Toxicity threshold and ecological risk of nitrate in rivers based on endocrine-disrupting effects: A case study in the Luan River basin, China.

Nitrate, as a crucial nutrient, is consistently targeted for controlling water eutrophication globally. However, there is considerable evidence suggesting that nitrate has endocrine-disrupting potential on aquatic organisms. In this study, the sensitivity of various adverse effects to nitrate nitrogen (nitrate-N) was compared, and a toxicity threshold based on endocrine-disrupting effects was derived. The spatiotemporal variations of nitrate-N concentrations in the Luan River basin were investigated, and the associated aquatic ecological risks were evaluated using a comprehensive approach. The results showed that reproduction and development were the most sensitive endpoints to nitrate, and their distribution exhibited significant differences compared to behavior. The derived threshold based on endocrine-disrupting effects was 0.65 mgL-1, providing adequate protection for the aquatic ecosystem. In the Luan River basin, the mean nitrate-N concentrations during winter (4.4 mgL-1) were significantly higher than those observed in spring (0.7 mgL-1) and summer (1.2 mgL-1). Tributary inputs had an important influence on the spatial characteristics of nitrate-N in the mainstream, primarily due to agricultural and population-related contamination. The risk quotients (RQ) during winter, summer, and spring were evaluated as 6.7, 1.8, and 1.1, respectively, and the frequency of exposure concentrations exceeding the threshold was 100 %, 64.3 %, and 42.5 %, respectively. At the ecosystem level, nitrate posed intermediate risks to aquatic organisms during winter and summer in the Luan River basin and at the national scale in China. We suggest that nitrate pollution control should not solely focus on water eutrophication but also consider the endocrine disruptive effect on aquatic animals.

Predictors of Substance Use Risk in Nurse Anesthetists.

BACKGROUND: Certified registered nurse anesthetists (CRNAs) are exposed daily to highly addictive substances and stressful work environments, placing them at risk for substance use disorders (SUDs). Previous research, which is scarce, indicated that drugs of choice were opioids and propofol. Therefore, the purpose of this study was to investigate predictors of SUD risk using the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test. METHOD: From June to July 2020, an online survey was sent via the American Association of Nurse Anesthesiology Research Survey Service to 3,000 CRNAs with a response of approximately 225 members. RESULTS: CRNAs were found to be at a moderate risk for SUDs in the following categories: 10.27% for tobacco, 23.56% for alcohol, and 6.28% for cannabis. Regression analysis by substance category includes robust, differing models in this homogeneous sample. Predictors for all three models include a collection of demographic variables, religiosity, anxiety, difficulties due to anxiety, depression, substance use history, contact with the American Association of Nurse Anesthesiology Peer Assistance Program, and organizational support. CONCLUSION: Over 10% of CRNAs are at risk for developing tobacco use disorder, and almost one quarter of those surveyed are at a moderate risk for developing alcohol use disorder. These data are of concern and may indicate a shift of preferred substances used by CRNAs from controlled substances to alcohol.

Nurses' Psychological Trauma and Cognitive Control in the COVID-19 Pandemic.

Introduction: During the COVID-19 pandemic, nurses have faced various nurse-specific traumas in their workplaces, but there is limited understanding of the resulting outcomes and factors that contribute to them. Objective: To address this gap, the study employed the middle-range theory of nurses' psychological trauma (NPT) to examine these relationships among frontline nurses working in critical care areas. Methods: In a quantitative cross-sectional study, the study compared nurses identified as probable cases of posttraumatic stress disorder (PTSD) with those identified as not probable cases. The study investigated the nurse-specific traumas they experienced, their individual personality traits, and the buffers they possessed. The study also sought to identify specific types of nurse-specific traumas that could be associated with negative outcomes, such as alcohol and drug use. Results: It was found that PTSD-probable nurses reported higher levels of trauma from disasters and system/medically induced trauma compared to not-probable nurses. They also experienced more nonwork-related humankind traumas and displayed lower resilience. Furthermore, PTSD-probable nurses identified with trait urgency and trait avoidance motivation. Additionally, trauma from disasters was associated with alcohol use. Conclusion: The study highlights the elevated levels of trauma, lower resilience, and specific psychological traits associated with PTSD-probable nurses, emphasizing the need for targeted interventions and support to mitigate the negative outcomes experienced by frontline nurses.

Voices from the COVID-19 frontline: Nurses' trauma and coping.

AIM: To describe the experiences of frontline nurses who are working in critical care areas during the COVID-19 pandemic with a focus on trauma and the use of substances as a coping mechanism. DESIGN: A qualitative study based on content analysis. METHODS: Data were collected from mid-June 2020 to early September 2020 via an online survey. Nurses were recruited through the research webpage of the American Association of Critical Care Nurses as well as an alumni list from a large, public Midwest university. Responses to two open-ended items were analysed: (1) personal or professional trauma the nurse had experienced; and (2) substance or alcohol use, or other mental health issues the nurse had experienced or witnessed in other nurses. RESULTS: For the item related to psychological trauma five themes were identified from 70 nurses' comments: (1) Psychological distress in multiple forms; (2) Tsunami of death; (3) Torn between two masters; (4) Betrayal; and (5) Resiliency/posttraumatic growth through self and others. Sixty-five nurses responded to the second item related to substance use and other mental health issues. Data supported three themes: (1) Mental health crisis NOW!!: 'more stressed than ever and stretched thinner than ever'; (2) Nurses are turning to a variety of substances to cope; and (3) Weakened supports for coping and increased maladaptive coping due to ongoing pandemic. CONCLUSIONS: This study brings novel findings to understand the experiences of nurses who care for patients with COVID-19, including trauma experienced during disasters, the use of substances to cope and the weakening of existing support systems. Findings also reveal nurses in crisis who are in need of mental health services. IMPACT: Support for nurses' well-being and mental health should include current and ongoing services offered by the organization and include screening for substance use issues.

Predictors of Substance Use in Registered Nurses: The Role of Psychological Trauma.

Substance use disorders (SUDs) in nursing have individual well-being, patient safety, and licensure/regulatory implications. Literature is scarce related to predicting SUDs in registered nurses; this study included specific items surrounding nurses' psychological trauma. An online survey, consisting of validated scales and investigator-generated items was distributed to 4,000 registered nurses in Indiana with a yield of 1,478 surveys. The World Health Organization: Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was used as the dependent variable to assess risk of SUDs. Three multivariate regression models with predictive variables for risk of tobacco (R2 = 0.08), alcohol (R2 = 0.09), and other substances (R2 = 0.10) use were found. Of concern, nurses are at moderate risk for tobacco use at 11.6%; alcohol use at 11.6% and for other substances at 10.4%. Each regression model contained distinct predictor variables; however, variables occurring in all three models were: depression, anxiety, and items surrounding psychological trauma (adverse childhood experiences, life events, lateral workplace violence).

Agreement Study Using Gesture Description Analysis.

Choosing adequate gestures for touchless interfaces is a challenging task that has a direct impact on human-computer interaction. Such gestures are commonly determined by the designer, ad-hoc, rule-based or agreement-based methods. Previous approaches to assess agreement grouped the gestures into equivalence classes and ignored the integral properties that are shared between them. In this work, we propose a generalized framework that inherently incorporates the gesture descriptors into the agreement analysis (GDA). In contrast to previous approaches, we represent gestures using binary description vectors and allow them to be partially similar. In this context, we introduce a new metric referred to as Soft Agreement Rate ( S A R ) to measure the level of agreement and provide a mathematical justification for this metric. Further, we performed computational experiments to study the behavior of S A R and demonstrate that existing agreement metrics are a special case of our approach. Our method was evaluated and tested through a guessability study conducted with a group of neurosurgeons. Nevertheless, our formulation can be applied to any other user-elicitation study. Results show that the level of agreement obtained by S A R is 2.64 times higher than the previous metrics. Finally, we show that our approach complements the existing agreement techniques by generating an artificial lexicon based on the most agreed properties.

[Community of Benthic Diatoms and Their Relationship with Aquatic Environmental Factors in the Tangwang River, China].

To reasonably evaluate the eco-environmental health of the Tangwang River, which is a tributary of the Songhua River in China, community structures of periphyton and cleanliness of the benthic diatom at 24 sampling sites were investigated using McNaughton's dominance index, clustering, and ecotype analysis, while the relationship between the environmental factors and the diatom communities were studied by principal component analysis, Spearman correlation test, and redundancy analysis, in August 2018 (flood season). A total of 99 species or variants of benthic diatoms have been identified, indicating that there were abundant diatoms in the Tangwang River. Achnanthidium minutissimum and other diatoms that can be used as clean water indicators were dominant species in the Tangwang River, which indicates that the eco-environmental quality of the Tangwang River was relatively healthy in the flood season. Of these, the dominant degree of A. minutissimum was 0.32, making it the absolute dominant species in Tangwang River. Sampling sites can be divided into three groups based on clustering analysis. The dominant species of group 1 and group 2 were mainly clean species, indicating that the two groups were in a relatively healthy state. Nitzschia palea, Ulnaria ulna, and other diatoms that can be used as eutrophication indicators were the dominant species of group 3, indicating that group 3 was less healthy than the other two groups. From groups 1 and 2, the results from ecotype analysis showed a decrease in the proportion of polyoxybiontic diatoms and an increase in the proportion of α-mesosaphrobe diatoms, polysaprobe diatoms, oligo-mesotrophic diatoms, mesotrophic diatoms, meso-eutrophic diatoms, and eutrophic diatoms. Compared to the other two groups, the results from ecotype analysis showed a significant increase in the proportion of α-mesosaphrobe diatoms, polysaprobe diatoms, eutrophic diatoms and hypereutrophic diatoms in group 3. The predominant aquatic influencing factors of diatom community structures for the Tangwang River were permanganate index, total nitrogen (TN), and ammonia nitrogen (NH4+-N), of which permanganate index was the main factor for group 2, while TN and NH4+-N were the main factors for group 3. As a result, the eco-environmental quality of the Tangwang River was good, and the benthic diatom was found to be an effective indicator of the nutritional conditions and saprophytic status.

Nurses' psychological trauma: "They leave me lying awake at night".

OBJECTIVE: To describe nurses' personal and professional psychological trauma. METHODS: A content analysis of 372 responses surrounding personal and professional trauma was performed. RESULTS: Five themes emerged. A new type of trauma was uncovered, heretofore undescribed in the literature: insufficient resource trauma caused by a lack of resources and staff needed to render quality, safe care. CONCLUSION: Nurses' reports were vivid, frequently indicating they were still recovering from traumatic experiences. Professional sources of trauma were categorized as inherent in the role of the nurse and those that could be mitigated through organizational policy, adequate resources, and oversight.

Pregnancy rest-activity patterns are related to salivary cortisol rhythms and maternal-fetal health indicators in women from a disadvantaged population.

Irregular rest-activity patterns can disrupt metabolic and hormonal physiology and potentially lead to disease. Little is known regarding rest-activity patterns during gestation and their association with hormonal rhythms and health in pregnant women. We conducted a pilot study to determine if 24 h rest-activity was related to saliva cortisol rhythms and maternal-fetal health in an economically disadvantaged population. Primiparous women wore a wrist actigraphy device for a week to record activity during gestational weeks 22 (G22; n = 50) and 32 (G32; n = 46) and postpartum week one (PPW1; n = 39). Participants collected saliva samples every 4 hr over a 24 hr period during G22 (n = 22), G32 (n = 20) and 24-48 hr postnatal (n = 20), and cortisol concentrations were measured with ELISA. Circadian rhythmicity was assessed using autocorrelation coefficient (r24) and cosinor analysis. Blood glucose levels, body mass index (BMI), gestational disease data, and gestational age of infant at birth were abstracted from medical charts. Time of cortisol peak (acrophase) during G22 was related with acrophase of activity (r = 0.66; p = 0.001) and blood glucose levels (r = 0.58; p = 0.006). During G22, minutes of wake after sleep onset was positively related to cortisol mesor and AUC (p <0.05). Rest-activity r24, R2, and mesor during G32 were positively (p<0.05) associated with gestational age of infant at birth. Across all three time points r24 of activity was related with cortisol amplitude (r = 0.33; p = 0.01). Findings support a relationship between rest-activity patterns and saliva cortisol rhythms during pregnancy. The association of less robust activity rhythms with earlier gestational age of infant at birth indicates a potential link between circadian system disruption and maternal-fetal health outcomes.

Substance Use in Registered Nurses: "I Heard About a Nurse Who . . ."

BACKGROUND: Estimates of substance use (SU) in nurses is on par with that of the general population: between 6% and 8%. However, collecting sensitive information such as SU is difficult based on social desirability and fears of disclosure. AIMS: Part of a larger study surrounding nurses' self-reports of SU (n = 1,478), the purpose was to explore open-ended responses of nurses (n = 373) who were invited to "Please add any additional comments related to substance or alcohol use that you have experienced or witnessed in registered nurses." METHOD: This qualitative study employed a content analysis of 373 nurses' open-ended responses collected via an online survey. RESULTS: The majority of nurses (n = 250) forwarded comments that described SU in other nurses, while 24 comments reflected the nurse's past or current SU. Content analysis revealed the following four themes: (1) differing social network proximity to SU; (2) individual process: vulnerability to adaptive/maladaptive coping resulting in positive and negative outcomes; (3) bedside, system, and organizational spaces and effects; and (4) there are no SU issues in nursing. CONCLUSIONS: Although direct reports of SU constitute approximately one quarter of the comments forwarded, nurses reported peers' struggles with SU, including observing nurses working in patient care while impaired and the use of substances to cope with work and personal stressors. Individual factors and system-related failures appear to be contributors to SU in nurses.

Preference elicitation: Obtaining gestural guidelines for PACS in neurosurgery.

OBJECTIVE: Accessing medical records is an integral part of neurosurgical procedures in the Operating Room (OR). Gestural interfaces can help reduce the risks for infections by allowing the surgical staff to browse Picture Archiving and Communication Systems (PACS) without touch. The main objectives of this work are to: a) Elicit gestures from neurosurgeons to analyze their preferences, b) Develop heuristics for gestural interfaces, and c) Produce a lexicon that maximizes surgeons' preferences. MATERIALS AND METHODS: A gesture elicitation study was conducted with nine neurosurgeons. Initially, subjects were asked to outline the gestures on a drawing board for each of the PACS commands. Next, the subjects performed one of three imaging tasks using gestures instead of the keyboard and mouse. Each gesture was annotated with respect to the presence/absence of gesture descriptors. Next, K-nearest neighbor approach was used to obtain the final lexicon that complies with the preferred/popular descriptors. RESULTS: The elicitation study resulted in nine gesture lexicons, each comprised of 28 gestures. A paired t-test between the popularity of the overall gesture and the top three descriptors showed that the latter is significantly higher than the former (89.5%-59.7% vs 19.4%, p < 0.001), meaning more than half of the subjects agreed on these descriptors. Next, the gesture heuristics were generated for each command using the popular descriptors. Lastly, we developed a lexicon that complies with surgeons' preferences. CONCLUSIONS: Neurosurgeons do agree on fundamental characteristics of gestures to perform image manipulation tasks. The proposed heuristics could potentially guide the development of future gesture-based interaction of PACS for the OR.

Delayed Lactogenesis II is Associated With Lower Sleep Efficiency and Greater Variation in Nightly Sleep Duration in the Third Trimester.

BACKGROUND: Metabolic and hormonal disturbances are associated with sleep disturbances and delayed onset of lactogenesis II. RESEARCH AIMS: The aim of this study was to measure sleep using wrist actigraphy during gestation weeks 22 and 32 to determine if sleep characteristics were associated with blood glucose, body mass index, gestational related disease, delayed onset of lactogenesis II, or work schedule. METHODS: Demographic data were collected at study intake from primiparous women who wore a wrist actigraph during gestation weeks 22 (n = 50) and 32 (n = 44). Start and end sleep time, total nighttime sleep, sleep efficiency, wake after sleep onset, and sleep fragmentation were measured. Night to night variability was assessed with the root mean square of successive difference. Blood glucose levels, body mass index, and gestational disease data were abstracted from medical charts. Timing of lactogenesis II was determined by survey. RESULTS: Between gestation week 22 and 32, sleep efficiency decreased and fragmentation increased (p < .05). During gestation week 32, blood glucose was negatively correlated with sleep duration, and positively related to fragmentation (p < .05). Women who experienced delayed lactogenesis II had lower sleep efficiency and greater fragmentation (p < .05), and greater night-to-night variability in sleep start and end time, efficiency, and duration during gestation week 32 (p < .05). CONCLUSION: Women with better sleep efficiency and more stable nightly sleep time are less likely to experience delayed onset of lactogenesis II. Interventions to improve sleep may improve maternal health and breastfeeding adequacy.

Relationship Between Sleep Quality, Depression Symptoms, and Blood Glucose in Pregnant Women.

Sleep quality during pregnancy affects maternal/child health. We aimed to assess changes in sleep quality during pregnancy and determine its relationship to maternal mood, blood glucose, and work schedule among primiparous women. We conducted a prospective/longitudinal/observational study. Ninety-two pregnant women were recruited from Midwestern hospital. Mood and sleep quality data were collected using Edinburgh Postnatal Depression Scale/Pittsburgh Sleep Quality Index at Gestational Weeks 22 and 32. Forty-three women completed the study. Twenty-six women (63%) were African American and the mean age was 23.64 (SD = 3.82) years. Rate of poor sleep quality increased during pregnancy with 25% of women had scores indicative of depression symptoms. Poor sleep quality score was related to mood scores (p < .05) and work schedule. Blood glucose was not significantly related to sleep duration. In conclusion, poor sleep quality during pregnancy was associated with poor mood and work schedule, suggesting that interventions targeting mental health and lifestyles are needed.

The Impacts of Land Use Patterns on Water Quality in a Trans-Boundary River Basin in Northeast China Based on Eco-Functional Regionalization.

The relationships between land use patterns and water quality in trans-boundary watersheds remain elusive due to the heterogeneous natural environment. We assess the impact of land use patterns on water quality at different eco-functional regions in the Songhua River basin during two hydrological seasons in 2016. The partial least square regression indicated that agricultural activities associated with most water quality pollutants in the region with a relative higher runoff depth and lower altitude. Intensive grazing had negative impacts on water quality in plain areas with low runoff depth. Forest was related negatively with degraded water quality in mountainous high flow region. Patch density and edge density had major impacts on water quality contaminants especially in mountainous high flow region; Contagion was related with non-point source pollutants in mountainous normal flow region; landscape shape index was an effective indicator for anions in some eco-regions in high flow season; Shannon's diversity index contributed to degraded water quality in each eco-region, indicating the variation of landscape heterogeneity influenced water quality regardless of natural environment. The results provide a regional based approach of identifying the impact of land use patterns on water quality in order to improve water pollution control and land use management.

Gestures for Picture Archiving and Communication Systems (PACS) operation in the operating room: Is there any standard?

OBJECTIVE: Gestural interfaces allow accessing and manipulating Electronic Medical Records (EMR) in hospitals while keeping a complete sterile environment. Particularly, in the Operating Room (OR), these interfaces enable surgeons to browse Picture Archiving and Communication System (PACS) without the need of delegating functions to the surgical staff. Existing gesture based medical interfaces rely on a suboptimal and an arbitrary small set of gestures that are mapped to a few commands available in PACS software. The objective of this work is to discuss a method to determine the most suitable set of gestures based on surgeon's acceptability. To achieve this goal, the paper introduces two key innovations: (a) a novel methodology to incorporate gestures' semantic properties into the agreement analysis, and (b) a new agreement metric to determine the most suitable gesture set for a PACS. MATERIALS AND METHODS: Three neurosurgical diagnostic tasks were conducted by nine neurosurgeons. The set of commands and gesture lexicons were determined using a Wizard of Oz paradigm. The gestures were decomposed into a set of 55 semantic properties based on the motion trajectory, orientation and pose of the surgeons' hands and their ground truth values were manually annotated. Finally, a new agreement metric was developed, using the known Jaccard similarity to measure consensus between users over a gesture set. RESULTS: A set of 34 PACS commands were found to be a sufficient number of actions for PACS manipulation. In addition, it was found that there is a level of agreement of 0.29 among the surgeons over the gestures found. Two statistical tests including paired t-test and Mann Whitney Wilcoxon test were conducted between the proposed metric and the traditional agreement metric. It was found that the agreement values computed using the former metric are significantly higher (p < 0.001) for both tests. CONCLUSIONS: This study reveals that the level of agreement among surgeons over the best gestures for PACS operation is higher than the previously reported metric (0.29 vs 0.13). This observation is based on the fact that the agreement focuses on main features of the gestures rather than the gestures themselves. The level of agreement is not very high, yet indicates a majority preference, and is better than using gestures based on authoritarian or arbitrary approaches. The methods described in this paper provide a guiding framework for the design of future gesture based PACS systems for the OR.

Trauma-Informed Parenting Classes Delivered to Rural Kinship Parents: A Pilot Study.

BACKGROUND: Without an informed approach, kinship parents, often grandparents, may struggle to effectively interact with their children who have experienced trauma. OBJECTIVES: The purpose of this pilot study was to describe the overall impact and acceptability of a trauma-informed parenting curriculum delivered to 16 rural-dwelling kinship parents. Nursing faculty partnered with Cooperative Extension Educators to deliver this curriculum, developed by the National Child Traumatic Stress Network. Semistructured interviews, an acceptability survey, and measures of parent, child, and family environment were used. DESIGN: This pilot, multisite, mixed-methods, intervention study employed a pre-post, paired test design. RESULTS: Significant differences were revealed on select items that measured parent-child nurturing and the families' cultural, political, and intellectual activities with posttest scores lower than pretest scores. Themes revealed processing the aftermath of child trauma and being a kinship parent. CONCLUSIONS: Although quantitative measures failed to demonstrate the impact of the curriculum, qualitative and satisfaction data provide preliminary evidence to support this intervention.

Addressing the wicked problem of childhood trauma through a nursing and cooperative extension system collaboration.

The purpose of this clinical concept report is to describe a public health project in rural Indiana that addressed the complex social issue or "wicked problem" of childhood trauma. The project was implemented through a unique partnership between nursing faculty and Cooperative Extension Educators, community-based workers who are associated with fulfilling the mission of Land Grant Universities. The core focus of the project entailed a nurse and a Cooperative Extension Educator co-teaching trauma-informed parenting classes to rural dwelling, kinship caregivers. Kinship caregivers are often grandparents who assume the parenting role after the child has been removed from the birth parents' care. The trauma-informed curriculum was developed by experts in child trauma and is available through the National Child Traumatic Stress Network. The unique partnership provided insight into the different missions of the two organizations, different values and workflow metrics, and different schedules, which at times proved to be barriers to implementation. This discussion focuses on deconstructing the goals and objectives of the project and retrospectively, describing recommendations so that public health nurses may partner with Extension Educators in their communities for optimal project success.

Cancelled Primary Care Appointments: A Prospective Cohort Study of Diabetic Patients.

Patients scheduled for primary care appointments often cancel or no show. For diabetic patients, nonattendance can affect continuity of care and result in higher emergency department (ED) and hospital use. Nonattendance also impacts appointment scheduling, patient access, and clinic work load. While no show has received significant attention, little research has addressed the prevalence and impact of appointment cancellation. Data on 46,710 appointments for 7586 adult diabetic patients was used to conduct a prospective cohort study examining primary care appointment behavior. The independent variable was the status of the INDEX appointment, which was attended, cancelled, or no showed. Dependent variables included the dates of (1) the last attended appointment, (2) scheduling the NEXT appointment, (3) the next attended follow-up appointment, and (4) ED visits and hospitalizations within six months of the INDEX. Cancellation was more prevalent than no show (17.7% vs 12.2%). Of those who cancelled and scheduled a next appointment, 28.8% experienced over 30 days delay between the INDEX and NEXT appointment dates, and 59.9% delayed rescheduling until on or after the cancelled appointment date. Delay in rescheduling was associated with an 18.6% increase in days between attended appointments and a 26.0% increase in ED visits. For diabetic patients, cancellation with late rescheduling is a prevalent and unhealthy behavior. Although more work is necessary to address the health, intervention, and cost issues, this work suggests that cancellation, like no show, may be problematic for many clinics and patients.

The Effect of Interactive Web-Based Monitoring on Breastfeeding Exclusivity, Intensity, and Duration in Healthy, Term Infants After Hospital Discharge.

OBJECTIVE: To determine whether a Web-based interactive breastfeeding monitoring system increased breastfeeding duration, exclusivity, and intensity as primary outcomes and decreased symptoms of postpartum depression as a secondary outcome. DESIGN: Two-arm, randomized controlled trial. SETTING: Three hospitals in the Midwestern United States. PARTICIPANTS: One hundred forty one (141) mother-newborn dyads were recruited before discharge. METHODS: Postpartum women were randomly assigned to the control or intervention groups. Women in the control group (n = 57) followed the standard hospital protocol, whereas women in the intervention group (n = 49) were given access to an online interactive breastfeeding monitoring system and were prompted to record breastfeeding and infant output data for 30 days. A follow-up online survey was sent to both groups at 1, 2, and 3 months to assess breastfeeding outcomes and postpartum depression. RESULTS: For mothers and infants, there were no significant differences in demographics between groups. No significant differences in breastfeeding outcomes were found between groups at discharge (p = .707). A significant difference in breastfeeding outcomes was found between groups at 1, 2, and 3 months (p = .027, p < .001, and p = .002, respectively). Members of the intervention group had greater exclusive breastfeeding rates at 1, 2, and 3 months. By the end of the third month, 84% of the intervention group was breastfeeding compared with 66% of the control group. Postpartum depression symptom scores decreased for both groups at 1, 2, and 3 months (control group: 4.9 ± 3.9, 4.3 ± 4.9, and 3.2 ± 3.9, respectively; intervention group: 4.7 ± 4.5, 3.0 ± 3.4, and 2.8 ± 3.6, respectively). However, there was no significant difference between groups at 1, 2, and 3 months (p = .389, .170, and .920, respectively) for depression. CONCLUSION: The Web-based interactive breastfeeding monitoring system may be a promising intervention to improve breastfeeding duration, exclusivity, and intensity.

The impact of interventions on appointment and clinical outcomes for individuals with diabetes: a systematic review.

BACKGROUND: Successful diabetes disease management involves routine medical care with individualized patient goals, self-management education and on-going support to reduce complications. Without interventions that facilitate patient scheduling, improve attendance to provider appointments and provide patient information to provider and care team, preventive services cannot begin. This review examines interventions based upon three focus areas: 1) scheduling the patient with their provider; 2) getting the patient to their appointment, and; 3) having patient information integral to their diabetes care available to the provider. This study identifies interventions that improve appointment management and preparation as well as patient clinical and behavioral outcomes. METHODS: A systematic review of the literature was performed using MEDLINE, CINAHL and the Cochrane library. Only articles in English and peer-reviewed articles were chosen. A total of 77 articles were identified that matched the three focus areas of the literature review: 1) on the schedule, 2) to the visit, and 3) patient information. These focus areas were utilized to analyze the literature to determine intervention trends and identify those with improved diabetes clinical and behavioral outcomes. RESULTS: The articles included in this review were published between 1987 and 2013, with 46 of them published after 2006. Forty-two studies considered only Type 2 diabetes, 4 studies considered only Type 1 diabetes, 15 studies considered both Type 1 and Type 2 diabetes, and 16 studies did not mention the diabetes type. Thirty-five of the 77 studies in the review were randomized controlled studies. Interventions that facilitated scheduling patients involved phone reminders, letter reminders, scheduling when necessary while monitoring patients, and open access scheduling. Interventions used to improve attendance were letter reminders, phone reminders, short message service (SMS) reminders, and financial incentives. Interventions that enabled routine exchange of patient information included web-based programs, phone calls, SMS, mail reminders, decision support systems linked to evidence-based treatment guidelines, registries integrated with electronic medical records, and patient health records. CONCLUSIONS: The literature review showed that simple phone and letter reminders for scheduling or prompting of the date and time of an appointment to more complex web-based multidisciplinary programs with patient self-management can have a positive impact on clinical and behavioral outcomes for diabetes patients. Multifaceted interventions aimed at appointment management and preparation during various phases of the medical outpatient care process improves diabetes disease management.