Nurse Education and Hospital Readmissions for Children With and Without a Mental Health Condition.

OBJECTIVES: In adults, receiving care in a hospital with more baccalaureate-prepared nurses improves outcomes. This relationship is magnified in adults with serious mental illness or cognitive impairment. Whether the same is true in children with and without a mental health condition is unknown. The study purposes were to determine 1) whether the proportion of baccalaureate-prepared nurses affected the odds of readmission in children; and 2) whether this relationship differed for children with a mental health condition. PATIENTS AND METHODS: We linked cross-sectional data from the 2016 Healthcare Cost and Utilization Project State Inpatient Databases, the RN4CAST-US nurse survey in Florida, and the American Hospital Association. Inclusion criteria were ages 3 to 21 years. Mental health conditions were defined as psychiatric or developmental/behavioral diagnoses. These were identified using the Child and Adolescent Mental Health Disorders Classification System. We used multivariable, hierarchical logistic regression models to assess the relationship between nurse training and readmissions. RESULTS: In 35 081 patients admitted to 122 hospitals with 4440 nurses, 21.0% of patients had a mental health condition and 4.2% had a 7-day readmission. For individuals without a mental health condition, each 10% increase in the proportion of baccalaureate-prepared nurses was associated with 8.0% lower odds of readmission (odds ratio = 0.92, 95% confidence interval = 0.87-0.97). For those with a mental health condition, each 10% increase in the proportion of baccalaureate-prepared nurses was associated with 16.0% lower odds of readmission (odds ratio = 0.84, 95% confidence interval = 0.78-0.91). CONCLUSIONS: A higher proportion of baccalaureate-educated nurses is associated with lower odds of readmission for pediatric patients. This association has a larger magnitude in patients with a mental health condition.

ECMO with vasopressor use during early endotoxic shock: Can it improve circulatory support and regional microcirculatory blood flow?

INTRODUCTION: While extracorporeal membrane oxygenation (ECMO) is effective in preventing further hypoxemia and maintains blood flow in endotoxin-induced shock, ECMO alone does not reverse the hypotension. In this study, we tested whether concurrent vasopressor use with ECMO would provide increased circulatory support and blood flow, and characterized regional blood flow distribution to vital organs. METHODS: Endotoxic shock was induced in piglets to achieve a 30% decrease in mean arterial pressure (MAP). Measurements of untreated pigs were compared to pigs treated with ECMO alone or ECMO and vasopressors. RESULTS: ECMO provided cardiac support during vasodilatory endotoxic shock and improved oxygen delivery, but vasopressor therapy was required to return MAP to normotensive levels. Increased blood pressure with vasopressors did not alter oxygen consumption or extraction compared to ECMO alone. Regional microcirculatory blood flow (RBF) to the brain, kidney, and liver were maintained or increased during ECMO with and without vasopressors. CONCLUSION: ECMO support and concurrent vasopressor use improve regional blood flow and oxygen delivery even in the absence of full blood pressure restoration. Vasopressor-induced selective distribution of blood flow to vital organs is retained when vasopressors are administered with ECMO.

Vasopressin decreases pulmonary-to-systemic vascular resistance ratio in a porcine model of severe hemorrhagic shock.

Vasopressors are gaining renewed interest as treatment adjuncts in hemorrhagic shock. The ideal vasoconstrictor will increase systemic blood pressure without increasing pulmonary vascular resistance (PVR), which hinders pulmonary perfusion and exacerbates hypoxemia. However, the selectivity of pressors for pulmonary versus systemic vasoconstriction during hemorrhage has not been characterized. The purpose of this study was to test the hypothesis that vasopressin (VP) has distinct effects on pulmonary versus systemic hemodynamics, unlike the catecholamine vasopressors norepinephrine (NE) and phenylephrine (PE). Anesthetized and ventilated pigs were assigned to resuscitation with saline only (n = 7) or saline with VP (n = 6), NE (n = 6), or PE (n = 6). Animals were hemorrhaged to a target volume of 30 mL/kg and a mean arterial pressure of 35 mmHg. One hour after the start of hemorrhage, animals were resuscitated with saline up to one shed blood volume, followed by either additional saline or a vasopressor. Hemodynamics and oxygenation were measured hourly for 4 h after the start of hemorrhage. Vasopressin increased systemic vascular resistance (SVR) while sparing the pulmonary vasculature, leading to a 45% decrease in the PVR/SVR ratio compared with treatment with PE. Conversely, NE induced pulmonary hypertension and led to an increased PVR/SVR ratio associated with decreased oxygen saturation. Phenylephrine and crystalloid had no significant effect on the PVR/SVR ratio. Sparing of pulmonary vasoconstriction occurs only with VP, not with administration of crystalloid or catecholamine pressors. The ability of VP to maintain blood oxygenation indicates that VP may prevent hypoxemia in the management of hemorrhagic shock.

The association between objectively measured neighborhood features and walking in middle-aged adults.

PURPOSE: Explore the role of the neighborhood environment in supporting walking. DESIGN: Cross-sectional study of 10,286 residents of 200 neighborhoods. Participants were selected using a stratified two-stage cluster design. Data were collected by mail survey (68.5% response rate). SETTING: Brisbane City Local Government Area, Australia, 2007. SUBJECTS: Brisbane residents aged 40 to 65 years. MEASURES: Environmental: street connectivity, residential density, hilliness, tree coverage, bikeways, and streetlights within a 1-km circular buffer from each resident's home; and network distance to nearest river or coast, public transport, shop, and park. Walking: minutes walked in the previous week: < 30 minutes, ≥ 30 to < 90 minutes, ≥ 90 to < 150 minutes, ≥ 150 to < 300 minutes, and ≥ 300 minutes. ANALYSIS: The association between each neighborhood characteristic and walking was examined using multilevel multinomial logistic regression, and the model parameters were estimated using Markov chain Monte Carlo simulation. RESULTS: After adjustment for individual factors, the likelihood of walking for more than 300 minutes (relative to < 30 minutes) was highest in areas with the most connectivity (odds ratio [OR] 5 1.93; 99% confidence intervals [CI], 1.32-2.80), greatest residential density (OR 5 1.47; 99% CI, 1.02-2.12), least tree coverage (OR 5 1.69; 99% CI, 1.13-2.51), most bikeways (OR 5 1.60; 99% CI, 1.16-2.21), and most streetlights (OR 5 1.50; 99% CI, 1.07-2.11). The likelihood of walking for more than 300 minutes was also higher among those who lived closest to a river or the coast (OR 5 2.06; 99% CI, 1.41-3.02). CONCLUSION: The likelihood of meeting (and exceeding) physical activity recommendations on the basis of walking was higher in neighborhoods with greater street connectivity and residential density, more streetlights and bikeways, closer proximity to waterways, and less tree coverage. Interventions targeting these neighborhood characteristics may lead to improved environmental quality as well as lower rates of overweight and obesity and associated chromic disease.

A randomized trial of a nursing intervention for HIV disease management among persons with serious mental illness.

OBJECTIVE: The heightened risk of persons with serious mental illness to contract and transmit HIV is recognized as a public health problem. Persons with HIV and mental illness may be at risk for poor treatment adherence, development of treatment-resistant virus, and worse outcomes. The objective of this study was to test the effectiveness of a community-based advanced practice nurse (APN) intervention (PATH, Preventing AIDS Through Health) to promote adherence to HIV and psychiatric treatment regimens. METHODS: Community-dwelling HIV-positive participants with co-occurring serious mental illnesses (N=238) were recruited from community HIV provider agencies from 2004 to 2008 to participate in the randomized controlled trial. Participants in the intervention group (N=128) were assigned an APN who provided community-based care management at a minimum of one visit per week and coordinated clients' medical and mental health care for one year. Viral load and CD4 cell count were evaluated at baseline and 12 months. RESULTS: Longitudinal models for continuous log viral load showed that compared with the control group, the intervention group exhibited a significantly greater reduction in log viral load at 12 months (d=-.361 log 10 copies per milliliter, p<.001). Differences in CD4 counts from baseline to 12 months were not statistically significant. CONCLUSIONS: This project demonstrated the effectiveness of community-based APNs in delivering a tailored intervention to improve outcomes of individuals with HIV and co-occurring serious mental illnesses. Persons with these co-occurring conditions can be successfully treated; with appropriate supportive services, their viral loads can be reduced.

Lack of fluoroquinolone resistance in non-typhoidal salmonella bacteremia in HIV-infected patients in an urban US setting.

Non-typhoidal salmonella (NTS) bacteremia is a significant cause of morbidity and mortality in HIV-infected individuals worldwide. Recent reports have noted increasing resistance of NTS isolates to fluoroquinolones, the recommended first-line therapy for NTS bacteremia. The outcomes and risk factors for NTS bacteremia in HIV-infected patients in an urban US setting were evaluated. From January 2002 to December 2006, 26 episodes of NTS bacteremia were identified in 16 patients. The risk factors for NTS bacteremia were low CD4 count, high viral load, and lack of antiretroviral therapy (ART). Recurrences appeared related to lack of immune reconstitution in patients not on ART. Unlike reports from Asia, no fluoroquinolone resistance was identified in any of the Salmonella strains isolated in this setting. Optimal treatment of NTS in the HIV-infected patient in the United States should include therapy with fluoroquinolones as well as attaining complete viral suppression and immune reconstitution with ART.

HABITAT: A longitudinal multilevel study of physical activity change in mid-aged adults.

BACKGROUND: Little is known about the patterns and influences of physical activity change in mid-aged adults. This study describes the design, sampling, data collection, and analytical plan of HABITAT, an innovative study of (i) physical activity change over five years (2007-2011) in adults aged 40-65 years at baseline, and (ii) the relative contribution of psychological variables, social support, neighborhood perceptions, area-level factors, and sociodemographic characteristics to physical activity change. METHODS/DESIGN: HABITAT is a longitudinal multi-level study. 1625 Census Collection Districts (CCDs) in Brisbane, Australia were ranked by their index of relative socioeconomic disadvantage score, categorized into deciles, and 20 CCDs from each decile were selected to provide 200 local areas for study inclusion. From each of the 200 CCDs, dwellings with individuals aged between 40-65 years (in 2007) were identified using electoral roll data, and approximately 85 people per CCD were selected to participate (N = 17,000). A comprehensive Geographic Information System (GIS) database has been compiled with area-level information on public transport networks, footpaths, topography, traffic volume, street lights, tree coverage, parks, public services, and recreational facilities Participants are mailed a questionnaire every two years (2007, 2009, 2011), with items assessing physical activity (general walking, moderate activity, vigorous activity, walking for transport, cycling for transport, recreational activities), sitting time, perceptions of neighborhood characteristics (traffic, pleasant surroundings, streets, footpaths, crime and safety, distance to recreational and business facilities), social support, social cohesion, activity-related cognitions (attitudes, efficacy, barriers, motivation), health, and sociodemographic characteristics. Analyses will use binary and multinomial logit regression models, as well as generalized linear latent growth models. DISCUSSION: HABITAT will provide unique information to improve our understanding of the determinants of physical activity, and to help identify "people" and "place" priority targets for public policy and health promotion aimed at increasing physical activity participation among mid-aged men and women.

Role of macrophages in virus-induced airway hyperresponsiveness and neuronal M2 muscarinic receptor dysfunction.

Viral infections exacerbate asthma. One of the pathways by which viruses trigger bronchoconstriction and hyperresponsiveness is by causing dysfunction of inhibitory M(2) muscarinic receptors on the airway parasympathetic nerves. These receptors normally limit acetylcholine (ACh) release from the parasympathetic nerves. Loss of M(2) receptor function increases ACh release, thereby increasing vagally mediated bronchoconstriction. Because viral infection causes an influx of macrophages into the lungs, we tested the role of macrophages in virus-induced airway hyperresponsiveness and M(2) receptor dysfunction. Guinea pigs infected with parainfluenza virus were hyperresponsive to electrical stimulation of the vagus nerves but not to intravenous ACh, indicating that hyperresponsiveness was due to increased release of ACh from the nerves. In addition, the muscarinic agonist pilocarpine no longer inhibited vagally induced bronchoconstriction, indicating M(2) receptor dysfunction. Treating animals with liposome-encapsulated dichloromethylene-diphosphonate depleted macrophages as assessed histologically. In these animals, viral infection did not cause airway hyperresponsiveness or M(2) receptor dysfunction. These data suggest that macrophages mediate virus-induced M(2) receptor dysfunction and airway hyperresponsiveness.