Lymphovascular invasion on explant is associated with presenting tumor characteristics and not direct acting antiviral utilization in hepatitis C candidates undergoing liver transplantation.

AIM OF THE STUDY: Utilization of direct acting antiviral (DAA) therapy in candidates with well-compensated hepatitis C virus (HCV) cirrhosis and hepatocellular carcinoma (HCC) accruing end stage liver disease (MELD) exception points is highly variable among transplant centers based on center location, local organ procurement dynamics, HCV(+) organ availability, and patient preference. The association between DAA utilization prior to transplant and incidence of lymphovascular invasion on explant is unknown. MATERIAL AND METHODS: Retrospective evaluation from 2013-2017 of patients on a liver transplant (LT) waitlist with HCV-related cirrhosis, MELD-Na < 15, and HCC (within T2/Milan criteria). The cohort was divided into the pre-LT DAA treated group and untreated group with clinical/viral demographics collected. Tumor presenting characteristics, locoregional treatments, wait time to LT, dropout rates and explant pathology were compared. RESULTS: DAAs were used in 44 patients prior to LT (SVR12 of 37/44 [84%]) and 19 left untreated with LT performed in 81% (51/63) of the waitlisted cohort. No significant differences were found between groups with regards to clinical/viral demographics, local-regional therapy (LRT) sessions, or frequency of lymphovascular invasion on explant. The untreated cohort had a higher rate of dropout (6.3% vs. 3.2%) (p = 0.041). On subgroup analysis of 51 subjects undergoing LT, AFP > 250 ng/ml (p = 0.003) and multifocal HCC (> 1 lesion) (p = 0.006) were associated with lymphovascular invasion on explant while DAA therapy was not (p = 0.578). CONCLUSIONS: DAA therapy for waitlist active HCV candidates accruing MELD exception points has no deleterious effects on bridging LRT, nor is it associated with increased frequency of lymphovascular invasion on explant. The latter appears driven by tumor related characteristics (AFP and number of lesions) irrespective of DAA utilization prior to LT.

Race and Gradient Difference Are Associated with Increased Risk of Hepatic Encephalopathy Hospital Admission After Transjugular Intrahepatic Portosystemic Shunt Placement.

BACKGROUND/AIMS: Hepatic encephalopathy (HE) is a well-recognized complication of transjugular intrahepatic portosystemic shunt (TIPS) placement. The aim of this investigation was to evaluate incidence and predictors of post-TIPS HE necessitating hospital admission in a non-clinical trial setting. METHODS: We performed a retrospective cohort study identifying 273 consecutive patients undergoing TIPS from 2010 to 2015 for any indication; 210 met inclusion/exclusion criteria. The primary endpoint was incidence of post-TIPS HE defined as encephalopathy with no other identifiable cause requiring hospitalization within 90 days of TIPS. Clinical demographics and procedural variables were collected and analyzed to determine predictors of readmission for post-TIPS HE. Categorical variables were analyzed using Fisher's exact test; continuous variables were compared using Levene's t-test and student's t-test; P < 0.05, significant. RESULTS: Forty-two of 210 patients (20%) developed post-TIPS HE requiring hospitalization within 90 days. On analysis of cohorts (post-TIPS HE vs. no post-TIPS HE): non-white race (31.0% vs. 17.5%, P = 0.022) and increased hepatic venous pressure gradient (HVPG) difference during TIPS (10.5 vs. 8.9 mmHg, P = 0.030) were associated with an increased incidence of HE requiring readmission within 90 days. CONCLUSIONS: HE remains a common complication of TIPS. Non-Caucasian race is a significant clinical demographic associated with increased risk for readmission. Independent of initial or final HVPG, HVPG difference appears to be a significant modifiable technical risk factor. In the absence of clear preventative strategies for post-TIPS encephalopathy, non-Caucasians with HVPG reductions >9 mmHg may require targeted follow up evaluation to prevent hospital readmission.

Refractory Hepatic Encephalopathy After Elective Transjugular Intrahepatic Portosystemic Shunt: Risk Factors and Outcomes with Revision.

BACKGROUND AND AIMS: Hepatic encephalopathy (HE) is a common complication of elective transjugular intrahepatic portosystemic shunt (TIPS) placement and is often successfully medically managed. Risk factors for refractory hepatic encephalopathy (RHE) necessitating revision of TIPS are not well defined. We evaluated the incidence, predictors, and outcomes of post-TIPS RHE necessitating TIPS revision. METHODS: In a retrospective cohort study of 174 consecutive patients undergoing elective TIPS placement (2010-2015), we evaluated the incidence of post-TIPS RHE. Clinical demographics and procedural variables were collected. 1-year outcomes after revision were collected. RESULTS: Ten of 174 patients (5.7%) developed post-TIPS RHE requiring revision. Significant differences between RHE and non-refractory groups were shunt size > 8 versus ≤ 8 mm (18.5 vs. 3.4%, p = 0.001), history of HE (14 vs. 2%, p = 0.007), and serum albumin levels ≤ 2.5 versus > 2.5 g/dL (13.1 vs. 3.1%, p = 0.020). On multivariate analysis, shunt size > 8 mm (p = 0.001), history of HE prior to TIPS (p = 0.006), and low serum albumin (≤ 2.5 g/dL) (p = 0.022) remained independent predictors of RHE, controlling for age and Model for End-Stage Liver Disease score. RHE improved in 8 of 10 patients but survival at 1 year without liver transplantation (LT) was only 10%. CONCLUSION: While TIPS revision successfully improves RHE in most cases, 1-year mortality rates are high, limiting the value of revision in non-LT candidates. Patients with previous history of HE and low serum albumin levels prior to TIPS may benefit most from the use of shunt sizes < 8 mm to mitigate the risk of RHE. LEVEL OF EVIDENCE: Level 4, case series.

Predictors of intermediate-term survival with destination locoregional therapy of hepatocellular cancer in patients either ineligible or unwilling for liver transplantation.

Intra-arterial or percutaneous locoregional therapies (LRT) are often employed to maintain potential liver transplant (LT) recipients with hepatocellular carcinoma (HCC) within T2/Milan criteria. Predictors of survival when LRT is used as destination therapy in those who are either ineligible or unwilling for LT remain poorly defined. We evaluated predictors of 3-year survival with destination LRT in a population of cirrhotic patients diagnosed with HCC, presenting within T2 criteria, and either ineligible or unwilling for LT. The cohort surviving 3 years had a significantly lower model for end-stage liver disease (MELD) score at HCC diagnosis (9.7 vs. 11.4, P=0.037) and MELD following initial locoregional therapy (10.7 vs. 13.3, P=0.008) compared to those not surviving three years despite similar demographic, tumor, and treatment variables. LRT as destination therapy results in modest intermediate term survival, with liver function at presentation and immediately following initiation of LRT predicting intermediate survival with this approach.

Profiling Neutrophil-to-Lymphocyte Ratio Changes in Response to Nucleoside Analog Therapy for Chronic Hepatitis B Infection.

BACKGROUND/AIM: The neutrophil-lymphocyte ratio (NLR) has gained attention as an index of inflammation in patients with chronic hepatitis B virus (HBV); however, changes with nucleoside analog therapy require investigation. PATIENTS AND METHODS: We carried out a retrospective study identifying monoinfected HBV patients initiated on therapy with NLR follow-up over 1 year. Biochemistries recorded at treatment initiation and 1 year included alanine aminotransferase (ALT), Model for End Stage Liver Disease (MELD) score, and NLR. RESULTS: A total of 67 patients were initiated on therapy and had baseline characteristics including e-antigen (eAg) (50, 74.6%) and cirrhosis (19, 28.4%). On subgroup analysis among those with HBV-associated cirrhosis, the NLR decreased over 1 year (3.08±0.39 vs. 1.77±0.18, p<0.001) as did MELD and ALT. Among the non-cirrhotic cohort, there was no difference in NLR (1.99±0.89 vs. 2.14±1.03, p=0.134) despite a decrease in ALT. CONCLUSION: Nucleoside analog therapy in HBV cirrhosis is associated with a decrease in NLR over 1 year that tracks with changes of established indices of inflammation/global hepatic function.

25-Vitamin D levels in chronic hepatitis C infection: association with cirrhosis and sustained virologic response.

BACKGROUND: Low serum 25-Vitamin D levels are associated with advanced fibrosis in hepatitis C infection. Vitamin D supplementation has been hypothesized to augment response rates to interferon-based therapy. To date, no investigation has evaluated vitamin D levels during direct-acting antiviral therapy. We aimed to evaluate the prevalence of vitamin D deficiency in cirrhotic and non-cirrhotic cohorts, the predictive value of pretreatment levels for a sustained virologic response, and the changes in 25-OH vitamin D levels during direct-acting antiviral therapy. METHODS: Two hundred eighteen patients with chronic hepatitis C who completed direct-acting antiviral therapy were consecutively enrolled. Vitamin D levels were measured using chemiluminescence immunoassay, prior to initiation and at completion of therapy. Advanced liver fibrosis (cirrhosis) was determined by biopsy, FibroSURE blood test, or imaging. RESULTS: A sustained virologic response was achieved in 79% (n=172) of patients, with 19% (n=44) relapsing. A total of 123 (56.4%) patients were cirrhotic. The prevalence of Vitamin D deficiency (10-20 ng/mL) and severe deficiency (<10 ng/mL) was significantly higher in cirrhotic patients (P=0.04). Pre-treatment vitamin D levels in cirrhotic patients were negatively correlated with Model for End-Stage Liver Disease score, total bilirubin and INR (P<0.05). Neither pretreatment vitamin D level nor the change during therapy was associated with an increased rate of sustained virologic response. CONCLUSIONS: The prevalence of vitamin D deficiency is higher in hepatitis-C-related cirrhotic cohorts compared to non-cirrhotic patients and correlates with components of hepatic function. Neither pretreatment vitamin D level nor the change during therapy was associated with an increased rate of sustained virologic response.

Multispecialty involvement in the management of type B aortic dissections in the endovascular era-Implications for training cardiothoracic residents.

PURPOSE: Involvement of qualified specialists with proficiency in endovascular therapies has created flux regarding the role of cardiothoracic surgeons, vascular surgeons, and other catheter-skilled specialists in the management of type B aortic dissections. We used manuscript authorship trends and recent match data in order to study how multi-specialty involvement in treating aortic dissections has changed in the endovascular era. METHODS: A PubMed review of published literature between 1998 and 2015 was performed with "aortic dissection" in the title. Case studies and entries with incomplete author or identifying information were excluded. Author number, specialty affiliation, and treatment focus were recorded. Available residency match data were obtained from the National Resident Matching Program (NRMP). RESULTS: Cardiothoracic surgeons represented 38.5% (10/23) of the authors for papers with an endovascular focus in 1998 compared with 27.7% (59/213) in 2015. Vascular surgeons represented 19.2% (5/23) and 37.1% (79/213) of authors in 1998 and 2015, respectively. Radiologists accounted for 30.4% (7/23) of authorship in 1998 and 8.9% (19/213) in 2015. NRMP match data revealed a 10.6% decrease in thoracic surgery matches from 2004 to 2015, while vascular surgery and interventional radiology increased by 74.7% and 191.1%, respectively. CONCLUSIONS: Endovascular technologies have resulted in significant changes as to which specialties manage complicated type B aortic dissections. Vascular surgeons, with both open and extensive endovascular training are optimally positioned to assume a major role in the care of aortic dissection patients. Continued emphasis on endovascular training and multispecialty collaboration is essential for cardiothoracic surgeons in the endovascular era.

Genotype specific peripheral lipid profile changes with hepatitis C therapy.

AIM: To evaluate magnitude/direction of changes in peripheral lipid profiles in patients undergoing direct acting therapy for hepatitis C by genotype. METHODS: Mono-infected patients with hepatitis C were treated with guideline-based DAAs at a university-based liver clinic. Patient characteristics and laboratory values were collected before and after the treatment period. Baseline demographics included age, ethnicity, hypertension, diabetes, hyperlipidemia, treatment regimen, and fibrosis stage. Total cholesterol (TCHOL), high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides (TG), and liver function tests were measured prior to treatment and ETR. Changes in lipid and liver function were evaluated by subgroups with respect to genotype. Mean differences were calculated for each lipid profile and liver function component (direction/magnitude). The mean differences in lipid profiles were then compared between genotypes for differences in direction/magnitude. Lipid profile and liver function changes were evaluated with Levene's test and student's t test. Mean differences in lipid profiles were compared between genotypes using ANOVA, post hoc analysis via the Bonferroni correction or Dunnett T3. RESULTS: Three hundred and seventy five patients enrolled with 321 (85.6%) achieving sustained-viral response at 12 wk. 72.3% were genotype 1 (GT1), 18.1% genotype 2 (GT2), 9.7% genotype 3 (GT3). Baseline demographics were similar. Significant change in lipid profiles were seen with GT1 and GT3 (ΔGT1, p and ΔGT3, p), with TCHOL increasing (+5.3, P = 0.005 and +16.1, P < 0.001), HDL increasing (+12.5, P < 0.001 and +7.9, P = 0.038), LDL increasing (+7.4, P = 0.058 and +12.5, P < 0.001), and TG decreasing (-5.9, P = 0.044 and -9.80 P = 0.067). Among genotypes (ΔGT1 v. ΔGT2 v. ΔGT3, ANOVA), significant mean differences were seen with TCHOL (+5.3 v. +0.1 v. +16.1, P = 0.017) and HDL (+12.3 v. +2 v. +7.9, P = 0.040). Post-hoc, GT3 was associated with a greater increase in TCHOL than GT1 and GT2 (P = 0.028 and P = 0.019). CONCLUSION: Successful DAA therapy results in increases in TCHOL, LDL, and HDL and decrease in TG, particularly in GT1/GT3. Changes are most pronounced in GT3.

Pretransplant Factors and Associations with Postoperative Respiratory Failure, ICU Length of Stay, and Short-Term Survival after Liver Transplantation in a High MELD Population.

Changes in distribution policies have increased median MELD at transplant with recipients requiring increasing intensive care perioperatively. We aimed to evaluate association of preoperative variables with postoperative respiratory failure (PRF)/increased intensive care unit length of stay (ICU LOS)/short-term survival in a high MELD cohort undergoing liver transplant (LT). Retrospective analysis identified cases of PRF and increased ICU LOS with recipient, donor, and surgical variables examined. Variables were entered into regression with end points of PRF and ICU LOS > 3 days. 164 recipients were examined: 41 (25.0%) experienced PRF and 74 (45.1%) prolonged ICU LOS. Significant predictors of PRF with univariate analysis: BMI > 30, pretransplant MELD, preoperative respiratory failure, LVEF < 50%, FVC < 80%, intraoperative transfusion > 6 units, warm ischemic time > 4 minutes, and cold ischemic time > 240 minutes. On multivariate analysis, only pretransplant MELD predicted PRF (OR 1.14, p = 0.01). Significant predictors of prolonged ICU LOS with univariate analysis are as follows: pretransplant MELD, FVC < 80%, FEV1 < 80%, deceased donor, and cold ischemic time > 240 minutes. On multivariate analysis, only pretransplant MELD predicted prolonged ICU LOS (OR 1.28, p < 0.001). One-year survival among cohorts with PRF and increased ICU LOS was similar to subjects without. Pretransplant MELD is a robust predictor of PRF and ICU LOS. Higher MELDs at LT are expected to increase need for ICU utilization and modify expectations for recovery in the immediate postoperative period.

A Socioecological Predication Model of Posttraumatic Stress Disorder in Low-Income, High-Risk Prenatal Native Hawaiian/Pacific Islander Women.

INTRODUCTION: Only recently has perinatal posttraumatic stress disorder (PTSD) been researched in any depth; however, the causes and consequences of this serious illness remain unclear. Most commonly, childbirth trauma and interpersonal violence have been reported as contributing factors. However, not all Native Hawaiian/Pacific Islander (NHPI) women who experience these events experience PTSD. The factors affecting PTSD are many and complex, intertwining individual, family, and community contexts. Using a socioecological framework, 3 levels of contextual variables were incorporated in this study (individual, family, and social/community). The purpose of this study was to determine the socioecological predictors associated with prenatal PTSD among NHPI. METHODS: A case-control design was used to collect retrospective data about socioecological variables from medical record data. The sample was low-income, high-risk NHPI women receiving perinatal health care at a rural community health center in Hawaii who screened positive (n = 55) or negative (n = 91) for PTSD. RESULTS: Hierarchical logistic regression was conducted to determine socioecological predictors of positive PTSD screening. Although the majority of women (66.4%) experienced some form of interpersonal violence, a constellation of significant predictor variables from all 3 levels of the model were identified: depression (individual level), lack of family support and family stress (family level), and violence (social/community level). DISCUSSION: Each of the predictor variables has been identified by other researchers as significantly affecting perinatal PTSD. However, it is because these variables occur together that a more complex picture emerges, suggesting the importance of considering multiple variables in context when identifying and caring for these women. Although additional research is needed, it is possible that the significant predictor variables could be useful in identifying women who are at higher risk for PTSD in other similar populations.

Are health science students' beliefs about infant nutrition evidence-based?

BACKGROUND: Globally, breastfeeding is a fundamental health promotion strategy, improving the health of mothers and infants, well beyond childhood. Healthcare professionals have the responsibility of providing breastfeeding education to families. Worldwide, most healthcare professionals do not receive sufficient evidence-based education to adequately support breastfeeding families. OBJECTIVES: (1) What experiences have university health science students had with breastfeeding? (2) What are university health science students' beliefs and attitudes toward breast and formula feeding of infants? (3) What are the perceptions of university health science students about how other important people in their lives regard breastfeeding? (4) What are the relationships between students' personal experiences with breastfeeding and their beliefs and attitudes about infant feeding choices? DESIGN: A descriptive cross-sectional survey conceptualized using the Theory of Planned Behavior. SETTING: The health science college within a major metropolitan research university in the United States. PARTICIPANTS: Health science undergraduate and graduate students (N=514), who were over the age of 18 and who were enrolled during the spring of 2011. METHODS: Validated survey instruments were used to collect the data on the Theory of Planned Behavior variables. The request for participants was done by emailing all health science students. If students chose to participate, they filled out an anonymous on-line survey. RESULTS: Most participants were not parents; however, the majority of the 95 (21.05%) students who were parents reported their child was breastfed. Significantly more positive attitudes and beliefs were found in graduate students (n=101; 20.10%) when compared to undergraduates (n=403; 89.9%). CONCLUSIONS: Health science students' beliefs and attitudes toward infant nutrition often were not evidence-based. However, all students were remarkably consistent in their responses concerning formula feeding. Incorporating adequate education about human lactation is an unmet responsibility of university health science programs.

One-hour glucose during an oral glucose challenge prospectively predicts ß-cell deterioration and prediabetes in obese Hispanic youth.

OBJECTIVE: In adults, 1-h glucose during an oral glucose tolerance test (OGTT) predicts the development of type 2 diabetes independent of fasting and 2-h glucose concentrations. The purpose of the current investigation was to examine the utility of elevated 1-h glucose levels to prospectively predict deterioration in ß-cell function and the development of prediabetes in high-risk youth. RESEARCH DESIGN AND METHODS: Obese Latino youth with a family history of type 2 diabetes (133 male and 100 female; age 11.1 ± 1.7 years) completed a baseline OGTT and were divided into two groups based upon a 1-h glucose threshold of 155 mg/dL (<155 mg/dL, n = 151, or ≥ 155 mg/dL, n = 82). Youth were followed annually for up to 8 years for assessment of glucose tolerance, body composition by dual-energy X-ray absorptiometry, and insulin sensitivity, insulin secretion, and the disposition index by the frequently sampled intravenous glucose tolerance test. RESULTS: Over time, the ≥ 155 mg/dL group exhibited a significantly greater decline in ß-cell function compared with youth with a 1-h glucose <155 mg/dL (ß = -327.8 ± 126.2, P = 0.01). Moreover, this decline was independent of fasting or 2-h glucose and body composition. When the data were restricted to only participants with normal glucose tolerance at baseline, a 1-h glucose ≥ 155 mg/dL was independently associated with a 2.5 times greater likelihood of developing prediabetes during follow-up (95% CI 1.6-4.1, P = 0.0001). CONCLUSIONS: These data suggest that a 1-h glucose ≥ 155 mg/dL during an OGTT is an independent predictor of ß-cell deterioration and progression to prediabetes among obese Latino youth.

Surgical treatment differences among Latina and African American breast cancer survivors.

PURPOSE/OBJECTIVES: To describe breast cancer treatment choices from the perspectives of Latina and African American breast cancer survivors. DESIGN: An interdisciplinary team conducted a mixed-methods study of women treated for stages I-IV breast cancer. SETTING: Participants' homes in metropolitan areas. SAMPLE: 39 participants in three groups: monolingual Spanish-speaking Latinas (n = 15), English-speaking Latinas (n = 15), and African American women (n = 9). METHODS: Individual participant interviews were conducted by racially and linguistically matched nurse researchers, and sociodemographic data were collected. Content and matrix analysis methods were used. MAIN RESEARCH VARIABLES: Perceptions of breast cancer care. FINDINGS: High rates of mastectomy were noted for early-stage treatment (stage I or II). Among the participants diagnosed with early-stage breast cancer, the majority of English-speaking Latinas (n = 9) and African American women (n = 4) received a mastectomy. However, the majority of the Spanish-speaking Latina group (n = 5) received breast-conserving surgery. Four factors influenced the choice of mastectomy over lumpectomy across the three groups: clinical indicators, fear of recurrence, avoidance of adjuvant side effects, and perceived favorable survival outcomes. Spanish-speaking Latinas were more likely to rely on physician treatment recommendations, and the other two groups used a shared decision-making style. CONCLUSIONS: Additional study is needed to understand how women select and integrate treatment information with the recommendations they receive from healthcare providers. Among the Spanish-speaking Latina group, limited English proficiency, the use of translators in explaining treatment options, and a lack of available educational materials in Spanish are factors that influenced reliance on physician recommendations. IMPLICATIONS FOR NURSING: Oncology nurses were notably absent in supporting the women's treatment decision making. Advanced practice oncology nurses, coupled with language-appropriate educational resources, may provide essential guidance in clarifying surgical treatment choices for breast cancer among culturally and linguistically diverse populations.

Management of venous thromboembolism for older adults in long-term care facilities.

PURPOSE: To provide information on current evidence-based clinical management of venous thromboembolism (VTE) for nurse practitioners working for older adults in long-term care facilities. METHODS AND DATA RESOURCES: A systematic review and summary using current clinical guidelines and reliable clinical research studies: American Medical Directors Association, American College of Chest Physicians, Medline, PubMed, Refworks, and CINAHL. CONCLUSIONS: The management of VTE focuses on a comprehensive approach including acute and long-term pharmacologic approach, surgical and mechanical approach, prophylaxis of recurrent VTE, maintaining INR, and monitoring lab values. IMPLICATIONS: Recommendations based on the most current clinical research studies and guidelines will facilitate a cost-effective management of venous thromboembolism for older adults in long-term care facilities.

Spanish translation and cross-language validation of a sleep habits questionnaire for use in clinical and research settings.

STUDY OBJECTIVES: To translate, back-translate and cross-language validate (English/Spanish) the Sleep Heart Health Study Sleep Habits Questionnaire for use with Spanish-speakers in clinical and research settings. METHODS: Following rigorous translation and back-translation, this cross-sectional cross-language validation study recruited bilingual participants from academic, clinic, and community-based settings (N = 50; 52% women; mean age 38.8 ± 12 years; 90% of Mexican heritage). Participants completed English and Spanish versions of the Sleep Habits Questionnaire, the Epworth Sleepiness Scale, and the Acculturation Rating Scale for Mexican Americans II one week apart in randomized order. Psychometric properties were assessed, including internal consistency, convergent validity, scale equivalence, language version intercorrelations, and exploratory factor analysis using PASW (Version18) software. Grade level readability of the sleep measure was evaluated. RESULTS: All sleep categories (duration, snoring, apnea, insomnia symptoms, other sleep symptoms, sleep disruptors, restless legs syndrome) showed Cronbach α, Spearman-Brown coefficients and intercorrelations ≥ 0.700, suggesting robust internal consistency, correlation, and agreement between language versions. The Epworth correlated significantly with snoring, apnea, sleep symptoms, restless legs, and sleep disruptors) on both versions, supporting convergent validity. Items loaded on 4 factors accounted for 68% and 67% of the variance on the English and Spanish versions, respectively. CONCLUSIONS: The Spanish-language Sleep Habits Questionnaire demonstrates conceptual and content equivalency. It has appropriate measurement properties and should be useful for assessing sleep health in community-based clinics and intervention studies among Spanish-speaking Mexican Americans. Both language versions showed readability at the fifth grade level. Further testing is needed with larger samples.

Perceived discrimination and ethnic identity among breast cancer survivors.

PURPOSE/OBJECTIVES: To examine ethnic identity and socio-demographic factors in minority patients' perceptions of healthcare discrimination in breast cancer care. DESIGN: Mixed methods. SETTING: Participants' homes in the metropolitan areas of Phoenix and Tucson, AZ. SAMPLE: 39 women treated for breast cancer in the past six years: 15 monolingual Spanish-speaking Latinas, 15 English-speaking Latinas, and 9 African Americans. METHODS: Two questionnaires were administered. Individual interviews with participants were conducted by nurse researchers. Quantitative, qualitative, and matrix analytic methods were used. MAIN RESEARCH VARIABLES: Ethnic identity and perceptions of discrimination. FINDINGS: Eighteen women (46%) believed race and spoken language affected the quality of health care. Perceived dis-respect from providers was attributed to participant's skin color, income level, citizenship status, and ability to speak English. Discrimination was more likely to be described in a primary care context, rather than cancer care. Ethnic identity and early-stage breast cancer diagnosis were the only study variables significantly associated with perceived healthcare discrimination. CONCLUSIONS: This article describes the first investigation examining ethnic identity and perceived discrimination in cancer care delivery. Replication of this study with larger samples is needed to better understand the role of ethnic identity and cancer stage in perceptions of cancer care delivery. IMPLICATIONS FOR NURSING: Identification of ethnic-specific factors that influence patient's perspectives and healthcare needs will facilitate development of more effective strategies for the delivery of cross-cultural patient-centered cancer care.

Effectiveness of intervention programs in preventing falls: a systematic review of recent 10 years and meta-analysis.

OBJECTIVE: To examine the reported effectiveness of fall-prevention programs for older adults by reviewing randomized controlled trials from 2000 to 2009. DESIGN: Systematic review and meta-analysis of randomized controlled trials. DATA SOURCES: A systematic literature search of articles was conducted using 5 electronic databases (Medline, PubMed, PsycINFO, CINAHL, and RefWorks), including articles describing interventions designed to prevent falls, in English with full text availability, from 2000 through 2009. REVIEW METHODS: Of a potential 227 studies, we identified 17 randomized controlled trials with a duration of intervention of at least 5 months of follow-up. Inclusion and exclusion criteria were used to assess the methodological qualities of the studies. We excluded unidentified study design, quasi-experimental studies, and/or studies that were nonspecific regarding inclusion criteria. DATA EXTRACTION: Primary outcome measures were number of falls and fall rate. Methodological quality assessment included internal and external validity, reporting, and power. Data were extracted independently by 2 investigators and analyzed using a random-effects model. We analyzed the effectiveness of these fall intervention programs using their risk ratios (RR) in 2 single-intervention versus 15 multifactorial intervention trials, 3 nursing homes versus 14 community randomized controlled trials, and 8 Model 1 (initial intervention with subsequent follow up) versus 9 Model II (ongoing intervention throughout the follow-up) studies. RESULTS: The combined RR for the number of falls among 17 studies was 0.855 (z = -2.168; p = .030; 95% CI = 0.742-0.985; Q = 196.204, df = 16, P = .000, I(2) = 91.845), demonstrating that fall-prevention programs across the studies were effective by reducing fall rates by 14%, but with substantial heterogeneity. Subgroup analysis indicated that there was a significant fall reduction of 14% in multifactorial intervention (RR = 0.856, z = -2.039, P = .041) with no variation between multifactorial and single-intervention groups (Q = 0.002, P = .961), 55% in the nursing home setting (RR = 0.453, z = -9.366, P = .000) with significant variation between nursing home and community groups (Q = 62.788, P = .000), and no significant effect was gained by dividing studies into either in Model I or II. Sensitivity analysis found homogeneity (Q = 18.582, df = 12, P = .099, I(2) = 35.423) across studies with a 9% overall fall reduction (RR = 0.906, 95% CI = 0.853-0.963, z = -3.179, P = .001), including a fall-reduction rate of 10% in multifactorial intervention (RR = 0.904, z = -3.036, P = .002), 9% in community (RR = 0.909, z = -3.179, P = .001), and 12% in Model I (RR = 0.876, z = -3.534, P = .000) with no variations among all the groups. Meta regression suggested that the model fit explained 68.6% of the relevant variance. CONCLUSIONS: The meta-sensitivity analysis indicates that randomized controlled trials of fall-prevention programs conducted within the past 10 years (2000-2009) are effective in overall reduction of fall rates of 9% with a reduction of fall rates of 10% in multifactorial interventions, 9% in community settings, and 12% in Model I interventions (initial intervention efforts and then subsequent follow-up).

Identifying and treating the culture-bound syndrome of Hwa-Byung among older Korean immigrant women: recommendations for practitioners.

PURPOSE: To introduce advanced practice nurses to the concept of Hwa-Byung, a culture bound syndrome that is now accepted as a psychiatric term. DATA SOURCES: Information from the Diagnostic and Statistical Manual and selected research and clinical articles. CONCLUSIONS: Hwa-Byung is a culture-bound syndrome caused by long-standing suppressed anger prevalent among older immigrant women of Korean heritage. Although the concept of Hwa-Byung was reported more than a decade ago, it has not been studied cross-culturally nor described sufficiently in the literature. IMPLICATIONS FOR PRACTICE: The use of appropriate guidelines and an understanding of Hwa-Byung is essential for proper assessment, diagnosis (especially to distinguish it from clinical depression), and culturally sensitive management of this condition. Korean versions of screening tools are provided as online supporting information.

Psychometric evaluation of the index of self-regulation.

Index of Self-Regulation (ISR) is a nine-item scale designed primarily to measure individuals' level of self-regulation for physical activity. The aim of this study is to report psychometric characteristics of the ISR. The ISR scale was administered in a sample of 183 adult patients at 2 weeks following graduation from cardiac rehabilitation, 3 months following graduation, and 6 months following graduation. The internal consistency of the ISR was high at all three time points, with Cronbach's alphas of .81 to .96 across time points. The test-retest reliability was fairly high, with an overall coefficient of .73. There was evidence of concurrent validity of the ISR based on its moderately significant correlations with other theoretically relevant variables, including self-knowledge and motivational appraisal for physical activity. In conclusion, the ISR is a reliable and valid measure to assess the level of self-regulation in the maintenance of physical activity.