Teaching Guided Imagery and Relaxation Techniques in Undergraduate Nursing Education.

Guided imagery and relaxation techniques have many documented benefits yet are not traditionally taught in undergraduate nursing education. These techniques can also be used by clinicians and students to manage their own stress. The impact of teaching guided imagery in an experiential skills lab on undergraduate nursing students was examined in this mixed-methods research study. Goals were to evaluate whether students learning these skills would be more likely to use them in clinical practice, to examine whether learning these skills would provide personal benefits, and to compare personal instruction with video instruction. Students completed questionnaires evaluating the experience in terms of satisfaction, personal benefit, and intent to use. Students provided comments and answered open-ended questions regarding personal and professional benefits and ability to apply knowledge and skills. Results were positive, with students reporting satisfaction with the format, personal benefit from the course, and increased likelihood that they will use the techniques with clients in the future. The lowest scores were on confidence in using the technique with clients. A statistically significant finding is that students preferred personal instruction in the areas of satisfaction with the content, satisfaction with the format, and the value of experience in advance of using these skills with patients (p < .05).

A review of global health technology assessments of non-VKA oral anticoagulants in non-valvular atrial fibrillation.

BACKGROUND: This review assessed global health technology assessment (HTA) reports and recommendations of non-vitamin K oral anticoagulants (NOACs) in non-valvular atrial fibrillation (NVAF). METHODS: NHTA agency websites were searched for HTA reports evaluating NOACs versus NOACs or vitamin K antagonists. HTA methods and information on patient involvement/access were collected and empirically analyzed. RESULTS: The review identified 38 unique HTA reports published between 2012 and 2017 in 16 countries including 11 in Europe. NOACs that were cost-effective per local willingness-to-pay (WTP) thresholds were positively recommended for the treatment of NVAF. WTP thresholds ranged from €20,000 to 69,000. Apixaban was recommended in 10/12 (83%) countries, dabigatran in 9/13 (69%) countries, and rivaroxaban in 10/13 (76%) over warfarin. Edoxaban was recommended in 5/7 (71%) countries. Economic evaluations and recommendations comparing NOACs were sparse (two or three countries per NOAC) and generally favored apixaban and edoxaban, followed by dabigatran. Eleven HTA reports from four countries considered the patient voice (Canada [n = 3], Scotland [n = 3], England [n = 4], Brazil [n = 1]); however, only 2/11 (18%) developed recommendations based on this. Among the reports with a positive recommendation, 26/30 (87%) featured a decision that aligned with the approved regulatory label. CONCLUSIONS: Most agencies recommended NOACs over warfarin for patients with NVAF. Few countries made statements recommending one NOAC over another. Given different WTP thresholds, a drug that is cost-effective in one market may not be in another. Therefore, the various NOAC recommendations from HTA agencies cannot be generalized across different countries.

Change in Cardiometabolic Risk Factors Associated With Magnitude of Weight Regain 3 Years After a 1-Year Intensive Lifestyle Intervention in Type 2 Diabetes Mellitus: The Look AHEAD Trial.

Background Weight regain after weight loss is common. The impact on cardiometabolic risk factors is not well established. Methods and Results Publicly available data were analyzed from participants of the Look AHEAD (Action for Health in Diabetes) trial with ≥3% initial weight loss (n=1561) during a 1-year intensive lifestyle intervention and with year 4 follow-up data. Participants who regained (regainers) or maintained (maintainers) weight loss were defined with 5 dichotomized cut points (0%, 25%, 50%, 75%, and 100%) of percentage weight loss regained (weight change from years 1-4 as percentage of first year weight loss). Change in cardiometabolic risk factors after initial weight loss was compared in maintainers and regainers, after controlling for demographics, medications, and baseline and year 1 change in body mass index. The effect was assessed separately in participants with <10% and ≥10% initial weight loss, and women and men. Maintainers exhibited significant improvements to the cardiometabolic risk factors assessed compared with regainers. No weight regain cut point maximized risk difference between maintainers and regainers across risk factors or sex/initial weight loss subgroups. For many risk factors, allowing more regain as part of maintenance (increasing cut point) diminished the cardiometabolic benefit among maintainers. Conclusions Maintaining weight loss was better than regain for all risk factors. No single cut point maximized the risk difference between maintainers and regainers. Maintainers who kept off ≥75% of weight lost had the greatest benefit. These findings emphasize the importance of intervention programs focusing not only on weight loss but weight loss maintenance, given the adverse consequences of the latter. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00017953.

Systematic review of societal costs associated with stroke, bleeding and monitoring in atrial fibrillation.

Aim: Economic consequences associated with the rise in nonvitamin K antagonist oral anticoagulant use on a societal level remain unclear. Materials & methods: Evidence from the past decade on the societal economic burden associated with stroke, bleeding and international normalized ratio monitoring in atrial fibrillation was collected and summarized through a systematic literature review. Results: There were 14 studies identified that reported indirect costs, which were highest among patients with hemorrhagic stroke and intracranial hemorrhage. The contribution of indirect costs to the total was marginal during acute treatment but substantially increased (30-50%) 2 years after stroke and bleeding events. Conclusion: Limited data were available on societal costs in atrial fibrillation and further research is warranted.

Anticoagulant selection for patients with VTE-Evidence from a systematic literature review of network meta-analyses.

The aim of this study was to systematically review published network meta-analyses (NMAs) that compare venous thromboembolism (VTE) treatments. A systematic literature search (in MEDLINE, Embase, and Cochrane Database of Systematic Reviews through September 2017) was conducted to identify NMAs that compared the safety and efficacy of direct oral anticoagulants (DOACs) for the treatment of VTE in the acute and extended treatment settings. The NMAs included randomized controlled trials comparing multiple DOACs, low-molecular weight heparin, unfractionated heparin, and vitamin K antagonists (VKAs). The quality of the NMA results were evaluated using the Grading of Recommendations and Evaluation (GRADE) assessment. The SLR identified 294 records and nine NMAs (68 trials). Among the NMAs, three evaluated the acute treatment setting, five the extended, and one in both treatment settings. The NMAs showed a significant reduction in major bleeding and clinically relevant bleeding (CRB) with apixaban compared to other DOACs. Major bleeding with apixaban was reduced compared to dabigatran, edoxaban, and fondaparinux-VKA combination in all comparisons in the acute setting (range of effect estimates: 0.30-0.43). CRB was reduced with apixaban compared to dabigatran, edoxaban, and rivaroxaban in the acute and extended settings (range of effect estimates: 0.23-0.72). No significant differences were seen in efficacy outcomes between the DOACs. This SLR of NMAs systematically collected all indirect evidence of the impact of apixaban compared to other anticoagulants in patients with VTE. In the absence of head-to-head trials, well-conducted NMAs provide the best evidence.

Investigation of the C-3-epi-25(OH)D3 of 25-hydroxyvitamin D3 in urban schoolchildren.

The physiological relevance C-3 epimer of 25-hydroxyvitamin D (3-epi-25(OH)D) is not well understood among youth. The objective of this study was to assess whether demographic/physiologic characteristics were associated with 3-epi-25(OH)D3 concentrations in youth. Associations between 3-epi-25(OH)D3 and demographics and between 3-epi-25(OH)D3, total 25-hydroxyvitamin (25(OH)D) (25(OH)D2 + 25(OH)D3), total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides were examined in racially/ethnically diverse schoolchildren (n = 682; age, 8-15 years) at Boston-area urban schools. Approximately 50% of participants had detectable 3-epi-25(OH)D3 (range 0.95-3.95 ng/mL). The percentage of 3-epi-25(OH)D3 of total 25(OH)D ranged from 2.5% to 17.0% (median 5.5%). Males were 38% more likely than females to have detectable 3-epi-25(OH)D3 concentrations. Both Asian and black race/ethnicity were associated with lower odds of having detectable 3-epi-25(OH)D3 compared with non-Hispanic white children (Asian vs. white, odds ratio (OR) 0.28, 95% confidence interval (CI) 0.14-0.53; black vs. white, OR 0.38, 95%CI 0.23-0.63, p < 0.001). Having an adequate (20-29 ng/mL) or optimal (>30 ng/mL) 25(OH)D concentration was associated with higher odds of having detectable 3-epi-25(OH)D3 than having an inadequate (<20 ng/mL) concentration (OR 4.78, 95%CI 3.23-6.94 or OR 14.10, 95%CI 7.10-28.0, respectively). There was no association between 3-epi-25(OH)D3 and blood lipids. However, when considering 3-epi-25(OH)D3 as a percentage of total 25(OH)D, total cholesterol was lower in children with percent 3-epi-25(OH)D3 above the median (mean difference -7.1 mg/dL, p = 0.01). In conclusion, among schoolchildren, sex, race/ethnicity, and total serum 25(OH)D concentration is differentially associated with 3-epi-25(OH)D. The physiological relevance of 3-epi-25(OH)D3 may be related to the 3-epi-25(OH)D3 as a percentage of total 25(OH)D and should be considered in future investigations.

Comparison among criteria to define successful weight-loss maintainers and regainers in the Action for Health in Diabetes (Look AHEAD) and Diabetes Prevention Program trials.

Background: Given the low rates of successful weight maintenance after lifestyle-induced weight loss, it is critical to develop approaches that distinguish successful weight-loss maintainers from regainers.Objective: The aim of this study was to compare published categorization criteria that differentiate maintainers and regainers via quantitative agreement.Design: The study used publicly available data from Look AHEAD (Action for Health in Diabetes; n = 1791) and Diabetes Prevention Program (DPP; n = 613) participants with ≥3% initial weight loss after lifestyle interventions and 4-y follow-up data. Eight previously published criteria defining maintainers and regainers were compared with respect to number of participants and concordance via agreement statistics. Criteria were assessed separately among those with 3-9% and ≥10% initial weight loss.Results: Regainers had higher body weight at year 4 than did maintainers (mean difference range: 6.6-11.9 kg in Look AHEAD; 11.5-14.6 kg in DPP; P < 0.0001). Assessing concordance among criteria, agreement was dependent on initial weight loss. Among those with 3-9% initial weight loss in both cohorts, 9 of 28 comparisons were concordant (agreement ≥80%). Among those with ≥10% initial weight loss, 7 of 28 comparisons in Look AHEAD and 13 of 28 in the DPP were in high agreement. The definition of successful weight-loss maintenance "regaining ≤25% of initial weight loss during maintenance" showed high agreement with the most commonly used definition of "staying ≥10% below initial weight" among those with ≥10% initial weight loss (agreement: 85.0% in Look AHEAD; 87.4% in DPP). The same definition of ≤25% regain showed high agreement with the definition of staying ≥5% below initial weight among those with 3-9% initial weight loss (agreement: 91.6% in Look AHEAD; 90.5% in DPP).Conclusions: Although all of the criteria discriminated on the basis of weight loss, many showed low agreement, which limited cross-study comparisons. Among criteria with high agreement, the definition of successful weight maintenance "regaining ≤25% of initial weight loss during maintenance" is a preferred definition of success, given the realistic challenges of maintaining 100% weight loss and flexible application in populations with high initial weight-loss variations. This trial was registered at clinicaltrials.gov as NCT00017953 (Look AHEAD) and NCT00004992 (DPP).

The iconography of mourning and its neural correlates: a functional neuroimaging study.

The present functional neuroimaging study focuses on the iconography of mourning. A culture-specific pattern of body postures of mourning individuals, mostly suggesting withdrawal, emerged from a survey of visual material. When used in different combinations in stylized drawings in our neuroimaging study, this material activated cortical areas commonly seen in studies of social cognition (temporo-parietal junction, superior temporal gyrus, and inferior temporal lobe), empathy for pain (somatosensory cortex), and loss (precuneus, middle/posterior cingular gyrus). This pattern of activation developed over time. While in the early phases of exposure lower association areas, such as the extrastriate body area, were active, in the late phases activation in parietal and temporal association areas and the prefrontal cortex was more prominent. These findings are consistent with the conventional and contextual character of iconographic material, and further differentiate it from emotionally negatively valenced and high-arousing stimuli. In future studies, this neuroimaging assay may be useful in characterizing interpretive appraisal of material of negative emotional valence.

The Role of Community Education in Increasing Knowledge of Breast Health and Cancer: Findings from the Asian Breast Cancer Project in Boston, Massachusetts.

In the past decade, cancer rates have significantly decreased in the USA, but breast cancer survival is lower in Asian American women, likely due to lower rates of screening behaviors in Asian Americans compared to other ethnicities, which could lead to later stage cancer diagnosis and increased mortality. This paper reports on the Asian Breast Cancer (ABC) Project, a three-phase peer-led community program designed to promote cancer prevention by improving breast cancer screening rates among Chinese and Vietnamese women in the Greater Boston area. The three phases of planning and coalition building, community health worker training, and the community workshop intervention are described. The workshop intervention was evaluated by comparing pre- and post-workshop questionnaires evaluating knowledge about breast cancer screening and prevention. Two hundred fifty-two women participated in the program across 14 workshops. Each participant completed questionnaires about demographics, access to health care, and a five-item self-administered questionnaire about breast cancer knowledge. Results showed that the majority of the women had received a clinical breast exam or mammogram in the past 12 months (69 and 59 %, respectively), and older women were more likely to get a mammogram (85 %) or clinical breast exams (74 %) compared to younger women. Eighty-one percent of women were interested in reminder systems. Baseline knowledge was high for three survey questions about mammograms and breast cancer risk (88-97 %). For questions with fewer correct answers at baseline, knowledge about the meaning of lumps in the breast significantly increased (69 to 80 % correct, p < 0.0001), as well as knowledge about frequency of clinical breast exam (48 to 67 % correct, p < 0.0001). This pilot project indicated a partial effectiveness of the community workshop in a population with high baseline knowledge. The education workshop increased knowledge about breast lumps and clinical exam frequency. We also identified that reminder systems and appointment assistance are desired by this population. Our findings inform future cancer screening strategies for Asian Americans.

Appropriate initial antibiotic therapy in hospitalized patients with gram-negative infections: systematic review and meta-analysis.

BACKGROUND: The rapid global spread of multi-resistant bacteria and loss of antibiotic effectiveness increases the risk of initial inappropriate antibiotic therapy (IAT) and poses a serious threat to patient safety. We conducted a systematic review and meta-analysis of published studies to summarize the effect of appropriate antibiotic therapy (AAT) or IAT against gram-negative bacterial infections in the hospital setting. METHODS: MEDLINE, EMBASE, and Cochrane CENTRAL databases were searched until May 2014 to identify English-language studies examining use of AAT or IAT in hospitalized patients with Gram-negative pathogens. Outcomes of interest included mortality, clinical cure, cost, and length of stay. Citations and eligible full-text articles were screened in duplicate. Random effect models meta-analysis was used. RESULTS: Fifty-seven studies in 60 publications were eligible. AAT was associated with lower risk of mortality (unadjusted summary odds ratio [OR] 0.38, 95 % confidence interval [CI] 0.30-0.47, 39 studies, 5809 patients) and treatment failure (OR 0.22, 95 % CI 0.14-0.35; 3 studies, 283 patients). Conversely, IAT increased risk of mortality (unadjusted summary OR 2.66, 95 % CI 2.12-3.35; 39 studies, 5809 patients). In meta-analyses of adjusted data, AAT was associated with lower risk of mortality (adjusted summary OR 0.43, 95 % CI 0.23-0.83; 6 studies, 1409 patients). Conversely, IAT increased risk of mortality (adjusted summary OR 3.30, 95 % CI 2.42-4.49; 16 studies, 2493 patients). A limited number of studies suggested higher cost and longer hospital stay with IAT. There was considerable heterogeneity in the definition of AAT or IAT, pathogens studied, and outcomes assessed. DISCUSSION: Using a large set of studies we found that IAT is associated with a number of serious consequences,including an increased risk of hospital mortality. Infections caused by drug-resistant, Gram-negative organisms represent a considerable financial burden to healthcare systems due to the increased costs associated with the resources required to manage the infection, particularly longer hospital stays. However, there were insufficient data that evaluated AAT for the outcome of costs among patients with nosocomialGram-negative infections. CONCLUSIONS: IAT in hospitalized patients with Gram-negative infections is associated with adverse outcomes. Technological advances for rapid diagnostics to facilitate AAT along with antimicrobial stewardship, surveillance, infection control, and prevention is needed.

Dietary cholesterol and cardiovascular disease: a systematic review and meta-analysis.

BACKGROUND: Dietary cholesterol has been suggested to increase the risk of cardiovascular disease (CVD), which has led to US recommendations to reduce cholesterol intake. OBJECTIVE: The authors examine the effects of dietary cholesterol on CVD risk in healthy adults by using systematic review and meta-analysis. DESIGN: MEDLINE, Cochrane Central, and Commonwealth Agricultural Bureau Abstracts databases were searched through December 2013 for prospective studies that quantified dietary cholesterol. Investigators independently screened citations and verified extracted data on study and participant characteristics, outcomes, and quality. Random-effect models meta-analysis was used when at least 3 studies reported the same CVD outcome. RESULTS: Forty studies (17 cohorts in 19 publications with 361,923 subjects and 19 trials in 21 publications with 632 subjects) published between 1979 and 2013 were eligible for review. Dietary cholesterol was not statistically significantly associated with any coronary artery disease (4 cohorts; no summary RR), ischemic stroke (4 cohorts; summary RR: 1.13; 95% CI: 0.99, 1.28), or hemorrhagic stroke (3 cohorts; summary RR: 1.09; 95% CI: 0.79, 1.50). Dietary cholesterol statistically significantly increased both serum total cholesterol (17 trials; net change: 11.2 mg/dL; 95% CI: 6.4, 15.9) and low-density lipoprotein (LDL) cholesterol (14 trials; net change: 6.7 mg/dL; 95% CI: 1.7, 11.7 mg/dL). Increases in LDL cholesterol were no longer statistically significant when intervention doses exceeded 900 mg/d. Dietary cholesterol also statistically significantly increased serum high-density lipoprotein cholesterol (13 trials; net change: 3.2 mg/dL; 95% CI: 0.9, 9.7 mg/dL) and the LDL to high-density lipoprotein ratio (5 trials; net change: 0.2; 95% CI: 0.0, 0.3). Dietary cholesterol did not statistically significantly change serum triglycerides or very-low-density lipoprotein concentrations. CONCLUSION: Reviewed studies were heterogeneous and lacked the methodologic rigor to draw any conclusions regarding the effects of dietary cholesterol on CVD risk. Carefully adjusted and well-conducted cohort studies would be useful to identify the relative effects of dietary cholesterol on CVD risk.

Fructose, high-fructose corn syrup, sucrose, and nonalcoholic fatty liver disease or indexes of liver health: a systematic review and meta-analysis.

BACKGROUND: Concerns have been raised about the concurrent temporal trend between simple sugar intakes, especially of fructose or high-fructose corn syrup (HFCS), and rates of nonalcoholic fatty liver disease (NAFLD) in the United States. OBJECTIVE: We examined the effect of different amounts and forms of dietary fructose on the incidence or prevalence of NAFLD and indexes of liver health in humans. DESIGN: We conducted a systematic review of English-language, human studies of any design in children and adults with low to no alcohol intake and that reported at least one predetermined measure of liver health. The strength of the evidence was evaluated by considering risk of bias, consistency, directness, and precision. RESULTS: Six observational studies and 21 intervention studies met the inclusion criteria. The overall strength of evidence for observational studies was rated insufficient because of high risk of biases and inconsistent study findings. Of 21 intervention studies, 19 studies were in adults without NAFLD (predominantly healthy, young men) and 1 study each in adults or children with NAFLD. We found a low level of evidence that a hypercaloric fructose diet (supplemented by pure fructose) increases liver fat and aspartate aminotransferase (AST) concentrations in healthy men compared with the consumption of a weight-maintenance diet. In addition, there was a low level of evidence that hypercaloric fructose and glucose diets have similar effects on liver fat and liver enzymes in healthy adults. There was insufficient evidence to draw a conclusion for effects of HFCS or sucrose on NAFLD. CONCLUSIONS: On the basis of indirect comparisons across study findings, the apparent association between indexes of liver health (ie, liver fat, hepatic de novo lipogenesis, alanine aminotransferase, AST, and γ-glutamyl transpeptase) and fructose or sucrose intake appear to be confounded by excessive energy intake. Overall, the available evidence is not sufficiently robust to draw conclusions regarding effects of fructose, HFCS, or sucrose consumption on NAFLD.