Individual and organizational factors influencing well-being and burnout amongst healthcare assistants: A systematic review.

Background: Increasing evidence suggests that clinician well-being influences patient, workforce, and organizational outcomes. Despite increasing attention to well-being among licensed clinicians (e.g., nurses and physicians), collective evidence about well-being among healthcare assistants, such as nursing and medical assistants, is limited. Healthcare assistants make up a substantial portion of the clinical workforce delivering direct patient care. The well-being of healthcare assistants is critical to ensure an ample workforce supply. The objective of this systematic review was to contribute a reproducible search, summary, appraisal, synthesis, and critique of the literature about well-being among healthcare assistants, including factors that induce or inhibit burnout, and to identify gaps in evidence that warrant future research. Methods: We performed a literature search across 4 databases with keywords using BOOLEAN operators. After an initial title and abstract screen, a search of relevant reference lists, and full text review was peformed independently by 2 researchers. Study quality was evaluated using Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies. We extracted study characteristics, results, and deductively analyzed each study's alignment with the United States National Academy of Medicine's Clinician Well-Being Model. Results: We identified 28 articles meeting our inclusion criteria. Our synthesis indicated that most studies investigated personal factors (e.g., financial stressors or physical, emotional, and spiritual health) as opposed to organizational or policy factors (e.g., occupational policies or workplace culture) that may impact well-being. Younger workers and those with fewer years of experience appear to have higher burnout risk. Sleep health, improved unit-based culture (respect and increased decision-making with nurses), shorter shifts, and increased social support appear to be the most protective against burnout. Discussion: There remains a scarcity of evidence about factors impacting well-being among healthcare assistants. Existing literature focuses on individual, as opposed to external or organizational, contributory factors to burnout or well-being risk. Future studies should use specific methods to define and measure healthcare assistant roles, isolate harmful individual and organizational factors, and measure more specific sub-concepts of well-being such as depression. Such studies can contribute greatly to the overall understanding of healthcare assistant health and wellness, which subsequently may promote optimal patient and organizational outcomes. Tweetable abstract: The hidden workforce: Systematic review demonstrates gaps in evidence about wellbeing and burnout among healthcare assistants and aides.

Intrinsic Factors and Psychological Safety Among Nursing Students During Simulation-Based Learning-A Correlational Design.

INTRODUCTION: Well-designed simulation-based learning (SBL) experiences enhance students' self-confidence, self-efficacy, clinical judgment, and psychomotor skill development. An emerging concept in SBL research is psychological safety. There is currently no research on factors influencing psychological safety specifically related to the SBL environment, nor is there any literature found to determine whether intrinsic student characteristic, such as self-compassion and resilience, contributes to SBL learning outcomes. The aim of this study is to determine whether there is a relationship between nursing students' intrinsic characteristics (self-compassion, resilience, and anxiety sensitivity) and their psychological safety. METHODS: Bivariate correlation was used to examine associations among sociodemographic variables and outcome variables. Multiple regression was used to determine the predictive nature of the sociodemographic variables. Assumptions for variables in multiple regression models were tested (normal distribution, heteroscedasticity, multicollinearity). All data were analyzed in SPSS, Version 28. The P value of significance was set at 0.05 for all analyses. RESULTS: Most of the 118 participants were non-Hispanic (89%), White (65%), and females (95%). Results of the demographic bivariate analysis revealed no significant differences among this diverse group or semester in the curriculum for psychological safety. The multiple regression found self-compassion (ß = 29, P = 0.004), anxiety sensitivity (ß = -0.16, P = 0.049), and resilience (ß = 0.26, P = 0.004) predict psychological safety. CONCLUSIONS: The importance of creating a psychologically safe learning environment has been recognized as essential to best practices. Our findings suggest that an understanding of student characteristics that impact their perception of psychological safety will allow educators to develop strategies to better support learners in the simulation environment.

Organizational trust breaches among nurses and aides: A qualitative study.

BACKGROUND: Healthcare worker retention and burnout are confounding issues. Trust among workers and their employer, that is, organization, is an important yet underexplored concept in research. RESEARCH AIM: The aim of this qualitative study is to explore organizational actions and systems that promote or denigrate trust among registered nurses and patient care aides (aides). RESEARCH DESIGN: The study uses the Model of Psychological Contract as a theoretical framework. Focus groups were conducted to explore the concept of organizational trust and the consequences of broken trust. PARTICIPANTS: Registered nurses (RNs) (n=6) and aides (n=6) participated in the study. Six focus groups (three RN and three aide) were conducted, with two participants per group. Focus groups were conducted online. ETHICAL CONSIDERATIONS: The study's methods were reviewed by the University of Pittsburgh Institutional Review Board. FINDINGS: Among RNs and aides, a sense of trust and feeling valued were important to their sense of relationship with their employers. Trust was breached when resources were scarce, employees did not feel validated and listened to, and problems were not addressed. RNs and aides described feeling devalued when compensation practices were unjust or inequitable, they had limited autonomy, and the employer created an organizational climate where business needs superceded human caring. Consequences of trust breach included burnout, dejection, and feelings of non-belonging. DISCUSSION: Tangible organizational resources (compensation and staffing) and intangible resources (value, respect, autonomy) are important to RNs and aides alike. Inability to provide these resources diminishes trust and even causes a sense of betrayal. CONCLUSION: Future research can explore the concepts of organizational justice and interventions to restore lost trust and improve healthcare worker well-being. This is one of only a few identified studies to explore organizational factors and well-being among aides and more research among this healthcare worker population is warranted.

Construct Validity Testing of the Provider Co-Management Index to Measure Shared Care in Provider Dyads.

BACKGROUND: Co-management encompasses the dyadic process between two healthcare providers. The Provider Co-Management Index (PCMI) was initially developed as a 20-item instrument across three theory-informed subscales. OBJECTIVE: This study aimed to establish construct validity of the PCMI with a sample of primary care providers through exploratory and confirmatory factor analyses. METHODS: We conducted a cross-sectional survey of primary care physicians, nurse practitioners, and physician assistants randomly selected from the IQVIA database across New York State. Mail surveys were used to acquire a minimum of 300 responses for split sample factor analyses. The first subsample (derivation sample) was used to explore factorial structure by conducting an exploratory factor analysis. A second (validation) sample was used to confirm the emerged factorial structure using confirmatory factor analysis. We performed iterative analysis and calculated good fit indices to determine the best-fit model. RESULTS: There were 333 responses included in the analysis. Cronbach's alpha was high for a three-item per dimension scale within a one-factor model. The instrument was named PCMI-9 to indicate the shorter version length. DISCUSSION: This study established the construct validity of an instrument that scales the co-management of patients by two providers. The final instrument includes nine items on a single factor using a 4-point, Likert-type scale. Additional research is needed to establish discriminant validity.

Critical Care Nurses' Moral Resilience, Moral Injury, Institutional Betrayal, and Traumatic Stress After COVID-19.

BACKGROUND: Traumatic stress and moral injury may contribute to burnout, but their relationship to institutional betrayal and moral resilience is poorly understood, leaving risk and protective factors understudied. OBJECTIVES: To examine traumatic stress symptoms, moral injury symptoms, moral resilience, and institutional betrayal experienced by critical care nurses and examine how moral injury and traumatic stress symptoms relate to moral resilience, institutional betrayal, and patient-related burnout. METHODS: This cross-sectional study included 121 critical care nurses and used an online survey. Validated instruments were used to measure key variables. Descriptive statistics, regression analyses, and group t tests were used to examine relationships among variables. RESULTS: Of participating nurses, 71.5% reported significant moral injury symptoms and/or traumatic stress. Both moral injury symptoms and traumatic stress were associated with burnout. Regression models showed that institutional betrayal was associated with increased likelihood of traumatic stress and moral injury. Increases in scores on Response to Moral Adversity subscale of moral resilience were associated with a lower likelihood of traumatic stress and moral injury symptoms. CONCLUSIONS: Moral resilience, especially response to difficult circumstances, may be protective in critical care environments, but system factors (eg, institutional betrayal) must also be addressed systemically rather than relying on individual-level interventions to address nurses' needs.

Relationships of organizational behavior/mission congruence with burnout, secondary traumatic stress, and compassion satisfaction among nurses.

OBJECTIVE: The current study focuses on organizational culture as a determinant of well-being among nurses. BACKGROUND: Nurse well-being is an increasing concern for organizational operations and patient care quality. There are limited studies on the aspects of organizational culture, such as leadership and perception of organizational mission, that relate to clinician well-being. METHODS: A cross-sectional survey study was conducted among nurses in a U.S. hospital. Measures were professional quality of life, organizational culture, and authentic leadership. Statistical methods were used to analyze findings. RESULTS: Among the nurses (N = 147), after controlling for significant demographic factors, organizational culture and authentic leadership had significant correlations with burnout, secondary traumatic stress, and compassion satisfaction. In multivariate analyses, organizational culture was a significant predictor for burnout and compassion satisfaction. CONCLUSION: This study provides empirical evidence that organizational behavior is important to staff well-being. Organizations that act with fidelity to their missions of caring and quality patient care are more likely to have nursing staff that are emotionally healthy in the workplace.

Analyzing the Effects of Family Presence and Visitation Restrictions During the COVID-19 Pandemic Among Nurse Leaders and Non-Nurse Leaders.

AIM: This analysis seeks to identify the effect of family presence and visitation during COVID-19 pandemic among nurses and nurse leaders. BACKGROUND: Visitation restrictions were widespread during the initial months of the COVID-19 pandemic and were a potential source of distress for nurses. Few studies have examined sources of distress, such as visitation restrictions, among nurse leaders and non-nurse leaders. METHODS: Secondary analysis was performed using a national survey of nurses conducted by the American Nurses Foundation. RESULTS: More nurse leaders than nonleaders reported that nurses were involved in policy decisions/discussions and that visitation restrictions created additional burdens. There was similar level of agreement among nurse leaders and nonleaders that restrictions were not in the best interest of the patients. Many nurses reported the restrictions impacted their own well-being. CONCLUSION: Visitation restrictions were a likely source of distress. Improvements to communication, planning, and transparency should be considered in preparation for future emergencies that may require visitation restrictions.

Initial psychometric properties of the provider-co-management index-RN to scale registered nurse-physician co-management: Implications for burnout, job satisfaction, and intention to leave current position.

Team-based care has become a cornerstone of care delivery to meet the demands of high-quality patient care. Yet, there is a lack of valid and reliable instruments to measure the effectiveness of co-management between clinician dyads, particularly physicians and registered nurses (RNs). The purpose of this study was to adapt an existing instrument, Provider Co-Management Index (PCMI), previously used among primary care providers into a new version to scale RN-physician co-management (called PCMI-RN). We also aimed to explore preliminary associations between RN-physician co-management and burnout, job satisfaction, and intention to leave current job. Face, cognitive, and content validity testing, using mixed methods approaches, were preceded by initial pilot testing (n = 122 physicians and nurses) in an acute care facility. The internal consistency reliability (α=.83) was high. One-quarter of participants reported burnout, 27% were dissatisfied with their job, and 20% reported intention to leave their job. There was a weak significant correlation between co-management and burnout (p = .010), and co-management and job satisfaction (p = .009), but not intention to leave current position. Construct validity testing is recommended. Future research using PCMI-RN may help to isolate factors that support or inhibit effective physician-nurse co-management.

Health Insurance Status as a Predictor of Mode of Colon Cancer Detection but Not Stage at Diagnosis: Implications for Early Detection.

OBJECTIVE: For colon cancer patients, one goal of health insurance is to improve access to screening that leads to early detection, early-stage diagnosis, and polyp removal, all of which results in easier treatment and better outcomes. We examined associations among health insurance status, mode of detection (screen detection vs symptomatic presentation), and stage at diagnosis (early vs late) in a diverse sample of patients recently diagnosed with colon cancer from the Chicago metropolitan area. METHODS: Data came from the Colon Cancer Patterns of Care in Chicago study of racial and socioeconomic disparities in colon cancer screening, diagnosis, and care. We collected data from the medical records of non-Hispanic Black and non-Hispanic White patients aged ≥50 and diagnosed with colon cancer from October 2010 through January 2014 (N = 348). We used logistic regression with marginal standardization to model associations between health insurance status and study outcomes. RESULTS: After adjusting for age, race, sex, and socioeconomic status, being continuously insured 5 years before diagnosis and through diagnosis was associated with a 20 (95% CI, 8-33) percentage-point increase in prevalence of screen detection. Screen detection in turn was associated with a 15 (95% CI, 3-27) percentage-point increase in early-stage diagnosis; however, nearly half (47%; n = 54) of the 114 screen-detected patients were still diagnosed at late stage (stage 3 or 4). Health insurance status was not associated with earlier stage at diagnosis. CONCLUSIONS: For health insurance to effectively shift stage at diagnosis, stronger associations are needed between health insurance and screening-related detection; between screening-related detection and early stage at diagnosis; or both. Findings also highlight the need to better understand factors contributing to late-stage colon cancer diagnosis despite screen detection.

Institutional betrayal in nursing: A concept analysis.

BACKGROUND: Ethical relationships are important among many participants in healthcare, including the ethical relationship between nurse and employer. One aspect of organizational behavior that can impact ethical culture and moral well-being is institutional betrayal. RESEARCH AIM: The purpose of this concept analysis is to develop a conceptual understanding of institutional betrayal in nursing by defining the concept and differentiating it from other forms of betrayal. DESIGN: This analysis uses the method developed by Walker and Avant. RESEARCH CONTEXT: Studies were reviewed using health literature databases with no date restrictions. ETHICAL CONSIDERATIONS: Analysis was conducted using established guidelines for ethical research. FINDINGS: Although institutional betrayal is a concept applied in the literature, there was a paucity of studies exploring the concept within nursing. Examples of the concept in the literature include violation of trust between organization (i.e. employer) and nurse, such as provision of inadequate workplace protections, ineffective or hostile management, and gaslighting of those who experience negative events. Examples of institutional betrayal have become more visible during the COVID-19 pandemic. DISCUSSION: A conceptual definition of institutional betrayal is a deep violation of trust or confidence or violation of moral standards committed by an institution toward a nurse. This definition incorporates experiences and issues suggested by the literature. Outcomes are likely negative, including impacts on nurse psychological and workplace well-being. This concept likely fits within a framework of ethical workplaces and has conceptual relationships with moral distress and moral resilience. Further studies can help qualitatively explore and empirically measure this concept. CONCLUSION: In the pursuit of improving the ethical culture of healthcare workplaces, this concept can provide meaningful insight into organizational behavior and its consequences. Naming and describing the concept can promote conceptual clarity and equip researchers, nurses, and leaders to identify and mitigate the issue.

Race and Gender Differences in Awareness of Colorectal Cancer Screening Tests and Guidelines Among Recently Diagnosed Colon Cancer Patients in an Urban Setting.

The purpose of this study was to first characterize the prevalence of recall, recognition, and knowledge of colon cancer screening tests and guidelines (collectively, "awareness") among non-Hispanic black (NHB) and NH white (NHW) urban colon cancer patients. Second, we sought to examine whether awareness was associated with mode of cancer detection. Low awareness regarding colon cancer screening tests and guidelines may explain low screening rates and high prevalence of symptomatic detection. We examined recall, recognition, and knowledge of colorectal cancer (CRC) screening tests and guidelines and their associations with mode of cancer detection (symptomatic versus screen-detected) in 374 newly diagnosed NHB and NHW patients aged 45-79. Patients were asked to name or describe any test to screen for colon cancer (recall); next, they were given descriptions of stool testing and colonoscopy and asked if they recognized each test (recognition). Lastly, patients were asked if they knew the screening guidelines (knowledge). Overall, awareness of CRC screening guidelines was low; just 20% and 13% of patients knew colonoscopy and fecal test guidelines, respectively. Awareness of CRC screening tests and guidelines was especially low among NHB males, socioeconomically disadvantaged individuals, and those diagnosed at public healthcare facilities. Inability to name or recall a single test was associated with reduced screen-detected cancer compared with recall of at least one test (36% vs. 22%, p = 0.01). Low awareness of CRC screening tests is a risk factor for symptomatic detection of colon cancer.

Gender- and Race-Based Differences in Barriers and Facilitators to Early Detection of Colon Cancer.

Background: Early detection of colon cancer is essential to successful treatment and survival, yet most patients are diagnosed only after onset of symptoms. Previous studies suggest differences in colon cancer screening and presentation by gender and race, but reasons for this are not understood. The purpose of this study was to identify barriers and facilitators to early detection of colon cancer and to compare by gender and race. Materials and Methods: In the Colon Cancer Patterns of Care in Chicago study, non-Hispanic Black and White (NHB, NHW) patients aged 30-79 newly diagnosed with colon cancer between 2010 and 2014 (n = 249) underwent in-depth semistructured interviews regarding the pathway to colon cancer diagnosis. Mixed qualitative and quantitative methods were used to analyze patient narratives and to compare response patterns by gender and race within prespecified domains: health care access factors, provider-related factors, patient-related factors, and diagnostic workup factors. Results: Women reported more barriers than facilitators to early detection than men (barrier: facilitator ratio of 0.60 vs. 0.48). Thematic differences were seen, with women reporting more barriers related to health care access, scheduling of follow-ups, symptom recognition, and inappropriate or inconclusive diagnostic tests. Fewer women than men reported facilitators related to provider factors such as ease of scheduling follow-ups and receiving referrals for screening or a specialist. NHBs and NHWs reported similar ratios of barriers to facilitators (0.55 vs. 0.53), but more NHBs than NHWs reported barriers related to health care access, scheduling follow-ups, and clinical delays, and fewer NHBs reported facilitators related to health care accessibility (existing relationship with provider, ease of scheduling follow-ups). Conclusions: In this diverse population of patients recently diagnosed with colon cancer, we identified substantive gender- and race-based differences in the types and burden of barriers and facilitators to early detection experienced in the path to diagnosis. These differences should be explored further as they may contribute to disparities in the diagnosis and prognosis of colon cancer.

Workplace bullying among nurses and organizational response: An online cross-sectional study.

AIMS: To examine prevalence of bullying among nurses and explore associations of organizational betrayal and support with well-being among nurses exposed to bullying. BACKGROUND: Bullying is a problem in many nursing workplaces, and organizations have an obligation to support nurses who are bullied. Support or betrayal after bullying could affect nurse well-being, including burnout. METHODS: In this cross-sectional study among U.S. nurses, data were collected in a survey using the Negative Acts Questionnaire-Revised for Nursing, the Institutional Betrayal Questionnaire for Health, the Well-Being Index, a job satisfaction scale and demographic questions. RESULTS: Prevalence of weekly/daily bullying was 31% (N = 242). Among nurses exposed to any bullying (N = 173), organizational betrayal increased odds of burnout (OR 2.62, p = .02), job dissatisfaction (OR 2.97, p = .04) and absenteeism (OR 6.11, p < .001). Organizational support decreased odds of job dissatisfaction (OR 0.30, p = .001) and absenteeism (OR 0.50, p = .04). CONCLUSION: Analysis of study findings suggests organizational betrayal increases likelihood of burnout, job dissatisfaction and absenteeism, and support decreases likelihood of dissatisfaction and absenteeism. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse leaders should be aware of the issue of organizational betrayal and support in relation to well-being. Future studies can further explore the concepts of betrayal and support to provide additional evidence.

Association of externalizing religious and spiritual beliefs on stage of colon cancer diagnosis among black and white multicenter urban patient populations.

BACKGROUND: This study explores whether externalizing religious and spiritual beliefs is associated with advanced-stage colon cancer at initial oncology presentation and whether this association is stronger for blacks than for whites. METHODS: Patients who had newly diagnosed, invasive colon cancer were recruited at 9 sites in the Chicago metropolitan area. Eligible patients were non-Hispanic white or black, ages 30 to 79 years, and diagnosed with a primary invasive colon cancer. Patients were interviewed on prior screening and diagnosis. Social and attitudinal constructs were measured, including the God Locus of Health Control (GLHC) and Religious Problem Solving. The final response rate was 52% and included 407 patients. RESULTS: The median age was 59 years (range, 30-79 years), and 51% of participants were black. Cancer stage was available for 389 (96%) patients and was divided between late stage (stages III-IV; 60%) and early stage (stages I-II; 40%). Multivariate analysis indicated that patients in the highest tertile of scores on the GLHC were more likely have an advanced stage of disease at presentation (odds ratio, 2.14; 95% confidence interval, 1.00-4.59; P = .05) compared with those in the lowest tertile. No significant interaction was identified between race and GLHC scores for stage at presentation (P = .78). CONCLUSIONS: In a large sample of black and white individuals across diverse health care systems, higher scores on the GLHC predicted late disease stage at presentation. Although blacks had significantly higher GLHC scores, race was not associated with stage at presentation, nor was the association between GLHC and stage limited to blacks. Further work is needed to better understand this association and to develop interventions to better connect the religious and health care spheres. Cancer 2018;124:2578-87. © 2018 American Cancer Society.

Examining racial disparities in colon cancer clinical delay in the Colon Cancer Patterns of Care in Chicago study.

PURPOSE: We explored a potential racial disparity in clinical delay among non-Hispanic (nH) Black and White colon cancer patients and examined factors that might account for the observed disparity. METHODS: Patients aged 30-79 years with a newly diagnosed colon cancer from 2010 to 2014 (n = 386) were recruited from a diverse sample of nine public, private, and academic hospitals in and around Chicago. Prolonged clinical delay was defined as 60 days or more or 90 days or more between medical presentation (symptoms or a screen-detected lesion) and treatment initiation (surgery or chemotherapy). Multivariable logistic regression with model-based standardization was used to estimate the disparity as a difference in prevalence of prolonged delay by race. RESULTS: Prevalence of delay in excess of 60 days was 12 percentage points (95% confidence interval: 2%, 22%) higher among nH Blacks versus Whites after adjusting for age, facility, and county of residence. Travel burden (time and distance traveled from residence to facility) explained roughly one-third of the disparity (33%, P = .05), individual and area-level socioeconomic status measures explained roughly one-half (51%, P = .21), and socioeconomic measures together with travel burden explained roughly four-fifths (79%, P = .08). CONCLUSIONS: Low socioeconomic status and increased travel burden are barriers to care disproportionately experienced by nH Black colon cancer patients.

Trends in Use of Biomarker Protocols for the Evaluation of Possible Myocardial Infarction.

BACKGROUND: Various combinations of creatine kinase-MB, myoglobin, and cardiac troponin I or T (cTnI/cTnT) have been used to evaluate patients with suspected acute coronary syndromes. The current recommendation is to use the 99th percentile of cTnI/cTnT as the sole marker for diagnosis of acute myocardial infarction. METHODS AND RESULTS: We retrospectively analyzed cardiac marker protocols collected from 824 US hospitals undergoing Chest Pain Center Accreditation through the Society of Cardiovascular Patient Care from 2009 to 2014. Data were obtained by a self-reported survey that addressed cardiac marker(s), sampling time periods, and cut points used for evaluation of suspected acute myocardial infarction. The combination of cTnI or cTnT with creatine kinase-MB was the most commonly used biomarker strategy. Use of cTnI or cTnT as the sole marker increased over time (14-37%; P<0.0001), as did use of the 99th percentile cut point for cTnI/cTnT (30-60%; P<0.0001). CONCLUSION: There is considerable variation in cardiac marker testing strategies used in US hospitals for evaluation of suspected acute myocardial infarction. Although increasing, 24% of hospitals used a cTn alone strategy, and only 49% used cTn at the recommended 99th percentile cut point. This has important implications for the diagnosis and treatment of patients with acute myocardial infarction.

Inner Retinal Oxygen Delivery, Metabolism, and Extraction Fraction in Ins2Akita Diabetic Mice.

PURPOSE: Retinal nonperfusion and hypoxia are important factors in human diabetic retinopathy, and these presumably inhibit energy production and lead to cell death. The purpose of this study was to elucidate the effect of diabetes on inner retinal oxygen delivery and metabolism in a mouse model of diabetes. METHODS: Phosphorescence lifetime and blood flow imaging were performed in spontaneously diabetic Ins2Akita (n = 22) and nondiabetic (n = 22) mice at 12 and 24 weeks of age to measure retinal arterial (O2A) and venous (O2V) oxygen contents and total retinal blood flow (F). Inner retinal oxygen delivery (DO2) and metabolism (MO2) were calculated as F ∗ O2A and F ∗ (O2A - O2V), respectively. Oxygen extraction fraction (OEF), which equals MO2/DO2, was calculated. RESULTS: DO2 at 12 weeks were 112 ± 40 and 97 ± 29 nL O2/min in nondiabetic and diabetic mice, respectively (NS), and 148 ± 31 and 85 ± 37 nL O2/min at 24 weeks, respectively (P < 0.001). MO2 were 65 ± 31 and 66 ± 27 nL O2/min in nondiabetic and diabetic mice at 12 weeks, respectively, and 79 ± 14 and 54 ± 28 nL O2/min at 24 weeks, respectively (main effects = NS). At 12 weeks OEF were 0.57 ± 0.17 and 0.67 ± 0.09 in nondiabetic and diabetic mice, respectively, and 0.54 ± 0.07 and 0.63 ± 0.08 at 24 weeks, respectively (main effect of diabetes: P < 0.01). CONCLUSIONS: Inner retinal MO2 was maintained in diabetic Akita mice indicating that elevation of the OEF adequately compensated for reduced DO2 and prevented oxidative metabolism from being limited by hypoxia.

The Effects of Diabetic Retinopathy Stage and Light Flicker on Inner Retinal Oxygen Extraction Fraction.

PURPOSE: We determined the effects of light flicker and diabetic retinopathy (DR) stage on retinal vascular diameter (D), oxygen saturation (SO2), and inner retinal oxygen extraction fraction (OEF). METHODS: Subjects were categorized as nondiabetic control (NC, n = 42), diabetic with no clinical DR (NDR; n = 32), nonproliferative DR (NPDR; n = 42), or proliferative DR (PDR; n = 14). Our customized optical imaging system simultaneously measured arterial and venous D (DA, DV) and SO2 (SO2A, SO2V) before and during light flicker. Inner retinal OEF was derived from SO2 values. Light flicker-induced ratios of metrics (DAR, DVR, SO2AR, SO2VR, OEFR) were calculated. RESULTS: Arterial D was larger in NPDR compared to NC (P = 0.01) and PDR (P = 0.002), whereas DV was similar among groups (P ≥ 0.16). Light flicker increased DA and DV (P ≤ 0.004), but DAR and DVR were similar among groups (P ≥ 0.09). Arterial SO2 was higher in all groups compared to NC (P ≤ 0.02) and higher in PDR compared to NDR and NPDR (P<0.001). Arterial SO2 did not change with light flicker (P ≥ 0.1). Venous SO2 was higher in NPDR and PDR compared to NC and NDR (P ≤ 0.02). Light flicker increased SO2V in NC, NDR, and PDR (P ≤ 0.003), and SO2VR was lower in NPDR compared to NC and NDR (P ≤ 0.05). Inner retinal OEF was lower in NPDR compared to NDR and PDR (P ≤ 0.02). Light flicker decreased OEF (P ≤ 0.03), but OEFR was greater in NPDR compared to NC and NDR (P ≤ 0.03). CONCLUSIONS: The findings of alterations in retinal D, SO2, OEF, and their light flicker-induced responses at stages of DR may be useful to elucidate the pathophysiology of DR.

The effect of time on racial differences in epithelial ovarian cancer (OVCA) diagnosis stage, overall and by histologic subtypes: a study of the National Cancer Database.

PURPOSE: Previous studies assessing racial and ethnic differences in ovarian cancer (OVCA) diagnosis stage fail to present subtype-specific results and provide historic data on cases diagnosed between 10 and 20 years ago. The purpose of this analysis is to assess non-Hispanic Black (NHB) and non-Hispanic White (NHW) differences in late-stage diagnosis including; (1) factors associated with late-stage diagnosis of invasive epithelial OVCA overall and by histologic subtypes, (2) potential changes across time and (3) current patterns of trends in a national cancer registry in the USA and Puerto Rico between 1998 and 2011. METHODS: NHB and NHW OVCA cases were derived from the National Cancer Database (NCDB). Diagnosis stage was analyzed as a dichotomous and a four level-category variable, respectively; early (stages I and II; localized) versus late (stages III and IV; regional and distant) and stages I, II, III and IV. Diagnosis period was trichotomized (1998-2002, 2003-2007, 2008-2011). Racial differences in stage were tested using Chi-square statistics. Odds ratios (OR) and 95 % confidence intervals (95 % CI) were estimated using multivariable binomial and generalized ordered logistic regressions. Interactions between race and diagnosis period were evaluated. RESULTS: Between 1998 and 2011, 11,562 (7.8 %) NHB and 137,106 (92.2 %) NHW were diagnosed with OVCA. In adjusted models, NHB were significantly more likely diagnosed with late-stage OVCA than NHW (ORadj 1.26, 95 % CI 1.19-1.33). Interaction between race and diagnosis period was marginally significant (p value = 0.09), with racial differences in stage decreasing over time (1998-2002: ORadj 1.36, 95 % CI 1.23-1.49; 2003-2007: ORadj 1.27, 95 % CI 1.15-1.39; 2008-2011; ORadj 1.15, 95 % CI 1.05-1.27). NHB were also more likely to be diagnosed with stage 4 high-grade serous (ORadj 1.46, 95 % CI 1.22-1.74), clear cell (ORadj 2.71, 95 % CI 1.94-3.79) and mucinous (ORadj 2.78, 95 % CI 2.24-3.46) carcinomas than NHW. CONCLUSIONS: Racial differences in late-stage OVCA diagnosis exist; however, these differences are decreasing with time. Within NCDB, NHB are significantly more likely diagnosed with late-stage OVCA and more specifically high-grade serous, clear cell and mucinous carcinomas than NHW.