Addressing mental and emotional health concerns experienced by nurses during the COVID-19 pandemic.

BACKGROUND: Nurses are the majority of the world's health work force and the frontline responders during pandemics. The mental/emotional toll can be profound if it is not identified and treated. PURPOSE: In March 2020, with New York City as the epicenter of the COVID-19 pandemic in the United States, Columbia University School of Nursing organized support circles for faculty and students providing clinical care as a healing method to address trauma. METHODS: Columbia University School of Nursing adapted guidelines and conducted Circles of Care to share, listen, and acknowledge the new challenges for nurses via Zoom. Analysis of these sessions produced major themes of concern for nurses. FINDINGS: Between March 31 and May 31, 2020, we facilitated 77 sessions with 636 attendees. Eight major themes emerged: coping mechanisms, patients suffering and dying, feelings of helplessness, frustration with COVID-19 response, silver lining, disconnection from the world, the thread that holds nurses together, and exhaustion. DISCUSSION: This report offers insight into the mental/emotional outcomes of being on the frontlines. Addressing these issues is essential for the well-being of nurses and all health care providers for an effective pandemic response.

Doctor of nursing practice (DNP) degree in the United States: Reflecting, readjusting, and getting back on track.

BACKGROUND: In 2004, the American Association of Colleges of Nursing (AACN) called for all nursing schools to phase out master's-level preparation for advanced practice registered nurses (APRNs) and transition to doctor of nursing practice (DNP) preparation only by 2015. Today, five years after the AACN's deadline, nursing has not yet adopted a universal DNP standard for APRN practice entry. PURPOSE: The purpose of this paper is to examine the factors influencing the ability of nursing schools to implement a universal DNP standard for APRNs. METHODS: Deans from top-ranked nursing schools explore the current state of the DNP degree in the US. The authors draw upon their collective experience as national leaders in academic nursing, long-time influencers on this debate, and heads of DNP programs themselves. This insight is combined with a synthesis of the literature and analysis of previously unpublished data from the AACN on trends in nursing doctoral education. FINDINGS: This paper highlights issues such as the long history of inconsistency (in messaging, curricula, etc.) surrounding the DNP, certification and accreditation challenges, cost barriers, and more. The authors apply COVID-19 as a case study to help place DNP graduates within a real-world context for health system stakeholders whose buy-in is essential for the success of this professional transition. DISCUSSION: This paper describes the DNP's standing in today's professional environment and advances the conversation on key barriers to its adoption. Insights are shared regarding critical next steps to ensure national acceptance of the DNP as nursing's terminal practice degree.

Comparative effectiveness of outpatient cardiovascular disease and diabetes care delivery between advanced practice providers and physician providers in primary care: Implications for care under the Affordable Care Act.

BACKGROUND: The objective was to compare quality of diabetes and cardiovascular disease (CVD) care between advanced practice providers (APPs) and physicians in a primary care setting. METHODS: We identified diabetes (n=1,022,588) and CVD (n=1,187,035) patients receiving primary care between October 2013 and September 2014 in 130 Veterans Affairs facilities. We compared glycemic control (hemoglobin A1c <7%) in diabetic patients, blood pressure (BP) <140/90 mmHg in diabetic or CVD patients, cholesterol control (low-density lipoprotein cholesterol<100 mg/dL, receiving a statin) in diabetic or CVD patients, and those receiving a ß-blocker (with history of myocardial infarction in the last 2 years) among patients receiving care from physicians and APPs. We also compared the proportion meeting composite measure (glycemic, BP, and cholesterol control in diabetic patients; BP, cholesterol control, and receipt of ß-blocker among eligible CVD patients). RESULTS: Diabetic patients receiving care from APPs were statistically more likely to have glycemic (50% vs 51.4%, odds ratio [OR] 1.06 [1.05-1.08]) and BP control (77.5% vs 78.4%, OR 1.04 [1.03-1.06]), whereas patients receiving care from physicians were more likely to have cholesterol control (receipt of statin 68% vs 66.5%, OR 0.94 [0.93-0.95]) in adjusted models, although these differences are not clinically significant. Similar results were seen in CVD patients. Few patients met the composite measure (27.1% and 27.6% of diabetic and 54.0% and 54.8% of CVD patients receiving care from physicians and APPs, respectively). CONCLUSIONS: Diabetes and CVD care quality was comparable between physicians and APPs with clinically insignificant differences. Regardless of provider type, there is a need to improve performance on eligible measures in diabetes or CVD patients.

Using a single screening question for depressive symptoms in patients with acute coronary syndrome.

BACKGROUND: Despite the prevalence of depressive symptoms and increased risk for future cardiovascular events, depressive symptoms frequently go underrecognized in patients hospitalized for acute coronary syndrome (ACS). Identifying an effective approach to depressive symptom screening is imperative in this population. OBJECTIVE: The purpose of this cross-sectional study was to explore the agreement between Beck Depression Inventory-II (BDI-II) scores and a single screening question for depressive symptoms in 1122 patients hospitalized for ACS. METHODS: Independent-samples t tests and χ tests were used to compare the groups with BDI-II scores of 14 or higher and lower than 14. Three separate agreement analyses were conducted using categorized BDI-II scores (≥14, ≥20, and ≥29). Agreement of the BDI-II categories with the responses to the single screening question was assessed with the simple κ statistic. Sensitivity and specificity were calculated using the BDI-II categories as the criterion standards for depressive symptom screening. RESULTS: The agreement analysis revealed a moderate level of agreement (κ coefficient = 0.42) between the BDI-II scores of 14 or higher and the single screening question. Of the participants who reported a BDI-II score of 14 or higher, 61.65% answered yes to the single screening question (sensitivity, 0.62). For those who had BDI-II scores of lower than 14, a total of 82% responded no to the single screening question (specificity, 0.82). When using higher BDI-II scores to define depressive symptoms (≥20 and ≥29), the level of agreement decreased, whereas sensitivity increased to 0.76 and 0.90, with a trade-off in specificity (0.79 and 0.74, respectively). CONCLUSIONS: These results suggest that the single screening question for depressive symptoms correctly identifies depressive symptoms 62% of the time but inappropriately identifies depressive symptoms 18% of the time in patients hospitalized for ACS. This suggests that the single screening question for depressive symptoms may be used with caution to initially screen patients with ACS, who can then undergo a more thorough assessment for clinical depression.

The role of platelet serotonin and depression in the acute coronary syndrome population.

Platelet serotonin has been associated with depression and coronary artery disease. Understanding the association between platelet serotonin and depressive symptoms during acute coronary syndrome (ACS) may explain some of the ACS events seen in depressed individuals. The objectives were to evaluate whether levels of platelet serotonin during an ACS event differ between individuals who screen positive or negative for depressive symptoms and to determine if a linear relationship exists. In this cross-sectional study, data were collected on 51 patients with ACS. Multiple linear regression models were examined. Platelet serotonin levels were not significantly different between the depressed and non-depressed groups (ß = -4.093 and p = .293); a linear relationship was not found (ß = -.254 and p = .250). In conclusion, a relationship between platelet serotonin and depressive symptoms was not found. It remains unclear if an association exists between platelet serotonin levels and depressive symptoms during hospitalization for ACS.

Mutations in smooth muscle alpha-actin (ACTA2) cause coronary artery disease, stroke, and Moyamoya disease, along with thoracic aortic disease.

The vascular smooth muscle cell (SMC)-specific isoform of alpha-actin (ACTA2) is a major component of the contractile apparatus in SMCs located throughout the arterial system. Heterozygous ACTA2 mutations cause familial thoracic aortic aneurysms and dissections (TAAD), but only half of mutation carriers have aortic disease. Linkage analysis and association studies of individuals in 20 families with ACTA2 mutations indicate that mutation carriers can have a diversity of vascular diseases, including premature onset of coronary artery disease (CAD) and premature ischemic strokes (including Moyamoya disease [MMD]), as well as previously defined TAAD. Sequencing of DNA from patients with nonfamilial TAAD and from premature-onset CAD patients independently identified ACTA2 mutations in these patients and premature onset strokes in family members with ACTA2 mutations. Vascular pathology and analysis of explanted SMCs and myofibroblasts from patients harboring ACTA2 suggested that increased proliferation of SMCs contributed to occlusive diseases. These results indicate that heterozygous ACTA2 mutations predispose patients to a variety of diffuse and diverse vascular diseases, including TAAD, premature CAD, ischemic strokes, and MMD. These data demonstrate that diffuse vascular diseases resulting from either occluded or enlarged arteries can be caused by mutations in a single gene and have direct implications for clinical management and research on familial vascular diseases.

Chromosome 9p21 single nucleotide polymorphisms are not associated with recurrent myocardial infarction in patients with established coronary artery disease.

BACKGROUND: Chromosome 9p21 single nucleotide polymorphisms (SNPs) have been shown to be associated with coronary heart disease in multiple studies. The aim of the present study was to identify whether these SNPs are associated with recurrent myocardial infarction (MI), revascularization, or death in acute coronary syndrome (ACS) patients or in those undergoing coronary artery bypass grafting (CABG). METHODS AND RESULTS: TexGen registry participants with ACS (n=2,067) or CABG (n=1,176) were evaluated, to assess whether 9p21 SNPs (rs1333049, rs2383206, rs10757278, rs10757274) were associated with recurrent MI (primary outcome), recurrent revascularization, or death (secondary outcomes) at approximately 3.2 years of follow-up. Carriers of risk allele (C) for rs1333049 presented at an earlier age (62 vs. 63.5 years in non-carriers, P=0.0004) with more extensive disease (number of vessels with significant stenosis: 1.9 vs. 1.7 in non-carriers, P=0.001) in the ACS group. In adjusted models, the C allele was not associated with recurrent MI (hazard ratio [HR], 1.01; 95% confidence interval [CI]: 0.74-1.38), recurrent revascularization (HR, 0.98; 95%CI: 0.78-1.23), or death (HR, 0.91; 95%CI: 0.69-1.18) in the ACS or CABG groups (recurrent MI: HR, 0.64; 95%CI: 0.40-1.05; recurrent revascularization: HR, 0.98; 95%CI: 0.61-1.55; death: HR, 0.89; 95%CI: 0.61-1.30). Results were similar for the other 3 SNPs. CONCLUSIONS: 9p21 SNPs were not associated with recurrent MI, revascularization, or mortality after ACS or CABG. Individuals with the rs1333049 C allele, however, may present with earlier and more extensive disease.

An Innovative Academic Practice Model for Clinical Nursing Education During the COVID-19 Pandemic.

In March of 2020, Columbia University School of Nursing (CUSON) Masters Direct Entry (MDE) program and New York Presbyterian Hospital (NYPH) created an innovative academic partnership to address the clinical needs of students and to help alleviate the burden of surging COVID-19 cases on nurses and the health care system. Through this partnership, students were hired as nurse technicians to assist with patient care during the first wave of the COVID-19 pandemic. As a result of this enhanced relationship, a pipeline of well-qualified graduate nurses with unique skills to adapt to a rapidly changing practice environment was created. Student participants in this opportunity developed an understanding of the organizational and leadership structures of the health care institution. The understanding of organizational and leadership structures will help transform the delivery of care.

The role of serotonin in depression and clotting in the coronary artery disease population.

BACKGROUND: Despite the strong evidence that depression is an independent risk factor for coronary artery disease (CAD), the underlying physiological mechanisms linking depression and CAD remain poorly understood. OBJECTIVE: This review of the literature focuses on the current understanding of the physiological effects of serotonin on depression and clotting as well as its role in CAD. METHODS: Articles for this review were identified using CINAHL, PsychINFO, and MEDLINE searches. RESULTS: Results revealed that depression is an independent risk factor for CAD. Although the physiological mechanisms underlying depression and related increases in acute coronary events remain unclear, serotonin plays an important role in depression and CAD. Elevated platelet serotonin levels promote clotting, which may be a potential underlying mechanism linking depression with CAD. CONCLUSIONS: This review of the literature suggests that elevated platelet serotonin levels may be associated with depression and the occurrence of major adverse coronary events. Future research should investigate if platelet serotonin levels contribute at least in part to the acute coronary events seen in patients with CAD who have elevated levels of platelet serotonin when depressed.

Exploring violence against women and adverse health outcomes in middle age to promote women's health.

A history of intimate partner violence (IPV) is linked to cardiovascular disorders among women. Static autonomic nervous system (ANS) imbalance may result from chronic stress associated with exposure to IPV. Autonomic nervous system imbalance is associated with an excessive proinflammatory response that may increase the risk for inflammatory diseases, including atherosclerosis. To better understand the process from IPV to poorer health outcomes in women diagnosed with acute coronary syndrome (ACS) we developed and tested a biobehavioral model of the psychological and biological pathway from IPV to chronic illness. We hypothesized that among women hospitalized for ACS, those who reported sexual abuse, with or without physical abuse, would have greater alterations in their serum levels of neuroendocrine markers, proinflammatory cytokines, and cell adhesion molecules and a chemotactic cytokine, at time of hospitalization for ACS, and 3 and 6 months later, than do women with physical abuse only. Participants were 45 women, primarily African American, admitted to a county hospital with a diagnosis of ACS. We evaluated 11 biomarkers and found a moderate group effect size for vascular cell adhesion molecule-1. All others had a small effect size.

Connecting the dots of heart disease, poor mental health, and abuse to understand gender disparities and promote women's health: a prospective cohort analysis.

Heart disease, poor mental health, and abuse are epidemic among women worldwide. Our purpose was to identify a group of women with heart disease and explore the relationship between a history of abuse and existing symptoms of depression and post-traumatic stress disorder (PTSD) and analyze the relationships over time. A prospective cohort analysis design with mental health measures repeated at 3 and 6 months postintake was followed. Abused women (n = 25) reported significantly more symptoms of depression (p = .004) and PTSD (p = .003) compared with nonabused women (n = 14). To promote global mental health among women with heart disease, interventions must address a history of abuse.

A systematic review of exercise interventions in patients with heart failure.

The incidence of heart failure (HF) is increasing as the population ages. Pharmacotherapy is an important component of treatment and yields significant improvements in survival and quality of life. In recent decades, exercise has gradually become accepted as an intervention beneficial to patients with HF, but more information is needed to clarify the effects of exercise and optimize interventions. Therefore, a systematic review of randomized controlled trials published from 1966 to October 2006 was carried out via PubMed. About 69 trials were reviewed, which used as main outcome measures: (a) central hemodynamic parameters, (b) peripheral blood flow, (c) endothelial function, (d) activation of neurohormones and cytokine systems, (e) structure of and metabolism in skeletal muscles, and/or (f) quality of life. Study findings suggest that the favorable physiological responses to exercise might slow some of the pathophysiological progression of HF. However, most of the trials reviewed here were based on relatively small samples and selected participant groups, and the exercise programs varied widely. These limitations and inconsistencies need to be addressed through further studies. Furthermore, reliable strategies for maintaining the positive effects of exercise and extending them to patients' daily life and quality of life are scarce in these trials. These domains need further exploration through rationally designed, large-scale randomized controlled trials.

Biobanks and biomarker research in cardiovascular disease.

PURPOSE: The purpose of this article is to describe biobank processes and the sociocultural and nursing challenges of these processes. The article will present ways that thinking genetically can challenge cardiovascular nurses and help in the development of biobanks for cardiovascular research. It will emphasize the importance of the contributions of nursing to the development of biobanks and biobanking research. CONCLUSIONS: The influence of cardiovascular nurses on the development of biobanks for research in cardiovascular disease will result in accelerated discoveries that will lead to innovative, safe, effective therapeutics (translational research and personalized healthcare). The challenge is to educate and encourage clinicians to think genetically and use biobanks for research.

Effects of Gender-Specific Differences, Inflammatory Response, and Genetic Variation on the Associations Among Depressive Symptoms and the Risk of Major Adverse Coronary Events in Patients With Acute Coronary Syndrome.

Depressive symptoms independently contribute to major adverse coronary events (MACEs), with the biological immune response to depression being a likely mediator of this relationship. To determine whether genetic- and/or gender-specific phenotypic differences contribute to associations among depressive symptoms, inflammatory response, and risk of MACE in patients with acute coronary syndrome (ACS), we conducted a prospective study of 1,117 ACS patients to test a gender-specific model in which depressive symptoms (Beck Depression Inventory-II [BDI-II]) are associated with risk of MACE. Cox proportional hazards models were used to model time to incident MACE and determine whether single-nucleotide polymorphisms (SNPs) in specific inflammatory protein-coding genes and depressive symptoms interact to influence levels of inflammatory proteins or risk of MACE. Females had significantly higher high-sensitivity C-reactive protein and monocyte chemoattractant protein-1 levels. Depression status differed by gender (29.9% of females and 21.1% of males had BDI-II scores indicative of depression [ p = .0014]). Depressive symptoms were associated with MACE; however, the interaction between these symptoms and gender was not significant. SNPs and depressive symptoms did not interact to influence inflammation or MACE. More females than males had BDI-II scores indicative of depression, yet the association between positive depressive symptom status and MACE did not vary by gender. Nor did the SNPs interact with depressive symptoms to influence inflammation or MACE. It remains of interest to identify a high-risk subgroup of ACS patients with genetic polymorphisms that result in immunoinflammatory dysregulation in the presence of depressive symptoms.

Quantification of roughness of calcific deposits in computed tomography scans of human coronary arteries.

OBJECTIVES: The incidence of coronary artery disease has been shown to be greater in patients with calcific deposits than in those without. It has been suggested that the pattern of distribution of coronary calcific deposits within coronary arteries is of greater predictive value for acute coronary events than the overall quantity. Whether roughness of calcific deposits is a predictor of acute coronary events is not known. We derived and tested an algorithm, Voxel-Based Bosselation (VBB), for noninvasive quantification of roughness of calcific deposits in human coronary arteries imaged by computed tomography (CT). METHODS AND RESULTS: VBB was tested on 213 coronary calcific deposits from electron beam CT scans of 27 patients. This algorithm evaluates the 3-dimensional connectedness of surface voxels of each deposit: smooth masses have low VBB and rough masses high VBB. The algorithm was calibrated with artificially generated phantoms as well as background noise mimicking calcific deposits and surrounding heart tissue. The VBB algorithm is applicable to calcific deposits of all scales and gradations. The VBB values of the deposits in this study did not correlate with deposit size further supporting its validity as a measurement of roughness. The VBB index corresponded directly with visual reconstruction using Phong-shaded algorithms. CONCLUSIONS: The VBB index, derived here, is a noninvasive method of quantifying the roughness of calcific deposits in CT scan data which can now be used in future clinical studies to determine possible correlations with increased plaque vulnerability and major acute coronary events.

Three-dimensional isotropic wavelets for post-acquisitional extraction of latent images of atherosclerotic plaque components from micro-computed tomography of human coronary arteries.

RATIONALE AND OBJECTIVES: The capability of wavelet transforms to separate signals into frequency bands is the basis for its use in image compression and storage, data management and transmission, and, recently, extraction of latent images of tissue components from noisy medical images. Analysis of temporal variations of radiofrequency backscatter of intravascular ultrasound with one-dimensional wavelets can detect lipid-laden plaque in coronary arteries with a sensitivity and specificity of >80%. In this study we evaluate the capability of a novel, 3-dimensional isotropic wavelet analysis to perform high resolution, non-directionally biased, statistically reliable, non-invasive discrimination between components of human coronary atherosclerotic plaques in micro-CT. MATERIALS AND METHODS: Coronary artery segments (5-15 mm) were excised at necropsy from 18 individuals with advanced coronary atherosclerosis. Specimens were imaged using a GE Locus SP ex vivo micro-CT scanner and processed for histological correlation (833 sections). The isotropic wavelet constructs were applied to the entire volume of CT data of each arterial segment to distinguish tissue textures of varying scales and intensities. Voxels were classified and plaque characterization achieved by comparing the relative magnitudes of these wavelet constituents to that of several reference plaque tissue components. RESULTS: Processing of micro-CT images via these isotropic wavelet algorithms permitted 3-D, color-coded, high resolution, digital discrimination between lumen, calcific deposits, lipid-rich deposits, and fibromuscular tissue providing detail not possible with conventional thresholding based on Hounsfield intensity units. Using the isotropic wavelets (with histology as the gold standard), lipid-rich pools approaching the size of the filter for the isotropic wavelet algorithm (0.25 mm [250 microns] in length) were identified with 81% sensitivity and 86% specificity. Calcific deposits, fibromuscular tissue, and lumen equal to or larger than the wavelet filter size were detected without error (100% sensitivity and specificity). CONCLUSION: Isotropic wavelet analysis permits high resolution, multi-dimensional identification of coronary atherosclerotic plaque components in micro-CT with sensitivity and specificity similar to that achieved with data obtained invasively (from IVUS in vivo) using one-dimensional wavelets. Further studies are necessary to test the applicability of this technology to clinical, multi-detector scanners.

Examining older adults' perceptions of health care providers: identifying important aspects of older adults' relationships with physicians and nurses.

This article describes older adults' conversations about their relationships with health care providers. Focus group participants (N = 23) were from three ethnic groups (Black, White, and Hispanic) and ages 53 to 92. All but three of the participants were women. Content analysis revealed an overarching theme of genuine caring and three sub-themes: interest in patients' well-being, respectful dialogue, and sharing of information. Older adults' perceptions of genuine caring by physicians and nurses did not differ by ethnicity. Older adults want to engage in a caring, respectful, and educational relationship with their health care providers, which is consistent with fundamental professional values.

Two-year prognosis after acute coronary syndrome in younger patients: Association with feeling depressed in the prior year, and BDI-II score and Endothelin-1.

OBJECTIVE: To examine the effects of depressive symptoms and Endothelin (ET)-1 on 2-year prognosis in younger patients with acute coronary syndrome (ACS). Depression is associated with poor post-ACS prognosis; however, few investigations have focused on younger patients. Importantly, the studies that did emphasize younger patients suggested that the influence of depression on prognosis could be more robust in younger subgroups. The particular links between depression and poor prognosis in younger patients have yet to be definitively determined. ET-1 is a potent endogenous vasoconstrictor that has been previously linked to adverse post-ACS outcomes. METHODS: The sample (n=153) included male (age≤50years) and female (age≤55years) ACS patients. Blood samples for ET-1 assessment were collected within 2-3h of ACS hospital admission. Depressive symptoms were assessed with the Beck Depression Inventory (BDI) II within 2-5days of admission. The primary outcome was defined as a composite of major adverse cardiovascular events (MACE), including recurrent myocardial infarction, emergent coronary revascularization, and all-cause mortality within 2years after index admission. RESULTS: During the follow-up period, 23 patients experienced MACE. Neither the BDI-II score nor ET-1 predicted MACE in unadjusted analyses or in analyses adjusted for demographic characteristics, comorbidities and troponin levels. In the supplementary analyses, feeling depressed in the year preceding ACS predicted MACE. CONCLUSIONS: In this cohort of younger ACS patients, feeling depressed in the year preceding ACS admission predicted MACE in the 2years after baseline ACS event, while neither the BDI-II score, nor circulating ET-1 level predicted this outcome.

Usefulness of multidetector computed tomography for noninvasive evaluation of coronary arteries in asymptomatic patients.

This editorial addresses the capabilities, limitations, and potential of multidetector computed tomography (MDCT) for the noninvasive evaluation of coronary arteries in asymptomatic patients. The quantification of coronary calcium with MDCT correlates highly with that obtained by electron-beam computed tomography, but to date, neither has the capability of assessing the distribution of various morphologic patterns of calcium and their relation to other "soft" plaque components. Although MDCT can assess the thickness of the atherosclerotic wall and can readily identify calcific deposits, further plaque characterization (e.g., lipid pools and fibrous tissue), a prerequisite for the identification of most vulnerable lesions, is not yet a workable reality, even with the 64-slice machines in their current configuration. The noninvasive identification by MDCT of plaque components subtending vulnerable lesions will require additional improvement in the primary instrumentation, the use of hybrid constructs (e.g., with positron emission tomography and magnetic resonance imaging), the development of novel methods of post-acquisitional analysis to extract latent images of plaque components (e.g., signal analysis based on 3-dimensional wavelets), or the adaptation of molecular imaging techniques at the cell and gene levels to computed tomography. Such unique approaches may soon contribute a long list of additional parameters that could be evaluated on a noninvasive basis as predictors of acute coronary syndromes and overall patient vulnerability.