Clinical utility of inflammatory and genetic biomarkers for cardiovascular disease prevention, categorization, and treatment.

ABSTRACT: The complex interplay of increased atherogenic lipoproteins, inflammation, and immune activation hallmarks the pathogenesis of atherosclerotic cardiovascular disease (ASCVD). Atherosclerotic cardiovascular disease remains a leading cause of death, yet risk estimator tools lack comprehensiveness for genetic/inflammatory biomarkers associated with ASCVD. Unexplained ASCVD risk necessitates a better understanding of primary, secondary, and tertiary prevention variables. This article discusses the clinical utility of genetic and inflammatory biomarkers for ASCVD risk prediction, management, treatment, and recategorization into primary, secondary, and tertiary prevention. Furthermore, nurse practitioners (NPs) should use a ternary prevention classification system instead of the current binary system to mitigate risk in the large group of patients with subclinical ASCVD. High-sensitivity C-reactive protein (hs-CRP)-linearly associated with ASCVD-and lipoprotein-associated phospholipase-A 2 (Lp-PLA 2 ) and myeloperoxidase (MPO), both associated with plaque vulnerability/rupture, are inflammatory biomarkers. Elevated hs-CRP, MPO, and Lp-PLA 2 treatment requires addressing root causes of elevation (e.g., obesity, insulin resistance, tobacco use, gingival disease, and chronic autoimmune/infectious conditions). In addition, haptoglobin (Hp) phenotype determines the antioxidant potential of Hp. Haptoglobin phenotype, a root cause of ASCVD, is a one-time test. Individuals with Hp 2-2 should adopt a gluten-free diet to reduce endothelial and intestinal inflammation. Nurse practitioners should use stricter glycemic goals (hemoglobin A1c ≤6.5%) and add daily vitamin E if this group has type 2 diabetes. Genetic/inflammatory biomarkers should be used to better predict ASCVD risk and tailor primary, secondary, and tertiary prevention treatment. Clinical use of these biomarkers reaches beyond the standard of care to reduce residual ASCVD risk.

Journey to a new era: An innovative academic-practice partnership.

Successful academic-clinical partnerships are mutually beneficial for academic nursing and clinical organizations, supporting the long-term success of nursing programs while simultaneously improving patient outcomes. Advocated by the American Association of Colleges of Nursing in their 2016 report, Advancing Healthcare Transformation: New Era for Academic Nursing, this position paper provides six actions for transforming academic nursing. However, developing sustainable academic-practice models has proven challenging despite this roadmap, as research has not substantiated their benefits. This article describes an innovative academic-practice model that transitioned advanced practice registered nurses practicing at Le Bonheur Children's Hospital to full-time faculty, with a continued primary clinical practice role, in the College of Nursing at the University of Tennessee Health Science Center. We present the origin, development, and implementation of this academic-practice partnership model, offering recommendations for its replication by other universities and clinical agencies on this journey. Creating a sustainable model requires a shared vision, buy-in at all levels, frequent and transparent communication, planning that considers the individual policies of the partnering agencies, and persistence despite leadership changes. Two years into the partnership and remaining intact despite critical leadership changes within the clinical agency, the next phase of the relationship will permit us to document the model's impact on academic and clinical outcomes.

Long-term Effectiveness of a Peer-Led Asthma Self-management Program on Asthma Outcomes in Adolescents Living in Urban Areas: A Randomized Clinical Trial.

Importance: Long-term effectiveness of a peer-led asthma self-management program in improving asthma outcomes in adolescents living in urban areas has not been established. Objective: To determine the long-term effects of a peer-led program on asthma control, quality of life, and asthma management among predominantly racial and ethnic minority adolescents living in urban areas. Design, Setting, and Participants: A parallel-group, randomized clinical trial was conducted in 2015 to 2019 in 3 metropolitan cities in the US: Buffalo, New York; Baltimore, Maryland; and Memphis, Tennessee. Adolescents aged 12 to 17 years old with persistent asthma were recruited mainly through clinical practices and schools. Participants were followed-up for 15 months after the intervention. Double-blinding was achieved for baseline. Data analysis was performed from June 2019 to June 2020. Interventions: The intervention group received a peer-led asthma self-management program; the control group received the identical program led by adult health care professionals. Peer leaders made follow-up contacts every other month for 12 months. Main Outcomes and Measures: The primary outcome was quality of life measured by the Pediatric Asthma Quality of Life Questionnaire, which consists of 3 subscales that measure symptoms (10 items), activity limitations (5 items), and emotional functioning (8 items) in the past 2 weeks. Each item was measured on a 7-point scale, with higher mean scores indicating better quality of life. Secondary measures included the Asthma Control Questionnaire and an asthma self-management index capturing steps to prevent and manage symptoms, self-efficacy, and lung function. Results: Of 395 eligible adolescents, 35 refused, 38 did not show or were lost to contact, and 2 withdrew before randomization; 320 adolescents participated (mean [SD] age, 14.3 [1.71] years), including 168 boys (52.5%), 251 Black or African American adolescents (78.4%), and 232 adolescents (72.5%) with public health insurance. Of 320 enrolled, 303 were included in the longitudinal analysis. Response rates were 80% or higher at all time points. The peer-led group had greater improvement in outcomes than the adult-led group, with adjusted mean differences (AMDs) between baseline and 15 months of 0.75 vs 0.37 for quality of life (between-group AMD, 0.38; 95% CI, 0.07 to 0.63) and -0.59 vs -0.31 for asthma control (between-group AMD, -0.28; 95% CI, -0.51 to -0.01). Outcomes were not affected by bimonthly contact doses. Conclusions and Relevance: In this randomized clinical trial, a peer-led asthma self-management education was more effective than an adult-led program in improving asthma outcomes, with the improvements sustained for up to 15 months. These findings suggest that a peer-led asthma self-management program should be considered in addressing the disproportionate asthma burden in racial and ethnic minority adolescents living in urban communities. Trial Registration: ClinicalTrials.gov Identifier: NCT02293499.

Family Caregivers' Experience of Patients With Delirium in Critical Care Units: A State-of-the-Science Integrative Review.

BACKGROUND: Delirium as a sudden cognitive and behavioral change can be traumatic for family caregivers. An understanding of family caregivers' experiences with delirium in their loved one in an intensive care unit (ICU) will help clinicians provide family-centered care. OBJECTIVE: To explore the impact of delirium on, and the needs of, family caregivers of ICU patients with delirium. METHODS: A comprehensive search was done of literature in the PubMed, CINAHL, and Scopus databases published from 2000 to 2020. Primary studies written in English and done in critical care settings were included. Studies that did not focus on the family experience of delirium were excluded. Additional studies were identified by reviewing the reference lists of selected articles. Evidence was synthesized, and common themes were identified. RESULTS: Among 210 studies, 7 were included after irrelevant and duplicate studies had been removed. Findings were categorized as (1) psychological impacts of a patient's delirium on family caregivers and (2) family caregivers' needs. Common psychological impacts included anxiety, depression, concern, fear, anger, uncertainty, shock, insecurity, and disappointment. Family caregivers reported needing informational and emotional support from, and effective communication with, health care professionals. CONCLUSIONS: Family caregivers' health is crucial to ensuring the effectiveness of family engagement in delirium management. Future studies should consider family caregiver characteristics that could be used to predict psychological symptoms when caregivers are exposed to a patient's delirium and explore whether specific types of delirium cause more psychological impacts and needs among family caregivers than other types of delirium cause.

Enhanced access to healthcare utilization data through medical record review: Lessons learned from a community-based, multi-site project.

Collecting accurate healthcare utilization (HCU) data on community-based interventions is essential to establishing their clinical effectiveness and cost-related impact. Strategies used to enhance receiving medical records for HCU data extraction in a multi-site longitudinal randomized control trial with urban adolescents are presented. Successful strategies included timely assessment of procedures and practice preferences for access to electronic health records and hardcopy medical charts. Repeated outreach to clinical practice sites to identify and accommodate their preferred procedure for medical record release and flexibility in obtaining chart information helped achieve a 75% success rate in this study. Maintaining participant contact, updating provider information, and continuously evaluating site-specific personnel needs are recommended.

Health-Related Quality of Life of Children with Congenital Adrenal Hyperplasia: A Mixed Methods Study.

PURPOSE: The purpose of this study was to examine the health-related quality of life (HRQOL) of female children with CAH as reported by children and their caregivers. DESIGN AND METHODS: A convergent mixed methods design was selected whereby quantitative and qualitative results were merged to provide a comprehensive understanding of HRQOL of children. Semi-structured interviews were conducted with 20 child-caregiver dyads. The full sample of child-caregiver dyads (N = 25) completed KINDL-R questionnaires, which provided a quantitative measure of children's HRQOL. RESULTS: Children and their caregivers reported good overall HRQOL. Children scored significantly lower on the KINDL-R School subscale compared to their caregivers. Associations were observed between the HRQOL score from one graphic rating scale item and the child's other health issues and child's diagnosis. Themes emerging from the child and caregiver interviews were health-related quality of life, impact of stigma on psychological well-being, information-sharing and disclosure of CAH, and improving the quality of life of children with CAH. CONCLUSION: This mixed methods study provided evidence to understand the health and complex needs of children with CAH. IMPLICATIONS: Clinicians may better support children and caregivers by expanding the focus beyond medication management to include: 1) psychological support and resources (i.e., developmentally appropriate coping and adaptation strategies); 2) continuous education for clinical staff, school nurses, emergency medical transport staff, and providers; and 3) public awareness beyond the clinic and hospital settings.

Influence of social support on asthma self-management in adolescents.

OBJECTIVE: Adolescents with asthma are influenced by peers and family. The objective was to better understand family social support and test its association with medication adherence, asthma control, and Emergency Department (ED) use. METHODS: This study is a cross-sectional secondary data analysis from a randomized controlled trial with urban adolescents from three U.S. cities. Participants (12-20 years old) with asthma completed the Perceived Family Support Scale (PFS) and Horne's Medication Adherence Report Scale (MARS). Data from both tools were classified into 2 categories- high and low (< 25th percentile) perceived family support and high (total score >10) and low medication adherence, respectively. Chi-square statistic and logistic regression were used for analysis. RESULTS: Of the 371 participants, the majority were young (96% ≤ 17 years), African American or Bi-racial (85%), and Medicaid-insured (72%); over one-third had maternal family history of asthma. Among those on a controller medication (n = 270), only 37% reported its use ≥8 days over 2 weeks. Asthma control was poor with 50% categorized "not well controlled," 34% "very poorly controlled." Participants responded positively to most social support items. One item, providing and receiving social support to and from family members, was less often positively reported. Low medication adherence was significantly associated with lower perceived social support (p = 0.018). CONCLUSION: This study underscores the importance of family social support in understanding the extent of adolescents' self-management, particularly medication adherence.

Factors Associated With Quality of Life of Family Caregivers of Dialysis Recipients.

Chronic kidney failure may contribute to the diminished quality of life of African American women who care for adults affected by the disorder. Few studies document the quality of life of these caregivers. For this descriptive correlational study, caregiver demographic, caregiver burden, depressive symptoms, family functioning, and quality-of-life self-report data from 75 African American women were extracted from an existing database. Ferrans' Conceptual Model of Quality of Life guided the selection of study variables. Several significant associations were found. Caregiver education, employment status, marital status, and caregiver burden explained 63% of the variance in the caregivers' quality of life. Findings support the need to explore further and design interventions to improve the quality of life of working African American women supporting individuals with chronic kidney failure.

Fidelity of a peer-led asthma self-management intervention and its attention control in a multisite study of urban adolescents.

In this paper we compare the fidelity of a Peer-Led Asthma Self-Management Program for Adolescents (PLASMA) and its attention control. A randomized controlled trial involving two groups-the PLASMA group and the attention control group-was conducted between 2015 and 2018. Adolescents 12-17 years old (N = 259) in three cities in the United States received asthma self-management education implemented at a day camp, followed by bi-monthly, follow-up contact for 12 months. Thirty-five peer leaders and six adult educators implemented education sessions for the PLASMA and the attention control groups, respectively. The intervention was the peer-led delivery of the content instead of the educational content itself. This study compares the extent to which the education sessions and follow-up contacts were implemented in accordance with the study protocol by the peer and adult educators. Most topics on asthma knowledge and skills (85-95%) were delivered as intended at an adequate pace in both groups. Peer leaders missed more content in the psychosocial domain than adult educators-14% versus 0%, respectively (t = -3.7; p = .010). PLASMA participants reported high content and time fidelity for all education sessions (94% to 97.6%). Greater success in bimonthly follow-up contacts was reported in the attention control groups, with 4.6 ( ± 1.5) contacts on average compared to 2.6 (±2.02) in the PLASMA groups (t = 9.02; p < .001). Most components of the asthma self-management program were implemented with high fidelity in both groups. The relatively low fidelity in delivering psychosocial content and performing follow-up contacts in the PLASMA groups underscores the need for intensive training to enhance peer leaders' competency with managing these aspects of PLASMA to maximize fidelity. Peer leaders can implement asthma self-management educational components of the intervention with high fidelity similar to adult educators.

Living with an invisible illness: a qualitative study exploring the lived experiences of female children with congenital adrenal hyperplasia.

PURPOSE: Many chronic illnesses are self-evident. However, disorders like congenital adrenal hyperplasia (CAH) are invisible to the naked eye and unnoticeable to others. Therefore, invisible illness is often a shared, misconstrued experience for children with CAH, their caregivers, and the medical community. This experience, along with its lack of awareness and added stigma, may impact overall quality of life (QOL) of such individuals. To facilitate our understanding of QOL of children with CAH, we must first explore their subjective experiences. This study aimed to capture their lived experiences and provide recommendations to support children with CAH. METHODS: We conducted semi-structured interviews with 20 female children with CAH between 7 and 18 years and their caregivers. Interviews were transcribed verbatim, checked for accuracy, and independently coded by the first and second author. Content analysis was used to organize data so that codes could be condensed into categories and themes. Differences around code, category, and theme description were reconciled. RESULTS: Participants' experiences were described in five themes: (1) Making sense of the situation; (2) Emotional and psychological impact of an invisible illness; (3) Normalcy; (4) Disclosure of diagnosis; and (5) Improving the care of children with CAH CONCLUSION: Exploring children's views about living with an invisible illness illuminated individual aspects contributing to our in-depth understanding of experiences of children with CAH. Ongoing education and awareness of CAH is necessary to help mitigate the stigma associated with living with CAH.

Cognitive factors predict medication adherence and asthma control in urban adolescents with asthma.

PURPOSE: Adolescents with asthma often report poor medication adherence and asthma control. Cognitive factors embedded in the social cognitive theory including self-efficacy, outcome expectations, and barrier perceptions may explain poor asthma outcomes in this population. This study was performed to examine the extent to which these cognitive factors are intercorrelated and explain medication adherence and asthma control in urban adolescents. PATIENTS AND METHODS: A total of 373 urban adolescents (12-20 years) with asthma completed questionnaires measuring asthma-related self-efficacy, outcome expectations, barrier perceptions, medication adherence, and asthma control. Multiple linear regression was conducted to examine the extent to which the three cognitive factors predicted medication adherence and asthma control after controlling for covariates including age, sex, household income, and age at diagnosis. RESULTS: Participants' ages were on average 14.68 (±1.94) years; 50% were female, and most (78.6%) were African American. Higher self-efficacy associated with lower barrier perceptions and higher outcome expectations (r=0.50, p<0.001; r=-0.26, p<0.001, respectively). Self-efficacy predicted better asthma control (B=-0.098, p=0.004) and adherence (B=0.426, p=0.011), whereas barrier perceptions predicted poorer asthma control (B=0.13, p<0.001) and adherence (B=-0.568, p<0.001). Self-efficacy independently predicted fewer missed doses (B=-0.621, p=0.006), and barrier perception independently predicted asthma control (B=0.12, p<0.001) and adherence (B=-0.519, p<0.001). CONCLUSION: Improving medication adherence and asthma control among adolescents may require a multifaceted approach. Interventions focused on increasing self-efficacy and addressing barriers, actual or potential, to medication adherence could ameliorate asthma disparities in urban adolescents.