Pathways and processes to the embodiment of historical trauma secondary to settler colonialism.

AIM(S): This discursive article aims to examine how systemic factors of settler colonialism influence health outcomes among Indigenous peoples in the United States through pathways and processes that may lead to the embodiment of historical trauma. DESIGN: Discursive paper. METHODS: We completed a comprehensive search of empirical and grey literature between September 2022 and January 2023 in PubMed, CINAHL and Google Scholar. Using these articles as a foundation, we explored factors related to the pathways and processes leading to the embodiment of historical trauma rooted in settler colonialism. RESULTS: A conceptual framework of the pathways and processes of the embodiment of historical trauma secondary to settler colonialism was developed, and is presented. CONCLUSION: The societal and historical context for Indigenous peoples includes harmful settler colonial structures and ideologies, resulting in stressors and historical trauma that impact health outcomes and disparities through the phenomenon of the process of embodiment. IMPLICATIONS FOR NURSING: To provide holistic nursing care, nurses must be aware of settler colonialism as a determinant of health. They must be attuned to the pathways and processes through which settler colonial exposures may impact health among Indigenous peoples. Nurses must challenge existing structural inequities to advance health equity and social justice.

Relationship between resilience and self-care in people with chronic conditions: A systematic review and meta-analysis.

BACKGROUND: Living with chronic condition(s) is difficult, due in part to the complexities of effective disease self-care. Self-care has been considered a challenging process according to the literature which describes multiple barriers patients with chronic conditions experience. Resilience has the potential to buffer the adversities of daily self-care and maintain physical and emotional well-being. No systematic review and meta-analysis have been conducted to synthesise and quantify the relationship between resilience and self-care across chronic conditions. AIMS: (1) To examine how the definitions and measurements of self-care and resilience align with the middle-range theory of self-care of chronic illness (i.e. self-care maintenance, self-care monitoring, and self-care management) and 3 Rs of resilience process from the society-to-cells framework (i.e. resistance, recovery and rebound) across different chronic conditions; and (2) to examine whether and the degree to which resilience is correlated with self-care across different chronic conditions. DESIGN: Systematic review and meta-analysis, following PRISMA guidelines. METHODS: PubMed, CINAHL, SocINDEX and PsychINFO were searched for quantitative studies published from January 2000 through July 2020. Descriptive data were summarised using numerical counting to provide an overview of the study characteristics. Definitions and measurements of self-care and resilience were synthesised narratively based on self-care and resilience theories. Numerical data with Pearson's product-moment correlation among observational studies were examined using meta-analysis. RESULTS: This review included 20 articles, involving 9,269 individuals across 11 chronic conditions. Despite self-care and resilience being defined and operationalised in a variety of ways, most definitions shared some underlying core constructs. Meta-analysis showed a positive relationship between resilience and self-care across chronic conditions. Findings from interventional studies indicated a bidirectional relationship between resilience and self-care. CONCLUSIONS: Overall, resilience was positively associated with self-care in people with chronic conditions. Longitudinal and experimental studies are needed to better understand the causal relationship between resilience and self-care. RELEVANT TO CLINICAL PRACTICE: Resilience has the potential to buffer the adversities of daily self-care and maintain physical and emotional well-being. The positive relationship between resilience and self-care found in this review provides preliminary evidence for clinicians to not only focus on reducing barriers and risk factors of self-care but also to improve or increase patients' resilience through various evidence-based interventions.

Metabolic health disparities driven by financial stress: Behavioural adaptation or modification?

Financial stress has been linked to an increased risk of metabolic syndrome, yet, it remains unclear whether suboptimal sleep duration and physical inactivity are the adaptive responses to financial stress or effect modifiers in the association between financial stress and metabolic syndrome. Hence, this study aims to examine whether physical activity and sleep duration mediate or moderate the bivariate association between financial stress and metabolic syndrome. A prospective secondary analysis was conducted using data from the Wisconsin Sleep Cohort Study (N = 445, mean [SD] age = 64 [7] years). Baseline moderation effect was examined using subgroup analysis with model constraints; prospective mediation model was examined using bias-corrected bootstrap confidence intervals. Results indicate that participants with higher financial stress were less likely to meet physical activity and sleep recommendations. Baseline moderation analysis indicates that meeting current recommendations of sleep duration and physical activity attenuated the association between financial stress and metabolic syndrome. In the prospective mediation analysis, weekly physical activity levels partially mediated the relationship between financial stress and metabolic syndrome, but sleep duration did not mediate this relationship. In conclusion, the joint effect of optimal sleep duration and physical activity disassociates financial stress from the risk of metabolic syndrome. Future interventions addressing metabolic risk might achieve better outcomes if clinicians and researchers factor in the behavioral adaptation of physical inactivity in financially stressed adults (Clinical Trial Registration: NCT00005557).

Gender Differences in the Relationship Between Financial Stress and Metabolic Abnormalities.

BACKGROUND: Financial stress is associated with higher prevalence of metabolic abnormalities and cardiovascular disease, but the extent to which this association differs by type of metabolic abnormalities or gender is unclear. OBJECTIVES: The study aims were (a) to examine the association between financial stress and the prevalence of common metabolic abnormalities and (b) to test the association for gender differences. METHODS: A cross-sectional secondary analysis was conducted using data from the Retirement and Sleep Trajectories study, an ancillary study of the Wisconsin Sleep Cohort study. Composite indicator structural equation alpha modeling with a stacking approach was applied in the data analysis. RESULTS: After controlling for covariates, financial stress was positively associated with the prevalence of abdominal obesity, metabolic syndrome, and dyslipidemia, with significant gender differences. Among men, financial stress was positively associated with the prevalence of hypertriglyceridemia. Among women, financial stress was positively associated with the prevalence of prediabetes, abdominal obesity, metabolic syndrome, and dyslipidemia. CONCLUSION: Men living with financial stress are more likely to have hypertriglyceridemia, a specific metabolic abnormality and risk factor for acute cardiovascular events. However, financial stress in women is associated with a broader array of metabolic abnormalities (e.g., dyslipidemia, prediabetes, abdominal obesity, metabolic syndrome), highlighting a potential risk of multiple chronic conditions later in life.

Prescription Medications and Co-Morbidities in Late Middle-Age are Associated with Greater Cognitive Declines: Results from WRAP.

The present study investigated: 1) sex differences in polypharmacy, comorbidities, self-rated current health (SRH), and cognitive performance, 2) associations between comorbidities, polypharmacy, SRH, and objective measures of health, and 3) associations of these factors with longitudinal cognitive performance. Analyses included 1039 eligible Wisconsin Registry for Alzheimer's Prevention (WRAP) participants who were cognitively unimpaired at baseline and had ≥2 visits with cognitive composites, self-reported health history, and concurrent medication records. Repeated measures correlation (rmcorr) examined the associations between medications, co-morbidities, SRH, and objective measures of health (including LIfestyle for BRAin Health Index (LIBRA), and depression). Linear mixed-effect models examined associations between medications, co-morbidities, and cognitive change over time using a preclinical Alzheimer's cognitive composite (PACC3) and cognitive domain z-scores (executive function, working memory, immediate learning, and delayed recall). In secondary analyses, we also examined whether the number of medications interacted with co-morbidities and whether they modified age-related cognitive trajectories. The number of prescribed medications was associated with worse SRH and a higher number of self-reported co-morbidities. More prescribed medications were associated with a faster decline in executive function, and more comorbidities were associated with faster PACC3 decline. Those with a non-elevated number of co-morbidities and medications performed an average of 0.26 SD higher (better) in executive function and an average of 0.18 SD higher on PACC3 than those elevated on both. Associations between medications, co-morbidities, and executive function, and PACC3 suggest that persons with more co-morbidities and medications may be at increased risk of reaching clinical levels of impairment earlier than healthier, less medicated peers.

Cognitive Function in Liver Transplant Recipients Who Survived More Than 6 Months.

INTRODUCTION: Current research in the areas of liver transplant and cognitive function has primarily examined cognitive changes from pre- to 1-year posttransplant, resulting in an insufficient understanding of cognitive trajectory beyond early periods of transplant and its impact on self-management. This study aimed (1) to describe global and domain-specific cognitive function in liver transplant recipients who survived more than 6 months after transplant and (2) to describe patient and clinical characteristics of recipients with impaired global and/or domain-specific cognitive function. Further, this study explored the potential relationships between cognitive function and self-management by examining differences in cognitive function by levels of self-management. DESIGN: This secondary data analysis included 107 adult liver transplant recipients, who had a functioning transplant for at least 6 months. Data of cognitive function, demographic and clinical characteristics, and self-management were extracted for this study. T tests, Mann-Whitney tests, and Kruskal-Wallis tests were used to examine differences in cognitive function by variables. RESULTS: More than half of the recipients had global cognitive impairment. Significant differences were found in global and domain-specific cognitive function. Older, male, married, or deceased donor recipients had lower cognitive test scores than younger, female, single, or living donor recipients. There were no significant differences in global and domain-specific cognitive function by time since transplant and levels of self-management. DISCUSSION: Future longitudinal studies should examine the long-term trajectory of cognitive function posttransplant. Other factors such as caregivers' participation in self-management should be accounted for in future studies when examining the relationship between cognitive function and self-management.

Gender Differences in Hispanic Patients of Mexican Origin Hospitalized with Heart Failure.

BACKGROUND: More than 3 million women in the United States die of heart failure (HF) annually. Women are significantly underrepresented in studies that inform practice guidelines, especially women hospitalized for HF despite the associated negative outcomes. HF is common in Hispanic people, the largest ethnic minority group in the United States, who are mostly of Mexican origin. There are no studies of gender differences in Mexican-Hispanic persons hospitalized for HF. We sought to describe gender differences in demographic and clinical characteristics, clinical presentation, treatment, in-hospital outcomes, and discharge status in Mexican-Hispanic patients hospitalized for HF. METHODS: We conducted a secondary analysis of data collected for a study examining readmission in patients hospitalized with HF in a 107-bed community; hospital near the U.S.-Mexico border. RESULTS: Of 155 self-identified Hispanic patients, 43.2% (n = 67) were women. Compared with men, women were equally affected by obesity, on average 6 years older (p < .01), and more likely to be widowed (31% vs 6%; p < .001). Women had significantly higher ejection fractions, more total comorbid conditions, more hyperlipidemia, more arthritis, more anxiety, and were less likely to be treated with digoxin and more likely to be treated with calcium channel blockers. At discharge, women were significantly less likely to receive an angiotensin-converting enzyme inhibitor or an aldosterone receptor blocker and had a higher systolic blood pressure. CONCLUSIONS: Key gender differences in chronic illness burden, treatment, and discharge status were found, highlighting the heterogeneity of women with HF and the need for further gender-specific research to develop care strategies specific to women of all races and ethnicities.

Correction to: Does 24-h Activity Cycle Influence Plasma PCSK9 Concentration? A Systematic Review and Meta-Analysis.

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Does 24-h Activity Cycle Influence Plasma PCSK9 Concentration? A Systematic Review and Meta-Analysis.

PURPOSE OF REVIEW: Higher plasma proprotein convertase subtilisin/kexin type 9 (PCSK9) concentration has been associated with a higher risk of atherosclerotic cardiovascular disease (ASCVD). Animal and human studies have examined the relationship between 24-h activity cycles (24-HAC) and PCSK9, but conflicting results exist. Therefore, this review aimed to examine the relationship between 24-HAC and plasma PCSK9 concentration in animals and humans.Three databases (PubMed, CINAHL, and Web of Science) were searched for eligible articles. Descriptive data were summarized using network meta-analysis. The effect size was estimated using pairwise meta-analysis. RECENT FINDINGS: The interventions designed to increase moderate to vigorous physical activities (MVPA) did not significantly change plasma PCSK9 concentration (Hedges' g = 0.137; p = 0.337). However, the effect was influenced by statin therapy and intervention delivery mode. Specifically, physical activity interventions in conjunction with statin therapy significantly increased plasma PCSK9 concentration (Hedges' g = 0.275; p = 0.007). Supervised exercise training significantly increased plasma PCSK9 concentration (Hedges' g = 0.630; p = 0.001), but physical activity counseling did not (p = 0.845). The effects of MVPA on plasma PCSK9 may be moderated by statin therapy, intervention delivery mode, or other potential unknown mechanistic factors. Thus, caution should be taken when using plasma PCSK9 as an outcome indicator for physical activity interventions aimed at decreasing the risk of ASCVD. Graphical abstract.

The association between psychological stress and metabolic syndrome: A systematic review and meta-analysis.

Literature suggests that occupational stress is associated with a higher risk of metabolic syndrome; yet less is known whether other sources of stress have similar effects. This review aims to examine whether the relationship between psychological stress and metabolic syndrome differs by sources of stress. Three databases (PubMed, Web of Science, and CINAHL) were searched for eligible articles; meta-analyses were conducted using the random effects model. After controlling for covariates, adults in the high-stress groups had 45% higher chance of having metabolic syndrome than adults in the low-stress groups (odds ratio [OR] = 1.450; 95% confidence interval [CI], 1.211-1.735; P < .001). The subsequent meta-analysis based on cross-sectional studies suggested that occupational stress showed the strongest effect (OR = 1.692; 95% CI, 1.182-2.424; P = .004), while perceived general stress showed the weakest effect (OR = 1.217; 95% CI, 1.017-1.457; P = .032). Unfortunately, there is a lack of longitudinal studies for subsequent meta-analysis based on sources of stress. There is a need for continued research to examine the long-term relationship between different sources of stress and the risk of metabolic syndrome. Traditional recommendations for preventing metabolic syndrome (eg, low-fat diet and exercise) may not achieve the best outcome if clinicians overlook patients' psychosocial stress.

Predictors of Heart Failure Readmission in a High-Risk Primarily Hispanic Population in a Rural Setting.

BACKGROUND: High risk for readmission in patients with heart failure (HF) is associated with Hispanic ethnicity, multimorbidity, smaller hospitals, and hospitals serving low-socioeconomic or heavily Hispanic regions and those with limited cardiac services. Information for hospitals caring primarily for such high-risk patients is lacking. OBJECTIVE: The aim of this study was to identify factors associated with 30-day HF readmission after HF hospitalization in a rural, primarily Hispanic, low-socioeconomic, and underserved region. METHODS: Electronic medical records for all HF admissions within a 2-year period to a 107-bed hospital near the California-Mexico border were reviewed. Logistic regression was used to identify independent predictors of readmission. RESULTS: A total of 189 unique patients had 30-day follow-up data. Patients were primarily Hispanic (71%), male (58%), and overweight or obese (82.5%) with 4 or more chronic conditions (83%) and a mean age of 68 years. The 30-day HF readmission rate was 5.3%. Early readmission was associated with history of HF, more previous emergency department (ED) and hospital visits, higher diastolic blood pressure and hypokalemia at presentation, shorter length of stay, and higher heart rate, diastolic blood pressure, and atrial fibrillation (AF) at discharge. Using logistic regression, previous 6-month ED visits (odds ratio, 1.5; P = .009) and AF at discharge (odds ratio, 5.7; P = .039) were identified as independent predictors of 30-day HF readmission. CONCLUSIONS: Previous ED use and AF at discharge predicted early HF readmission in a high-risk, primarily Hispanic, rural population in a low-socioeconomic region.

Self-management in liver transplantation.

BACKGROUND: Self-management is crucial for liver transplant (LT) recipients to maintain transplants and optimize health outcomes. However, previous literature has been primarily limited to examining medication adherence; there is a knowledge gap regarding self-management in the LT population. AIM: The aims of this study were to 1) comprehensively describe self-management behaviors and activities in LT recipients, 2) explore levels of overall self-management, and 3) explore the relationships of self-efficacy, cognition, and health information seeking behavior with self-management. METHODS: Adult LT recipients (n = 113) who had a functioning transplant for at least 6 months participated in this cross-sectional, descriptive study. Participants were asked to identify self-management behaviors and rate their performance of those behaviors, including symptom management and medication adherence. They also completed a cognitive assessment and questionnaires measuring self-efficacy and health information seeking behavior. Descriptive statistics, latent profile analysis, and probit model for path analysis were used for the data analysis. RESULTS: LT recipients acknowledged engaging in various self-management behaviors including symptom management, physical activity, maintenance of positive attitudes, and communication with healthcare providers. Three levels of self-management (i.e., low, medium, and high) were found; a high level of self-management was related to self-efficacy and health information seeking behavior. CONCLUSIONS: The findings indicate that self-management may be improved with interventions aimed at increasing self-efficacy and health information seeking behavior. Findings from this study will inform future interventions, to improve self-management and subsequent health outcomes in this population. Future longitudinal studies are necessary to confirm the causality of the identified relationships.

The association of sleep-disordered breathing and white matter hyperintensities in heart failure patients.

Heart failure patients often manifest white matter hyperintensites on brain magnetic resonance imaging (MRI). White matter hyperintnsities have also been linked with cognitive problems in patients with heart failure. Sleep disordered breathing may contribute to structural brain changes in heart failure. The purpose of this study was to test the extent to which the apnea hypopnea index is associated with global and regional white matter hyperintensities, and is a moderating factor in the relationship between age and white matter hyperintensites. A total of 28 HF patients [mean age (SD) = 67.89 (5.8)] underwent T1-weighted and T2FLAIR MRI and a home sleep monitoring study. The apnea hypopnea index cut off of 10 was used to compare between higher and lower risks of sleep disordered breathing. Regression analysis was used to test the association between apnea hypopnea index and both global and regional white matter hyperintensities. The interaction term was entered to identify the moderation effect. Apnea hypopnea index was associated with higher regional white matter hyperintensities but not global white matter hyperintensities. There was a significant interaction between the apnea hypopnea index and age, such that older participants with the apnea hypopnea index ≥10 showed greater regional white matter hyperintensities than those with the apnea hypopnea index <10. The results of this preliminary study indicate that a higher apnea hypopnea index is associated with more white matter hyperintensities. The age-related white matter hyperintensities appear to be exacerbated by apnea hypopnea index in our individuals with heart failure. Future studies are needed to further investigate the underlying mechanisms.

Multiple chronic conditions: Implications for cognition - Findings from the Wisconsin Registry for Alzheimer's Prevention (WRAP).

INTRODUCTION: Several chronic illnesses have demonstrated relationships to cognitive decline in the context of aging. However, researchers have largely ignored the effects of multi-morbidity in the context of Alzheimer's disease and related dementias (ADRD) risk. The purpose of this study is to examine the relationship between multiple chronic conditions (MCC) and cognitive decline. METHODS: Latent class analysis (LCA) was completed to identify different subgroups of the 1285 participants from the Wisconsin Registry for Alzheimer's Prevention who were recognized based on their self-reported chronic illnesses. Differences between variables of interest (i.e., biomarkers and depressive symptom scores) and each of the individual classes were then explored. Chi-square tests were used to examine the association between MCC and cognitive status. RESULTS: LCA revealed a four-class model best fit solution. Participants in the sleep class had the highest incidence of new onset cognitive decline. DISCUSSION: Findings offer evidence of an association between specific MCC groups and the development of cognitive decline. Nurses should monitor and screen for cognitive decline in the presence of MCC in order to better target self-management interventions.

Sleep-disordered breathing, brain volume, and cognition in older individuals with heart failure.

BACKGROUND AND PURPOSE: Sleep-disordered breathing is common in individuals with heart failure and may contribute to changes in the brain and decreased cognition. However, limited research has explored how the apnea-hypopnea index contributes to brain structure and cognition in this population. The aims of this study were to explore how the apnea-hypopnea index is associated with brain volume and cognition in heart failure patients. METHODS: Data of 28 heart failure patients (mean age = 67.93; SD = 5.78) were analyzed for this cross-sectional observational study. We evaluated the apnea-hypopnea index using a portable multichannel sleep-monitoring device. All participants were scanned using 3.0 Tesla magnetic resonance imaging and neuropsychological tests. Brain volume was evaluated using a voxel-based morphometry method with T1-weighted images. We used multiple regressions to analyze how the apnea-hypopnea index is associated with brain volume and cognition. RESULTS: We found an inverse association between apnea-hypopnea index scores and white matter volume (ß = -0.002, p = 0.026), but not in gray matter volume (ß = -0.001, p = 0.237). Higher apnea-hypopnea index was associated with reduced regional gray and white matter volume (p < 0.001, uncorrected). Cognitive scores were not associated with the apnea-hypopnea index (p-values were >0.05). CONCLUSION: Findings from this study provide exploratory evidence that higher apnea-hypopnea index may be associated with greater brain volume reduction in heart failure patients. Future studies are needed to establish the relationship between sleep-disordered breathing, brain volume, and cognition in heart failure samples.

Multimodal brain imaging investigation of self-reported sleep quality and daytime sleepiness in older adults with heart failure.

PURPOSE OF THE STUDY: Individuals with heart failure (HF) have a high frequency of sleep problems. Patients with HF present with structural brain changes different from normal aging including reductions in brain volume, increases in white matter hyperintensity (WMH) and reduced cerebral blood flow. These structural changes in the brain may explain the pathophysiology of sleep and daytime problems. The objective of this study was to determine whether multimodal imaging data are related to self-reported sleep problems and daytime sleepiness in older adults with HF. METHODS: Participants in this study underwent magnetic resonance imaging scans on the General Electric 3.0 T Discovery MR750 to acquire WMH, cerebral blood flow and brain volume. Data on 37 stable HF patients (mean age = 68; SD = 5.75) were included. RESULTS: In this sample, WMH was associated with daytime sleepiness (p = 0.025). However, gray and white matter volume and cerebral blood flow were not associated with daytime sleepiness, sleep quality or insomnia. CONCLUSION: Although further studies are needed to determine the relationship between WMH and sleep and daytime problems, the findings preliminarily support that increases in WMH from ischemic changes could explain increases in daytime sleepiness among people with HF.

Self-management assessment in multiple chronic conditions: A narrative review of literature.

OBJECTIVES: Effective self-management in individuals with multiple chronic conditions is necessary to optimize health outcomes. Self-management in multiple chronic conditions involves an iterative process prioritizing multiple changing needs/conditions. However, self-management in multiple chronic conditions has been assessed with instruments designed to assess self-management of a single chronic illness. The instruments may not address the complexity of self-management in multiple chronic conditions. Thus, this review aimed to examine how self-management has been operationalized in the context of multiple chronic conditions. DESIGN: A narrative review method was used. DATA SOURCE: The online databases, Pubmed, CINAHL Plus, and PsycInfo, were searched. The search was conducted of the database from January 2006 through November 2017. REVIEW METHODS: Peer-reviewed research articles which operationalized self-management in adults with at least two or more chronic illnesses were selected for review. Two reviewers read full text of selected articles and extracted data regarding operational definitions of self-management and instruments used to assess self-management. Operational definitions were categorized to conceptualize how self-management has been assessed. RESULTS: A total of seven peer-reviewed research articles were selected for inclusion. This review found that self-management has been assessed through prerequisites of self-management and behaviors involved in self-management. Prerequisites of self-management included attitude, self-efficacy, perceived ability, and knowledge. Behaviors included an individual's engagement in self-management such as health-related behaviors, health service use, and medication adherence. CONCLUSIONS: This review revealed that current literature does not operationalize self-management in multiple chronic conditions as a process, indicating incomplete assessments of self-management. To obtain a more comprehensive understanding of self-management in multiple chronic conditions, future studies should consider self-management as an iterative process in addition to prerequisites for self-management and behaviors. Such studies will inform the development of patient-centered self-management interventions for individuals with multiple chronic conditions.

Self-Management in Liver Transplant Recipients: A Narrative Review.

INTRODUCTION: Although self-management is essential for liver transplant recipients, there is no review that has synthesized findings related to self-management in this population. OBJECTIVE: This narrative review aimed to synthesize the current findings and identify the gaps in knowledge about self-management in liver recipients. METHODS: A search of PubMed, CINAHL Plus, PsychINFO, ProQuest, and Web of Science was conducted using the following terms: [Self-care OR Self-management OR Health behavior] AND [Liver transplantation]. Peer-reviewed published research articles focusing on self-management of adult recipients were selected. A total of 23 articles were included for review. Two reviewers independently reviewed the full text of selected articles and extracted the data about definitions, measurements, and findings regarding self-management. RESULTS: Three areas of self-management were identified, including medication nonadherence (n = 11), alcohol recidivism (n = 11), and health maintenance (n = 5). Reported rates of medication nonadherence ranged from 8% to 66%. Medication nonadherence was related to recipients' demographic (eg, age or sex), transplant-related (eg, time since transplant), and pretransplant variables (eg, history of substance/alcohol abuse). Reported alcohol recidivism rates ranged from 3% to 95%. Age, pretransplant variables (eg, abstinent time before transplant), and personality disorder were identified to be related to alcohol recidivism after transplant. The health maintenance studies discussed behaviors such as smoking, clinic appointment attendance, or vaccination/health screening behaviors of recipients. DISCUSSION: Self-management studies in liver recipients have been narrowly focused on medication nonadherence and alcohol recidivism. To improve self-management in recipients, self-management beyond medication nonadherence and alcohol recidivism should be comprehensively examined.

Informed Consent and Cognitive Dysfunction After Noncardiac Surgery in the Elderly.

Cognitive dysfunction 3 months after noncardiac surgery in the elderly satisfies informed consent thresholds of foreseeability in 10%-15% of patients, and materiality with new deficits observed in memory and executive function in patients with normal test performance beforehand. At present, the only safety step to avoid cognitive dysfunction after surgery is to forego surgery, thereby precluding the benefits of surgery with removal of pain and inflammation, and resumption of normal nutrition, physical activity, and sleep. To assure that consent for surgery is properly informed, risks of both cognitive dysfunction and alternative management strategies must be discussed with patients by the surgery team before a procedure is scheduled.

Cost-Effectiveness of a Care Transition Intervention Among Multimorbid Patients.

The purpose of this pilot study was to assess the cost-effectiveness of four different doses (based on patients' level of cognition and activation) of a home-based care transitions intervention compared with usual care at 2 and 6 months after hospital discharge to home for 126 adult patients with three or more chronic diseases. Health care utilization was measured, and a cost-effectiveness analysis was used to estimate incremental costs and quality-adjusted life-years associated with each intervention arm. At 6 months, results from this pilot study are very promising and support cost-effectiveness for Group 2-low cognition/high activation, Group 3-normal cognition/low activation, and Group 4-normal cognition/high activation patients. However, Group 1-low cognition/low activation needs a more intensive treatment than what was provided in the intervention, because of their low cognition and activation levels. Our intervention strategies provided to the groups would be scalable to a larger patient population and across different facilities.