Residential Structural Racism and Prevalence of Chronic Health Conditions.

Importance: Studies elucidating determinants of residential neighborhood-level health inequities are needed. Objective: To quantify associations of structural racism indicators with neighborhood prevalence of chronic kidney disease (CKD), diabetes, and hypertension. Design, Setting, and Participants: This cross-sectional study used public data (2012-2018) and deidentified electronic health records (2017-2018) to describe the burden of structural racism and the prevalence of CKD, diabetes, and hypertension in 150 residential neighborhoods in Durham County, North Carolina, from US census block groups and quantified their associations using bayesian models accounting for spatial correlations and residents' age. Data were analyzed from January 2021 to May 2023. Exposures: Global (neighborhood percentage of White residents, economic-racial segregation, and area deprivation) and discrete (neighborhood child care centers, bus stops, tree cover, reported violent crime, impervious areas, evictions, election participation, income, poverty, education, unemployment, health insurance coverage, and police shootings) indicators of structural racism. Main Outcomes and Measures: Outcomes of interest were neighborhood prevalence of CKD, diabetes, and hypertension. Results: A total of 150 neighborhoods with a median (IQR) of 1708 (1109-2489) residents; median (IQR) of 2% (0%-6%) Asian residents, 30% (16%-56%) Black residents, 10% (4%-20%) Hispanic or Latino residents, 0% (0%-1%) Indigenous residents, and 44% (18%-70%) White residents; and median (IQR) residential income of $54 531 ($37 729.25-$78 895.25) were included in analyses. In models evaluating global indicators, greater burden of structural racism was associated with greater prevalence of CKD, diabetes, and hypertension (eg, per 1-SD decrease in neighborhood White population percentage: CKD prevalence ratio [PR], 1.27; 95% highest density interval [HDI], 1.18-1.35; diabetes PR, 1.43; 95% HDI, 1.37-1.52; hypertension PR, 1.19; 95% HDI, 1.14-1.25). Similarly in models evaluating discrete indicators, greater burden of structural racism was associated with greater neighborhood prevalence of CKD, diabetes, and hypertension (eg, per 1-SD increase in reported violent crime: CKD PR, 1.15; 95% HDI, 1.07-1.23; diabetes PR, 1.20; 95% HDI, 1.13-1.28; hypertension PR, 1.08; 95% HDI, 1.02-1.14). Conclusions and Relevance: This cross-sectional study found several global and discrete structural racism indicators associated with increased prevalence of health conditions in residential neighborhoods. Although inferences from this cross-sectional and ecological study warrant caution, they may help guide the development of future community health interventions.

Standardized Change-of-Shift Handoff: Nurses' Perspectives and Implications for Evidence-Based Practice.

BACKGROUND: Nursing handoff is a communication activity with a high risk for loss or omission of information. Efforts to improve handoffs include standardization of the processes and content of handoff communications. OBJECTIVES: To examine nurses' perspectives on the structure and organization of change-of-shift handoffs. METHODS: A qualitative descriptive approach was used to conduct a secondary analysis of focus group data. Thirty-four nurses from 4 critical care units participated in focus groups. RESULTS: Three themes emerged: handoff elements are defined by practice and culture; a clear, consistent, identified structure supports handoff; and personal preferences can disrupt handoff. CONCLUSIONS: A standardized approach to handoff based on unit and organizational needs will be more successful than a broad mandate of content and organization. Individual preference is prevalent and strongly influences the information conveyed and the structure of handoff communication.

Development of an electronic health records datamart to support clinical and population health research.

INTRODUCTION: Electronic health record (EHR) data have emerged as an important resource for population health and clinical research. There have been significant efforts to leverage EHR data for research; however, given data security concerns and the complexity of the data, EHR data are frequently difficult to access and use for clinical studies. We describe the development of a Clinical Research Datamart (CRDM) that was developed to provide well-curated and easily accessible EHR data to Duke University investigators. METHODS: The CRDM was designed to (1) contain most of the patient-level data elements needed for research studies; (2) be directly accessible by individuals conducting statistical analyses (including Biostatistics, Epidemiology, and Research Design (BERD) core members); (3) be queried via a code-based system to promote reproducibility and consistency across studies; and (4) utilize a secure protected analytic workspace in which sensitive EHR data can be stored and analyzed. The CRDM utilizes data transformed for the PCORnet data network, and was augmented with additional data tables containing site-specific data elements to provide additional contextual information. RESULTS: We provide descriptions of ideal use cases and discuss dissemination and evaluation methods, including future work to expand the user base and track the use and impact of this data resource. CONCLUSIONS: The CRDM utilizes resources developed as part of the Clinical and Translational Science Awards (CTSAs) program and could be replicated by other institutions with CTSAs.

Change-of-Shift Nursing Handoff Interruptions: Implications for Evidence-Based Practice.

BACKGROUND: The importance of change-of-shift handoffs in maintaining patient safety has been well demonstrated. Change-of-shift handoff is an important source of data used in surveillance, a nursing intervention aimed at identifying and preventing complications. Surveillance requires the nurse to acquire, process, and synthesize information (cues) encountered during patient care. Interruptions in handoff have been observed but there is a gap in the evidence concerning how interruptions during nurse-to-nurse handoff impact the change-of-shift handoff process. AIMS: To describe registered nurses' perceptions of interruptions experienced during change-of-shift handoff at the bedside in critical care units and analyze the number, type, and source of interruptions during change-of-shift handoff at the bedside. METHODS: An exploratory descriptive design was used. One hundred nurse-to-nurse handoffs were observed, and four focus groups were conducted. Observation data were analyzed with descriptive statistics and quantitative content analysis. Focus group data were analyzed with qualitative content analysis. RESULTS AND FINDINGS: Of the 1,196 interruptions observed, 800 occurred in the communication between the two nurses involved in the handoff. Over 80% (645) of these interruptions were from the nurse receiving handoff and included questions or clarification of information received. About half of the nurses reported that interruptions occurred during handoff. Focus group findings revealed that whether or not something is an interruption is determined by the individual nurse's appraisal of value added to their knowledge of the patient and/or plan of care at the time of handoff. LINKING EVIDENCE TO ACTION: Interruptions during handoff are evaluated as useful or disruptive based on the value to the nurse at the time. Strict structuring or mandating of handoff elements may limit nurses' ability to communicate information deemed most relevant to the care of a specific unique patient.

Psychosocial Stress and Preterm Birth: The Impact of Parity and Race.

Objectives Studies examining risk factors for preterm birth (PTB) such as psychosocial stress are often focused on women with a history of PTB; however, most preterm babies are born to women with no history of preterm birth. Our objective was to determine if the relationship between psychosocial stress and PTB is altered by parity. Non-Hispanic black (NHB) women have increased psychosocial stress and PTB; therefore, we further aimed to determine if race alters the relationship between psychosocial stress, parity, and PTB. Methods We performed a secondary analysis of the Healthy Pregnancy, Healthy Baby Study comparing pregnant women who were primiparous (first pregnancy), multiparous with history of preterm birth, or multiparous with history of term birth. Perceived stress, perceived racism, interpersonal support, John Henryism and self-efficacy were measured using validated instruments. Logistic regression was used to model the effect of psychosocial stress on PTB stratified by parity and race. Results The analysis entire cohort included 1606 subjects, 426 were primiparous, 268 had a history of presterm birth, and 912 had a history of term birth. In women with a history of term birth, higher self-efficacy was associated with lower odds of spontaneous PTB, and this association was amplified in NHB women. In women with a history of spontaneous PTB, John Henryism Active Coping was associated with lower odds of spontaneous PTB in the index pregnancy. Conclusions for Practice The relationship between psychosocial stress and PTB may be mediated by parity and race.

A Multidimensional Approach to Characterizing Psychosocial Health During Pregnancy.

Objectives Domains of psychosocial health have been separately connected to pregnancy outcomes. This study explores the relationship between five domains of psychosocial health and their joint association with prenatal health and pregnancy outcomes. Methods Women from a prospective cohort study in Durham, North Carolina were clustered based on measures of paternal support, perceived stress, social support, depression, and self-efficacy. Clusters were constructed using the K-means algorithm. We examined associations between psychosocial health and maternal health correlates, pregnancy intention, and pregnancy outcomes using Chi square tests and multivariable models. Results Three psychosocial health profiles were identified, with the first (Resilient; n = 509) characterized by low depression and perceived stress and high interpersonal support, paternal support, and self-efficacy. The second profile (Vulnerable; n = 278) was marked by high depression and perceived stress, and low interpersonal support, paternal support, and self-efficacy. The third profile (Moderate, n = 526) fell between the other profiles on all domains. Health correlates, pregnancy intention, and pregnancy outcomes varied significantly across profiles. Women with the vulnerable profile were more likely to have risky health correlates, have an unintended pregnancy, and deliver preterm. Women with the resilient profile had better birth outcomes and fewer deleterious health correlates, preconception and prenatally. Conclusions We posit that vulnerable psychosocial health, deleterious health correlates, and the stress which often accompanies pregnancy may interact to magnify risk during pregnancy. Identifying and intervening with women experiencing vulnerable psychosocial health may improve outcomes for women and their children.

Cadmium levels in a North Carolina cohort: Identifying risk factors for elevated levels during pregnancy.

The objectives of this study were to examine cadmium (Cd) levels and relationships to demographics in an observational, prospective pregnancy cohort study in Durham County, North Carolina. Multivariable models were used to compare blood Cd levels across demographic characteristics. The relative risk of having a blood Cd level that exceeds the US national median (0.32 µg/l) was estimated. Overall, >60% of the women had an elevated (>0.32 µg/l) blood Cd level. Controlling for confounding variables, smoking was associated with 21% (95% CI: 15-28%) increased risk for an elevated blood Cd level. High Cd levels were also observed in non-smokers and motivated smoking status-stratified models. Race, age, education, relationship status, insurance status and cotinine level were not associated with risk of elevated Cd levels among smokers; however, older age and higher cotinine levels were associated with elevated Cd levels among non-smokers. Taken together, more than half of pregnant women in this cohort had elevated blood Cd levels. Additionally, among non-smokers, 53% of the women had elevated levels of Cd, highlighting other potential sources of exposure. This study expands on the limited data describing Cd levels in pregnant populations and highlights the importance of understanding Cd exposures among non-smokers. Given the latent health risks of both smoking and Cd exposure, this study further highlights the need to biomonitor for exposure to toxic metals during pregnancy among all women of child-bearing age.

Methods and initial findings from the Durham Diabetes Coalition: Integrating geospatial health technology and community interventions to reduce death and disability.

OBJECTIVE: The Durham Diabetes Coalition (DDC) was established in response to escalating rates of disability and death related to type 2 diabetes mellitus, particularly among racial/ethnic minorities and persons of low socioeconomic status in Durham County, North Carolina. We describe a community-based demonstration project, informed by a geographic health information system (GHIS), that aims to improve health and healthcare delivery for Durham County residents with diabetes. MATERIALS AND METHODS: A prospective, population-based study is assessing a community intervention that leverages a GHIS to inform community-based diabetes care programs. The GHIS integrates clinical, social, and environmental data to identify, stratify by risk, and assist selection of interventions at the individual, neighborhood, and population levels. RESULTS: The DDC is using a multifaceted approach facilitated by GHIS to identify the specific risk profiles of patients and neighborhoods across Durham County. A total of 22,982 patients with diabetes in Durham County were identified using a computable phenotype. These patients tended to be older, female, African American, and not covered by private health insurance, compared with the 166,041 persons without diabetes. Predictive models inform decision-making to facilitate care and track outcomes. Interventions include: 1) neighborhood interventions to improve the context of care; 2) intensive team-based care for persons in the top decile of risk for death or hospitalization within the coming year; 3) low-intensity telephone coaching to improve adherence to evidence-based treatments; 4) county-wide communication strategies; and 5) systematic quality improvement in clinical care. CONCLUSIONS: To improve health outcomes and reduce costs associated with type 2 diabetes, the DDC is matching resources with the specific needs of individuals and communities based on their risk characteristics.

Maternal cadmium levels during pregnancy associated with lower birth weight in infants in a North Carolina cohort.

Cadmium (Cd) is a ubiquitous environmental contaminant, a known carcinogen, and understudied as a developmental toxicant. In the present study, we examined the relationships between Cd levels during pregnancy and infant birth outcomes in a prospective pregnancy cohort in Durham, North Carolina. The study participants (n = 1027) had a mean Cd level of 0.46 µg/L with a range of <0.08 to 2.52 µg/L. Multivariable models were used to establish relationships between blood Cd tertiles and fetal growth parameters, namely birth weight, low birth weight, birth weight percentile by gestational age, small for gestational age, pre-term birth, length, and head circumference. In multivariable models, high maternal blood Cd levels (≥0.50 µg/L) during pregnancy were inversely associated with birth weight percentile by gestational age (p = 0.007) and associated with increased odds of infants being born small for gestational age (p<0.001). These observed effects were independent of cotinine-defined smoking status. The results from this study provide further evidence of health risks associated with early life exposure to Cd among a large pregnancy cohort.

Discharge planning rounds to the bedside: a patient- and family-centered approach.

Discharge planning rounds done at the bedside is an effective patient-centered approach to discharge planning and does not take any longer than traditional rounds apart from the patient and caregiver. Bedside rounds may decrease patient utilization of health care resources after discharge.

Combined negative pressure wound therapy and ultrasonic MIST therapy for open surgical wounds: a case series.

BACKGROUND: Surgical wounds are at increased risk of infection when left open to heal through secondary intention; they increase length of hospital stay, hospital costs, readmission rates, and patient morbidity. New technologies and methods of treating acute and chronic wounds are emerging. Two recent developments for the treatment of open wounds are noncontact low-frequency ultrasound (NCLFU) treatment and negative pressure wound therapy (NPWT). METHODS: This case series reports findings from 4 hospitalized patients with complex conditions who underwent colorectal surgery resulting in open abdominal wounds. The wounds were treated with NCLFU in combination with NPWT. Data were collected via retrospective review of medical records. RESULTS: After concurrent treatment with NPWT (range, 13-18 days) and NCLFU (range, 5-9 treatments), wound areas in these 4 cases were reduced by 4.5% to 37% and wound volume decreased by 17% to 62%. Granulation tissue increased in the open tissue areas in all patients. In addition, 3 of the cases received a mesh graft. CONCLUSIONS: Combination treatment with NPWT and NCLFU therapy with or without sharp debridement enhanced wound healing in the open abdominal wounds of these 4 patients.

Male sling procedures for stress urinary incontinence.

Radical prostatectomy is the most common cause of urinary incontinence in males. Urinary slings are a relatively new treatment option for men. This article describes two urinary sling procedures as possible surgical approaches for incontinence in men.

Benign Prostatic Hyperplasia Implications for Pharmacologic Treatment and Perioperative Care.

This review provides an update on the treatment of benign prostatic hyperplasia and the pharmacologic considerations for perioperative care. By age 85 years, approximately 90% of men have prostate histologic characteristics consistent with benign prostatic hyperplasia. Pharmacologic treatment with an alpha1 receptor antagonist may reduce symptoms and, when given in combination with a 5-alpha-reductase inhibitor, may decrease the risk of urinary retention and the need for surgical intervention. Transurethral resection of the prostate has been the historical standard when surgical intervention is indicated. However, recent evidence suggests that Holmium laser enucleation of the prostate may have similar efficacy with less risk of complications and with decreased catheterization time. Prostatic urological operations may have perioperative complications, including urethral bleeding, acute urinary retention, urinary tract infection, urge incontinence, and venous thromboembolism. Pharmacist recommendations for the appropriate use of laxatives, antibiotics, anticoagulation, and urinary antispasmodics are key components of perioperative management. Surgical interventions improve symptoms but may have complications, providing the pharmacist an opportunity to improve perioperative care.

Effects of urinary catheter education for patients undergoing prostatectomy.

In a nonrandomized prospective study, significant decreases in patient anxiety with home urinary catheter management and in length of stay were reported when patients attended the preoperative prostatectomy class with standard postoperative education versus standard postoperative education.

The urban built environment and associations with women's psychosocial health.

The determinants that underlie a healthy or unhealthy pregnancy are complex and not well understood. We assess the relationship between the built environment and maternal psychosocial status using directly observed residential neighborhood characteristics (housing damage, property disorder, tenure status, vacancy, security measures, violent crime, and nuisances) and a wide range of psychosocial attributes (interpersonal support evaluation list, self-efficacy, John Henryism active coping, negative partner support, Perceived Stress Scale, perceived racism, Center for Epidemiologic Studies-Depression) on a pregnant cohort of women living in the urban core of Durham, NC, USA. We found some associations between built environment characteristic and psychosocial health varied by exposure categorization approach, while others (residence in environments with more rental property is associated with higher reported active coping and negative partner support) were consistent across exposure categorizations. This study outlines specific neighborhood characteristics that are modifiable risk markers and therefore important targets for increased research and public health intervention.

Bedside nurse-to-nurse handoff promotes patient safety.

UNLABELLED: Nurse-to-nurse beside handoff allows the oncoming nurse to visualize the patient and ask questions of the previous nurse. It encourages pateints to be involved actively in their care and allows standardized communication between nursing shifts. BACKGROUND: Patient handoff between nurses at shift change has been an important process in clinical nursing practice, allowing nurses to exchange necessary patient information to ensure continuity of care and patient safety. Bedside handoff allows the patient the ability to contribute to his or her plan of care. It also allows the oncoming nurse an opportunity to visualize the patient and ask questions. This is critical in meeting the Joint Commission's 2009 National Patient Safety Goals. It encourages patients to be involved actively in their care and it implements standardized handoff communication between nursing shifts. Bedside handoff promotes patient safety and allows an opportunity for patients to correct misconceptions. METHODS: A convenience sample of 60 patients was enrolled, 30 before the practice change and 30 after the change. All nursing staff were invited to participate. Both patients and staff were given self-designed surveys before and after the practice change. RESULTS: Fifteen nurses with a mean of 2 years in the profession completed the pre- and post-survey. A majority of staff were not satisfied with the current shift change report, but statistical improvement was achieved after the practice change. Also, statistical improvement was achieved with patients' satisfaction with involvement in their plan of care. CONCLUSIONS: Use of bedside nursing handoff promotes staff accountability, two-person IV medication reconciliation, and patient satisfaction.

Psychosocial differences between smokers and non-smokers during pregnancy.

Despite the well-established adverse birth and childhood health outcomes associated with maternal smoking, smoking rates among pregnant women remain high. Psychosocial health attributes, including anxiety, depression, perceived stress, self-efficacy, and personality characteristics, have especially important roles in smoking behavior. Understanding who smokes during pregnancy and what factors influence this behavior choice may be key to improving the effectiveness of smoking cessation intervention programs. We use data from a prospective cohort study of pregnant women to understand the psychosocial health profiles of women who choose to smoke during pregnancy compared to the profiles of women who do not smoke or successfully quit smoking during pregnancy. Multinomial logistic regression analyses on 1518 non-Hispanic black and non-Hispanic white women assessed the association between smoking status and psychosocial health while controlling for demographic characteristics. Higher levels of perceived stress, depression, neuroticism, negative paternal support, and perceived racism among non-Hispanic blacks were associated with higher odds of being a smoker than a non-smoker (p<0.05). Higher levels of self-efficacy, extraversion, agreeableness, conscientiousness, interpersonal support, positive paternal support, and perceived social standing were associated with lower odds of being a smoker than a non-smoker (p<0.05). Our analysis indicates that women who smoked during pregnancy experienced a more negative constellation of psychosocial adversities than women who did not smoke. Given the psychosocial needs and personality profiles experienced by smokers, more attention to the psychosocial strengths and weaknesses of these women may allow for more tailored smoking cessation programs, enhancing both the short- and long-term effectiveness of such interventions.

Pregnancy intention, demographic differences, and psychosocial health.

OBJECTIVES: We explore the psychosocial, demographic, and maternal characteristics across wanted, mistimed, and unwanted pregnancies. METHODS: Data from 1321 women from a prospective cohort study of pregnant women in Durham, NC, are analyzed. Psychosocial correlates were obtained through prenatal surveys; electronic medical records were used to ascertain maternal health and pregnancy outcomes. RESULTS: Sixty-two percent of the women indicated an unintended pregnancy, with 44% (578) mistimed and 18% (245) unwanted. Only 38% of the pregnancies were characterized as wanted. Women with unwanted and with mistimed pregnancies were similar demographically, but they differed significantly on psychosocial profiles and maternal characteristics. Women with mistimed and with wanted pregnancies differed in demographics and psychosocial profiles. Wanted pregnancies had the healthiest, mistimed an intermediate, and unwanted the poorest psychosocial profile. Women with unwanted pregnancies had the highest depression, perceived stress, and negative paternal support scores (p<0.05) and the lowest self-efficacy, social support, and positive paternal support scores (p<0.05). In multivariate analyses, women with riskier psychosocial profiles had higher odds of being in the unwanted category. Controlling for psychosocial and demographic variables, perceived stress and positive paternal support remained significant predictors of belonging to the unwanted and mistimed groups. CONCLUSIONS: Fully characterizing pregnancy intention and its relationship to psychosocial profiles may provide a basis for identifying women with highest risk during pregnancy and early motherhood. Women with unwanted and mistimed pregnancies may appear similar demographically but are different psychosocially. Women with unwanted pregnancies have multiple risk factors and would benefit from targeted interventions.

Using evidence to enhance the recovery of patients undergoing colorectal surgery: part 3.

This is the third part of a three-part series describing how an enhanced recovery clinical pathway uses a multidisciplinary team to reduce postoperative stress and complications, improve recovery, and decrease hospital length of stay without affecting patient safety for patients undergoing colorectal surgery. Last month, multimodal analgesia and standardized postoperative nausea and vomiting prophylaxis were discussed. This part discusses fluids, diet, tubes and drains, and early mobilization.

Using evidence to enhance the recovery of patients undergoing colorectal surgery: part 2.

This is the second part of a three-part series describing how an enhanced recovery clinical pathway uses a multidisciplinary team to reduce postoperative stress and complications, improve recovery, and decrease hospital length of stay without affecting patient safety for patients undergoing colorectal surgery. Last month, patient education and discharge planning were discussed. This part discusses multimodal analgesia and standardized postoperative nausea and vomiting prophylaxis. Next month, fluids, diet, tubes and drains, and early mobilization will be discussed.