healthcare delays during the COVID-19 pandemic, who initiated those delays has not been examined. This longitudinal study distinguishes rates of patient-from provider-cancelled healthcare appointments at three timepoints during the pandemic, and examines psychosocial factors associated with patient-cancelled appointments. METHODS: Cancer survivors (N = 147) in the United States completed psychosocial and health behavior measures three times between May and December 2020. We examined rates of patient- and provider-cancelled healthcare appointments, including cancer screening appointments, at each timepoint and change between timepoints. Logistic regression was used to determine if anxiety symptoms, depression symptoms, and COVID-19 fears were associated with self-cancelled healthcare appointments. RESULTS: In May 2020, one third (33.79%) of participants reported one or more self-cancelled appointments within the prior 2 months and nearly half (45.89%) reported one or more provider-cancelled appointments. Rates of provider-cancelled appointments decreased to 35.71% in June/July 2020 and to 9.24% in November/December 2020 (both reflected p < 0.05 reductions compared to the previous timepoint). Rates of self-cancelled appointments, however, remained more stable (ps > 0.144). In June/July and November/December 2020, higher depression and anxiety symptoms, but not COVID-19 fears, were associated with greater likelihood of self-cancelled appointments. CONCLUSIONS: Cancer survivors cancelled their healthcare appointments at a stable rate even as provider-cancelled appointments declined. Depression and anxiety symptoms, but not COVID-19 concerns, were associated with patient cancellations. Interventions that address anxiety and depression symptoms may help to promote adherence to cancer survivorship care during the pandemic.

Understanding disparities and barriers associated with pediatric transplant evaluation and time to listing: Moving toward a more comprehensive picture.

BACKGROUND: Delayed time to listing (TTL) for pediatric transplant patients is associated with increased risks of mortality and morbidity. The full range of health disparities, sociodemographic factors, and other barriers associated with delays in listing in the pediatric transplant candidate evaluation process has not been fully examined. METHODS: Retrospective chart reviews were conducted for 183 kidney, liver, and heart transplant candidates ages 0-18 who were referred for evaluation during 2012-2015. Demographic information and potential barriers (e g., social/medical factors, financial concerns) were gathered from pre-transplant evaluations and included in a comprehensive model to evaluate mechanisms that explain differences in TTL. Descriptive statistics, logistic regression models, Cox proportional hazards models, and path analysis were used for analyses. RESULTS: Candidates included 26.8% heart, 33.3% liver, and 39.9% kidney patients. The most common barrier to listing was financial (71.6%), followed by caregiver psychological or substance use (57.9%), and medical problems (49.7%). Higher age, kidney, and liver organ type (relative to the heart), and presence of social, medical, administrative/motivation, and financial barriers were all directly associated with longer TTL. Public insurance was indirectly associated with TTL through social, administrative/motivation, and financial barriers. Organ type was indirectly associated with TTL through financial barriers. CONCLUSIONS: Results suggest social problems, administrative issues, and financial issues act as mechanisms through which insurance type and liver transplant candidates face increased risk of delays in transplant listing time. There are numerous clinical implications and interventions that are warranted to reduce TTL among pediatric transplant candidates with co-occurring barriers.

A randomized controlled trial of a multi-modal palliative care intervention to promote advance care planning and psychological well-being among adults with advanced cancer: study protocol.

BACKGROUND: Up to half of adults with advanced cancer report anxiety or depression symptoms, which can cause avoidance of future planning. We present a study protocol for an innovative, remotely-delivered, acceptance-based, multi-modal palliative care intervention that addresses advance care planning (ACP) and unmet psychological needs commonly experienced by adults with metastatic cancer. METHODS: A two-armed, prospective randomized controlled trial (RCT) randomizes 240 adults with Stage IV (and select Stage III) solid tumor cancer who report moderate to high anxiety or depression symptoms to either the multi-modal intervention or usual care. The intervention comprises five weekly two-hour group sessions (plus a booster session one month later) delivered via video conferencing, with online self-paced modules and check-ins completed between the group sessions. Intervention content is based on Acceptance and Commitment Therapy (ACT), an acceptance, mindfulness, and values-based model. Participants are recruited from a network of community cancer care clinics, with group sessions led by the network's oncology clinical social workers. Participants are assessed at baseline, mid-intervention, post-intervention, and 2-month follow-up. The primary outcome is ACP completion; secondary outcomes include anxiety and depression symptoms, fear of dying, and sense of life meaning. Relationships between anxiety/depression symptoms and ACP will be evaluated cross-sectionally and longitudinally and theory-based putative mediators will be examined. DISCUSSION: Among adults with advanced cancer in community oncology settings, this RCT will provide evidence regarding the efficacy of the group ACT intervention on ACP and psychosocial outcomes as well as examine the relationship between ACP and anxiety/ depression symptoms. This trial aims to advance palliative care science and inform clinical practice. TRIAL REGISTRATION: Clinicaltrials.gov NCT04773639 on February 26, 2021.

Pathways Through Which Health Literacy Is Linked to Parental Oral Health Behavior in an American Indian Tribe.

BACKGROUND: Health literacy (HL) is the "ability to find, understand, evaluate and put information to use to improve decision making and, ultimately, improve health and quality of life." Parents with limited HL are less likely to follow recommended parental oral health behaviors. PURPOSE: We tested a theoretical framework designed to clarify mechanisms through which HL may influence parental oral health behavior. The framework proposed that HL: (a) has a direct effect on parental oral health knowledge, beliefs (i.e. self-efficacy; perceived susceptibility, severity, benefits, barriers), and behavior; (b) influences beliefs indirectly through knowledge; and (c) influences behavior indirectly through knowledge and beliefs. METHODS: We analyzed cross-sectional data from a randomized controlled trial designed to reduce dental decay in American Indian children (N = 521). Parents completed survey questions assessing sociodemographic characteristics, HL, and parental oral health knowledge, beliefs, and behavior. Path analysis was used to test the framework. RESULTS: HL exerted significant direct effects on knowledge and beliefs but not behavior. HL had significant indirect effects on all beliefs through knowledge. Significant indirect effects of HL on behavior occurred through self-efficacy (estimate: 0.99, 95% CI: 0.42, 1.83, p = .005), perceived barriers (estimate: 0.73, 95% CI: 0.29, 1.43, p = .010), knowledge to self-efficacy (estimate: 0.57, 95% CI: .31, 0.98, p = .001), and knowledge to perceived barriers (estimate: 0.24, 95% CI: 0.09, 0.47, p = .012). CONCLUSIONS: HL exerted an indirect effect on parental oral health behavior, with knowledge, self-efficacy, and perceived barriers being the primary constructs linking HL to behavior.

Motivational profiles and change in physical activity during a weight loss intervention: a secondary data analysis.

BACKGROUND: High levels of moderate-to-vigorous intensity physical activity (MVPA) are strongly associated with sustained weight loss, however the majority of adults are unsuccessful in maintaining high levels of MVPA long-term. Our goal was to identify profiles based on exercise motives, and examine the association between motivational profile and longitudinal changes in MVPA during a weight loss intervention. METHODS: Adults with overweight or obesity (n = 169, mean ± SE; age 39 ± 0.7 years, BMI 34.4 ± 0.3 kg/m2, 83% female) underwent an 18-month behavioral weight loss program, including 6 months of supervised exercise, followed by 6 months of unsupervised exercise. Participants self-reported behavioral regulations for exercise at baseline (BREQ-2). Latent profile analysis identified subgroups from external, introjected, identified, and intrinsic regulations measured at baseline. Mean differences in device-measured total MVPA were compared across motivational profiles at baseline, after 6 months of supervised exercise and after a subsequent 6 months of unsupervised exercise. RESULTS: Three motivational profiles emerged: high autonomous (high identified and intrinsic, low external regulations; n = 52), high combined (high scores on all exercise regulations; n = 25), and moderate combined (moderate scores on all exercise regulations; n = 92). Motivational profile was not associated with baseline level of MVPA or the increase in MVPA over the 6-month supervised exercise intervention (high autonomous: 21 ± 6 min/d; high combined: 20 ± 9 min/d; moderate combined: 33 ± 5 min/d; overall P > 0.05). However, during the transition from supervised to unsupervised exercise, MVPA decreased, on average, within all three profiles, but the high autonomous profile demonstrated the least attenuation in MVPA (- 3 ± 6 min/d) compared to the moderate combined profile (- 20 ± 5 min/d; P = 0.043). CONCLUSIONS: Results were in alignment with the Self-Determination Theory. Adults motivated by autonomous reasons (value benefits of exercise, intrinsic enjoyment) may be more likely to sustain increases in MVPA once support is removed, whereas participants with moderate-to-high scores on all types of exercise regulations may need additional long-term support in order to sustain initial increases in MVPA. CLINICAL TRIAL REGISTRATION: NCT01985568. Registered 24 October 2013.

Randomized Controlled Trial of an Alcohol-related Sexual Risk Reduction Intervention with Adolescents: The Role of Neurocognitive Activation During Risky Decision-Making.

Justice-involved youth are at a higher risk of negative outcomes from sexual activity and alcohol use relative to their non-justice involved peers. In the current study, we tested the extent to which variability in neurocognitive response (i.e., activation in the right superior parietal lobule; rSPL) during a risky decision-making task moderated the success of a sexual risk reduction intervention. In a cluster randomized trial blocked by gender, justice-involved adolescents (N = 269) first completed a risky decision-making task during a magnetic resonance imaging (MRI) session, then were assigned to an information-only control (GINFO) or sexual risk reduction intervention incorporating alcohol risk reduction content (GPI + GMET) and then re-contacted every three months for one year. Youth in the GPI + GMET intervention reported less sexual risk behavior 12 months after intervention than those in the control. Although neurocognitive activation was associated with sexual risk behavior, it did not moderate intervention outcomes. This risk-reduction intervention appears to work equally well across a range of neurocognitive responses.

Determination of Pain Phenotypes in Knee Osteoarthritis Using Latent Profile Analysis.

OBJECTIVE: To identify clinical phenotypes of knee osteoarthritis (OA) using measures from the following domains: 1) multimorbidity; 2) psychological distress; 3) pain sensitivity; and 4) knee impairment or pathology. DESIGN: Data were collected from 152 people with knee OA and from 31 pain-free individuals. In participants with knee OA, latent profile analysis (LPA) was applied to the following measures: normalized knee extensor strength, Functional Comorbidity Index (FCI), Pain Catastrophizing Scale (PCS), and local (knee) pressure pain threshold. Comparisons were performed between empirically derived phenotypes from the LPA and healthy older adults on these measures. Comparisons were also made between pheonotypes on pain intensity, functional measures, use of health care, and history of knee injury. RESULTS: LPA resulted in a four-group solution. Compared with all other groups, group 1 (9% of the study population) had higher FCI scores. Group 2 (63%) had elevated pain sensitivity and quadriceps weakness relative to group 4 and healthy older adults. Group 3 (11%) had higher PCS scores than all other groups. Group 4 (17%) had greater leg strength, except relative to healthy older adults, and reduced pain sensitivity relative to all groups. Groups 1 and 3 demonstrated higher pain and worse function than other groups, and group 4 had higher rates of knee injury. CONCLUSION: Four phenotypes of knee OA were identified using psychological factors, comorbidity status, pain sensitivity, and leg strength. Follow-up analyses supported the replicability of this phenotype structure, but future research is needed to determine its usefulness in knee OA care.

A longitudinal analysis of the relationships between depression, fatigue, and pain in patients with heart failure.

OBJECTIVES: Depression, pain, and fatigue are common and bothersome symptoms in heart failure, a serious illness in older adults. Understanding longitudinal pathways among depression, pain, and fatigue in heart failure could inform treatment and improve quality of life. METHODS: We completed secondary, longitudinal data analyses of a sample of older adults with heart failure (baseline N = 317). Bootstrapped mediation was used to examine two longitudinal models of pain and depression, with fatigue at 6-months as the mediator. The outcome variables were 12-month pain and depression. RESULTS: Depressive symptoms were associated with new onset of pain symptoms; however, this association was mediated by fatigue. Pain was not associated with new depression or fatigue symptoms in this sample. DISCUSSION: In patients with heart-failure, worsening pain symptoms appear to be directly related to levels of depression and fatigue. These findings demonstrate that depression and fatigue may be key to reducing pain symptoms in this population.

Cancer survivors' perceived vulnerability to COVID-19 and impacts on cognitive, affective, and behavioral responses to the pandemic.

STUDY OBJECTIVES: Given the uncertainty COVID-19 has caused for individuals with prior medical conditions, we examined the extent to which cancer survivors consider themselves at risk for the global COVID-19 pandemic (henceforth COVID), both in general and due to their cancer history. Additionally, we evaluated whether perceived vulnerability to COVID among cancer survivors predicts their cognitive/affective and behavioral responses to the pandemic. DESIGN/SAMPLE: Cancer survivors who completed primary cancer treatment (median months since treatment = 33.00) and were enrolled in prior behavioral trials with our research team (N = 146) completed two surveys in May-July 2020 (95.89% retention). METHODS: Participants rated perceived next-year risk of infection and of dying from COVID. We adapted established scales to assess perceived vulnerability to COVID generally versus as a cancer survivor, catastrophizing about possible COVID symptoms, COVID-related contamination fears, and adherence to COVID prevention behaviors. FINDINGS: In May 2020, on a 1-100 scale with 0 = no chance and 100 = definitely will occur, cancer survivors reported a chance in the next year of contracting COVID of M = 39.94 (SD = 23.90), and dying from COVID of M = 24.46 (SD = 24.84). Cancer survivors reported somewhat greater vulnerability to COVID compared to same-aged peers, increased contamination fears, and high adherence to COVID prevention measures. Similar findings emerged six weeks later, suggesting stability over time. In simple linear regression models, both general and cancer survivor-specific perceived COVID vulnerability predicted COVID symptom catastrophizing and contamination fears; in multivariable models, only general vulnerability remained a significant predictor. General perceived vulnerability and contamination fears predicted greater adherence to COVID prevention behaviors. CONCLUSIONS: Cancer survivors perceived elevated vulnerability to COVID even years after treatment, which predicted adherence to COVID prevention behaviors. Future research should identify the optimal balance between supporting cancer survivors' concerns and minimizing negative impacts on quality of life.

Evaluation of the longitudinal change in health behavior profiles across treatment groups in the TODAY clinical trial.

BACKGROUND: Individual health behaviors (ie, eating habits and sedentary lifestyle) are associated with type 2 diabetes (T2D). Health behavior profiles specific to adolescents with T2D have not been described. OBJECTIVE: To identify health behavior profiles in adolescents with T2D and examine how these profiles change over time. METHODS: Diet (via food frequency questionnaire) and activity behaviors (via 3-day physical activity recall) examined at baseline, 6 months, and 24 months from participants in the the Treatment Options for T2D in Adolescents and Youth (TODAY) study were used for this analysis. Latent profile analysis identified profiles of health behaviors within three time points, and latent transition probabilities were estimated to examine the change from baseline to 6 months (n = 450) and baseline to 24 months (n = 415). Multinomial logistic regressions were used to examine if the assigned TODAY treatment group (Metformin [Met], Met + Rosiglitazone [Rosi], or Met + Lifestyle) predicted change in health behavior profiles. RESULTS: Three profiles emerged: "most sedentary," "healthy eaters," and "active and eat most." At 6 months, 50% of males and 29% of females in the Met + Lifestyle treatment group improved in their health behavior profile. Among males only, the Met + Lifestyle treatment group were more likely to improve their profiles from baseline to 6 months (P = .01). CONCLUSIONS: Three health behavior profiles emerged and shifted over time. A high quality, lifestyle intervention had little effect on improving health behavior profiles. Optimizing outcomes in youth with T2D might require more robust and multifaceted interventions beyond family-level lifestyle, including more extensive psychosocial intervention, novel medication regimen, or bariatric surgery.

Integration of Person-Centered Narratives Into the Electronic Health Record: Study Protocol.

BACKGROUND: Incorporating a patient's personal narrative into the electronic health record is an opportunity to more fully integrate the patient's values and beliefs into care, thus creating opportunities to deliver high-quality/high-value, person-centered care. OBJECTIVES: The aim of the study was to present a study protocol of a narrative intervention to (a) compare the effects of the narrative intervention to usual care on primary outcome of person's (patient) perceptions of quality of communication, (b) compare the effects of the narrative intervention on secondary outcomes of biopsychosocial well-being, and (c) examine the feasibility and acceptability of the narrative intervention from the perspective of both persons: the patient and the acute care bedside nurse. METHODS: A randomized control trial is being conducted with a targeted enrollment of 80 patient participants and 80 nurse participants. The patient participants include individuals who are admitted to the acute care hospital for either heart failure or end-stage renal disease. An acute care beside nurse who has cared for the patient participant is also enrolled. Through a 1:1 random allocation scheme, stratified by illness, we will enroll 40 in the narrative intervention group and 40 in the usual care group. Patient participants will be assessed for patient-reported outcomes of patient's perception of quality of communication and biopsychosocial well-being. RESULTS: The study began in October 2019; 53 potential patient participants have been approached, 21 have enrolled, and 20 have completed the data collection process. DISCUSSION: The testing and integration of a person-centered narrative into the electronic health record is a novel approach to provide opportunities for improvement in communication between patients and nurses. The results from this study will provide important preliminary knowledge to inform future randomized clinical trials of narrative interventions leading to advances in how to best provide high-value, high-quality, person-centered care for persons living with serious illness.

Sex-specific effects of dehydroepiandrosterone (DHEA) on bone mineral density and body composition: A pooled analysis of four clinical trials.

OBJECTIVE: Studies of dehydroepiandrosterone (DHEA) therapy in older adults suggest sex-specific effects on bone mineral density (BMD) and body composition, but the ability of a single study to reach this conclusion was limited. We evaluated the effects of DHEA on sex hormones, BMD, fat mass and fat-free mass in older women and men enrolled in four similar clinical trials. DESIGN: Pooled analyses of data from four double-blinded, randomized controlled trials. PARTICIPANTS: Women (n = 295) and men (n = 290) aged 55 years or older who took DHEA or placebo tablet daily for 12 months. MEASUREMENTS: Twelve-month changes in BMD, fat mass, fat-free mass and serum DHEA sulphate (DHEAS), (17)estradiol, testosterone and insulin-like growth factor-1 (IGF-1). RESULTS: Women on DHEA had increases (mean ± SD; all P < 0.001 vs placebo) in DHEAS (231 ± 164 µg/dL), testosterone (18.6 ± 20.9 µg/dL), (17)estradiol (8.7 ± 11.0 pg/mL) and IGF-1 (25.1 ± 52.3 ng/mL), and men had increases in DHEAS (269.0 ± 177 µg/dL; P < 0.01), (17)estradiol (4.8 ± 12.2 pg/m; P < 0.01) and IGF-1 (6.3 ± 41.4 ng/mL; P < 0.05). Women on DHEA had increases in lumbar spine (1.0% ± 3.4%) and trochanter (0.5% ± 3.8%) BMD and maintained total hip BMD (0.0% ± 2.8%); men had no BMD benefit and a decrease in fat mass (-0.4 ± 2.6 kg; all P < 0.01 vs placebo). CONCLUSIONS: Dehydroepiandrosterone therapy may be an effective approach for preserving bone and muscle mass in women. Key questions are (a) the extent to which longer duration DHEA can attenuate the loss of bone and muscle in women, and (b) whether DHEA has a more favourable benefit-to-risk profile for women than oestrogen therapy.

Temporal Immediacy: A Two-System Theory of Mind for Understanding and Changing Health Behaviors.

BACKGROUND: Health promotion and chronic disease management both require behavior change, but people find it hard to change behavior despite having good intentions. The problem arises because patients' narratives about experiences and intentions are filtered through memory and language. These narratives inaccurately reflect intuitive decision-making or actual behaviors. OBJECTIVES: We propose a principle-temporal immediacy-as a moderator variable that explains which of two mental systems (narrative or intuitive) will be activated in any given situation. We reviewed multiple scientific areas to test temporal immediacy as an explanation for findings. METHODS: In an iterative process, we used evidence from philosophy, cognitive neuroscience, behavioral economics, symptom science, and ecological momentary assessment to develop our theoretical perspective. These perspectives each suggest two cognitive systems that differ in their level of temporal immediacy: an intuitive system that produces behavior in response to everyday states and a narrative system that interprets and explains these experiences after the fact. FINDINGS: Writers from Plato onward describe two competing influences on behavior-often with moral overtones. People tend to identify with the language-based narrative system and blame unhelpful results on the less accessible intuitive system, but neither is completely rational, and the intuitive system has strengths based on speed and serial processing. The systems differ based on temporal immediacy-the description of an experience as either "now" or "usually"-with the intuitive system generating behaviors automatically in real time and the narrative system producing beliefs about the past or future. DISCUSSION: The principle of temporal immediacy is a tool to integrate nursing science with other disciplinary traditions and to improve research and practice. Interventions should build on each system's strengths, rather than treating the intuitive system as a barrier for the narrative system to overcome. Nursing researchers need to study the roles and effects of both systems.

Beliefs About Child TV Viewing in Low-Income Mexican American Parents of Preschoolers: Development of the Beliefs About Child TV Viewing Scale (B-TV).

Objectives Parental beliefs about child television viewing may affect the way parents regulate child television viewing. Despite this, little research has focused on the development of measures of parental beliefs about child television viewing, particularly among ethnic minority parents and parents of young children. This study's objective was to develop and test a culturally-based measure of parental beliefs about television viewing in low-income Mexican American mothers of preschoolers. Methods Using a cross-sectional study design, 22 items reflecting parental beliefs about influences of TV on children were developed and assessed for psychometric properties in a sample of 312 low-income Mexican American mothers of preschoolers. Results Using exploratory factor analysis, we identified four factors reflecting four domains of parental beliefs: positive general beliefs, positive sleep-related beliefs, positive functional beliefs, and negative general beliefs. Internal reliabilities were acceptable (Cronbach's alpha = 0.70-0.89) for all factors except negative general beliefs (Cronbach's alpha = 0.61). Positive sleep-related beliefs and Positive Functional Beliefs were correlated with children's average daily hours of TV (r = 0.16, p < .01; r = 0.22, p < .001, respectively) and with mother's average daily hours of TV (r = 0.14, p < .05; r = 0.22, p < .001, respectively), providing initial support for construct validity. Conclusions for Practice The Beliefs about Child TV viewing scale measures four domains of parental beliefs regarding child TV viewing, and has good initial reliability and validity for three factors. Future use will allow investigators to conduct more in-depth evaluations on the influence of parental beliefs on the way parents shape their child's use of the TV.

Adolescent's Health Behaviors and Risk for Insulin Resistance: A Review of the Literature.

PURPOSE OF REVIEW: One-third of US adolescents are obese, and related comorbidities exist in this population. Preventing early indicators of these diseases, such as insulin resistance (IR), may impact future morbidity and mortality. Interventions to date have only focused on diet or exercise. Additional targets to prevent disease are needed. This paper reviews the evidence in adolescents examining multiple health behaviors that have been associated with IR. RECENT FINDINGS: Health behaviors (i.e., diet, activity, sleep) have been individually examined as possible contributors to disease, but an understanding of the complex interplay between these behaviors is lacking. A better understanding of how multiple health behaviors contribute to IR in adolescents is needed. Future studies using both advanced statistical methodology and robust measures of each health behavior may facilitate better understanding of the impact of lifestyle factors on IR and guide intervention strategies to reduce the risk of disease.