Travel distance to rifampicin-resistant tuberculosis treatment and its impact on loss to follow-up: the importance of continued RR-TB treatment decentralization in South Africa.

BACKGROUND: Understanding why patients experience loss to follow-up (LTFU) is essential for TB control. This analysis examines the impact of travel distance to RR-TB treatment on LTFU, which has yet to be analyzed within South Africa. METHODS: We retrospectively analyzed 1436 patients treated for RR-TB at ten South African public hospitals. We linked patients to their residential ward using data reported to NHLS and maps available from the Municipal Demarcation Board. Travel distance was calculated from each patient's ward centroid to their RR-TB treatment site using the georoute command in Stata. The relationship between LTFU and travel distance was modeled using multivariable logistic regression. RESULTS: Among 1436 participants, 75.6% successfully completed treatment and 24.4% were LTFU. The median travel distance was 40.96 km (IQR: 17.12, 63.49). A travel distance > 60 km increased odds of LTFU by 91% (p = 0.001) when adjusting for HIV status, age, sex, education level, employment status, residential locale, treatment regimen, and treatment site. CONCLUSION: People living in KwaZulu-Natal and Eastern Cape travel long distances to receive RR-TB care, placing them at increased risk for LTFU. Policies that bring RR-TB treatment closer to patients, such as further decentralization to PHCs, are necessary to improve RR-TB outcomes.

PRIME-nurse practitioner competency model validation and criterion based OSCE rubric interrater reliability.

The PRIME-NP (Professional-Reporter-Interpreter-Manager-Educator/Evaluation-Nurse Practitioner) Model is adapted from the RIME (Reporter-Interpreter-Manager-Educator) model used in medical education to guide medical student and resident education. The Delphi technique was used to validate the PRIME-NP Model. After two rounds of review by a group of experts in NP curriculum, the model was determined to be valid based on expert consensus. Agreement percent increase from the first round to the second round in all categories. Interrater reliability (IRR) was assessed using interclass correlation after instrument validation was completed for each of the five levels of the PRIME-NP model. Overall, the IRR of the instrument was found to be acceptable with some notable exceptions. No variance was noted in professional behaviors at any level. Variance was increased in management and educator/evaluator behaviors in higher/later course levels. The PRIME-NP Model and PRIME-NP OSCE Rubric is a valid and reliable instrument to assess NP student progression in objective structured clinical examinations. This instrument has the potential for adaptation for use in other types of health sciences education and settings.

Anti-inflammatory mouthwashes for the prevention of oral mucositis in cancer therapy: an integrative review and meta-analysis.

PURPOSE: Mucositis is severely painful and often reported as one of the most distressing adverse effects of cancer therapy; it is a significant threat to quality of life as well as life itself. Anti-inflammatory agents may modulate physiologic mechanisms that perpetuate mucositis and be useful in prevention efforts. Because systemic anti-inflammatory agents are not appropriate for many patients, locally acting agents (mouthwashes) may be more feasible for use. This review and meta-analysis evaluates the role that anti-inflammatory mouthwashes have in preventing or reducing oral mucositis associated with chemotherapy and radiation therapy. METHODS: A systematic literature review was conducted to identify studies evaluating the efficacy of anti-inflammatory mouthwashes to prevent therapy-associated mucositis. Meta-analysis was conducted to determine efficacy in preventing any mucositis and dose-limiting mucositis. RESULTS: Eight peer-reviewed publications were identified; corticosteroid and nonsteroidal anti-inflammatory mouthwashes are effective in reducing overall incidence of mucositis and are associated with lower severity of mucositis. Meta-analysis reveals significant reduction in symptomatic mucositis incidence (OR 6.00, 95% CI 4.39-8.20, p < 0.0001) and reduction of dose-limiting mucositis (OR 2.12, 95% CI 1.07-4.28, p = 0.032). CONCLUSION: Mouthwashes containing anti-inflammatory agents are a potential effective means to prevent or reduce mucositis associated with cancer therapy. There are limited adverse effects from these agents, and adherence is high, indicating safety and feasibility of use. Anti-inflammatory mouthwashes should be considered for supportive care in persons at risk for mucositis and must be further evaluated to investigate efficacy across multiple chemotherapy agents, adverse effects, and impacts on symptoms, pain, and quality of life.

A pilot clinical trial of a self-management intervention in patients with a left ventricular assist device.

Self-management is a health behavior known to predict treatment outcomes in patients with multiple co-morbidities and/or chronic conditions. However, the self-management process and outcomes in the left-ventricular assist device (LVAD) population are understudied. This pilot randomized control trial (RCT) evaluated the feasibility of a novel "smartphone app-directed and nurse-supported self-management intervention" in patients implanted with durable LVADs. Assessments included behavioral (self-efficacy and adherence), clinical (complications), and healthcare utilization (unplanned clinic, emergency room (ER) visits, and re-hospitalization) outcomes, completed at baseline (pre-hospital discharge) and months 1, 3, and 6 post-hospital discharge. Intervention patients (n = 14) had favorable patterns/trends of results across study outcomes than control patients (n = 16). Notably, intervention patients had much lower complications and healthcare utilization rates than controls. For example, intervention patients had 2 (14.3%) driveline infections in 6 months while control patients had 3 (19.0%). Additionally, at month 3, intervention patients had 0% ER visits versus 36% of control patients. At month 6, the mean cumulative number of re-hospitalizations for the control group was higher (0.9 ± 0.93) than intervention (0.3 ± 0.61) group. Despite the small sample size and limitations of feasibility/pilot studies, our outcomes data appeared to favor the novel intervention. Lessons learned from this study suggest the intervention should be implemented for 6 months post-hospital discharge. Further research is needed including large and rigorous multi-center RCTs to generate knowledge explaining the mechanism of the effect of self-management on LVAD treatment outcomes.

Survey Research: Do All RN Types Have the Same Perceptions Regarding Professional Nursing Governance?

OBJECTIVE: Researchers examined professional nursing governance perception differences by RN type (clinical, manager, and other RNs), and nurse-related outcome associations. BACKGROUND: Shared governance is associated with improved nurse-related outcomes. Understanding differences in RN types regarding shared governance perceptions is important and not well studied. METHODS: Mean Index of Professional Nursing Governance (IPNG) scores from 3 hospitals' 502 RNs were used to evaluate associations by RN type and unit-based nurse-related outcomes. Descriptive and inferential statistical methods were used. RESULTS: Shared governance was the predominant finding (overall score and 4 of 6 subscale scores) with no significant differences by RN type. Traditional governance was scored for 1 subscale (control over personnel), which was not significant. There were no significant differences in the IPNG score associations with outcomes data by RN type. CONCLUSIONS: Clinical nurses, managers, and other RN types perceived their governance as shared, without significant difference in the nurses' perceptions based on role.

"It All Depends": Patient and Decision Partner Experiences in Cancer Clinical Trial Decision-Making.

While the supporting role of families and friends has been widely recognized in cancer care, little data exist on how they influence patients' decisions regarding clinical trial participation, accounting for patients' decisional preferences. The goal of our study was to examine the process of clinical trial decision-making from the perspective of adults with cancer and their decision partners. Semi-structured interviews were conducted with 12 patients and 12 decision partners-family and friends engaged in the medical decision-making. Themes included: (1) having the ability and confidence to make decisions; (2) gaining insight about clinical trials; (3) trusting someone in the process; and (4) realizing readiness and context. Our findings will enhance understanding of how patients make clinical trial decisions based on decisional preferences from the perspectives of patients and decision partners. The findings may also help to increase clinician awareness and inclusion of decision partners in conversations regarding clinical trials.

A Multi-Site Thailand Heart Failure Snapshot Study.

BACKGROUND: The prevalence of heart failure (HF) is increasing in many low-income and middle-income countries, but the limited availability of data on patient profiles and clinical outcomes, particularly at a community level, challenges health service planning. METHODS: The Thai HF Snapshot Study was a multi-site, observational study conducted in Thailand between June 2017 to June 2019. It aimed to document demographic, clinical and sociodemographic characteristics, and to compare clinical outcomes by the level of the hospital. RESULTS: A total of 512 participants were recruited across Thailand: mean age was 64.9±15.3 years and 286 were female (55.9%). The most frequently identified admitting diagnosis was ischaemic heart disease (45.1%). Most patients (70.3%) were classified as New York Heart Association class II at discharge. Patients in university hospitals were frailer (3.2 vs 2.9; p=0.015), had more depressive symptoms (8.1 vs 5.7; p<0.001), and had lower functional status (66.2 vs 73.3; p<0.001) than those in tertiary care. CONCLUSION: Although HF patients admitted to university hospitals had access to advanced technology and health care specialists, clinical outcomes likely affected patient acuity. Interventions are urgently needed to ensure improved HF management considering the social determinants of health in Thailand.

Preparing the healthcare workforce in South Africa for short-course rifampicin-resistant TB treatment: inter-professional training and task-sharing considerations.

BACKGROUND: Treatment for rifampicin-resistant Mycobacterium tuberculosis (RR-TB) is complex, however, shorter treatment, with newer antimicrobials are improving treatment outcomes. The South African National Department of Health (NDoH) recently accelerated the rollout of 9-month, all-oral, RR-TB short-course regimens. We sought to evaluate an inter-professional training program using pre-test and post-test performance of Professional Nurses (PNs), Advanced Practice Professional Nurses (APPNs) and Medical Officers (MOs) to inform: (a) training needs across cadres; (b) knowledge performance, by cadres; and (c) training differences in knowledge by nurse type. METHODS: A 4-day didactic and case-based clinical decision support course for RR-TB regimens in South Africa (SA) was developed, reviewed and nationally accredited. Between February 2017 and July 2018, 12 training events were held. Clinicians who may initiate RR-TB treatment, specifically MOs and PN/APPNs with matched pre-post tests and demographic surveys were analyzed. Descriptive statistics are provided. Pre-post test evaluations included 25 evidence-based clinically related questions about RR-TB diagnosis, treatment, and care. RESULTS: Participants (N = 842) participated in testing, and matched evaluations were received for 800 (95.0%) training participants. Demographic data were available for 793 (99.13%) participants, of whom 762 (96.1%) were MOs, or nurses, either PN or APPNs. Average correct response pre-test and post-test scores were 61.7% (range 7-24 correct responses) and 85.9% (range 12-25), respectively. Overall, 95.8% (730/762) of participants demonstrated improved knowledge. PNs improved on average 25% (6.22 points), whereas MOs improved 10% (2.89 points) with better mean test scores on both pre- and post-test (p < 0.000). APPNs performed the same as the MOs on post-test scores (p = NS). CONCLUSIONS: The inter-professional training program in short-course RR-TB treatment improved knowledge for participants. MOs had significantly greater pre-test scores. Of the nurses, APPNs outperformed other PNs, and performed equally to MOs on post-test scores, suggesting this advanced cadre of nurses might be the most appropriate to initiate and monitor treatment in close collaboration with MOs. All cadres of nurse reported the need for additional clinical training and mentoring prior to managing such patients.

Effect of Shared Governance on Nurse-Sensitive Indicator and Satisfaction Outcomes by Magnet® Recognition Status.

OBJECTIVE: Researchers examined associations between Index for Professional Nursing Governance (IPNG) types and outcomes. BACKGROUND: Effects of professional nursing governance on nurse-related outcomes by Magnet® status are not well studied. METHODS: Associations were evaluated between average IPNG scores from 2170 RNs, and nurse-sensitive indicators (NSIs) as well as patient and RN satisfaction outcomes (N = 205 study units; 20 hospitals), following Magnet requirements. RESULTS: Magnet hospitals had significantly better IPNG shared governance scores than non-Magnet hospitals (Magnet, 106.7; non-Magnet, 101.3). For Magnet hospitals, units scoring as shared governance outperformed traditional governance for 9 of 19 outcomes (47.4%) (NSI, 2; patient satisfaction, 3; RN satisfaction, 4). Self-governance outperformed shared governance for 8 of 15 outcomes (53.3%) (NSI, 2; patient satisfaction, 6; RN satisfaction, 0). For non-Magnet hospitals, shared governance significantly outperformed traditional governance for 1 of 15 outcomes (6.7%) (patient satisfaction). CONCLUSIONS: Having shared or self-governance is a strategy that can be considered by nurse leaders to improve select nurse-related outcomes.

Effect of Shared Governance on Nurse-Sensitive Indicator and Satisfaction Outcomes: An International Comparison.

OBJECTIVE: Researchers examined associations between Index for Professional Nursing Governance (IPNG) scores and outcomes, by US and international hospitals. BACKGROUND: Nursing governance and effects on nurse-related outcomes are not well studied. METHODS: Associations were evaluated using average IPNG scores from 2170 RNs and nurse-sensitive indicators (NSIs) and patient and RN satisfaction outcomes (n = 205 study units, 20 hospitals, 4 countries). RESULTS: International units had better IPNG shared governance scores (113.5; US = 100.6; P < 0.001), and outcomes outperforming unit benchmarks (6 of 15, 40.0%; US = 2 of 15, 13.3%). Shared governance significantly outperformed traditional governance for 5 of 20 (25.0%) US outcomes (patient satisfaction = 1, RN satisfaction = 4) and for 3 of 11 (27.3%) international (patient satisfaction = 1, RN satisfaction = 2). Internationally, self-governance significantly outperformed traditional governance and shared governance for 5 of 12 (41.7%) outcomes (NSI = 2, patient satisfaction = 3). CONCLUSIONS: Shared governance is a strategy that can be considered by nurse leaders for improving select outcomes.

Exploring Health Literacy and the Correlates of Pap Testing Among African Immigrant Women: Findings from the AfroPap Study.

African immigrant (AI) women have low rates of Pap testing. Health literacy plays a pivotal role in health behaviors. Sources and types of health information could shape health literacy and inform the Pap testing behaviors of AI women. However, the influences of health literacy, sources, and types of health information along with cultural and psychosocial correlates on the Pap testing behaviors of AI women are poorly understood. To examine how sources and types of health information impact health literacy, and in turn, how health literacy and cultural and psychosocial factors influence the Pap testing behaviors of AI women. An adapted Health Literacy Skills Framework guided the selection of variables for this cross-sectional study. Convenience sampling was used to recruit 167 AI women, 21-65 years. Multivariate logistic regression was used to assess correlates of Pap testing after adjusting for covariates (age, education, English proficiency, employment, income, health insurance, access to primary care, marital status, and healthcare provider recommendation). Most participants (71%) had received a Pap test in the past and used multiple (two or more) sources (65%) and types (57%) of health information. Using multiple sources of health information (aOR 0.11, p < 0.01) but not types of health information was associated with Pap testing. Having negative cultural beliefs (aOR 0.17, p = 0.01) and having high self-efficacy (aOR 9.38, p < 0.01) were significantly associated with Pap testing after adjusting for covariates. High health literacy (OR 3.23, p < 0.05) and high decisional balance (OR 5.28, p < 0.001) were associated with Pap testing in bivariate models but did not remain significant after controlling for covariates. Cultural beliefs was a significant correlate of AI women's Pap testing behaviors regardless of other known social determinants of health (education, English proficiency, age, access to primary care). Disseminating health information through various sources has the potential to promote Pap testing among AI women. Larger studies which utilize a robust sampling strategy and include a diverse group of AI women are needed in order to optimize health interventions aimed at improving Pap test screening behaviors among AI women.

Aminoglycoside-induced Hearing Loss Among Patients Being Treated for Drug-resistant Tuberculosis in South Africa: A Prediction Model.

BACKGROUND: Individuals treated for drug-resistant tuberculosis (DR-TB) with aminoglycosides (AGs) in resource-limited settings often experience permanent hearing loss, yet there is no practical method to identify those at higher risk. We sought to develop a clinical prediction model of AG-induced hearing loss among patients initiating DR-TB treatment in South Africa. METHODS: Using nested, prospective data from a cohort of 379 South African adults being treated for confirmed DR-TB with AG-based regimens we developed the prediction model using multiple logistic regression. Predictors were collected from clinical, audiological, and laboratory evaluations conducted at the initiation of DR-TB treatment. The outcome of AG-induced hearing loss was identified from audiometric and clinical evaluation by a worsened hearing threshold compared with baseline during the 6-month intensive phase. RESULTS: Sixty-three percent of participants (n = 238) developed any level of hearing loss. The model predicting hearing loss at frequencies from 250 to 8000 Hz included weekly AG dose, human immunodeficiency virus status with CD4 count, age, serum albumin, body mass index, and pre-existing hearing loss. This model demonstrated reasonable discrimination (area under the receiver operating characteristic curve [AUC] = 0.71) and calibration (χ2[8] = 6.10, P = .636). Using a cutoff of 80% predicted probability of hearing loss, the positive predictive value of this model was 83% and negative predictive value was 40%. Model discrimination was similar for ultrahigh-frequency hearing loss (frequencies >9000 Hz; AUC = 0.81) but weaker for clinically determined hearing loss (AUC = 0.60). CONCLUSIONS: This model may identify patients with DR-TB who are at highest risk of developing AG-induced ototoxicity and may help prioritize patients for AG-sparing regimens in clinical settings where access is limited.

Nurse case management to improve the hepatitis C care continuum in HIV co-infection: Results of a randomized controlled trial.

The opportunity to eliminate hepatitis C virus (HCV) is at hand, but challenges remain that negatively influence progress through the care continuum, particularly for persons co-infected with HIV who are not well engaged in care. We conducted a randomized controlled trial to test the effect of nurse case management (NCM) on the HCV continuum among adults co-infected with HIV compared to usual care (UC). Primary outcomes included linkage to HCV care (attendance at an HCV practice appointment within 60 days) and time to direct-acting antiviral (DAA) initiation (censored at 6 months). Sixty-eight participants were enrolled (NCM n = 35; UC n = 33). Participants were 81% Black/African American, 85% received Medicaid, 46% reported illicit drug use, 41% alcohol use, and 43% had an undetectable HIV viral load. At day 60, 47% of NCM participants linked to HCV care compared to 25% of UC participants (P = .031; 95% confidence bound for difference, 3.2%-40.9%). Few participants initiated DAAs (12% NCM; 25% UC). There was no significant difference in mean time to treatment initiation (NCM = 86 days; UC = 110 days; P = .192). Engagement in HCV care across the continuum was associated with drinking alcohol, knowing someone who cured HCV and having a higher CD4 cell count (P < .05). Our results support provision of NCM as a successful strategy to link persons co-infected with HIV to HCV care, but interventions should persist beyond linkage to care. Capitalizing on social networks, treatment pathways for patients who drink alcohol, and integrated substance use services may help improve the HCV care continuum.

Delirium point prevalence studies in inpatient settings: A systematic review and meta-analysis.

AIMS: To examine the delirium point prevalence studies conducted in different inpatient settings and to discuss the implication of the findings for delirium screening, assessment, prevention and management. BACKGROUND: Delirium-a common and distressing condition manifesting as an acute decline of attention and cognition-is frequently overlooked, misdiagnosed or treated inappropriately. This neuropsychiatric syndrome manifests as changes in attention, cognition and awareness, with resultant impact on behaviour, function and emotions. Delirium is recognised as a patient management challenge in the inpatient setting, and there is a need to understand the current point prevalence and assessment practices of delirium. DESIGN: A systematic review and meta-analysis. METHODS: A systematic review of published delirium prevalence studies in inpatient settings was conducted and the implications of findings for delirium screening, assessment, prevention and management identified. The random-effects meta-analysis was conducted among studies measuring delirium point prevalence. The PRISMA statement was used to report systematic review and meta-analysis. RESULTS: Nine studies were included in the review, with sample sizes ranging from 47-1867. Delirium point prevalence ranged from 9%-32%. Hypoactive delirium was the most common subtype, ranging from 23%-78%. Fifteen delirium screening tools or assessment or diagnostic methods were used. Comorbid dementia was present in up to 50% of inpatients. CONCLUSIONS: Gaining a consensus on effective delirium instruments, the time windows for assessment and measurement will be crucial in driving benchmarking and quality improvement studies. RELEVANCE TO CLINICAL PRACTICE: Consistent identification of high-risk patients and treatment settings with elevated risk, accompanied by the implementation of effective preventive and management strategies, are critical to addressing delirium-a frequent and burdensome condition, that adversely affects patient outcomes.

The Self-Care of Heart Failure Index: A psychometric study.

BACKGROUND: The Self-Care of Heart Failure Index is an empirically tested instrument to measure self-care of heart failure patients across different populations and cultures. AIMS: To develop and evaluate the psychometric properties of the Nepali Self-Care of Heart Failure Index. DESIGN: This psychometric study used a cross-sectional, observational, study design to collect data. The study was guided and reported following the Strengthening the Reporting of Observational Studies in Epidemiology guideline. METHODS: To develop and culturally validate Nepali Self-Care of Heart Failure Index, a combination of the recommended methods for cross-cultural validation studies were applied such as translation, back translation, expert committee review of the translated version and validity/reliability testing. Face and content validity were ensured using expert review. Construct validity was examined using exploratory factor analysis and confirmatory factor analysis. Composite reliability scores were calculated for each sub-scale of the Nepali Self-Care of Heart Failure Index. RESULTS: A total of 221 heart failure patients in Nepal were enrolled in the study. Adequate face and content validity were ensured through expert review. Exploratory factor analysis and confirmatory factor analysis supported the original three-factor model. Although the three factors explained only 41% of the variance, confirmatory factor analysis fit indexes and error measures were found reasonable. The composite reliability coefficients for self-care maintenance, management and confidence scale were 0.6, 0.7 and 0.8, respectively. CONCLUSIONS: The Nepali Self-Care of Heart Failure Index is a theoretically based, culturally acceptable and appropriate instrument for use among Nepali heart failure patients. However, further studies are needed to refine its psychometric properties. RELEVANCE TO CLINICAL PRACTICE: Access to reliable, valid and culturally appropriate instruments is crucial in describing the state of the problem as well as for developing and evaluating tailored and targeted self-care practice interventions for Nepali patients living with heart failure.

Impact of three dementia-related behaviors on caregiver depression: The role of rejection of care, aggression, and agitation.

OBJECTIVE: The relationship of specific dementia-related behaviors to caregiver depression and moderating factors is unclear. We examined the role of rejection of care, aggression, and agitation to caregiver depression and if social support and mastery independently moderated associations. METHODS: The method used was a cross-sectional, secondary analysis using baseline data from two community-based clinical trials. We examined frequency of occurrence of presenting behaviors and their combinations in persons with dementia. Multiple logistic regression analyses examined associations between nonoverlapping behavioral clusters (agitation alone, agitation + rejection, agitation + aggression, and agitation + rejection + aggression) and caregiver depression. Multiple logistic regression with interaction terms was also used to investigate whether social support or caregiver mastery moderated the relationship between behavioral symptom clusters and caregiver depression. RESULTS: Three of four symptom clusters (all three behaviors [adjusted odds ratio (AOR) = 2.22; 95% CI, 1.02-4.83], agitation + rejection of care [AOR = 2.55; 95% CI, 1.06-6.13], and agitation + aggression [AOR = 2.63; 95% CI, 1.17-5.89]) had a positive association with caregiver depression, whereas agitation alone was not significantly associated with caregiver depression. Neither social support nor mastery significantly moderated the relationship between these three behavioral clusters and caregiver depression. CONCLUSION: Caregiver depression was associated with different combinations of behaviors but not with agitation alone. These results have implications for intervention development and identifying caregivers at risk for depression. Level of social support and mastery does not appear to moderate impact on caregiver depression.

Social Support Moderates the Relationship Between Perceived Stress and Quality of Life in Patients With a Left Ventricular Assist Device.

BACKGROUND: Living with a left ventricular assist device has significant psychosocial sequelae that affect health-related quality of life (HRQOL). OBJECTIVE: The purpose of this study was to (1) describe psychosocial indicators of stress including perceived stress, depression, fatigue, and coping; (2) examine relationships among stress indicators by level of perceived stress; (3) examine relationships among indicators of stress and clinical outcomes; and (4) test the moderation of social support on the relationship between stress and clinical outcomes. METHODS: Participants were recruited from 2 outpatient clinics in a cross-sectional study design. Standardized measures were self-administered via survey. Descriptive statistics, correlation, and multiple linear regression analysis were conducted. RESULTS: The sample (N = 62) was mostly male (78%), black (47%), and married (66%), with a mean age of 56.5 ± 13 years. The overall sample had a moderate stress profile: moderate perceived stress (mean, 11.7 ± 7), few depressive symptoms (mean, 3.2 ± 3.9), and moderate fatigue (mean, 14.3 ± 9.1). Increased perceived stress was associated with fatigue, depressive symptoms, and maladaptive coping (P < .001). Regression analysis demonstrated that perceived stress and fatigue were significant correlates of overall HRQOL (adj. R = 0.41, P < .0001). Social support moderated the relationship between perceived stress and HRQOL, controlling for fatigue (R = 0.49, P < .001). CONCLUSIONS: Individuals living with left ventricular assist device with high perceived stress have worse depressive symptoms, fatigue, and coping. The influence of high social support to improve the relationship between stress and HRQOL underscores the importance of a comprehensive plan to address psychosocial factors.

Heart Failure Rehospitalization and Delayed Decision Making: The Impact of Self-care and Depression.

BACKGROUND: Rehospitalization soon after discharge can be distressing for persons with heart failure (HF) and places a heavy burden on the healthcare system. OBJECTIVE: We investigated and explored the association of self-care decision making variables with (1) rehospitalization within 30 days of discharge and (2) delay in seeking medical assistance (delayed decision making). METHODS: A cross-sectional, explanatory sequential mixed methods design (quan > qual) was used to survey 127 hospitalized HF patients and interview 15 of these participants to explain their survey responses. The survey assessed rehospitalization within 30 days of discharge, delayed decision making, HF self-care, and psychosocial factors influencing self-care. RESULTS: The likelihood of delaying the decision to be hospitalized was more than 5 times higher among those with high depressive symptoms (odds ratio, 5.33; 95% confidence interval, 2.14-13.28). Those who delayed going to the hospital were uncertain about their prognosis and did not feel their symptoms were urgent. The likelihood of being rehospitalized within 30 days was more than doubled among those with high depressive symptoms (OR, 2.31; 95% confidence interval, 1.01-5.31). Those who were rehospitalized within 30 days were less likely to consult healthcare professionals in their decision making and wanted immediate relief from their symptoms. CONCLUSIONS: We recommend a patient-centered approach to help HF patients identify and adequately self-manage symptoms. The strong association between high depressive symptoms and rehospitalization within 30 days as well as delayed decision making highlights the critical need for clinicians to carefully assess and address depression among HF patients.

Care2Cure: A randomized controlled trial protocol for evaluating nurse case management to improve the hepatitis C care continuum within HIV primary care.

Co-infection with HIV and hepatitis C virus (HCV) results in a threefold increase in relative risk of progression to end stage liver disease and cirrhosis compared to HCV alone. Although curative treatments exist, less than one quarter of people with HCV are linked to care, and even fewer have received treatment. The Care2Cure study is a single-blinded, randomized controlled trial to improve the HCV care continuum among people co-infected with HIV. This ongoing study was designed to test whether a nurse case management intervention can (i) improve linkage to HCV care and (ii) decrease time to HCV treatment initiation among 70 adults co-infected with HIV who are not engaged in HCV care. The intervention is informed by the Andersen Behavioral Model of Health Services Use and consists of nurse-initiated referral, strengths-based education, patient navigation, appointment reminders, and care coordination for drug-drug interactions in the setting of HIV primary care. Validated instruments are used to measure participant characteristics including HCV knowledge, substance use, and depression. The primary outcome is linkage to HCV care (yes/no) within 60 days. In this protocol paper, we describe the first clinical trial to examine the effects of a nurse case management intervention to improve the HCV care continuum among people co-infected with HIV/HCV in the era of all-oral HCV treatment. We describe our work in progress, challenges encountered, and strategies to engage this hard-to-reach population.

Co-Occurrence and Predictors of Three Commonly Occurring Behavioral Symptoms in Dementia: Agitation, Aggression, and Rejection of Care.

OBJECTIVE: To investigate co-occurrences of agitation, aggression, and rejection of care in community-dwelling families living with dementia. METHODS: Cross-sectional, secondary analysis from a randomized controlled trial testing a nonpharmacological intervention to reduce behavioral symptoms. We examined frequency of occurrence of presenting behaviors at baseline and their combination. Omnibus tests compared those exhibiting combinations of behaviors on contributory factors. Multinomial logistic regression analyses examined relationships of contributory factors to combinations of behaviors. RESULTS: Of 272 persons with dementia (PwDs), 41 (15%) had agitation alone (Agi), 3 (1%) had aggression alone, 5 (2%) had rejection of care alone. For behavioral combinations, 65 (24%) had agitation and aggression (Agi+Aggr), 35 (13%) had agitation and rejection (Agi+Rej), 1 (0%) had aggression and rejection, and 106 (39%) had all three behaviors (All). Four behavioral subgroups (Agi, Agi+Aggr, Agi+Rej, and All) were examined. Kruskal-Wallis tests showed that there were significant group differences in PwD cognition, functional dependence, and caregiver frustration. PwDs in Agi+Rej and All were more cognitively impaired than those in Agi and Agi+Aggr. Also, caregivers in All were more frustrated than those in Agi. In logistic regression analyses, compared with Agi, greater cognitive impairment was a significant predictor of Agi+Rej and All, but not Agi+Aggr. In contrast, greater caregiver frustration was a significant predictor of Agi+Aggr and All, but not Agi+Rej. CONCLUSIONS: We found that agitation, aggression, and rejection are common but distinct behaviors. Combinations of these behaviors have different relationships with contributory factors, suggesting the need for targeting treatment approaches to clusters.