Clinical utility of inflammatory and genetic biomarkers for cardiovascular disease prevention, categorization, and treatment.

ABSTRACT: The complex interplay of increased atherogenic lipoproteins, inflammation, and immune activation hallmarks the pathogenesis of atherosclerotic cardiovascular disease (ASCVD). Atherosclerotic cardiovascular disease remains a leading cause of death, yet risk estimator tools lack comprehensiveness for genetic/inflammatory biomarkers associated with ASCVD. Unexplained ASCVD risk necessitates a better understanding of primary, secondary, and tertiary prevention variables. This article discusses the clinical utility of genetic and inflammatory biomarkers for ASCVD risk prediction, management, treatment, and recategorization into primary, secondary, and tertiary prevention. Furthermore, nurse practitioners (NPs) should use a ternary prevention classification system instead of the current binary system to mitigate risk in the large group of patients with subclinical ASCVD. High-sensitivity C-reactive protein (hs-CRP)-linearly associated with ASCVD-and lipoprotein-associated phospholipase-A 2 (Lp-PLA 2 ) and myeloperoxidase (MPO), both associated with plaque vulnerability/rupture, are inflammatory biomarkers. Elevated hs-CRP, MPO, and Lp-PLA 2 treatment requires addressing root causes of elevation (e.g., obesity, insulin resistance, tobacco use, gingival disease, and chronic autoimmune/infectious conditions). In addition, haptoglobin (Hp) phenotype determines the antioxidant potential of Hp. Haptoglobin phenotype, a root cause of ASCVD, is a one-time test. Individuals with Hp 2-2 should adopt a gluten-free diet to reduce endothelial and intestinal inflammation. Nurse practitioners should use stricter glycemic goals (hemoglobin A1c ≤6.5%) and add daily vitamin E if this group has type 2 diabetes. Genetic/inflammatory biomarkers should be used to better predict ASCVD risk and tailor primary, secondary, and tertiary prevention treatment. Clinical use of these biomarkers reaches beyond the standard of care to reduce residual ASCVD risk.

Long-term Effectiveness of a Peer-Led Asthma Self-management Program on Asthma Outcomes in Adolescents Living in Urban Areas: A Randomized Clinical Trial.

Importance: Long-term effectiveness of a peer-led asthma self-management program in improving asthma outcomes in adolescents living in urban areas has not been established. Objective: To determine the long-term effects of a peer-led program on asthma control, quality of life, and asthma management among predominantly racial and ethnic minority adolescents living in urban areas. Design, Setting, and Participants: A parallel-group, randomized clinical trial was conducted in 2015 to 2019 in 3 metropolitan cities in the US: Buffalo, New York; Baltimore, Maryland; and Memphis, Tennessee. Adolescents aged 12 to 17 years old with persistent asthma were recruited mainly through clinical practices and schools. Participants were followed-up for 15 months after the intervention. Double-blinding was achieved for baseline. Data analysis was performed from June 2019 to June 2020. Interventions: The intervention group received a peer-led asthma self-management program; the control group received the identical program led by adult health care professionals. Peer leaders made follow-up contacts every other month for 12 months. Main Outcomes and Measures: The primary outcome was quality of life measured by the Pediatric Asthma Quality of Life Questionnaire, which consists of 3 subscales that measure symptoms (10 items), activity limitations (5 items), and emotional functioning (8 items) in the past 2 weeks. Each item was measured on a 7-point scale, with higher mean scores indicating better quality of life. Secondary measures included the Asthma Control Questionnaire and an asthma self-management index capturing steps to prevent and manage symptoms, self-efficacy, and lung function. Results: Of 395 eligible adolescents, 35 refused, 38 did not show or were lost to contact, and 2 withdrew before randomization; 320 adolescents participated (mean [SD] age, 14.3 [1.71] years), including 168 boys (52.5%), 251 Black or African American adolescents (78.4%), and 232 adolescents (72.5%) with public health insurance. Of 320 enrolled, 303 were included in the longitudinal analysis. Response rates were 80% or higher at all time points. The peer-led group had greater improvement in outcomes than the adult-led group, with adjusted mean differences (AMDs) between baseline and 15 months of 0.75 vs 0.37 for quality of life (between-group AMD, 0.38; 95% CI, 0.07 to 0.63) and -0.59 vs -0.31 for asthma control (between-group AMD, -0.28; 95% CI, -0.51 to -0.01). Outcomes were not affected by bimonthly contact doses. Conclusions and Relevance: In this randomized clinical trial, a peer-led asthma self-management education was more effective than an adult-led program in improving asthma outcomes, with the improvements sustained for up to 15 months. These findings suggest that a peer-led asthma self-management program should be considered in addressing the disproportionate asthma burden in racial and ethnic minority adolescents living in urban communities. Trial Registration: ClinicalTrials.gov Identifier: NCT02293499.

Family Caregivers' Experience of Patients With Delirium in Critical Care Units: A State-of-the-Science Integrative Review.

BACKGROUND: Delirium as a sudden cognitive and behavioral change can be traumatic for family caregivers. An understanding of family caregivers' experiences with delirium in their loved one in an intensive care unit (ICU) will help clinicians provide family-centered care. OBJECTIVE: To explore the impact of delirium on, and the needs of, family caregivers of ICU patients with delirium. METHODS: A comprehensive search was done of literature in the PubMed, CINAHL, and Scopus databases published from 2000 to 2020. Primary studies written in English and done in critical care settings were included. Studies that did not focus on the family experience of delirium were excluded. Additional studies were identified by reviewing the reference lists of selected articles. Evidence was synthesized, and common themes were identified. RESULTS: Among 210 studies, 7 were included after irrelevant and duplicate studies had been removed. Findings were categorized as (1) psychological impacts of a patient's delirium on family caregivers and (2) family caregivers' needs. Common psychological impacts included anxiety, depression, concern, fear, anger, uncertainty, shock, insecurity, and disappointment. Family caregivers reported needing informational and emotional support from, and effective communication with, health care professionals. CONCLUSIONS: Family caregivers' health is crucial to ensuring the effectiveness of family engagement in delirium management. Future studies should consider family caregiver characteristics that could be used to predict psychological symptoms when caregivers are exposed to a patient's delirium and explore whether specific types of delirium cause more psychological impacts and needs among family caregivers than other types of delirium cause.

Factors Associated With Quality of Life of Family Caregivers of Dialysis Recipients.

Chronic kidney failure may contribute to the diminished quality of life of African American women who care for adults affected by the disorder. Few studies document the quality of life of these caregivers. For this descriptive correlational study, caregiver demographic, caregiver burden, depressive symptoms, family functioning, and quality-of-life self-report data from 75 African American women were extracted from an existing database. Ferrans' Conceptual Model of Quality of Life guided the selection of study variables. Several significant associations were found. Caregiver education, employment status, marital status, and caregiver burden explained 63% of the variance in the caregivers' quality of life. Findings support the need to explore further and design interventions to improve the quality of life of working African American women supporting individuals with chronic kidney failure.

Cognitive factors predict medication adherence and asthma control in urban adolescents with asthma.

PURPOSE: Adolescents with asthma often report poor medication adherence and asthma control. Cognitive factors embedded in the social cognitive theory including self-efficacy, outcome expectations, and barrier perceptions may explain poor asthma outcomes in this population. This study was performed to examine the extent to which these cognitive factors are intercorrelated and explain medication adherence and asthma control in urban adolescents. PATIENTS AND METHODS: A total of 373 urban adolescents (12-20 years) with asthma completed questionnaires measuring asthma-related self-efficacy, outcome expectations, barrier perceptions, medication adherence, and asthma control. Multiple linear regression was conducted to examine the extent to which the three cognitive factors predicted medication adherence and asthma control after controlling for covariates including age, sex, household income, and age at diagnosis. RESULTS: Participants' ages were on average 14.68 (±1.94) years; 50% were female, and most (78.6%) were African American. Higher self-efficacy associated with lower barrier perceptions and higher outcome expectations (r=0.50, p<0.001; r=-0.26, p<0.001, respectively). Self-efficacy predicted better asthma control (B=-0.098, p=0.004) and adherence (B=0.426, p=0.011), whereas barrier perceptions predicted poorer asthma control (B=0.13, p<0.001) and adherence (B=-0.568, p<0.001). Self-efficacy independently predicted fewer missed doses (B=-0.621, p=0.006), and barrier perception independently predicted asthma control (B=0.12, p<0.001) and adherence (B=-0.519, p<0.001). CONCLUSION: Improving medication adherence and asthma control among adolescents may require a multifaceted approach. Interventions focused on increasing self-efficacy and addressing barriers, actual or potential, to medication adherence could ameliorate asthma disparities in urban adolescents.

Psychometric evaluation of the nursing child assessment teaching (NCAT) scale in a community-based sample.

The effect of the mother-child relationship on long-term child development has received research attention for decades. Because the quality and quantity of mother-infant interactions have been established as important predictors of the child's development, early identification of areas in the relationship requiring support and intervention is essential for promoting positive child outcomes. The Nursing Child Assessment Teaching Scale (NCAT) is an instrument long used to quantify the quality of interaction in the mother-child relationship during the first 36 months of a child's life. While the NCAT has been shown to be a reliable and valid instrument, limited evidence exists of the theoretical congruence between the Barnard Model it is based on and the NCAT scale. The psychometric properties of the NCAT scale and subscales were examined using item response theory in relation to characteristics of interactions in the Barnard Model using data collected during a clinic visit at 12 months of infant age in a sample of mothers and children (N = 1,121 dyads) from a community-based sample in Shelby County, TN. In this secondary analysis, descriptive statistics, reliabilities, and factor loadings for the NCAT were obtained using confirmatory factor analysis and augmented to form multiple indicators, multiple causes models, linking demographic predictors of the mothers and children to the NCAT subscales. Results supported scale abbreviation and theoretical congruence with the Barnard Model, which may provide researchers and practitioners with a more concise, reliable way of measuring maternal-child interaction in community settings.

Quality of Life and African American Women Who are Family Caregivers: A Literature Review with Implications for Psychiatric Mental Health Advanced Practice Registered Nurses.

PURPOSE: To identify factors affecting the quality of life (QOL) of African American women (AAW) family caregivers of individuals with kidney failure. METHODS: Ferrans' Conceptual Model of QOL provided the framework for this literature review. Included studies were (a) peer- reviewed, (b) published within the last ten years, (c) written in English, and (d) examined QOL of AAW family caregivers. Using CINAHL© and PubMed©, we found 14 studies that described factors associated with these caregivers' QOL. SCOPE: Few studies document the QOL of AAW who are family caregivers, especially in the context of kidney failure. Psychiatric Mental Health Advanced Practice Registered Nurses need to learn about the factors influencing the QOL of these caregivers. RESULTS: No studies were found within the last ten years that explored the QOL of AAW family caregivers of individuals with kidney failure. Findings reflected the QOL of AAW family caregivers in the context of other chronic conditions. Various factors such as stress, insomnia, and employment were linked to an impaired QOL. Implications for practice, research and education for PMH-APRNs are suggested. CONCLUSION: PMH-APRNs are uniquely trained to address many factors that affect the QOL of these caregivers and may provide holistic care aimed at promoting satisfactory QOL for these caregivers.

Male Caregivers of Persons with End Stage Renal Disease: A Qualitative Study.

This study explored experiences associated with burden, depressive symptoms, and perceived health in six male caregivers of persons with end stage renal disease (ESRD) using qualitative interviews. Analysis employed open coding and analysis to generate codes and categories. Eighty-three percent of the participants reported significant subjective and objective burden. Linkages occurred between sociodemographic characteristics, care recipient attributes, and caregiver-care recipient relationship, and caregivers' experience of burden and depressive symptoms. Findings suggest the need for intervention trials targeting new coping strategies to help improve the well-being of this population.

A Summer Prematriculation Program: Bridging the Gap for Disadvantaged Underrepresented Minority Students Interested in a Nursing Career.

BACKGROUND: The nursing and health care workforce needs diverse clinicians who can provide culturally competent and high-quality care to an increasingly diverse U.S. POPULATION: Achieving this goal requires creating learning environments that foster the success of disadvantaged underrepresented minority (URM) students seeking nursing careers. METHOD: This 4-week summer prematriculation program introduced 33 URM individuals from disadvantaged backgrounds to nursing as a career through financial support, academic enrichment, and social support to enhance nursing program admission success. Federal guidelines were used to establish URM and economically disadvantaged status. RESULTS: To date, one third of program participants have been admitted to nursing programs. CONCLUSION: Fundamental reforms in pre-college education systems, such as the evidence-based strategies implemented in our summer prematriculation program, may be needed to achieve a diverse, culturally competent workforce that can help eliminate persistent health and health care disparities. [J Nurs Educ. 2016;55(8):471-475.].

Male Caregivers of Persons with End Stage Renal Disease: A Literature Review.

This literature review examined burden, depressive symptoms, and perceived health reported by male caregivers of persons with end stage renal disease. These studies suggest that male caregivers often experience negative outcomes. Compared to non-caregivers, male caregivers had higher levels of anxiety and depressive symptoms. Qualitative studies suggest depression is common and associated with conflict between caregiving responsibilities and work, poor caregiver health, and fears about the future outcomes of relatives for whom they provide care. Future research will assist healthcare providers to identify at-risk male caregivers and develop effective interventions to support this understudied caregiver population.

Characterizing dietary intake and physical activity affecting weight gain in kidney transplant recipients.

CONTEXT: Weight gain after kidney transplantation affects 50% to 90% of kidney transplant recipients. Factors leading to weight gain in recipients are thought to include a change in lifestyle (eg, dietary intake and physical activity), age, race, sex, and immunosuppressant medications. OBJECTIVE: To examine dietary intake and physical activity of kidney transplant recipients at baseline and 3 and 6 months after transplantation to identify contributing factors to weight gain. DESIGN: Descriptive, correlational study using secondary data from a larger parent study examining genetic and environmental contributors to weight gain after kidney transplantation. PARTICIPANTS AND SETTING: Forty-four kidney transplant recipients at a mid-South university hospital-based transplant institute who had dietary intake, physical activity, and clinical data at baseline and 3 and 6 months were included. MAIN OUTCOME MEASURES: Dietary intake, physical activity, weight, and body mass index. RESULTS: Mean weight gain increased by 6% from baseline to 6 months. Interestingly, dietary intake did not change significantly from baseline to 6 months. Hours of sleep per day decreased during the same period (P = .02). Dietary intake, physical activity, age, race, sex, and immunosuppression showed no significant relationship to weight gain at 6 months. CONCLUSION: Little consideration has been given to dietary intake and physical activity of kidney transplant recipients and the effects of these variables on weight gain. Further studies with a larger sample are needed, as weight gain after transplantation is a significant risk factor for diminished long-term outcomes.

Effect of obesity on cardiovascular disease risk factors in African American women.

Obesity is a growing health care concern with implications for cardiovascular disease (CVD). Obesity and CVD morbidity and mortality are highly prevalent among African American women. This pilot study examined the association between obesity and the traditional and emerging CVD risk factors in a sample of African American women. Participants comprised 48 women (27 obese, 21 normal weight) aged 18-45. with no known history of CVD. The women completed demographic and 7-day physical activity recall questionnaires. Height and weight were used to determine body mass index (BMI). Hypertension risk was assessed using the average of two resting blood pressure (BP) measurements. Lipid profile, blood glucose, fibrinogen, high-sensitivity C-reactive protein (hs-CRP), plasminogen activator inhibitor-1 (PAI-1), soluble intercellular adhesion molecule-1 (sICAM-1), and E-selectin (eSel) levels were assessed using fasting blood samples. Laboratory findings were interpreted using the American Diabetes Association (ADA) and Adult Treatment Panel (ATP) III reference guidelines as well as manufacturers' reference ranges for the novel CVD risk factors. The most common traditional risk factors were physical inactivity (72.9%), positive family history of CVD (58.3%), and obesity (56.3%). Obese individuals had elevated systolic BP (p = .0002), diastolic BP (p = .0007) and HDL-cholesterol (p = .01), triglyceride (p = .02), hs-CRP (p = .002), and fibrinogen (p = .01), when compared with normal-weight women. The findings suggest an association between obesity and higher prevalence of both traditional and emerging CVD risk factors in young African American women.

Cost burden of the presenteeism health outcome: diverse workforce of nurses and pharmacists.

OBJECTIVES: To describe presenteeism, its cost burden, and comparative and interactive effects of race/ethnicity in nurses and pharmacists. METHODS: Using 226 self-reports, ordinal logistic regression with marginal/interactive effects modeled 12 presenteeism predictors, contingency tables detected differences/associations, and Human Capital Approach determined cost burden. RESULTS: Presenteeism's prevalence was 52.65% with mean productivity decrement 13.2%. Minorities had lower base presenteeism rates; however, race/ethnicity differences were not significant. Physical symptoms and mental conditions were associated with increased presenteeism likelihood, while decreased likelihood was associated with no medications or lack of resumption of previous medications. Indirect cost burden in 2008 averaged $12,605 per professional for $36 billion nationally. CONCLUSIONS: Prevention of symptoms and conditions impacting cognitions, pain, and perceptions can decrease presenteeism. Minorities' lower rates of presenteeism can be viewed both positively and negatively.

A pilot study of the self-reported quality of life for patients with chronic obstructive pulmonary disease.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) experience significant impairment in their quality of life (QOL). However, relatively few studies have examined overall and global QOL in patients with COPD using both generic QOL and health-related quality of life (HRQOL) measures. PURPOSE: The purposes of this pilot study were to describe the self-reported QOL (overall and global), disease-specific HRQOL, depressive symptoms, and disease-specific symptoms and experiences of patients with COPD and to examine the relationship among disease-specific HRQOL, depressive symptoms, disease-specific symptoms and experiences, and QOL (overall and global) in patients diagnosed with moderate to severe COPD. METHODS: A descriptive correlational design was used. Thirty-six participants completed overall QOL, global QOL, disease-specific HRQOL, depressive symptoms, and disease-specific symptoms and experiences questionnaires. RESULTS: Overall QOL was low; global QOL was at the median of scale range. Overall QOL scores were significantly correlated with the disease-specific St George Respiratory Questionnaire total score, symptoms and impact subscale, depressive symptoms, and 7 Bronchitis Emphysema Symptom Checklist subscales. CONCLUSION: Findings provided partial support for the association between QOL and disease-specific HRQOL and the usefulness of disease-specific questionnaires when assessing QOL.

African-American women's perceived health status while caring for a relative with end stage renal disease.

This study describes health status, health status changes, and factors predicting perceived health status of 75 African-American women caring for relatives with end stage renal disease. One-third of participating caregivers rated their health as fair or poor; others reported good health. Increased worry, mood changes, and stress/tension were problematic. Numbers of prescription medications, physician office visits in the past 6 months, and health problems- along with caregiver age and depression total score-explained 31% (p = 0.000) of total variance in perceived health status. This caregiver population would benefit from health promotion interventions.

Ascorbic acid does not influence consciousness recovery after anesthesia.

Several studies have examined the influence of general anesthesia on changes in consciousness and unconscious cognitive processes. However, much remains to be learned about potential moderators of general anesthetic agents, such as antioxidants including ascorbic acid, and their influence on the recovery of consciousness following general anesthesia. General anesthesia potentially affects plasma ascorbic acid levels and may impair consciousness during the postoperative period; however, published literature regarding these relationships is equivocal. Ascorbic acid is important for brain function and may be related to the return of postoperative consciousness through action on the synaptic receptors in the brain. This study was designed as a pretest-posttest repeated measures investigation. Ascorbic acid levels were measured at four time periods in patients (N = 50) undergoing surgery and general anesthesia. Following surgery, patients were administered a paper-and-pencil measure of concentration that served as an index of post-anesthesia consciousness. The results suggest that changes occur in plasma ascorbic acid levels at different time points during the anesthesia regimen in nonemergent surgical patients. No statistically significant relationships were found between plasma ascorbic acid levels and improved post-anesthesia consciousness, suggesting that ascorbic acid does not influence recovery of consciousness following general anesthesia.

Health risk characteristics of Black female informal caregivers on welfare.

This exploratory study examines differences in health risk characteristics and perceived health by caregiver status in two groups of Black women, 37 informal caregivers and 20 noncaregivers, transitioning from welfare to work. Health risk characteristics were assessed with the Center for Epidemiologic Studies Depression Scale and Healthier People Network Health Risk Appraisal-Version 6. Body mass index (BMI) calculations were based on the standard Centers for Disease Control formula. Perceived health status was assessed using a single-item Cantril ladder. Results show no statistically significant between-group differences in perceived health status, depressive symptoms, frequency of lifestyle behaviors, or BMI. Clinically significant proportions of participants in both groups rated their health as poor or fair; reported mild to severe depressive symptoms; smoked cigarettes; did not perform monthly self-breast exams; were physically inactive, overweight, or obese; and consumed high-fat diets. Black women receiving welfare show increased risk for premature chronic health problems, which warrants development of effective community-based risk-reduction programs.

Perceived barriers and facilitators to physical activity in kidney transplant recipients.

BACKGROUND: Relatively few transplant recipients participate in regular physical activity. There is a paucity of information regarding barriers and facilitators to physical activity in kidney transplant recipients. OBJECTIVE: To investigate factors that transplant recipients perceive as barriers and facilitators to physical activity and whether these barriers and facilitators differ on the basis of transplant patients' reported level of physical activity. METHOD: Using a descriptive, cross-sectional design, a convenience sample of 100 kidney transplant recipients provided survey data on a physical activity questionnaire on their current levels of physical activity and determinants that influence participation in physical activity. RESULTS: The "rarely/never" (32%) physical activity group reported more frequent barriers and the "often" (20%) group reported the least. Overall, perceived facilitators were reported most frequently by the "often" (80%) physical activity group and least by the "rarely/never" (67%) group. CONCLUSIONS: Motivational interventions should focus on diminishing perceived barriers in the less physically active transplant recipients and enhancing perception of health-related facilitators. Nurses should be innovative in customizing interventions, recommending structured physical activity programs, and encouraging less structured, enjoyable ways to increase activities that expend energy. Interventions with achievable outcomes and realistic expectations are more acceptable to patients.

INSIGHT potentially prevents and treats depressive and anxiety symptoms in black women caring for chronic hemodialysis recipients.

End stage renal disease (ESRD) unduly affects black families in the U.S., including black women who are the family caregivers of affected patients. Nephrology nurses who support chronic hemodialysis recipients may be the first to recognize depressive and anxiety symptoms in this understudied caregiver population. This article describes the risk factors for depression in black women who care for persons receiving chronic hemodialysis therapy and INSIGHT therapy as a potential intervention to reduce depressive symptoms.

Evaluation of an immunosuppressant side effect instrument.

BACKGROUND: Clinicians continue to be compelled to evaluate the impact of immunosuppressive medication side effects on the quality of life of transplant recipients. We Were asked to develop an instrument to measure side effects in immunosuppressed transplant recipients. OBJECTIVE: To construct an instrument that measures the impact and severity of side effects of immunosuppressive medications used in transplantation and to assess the reliability and validity of the newly developed instrument called the Memphis Survey. DESIGN: The instrument was constructed by a panel of physicians, nurses, and pharmacists with experience in treating transplant recipients. A small group of kidney transplant recipients (n= 13) provided pilot data for refining and testing the instrument. A national sample of kidney, liver, and heart transplant recipients (n = 505) provided data that were used to further develop the instrument. ANALYSIS: Factor analysis was used to determine the psychological dimensions underlying the instrument and to guide the construction of scales from the survey items. The instrument scales were then computed from the dataset of 505 transplant recipients to quantify the impact of immunosuppressant side effects on the quality of life of transplant recipients. RESULTS AND CONCLUSION: Analyses showed the final instrument scales to be valid and reliable. Exploratory analysis suggests the need for further testing of the instrument to determine gender differences.