Health-related quality of life over chemotherapy course among individuals with early-stage breast cancer: the association of social determinants of health and neighborhood socioeconomic disadvantage.

PURPOSE: This study aimed to examine relationships between health-related quality of life (HRQOL), social determinants of health, and neighborhood socioeconomic disadvantage in individuals with early-stage breast cancer (ESBC) during chemotherapy. METHODS: This is a longitudinal study that recruited Black and White women with ESBC receiving chemotherapy. Participants completed questionnaires recording their sociodemographic information at baseline and the Functional Assessment of Cancer Therapy-General (FACT-G) to report their HRQOL before each chemotherapy cycle. Linear mixed modeling was employed to examine the associations between FACT-G scores, self-reported race, and area deprivation index (ADI) before and at the last chemotherapy cycle, with the duration of chemotherapy treatment as a covariate. RESULTS: A total of 84 Black and 146 White women with ESBC completed the surveys. Linear mixed modeling results suggested that women with ESBC who reported being Black experienced significantly worse physical well-being than those who reported being White throughout chemotherapy, with a 0.22-point lower average (p = 0.02). Both Black and White women with ESBC experienced decreased functional well-being over the chemotherapy, and Black women consistently reported lower scores than White women, with the change in functional well-being over time differing between racial groups (p = 0.03). Participants' ADI national percentiles were not significantly associated with their HRQOL throughout chemotherapy. CONCLUSIONS: These findings underscore possible racial differences in some dimensions of HRQOL during chemotherapy among women with ESBC. Future research should consider further assessing life stressors and past experiences of discrimination and racism that may contribute to these disparities and guide proactive interventions.

Mixed-Methods Assessment of Maternal Anxiety During the First 8 Weeks After Birth.

OBJECTIVE: To describe and compare the experiences of postpartum anxiety among women with generalized anxiety and postpartum-specific anxiety. DESIGN: Prospective, longitudinal, mixed methods. SETTING: Academic tertiary center in the mid-Atlantic United States. Study activities were remote. PARTICIPANTS: Women at 1 to 8 weeks after birth (N = 34). METHODS: We used mobile surveys to measure daily anxiety ratings and responses to open-ended, theory-driven questions about anxiety. We used the cutoff scores on the State-Trait Anxiety Inventory and Postpartum Specific Anxiety Scale administered 8 weeks after birth to determine the presence of generalized and postpartum-specific anxiety. Participants' responses were analyzed with qualitative description and sorted by anxiety questionnaire scores at 8 weeks after birth. We compared qualitative findings between participants with generalized anxiety and postpartum-specific anxiety. RESULTS: Participants with generalized anxiety had high levels of overwhelm and felt ill-equipped to handle daily stressors, whereas those with postpartum-specific anxiety felt adept at coping. Participants with generalized anxiety lacked emotional and physical support, and those with postpartum-specific anxiety reported more physical but variable emotional support. Sources of daily anxiety in participants with postpartum-specific anxiety were infant-centric (e.g., infant health, end of maternity leave, breastfeeding), whereas anxiety sources for participants with generalized anxiety were varied (e.g., self-health, partner concerns). Participants with generalized anxiety versus postpartum-specific anxiety were more likely to be multiparous and have comorbid depression symptoms. CONCLUSION: Symptoms, levels of perceived support, and sources of anxiety differed between participants with generalized versus postpartum-specific anxiety. Our findings can inform postpartum anxiety screening strategies and support interventions.

Economic Hardship and Associated Factors of Women With Early-Stage Breast Cancer Prior to Chemotherapy Initiation.

INTRODUCTION: Economic hardship (EH) can negatively influence cancer outcomes. Little is known about the factors that are associated with higher levels of EH among patients with breast cancer (BC). This paper describes EH in women with early-stage BC prior to or at their first chemotherapy treatment (baseline) and explores whether there are differences by race, area deprivation, stress, symptom distress, and social support. PATIENTS AND METHODS: A descriptive comparative/correlational design was employed using baseline data of a multisite, longitudinal, multimethod study comparing the symptom experience and management prior to prescribed chemotherapy for women with early-stage BC. Participants completed measures for EH, perceived stress, symptom distress, and social support. Race was measured by self-report. Area deprivation indices (ADI) measuring neighborhood economic factors were calculated from publicly available websites. RESULTS: Participants (N = 248; age = 52.9 ± 12.3 years) were 62% White and 38% Black, 54% partnered, and 98% insured. Compared to White patients, Black patients reported higher (worse) EH (1.2 ± 3.0 vs. -0.7 ± 2.4), lived in areas of greater deprivation (80.1 ± 2.1 vs. 50.5 ± 23.5),and were more likely to report inadequate household income (Black: 30.5%; White: 11.1%). Adjusting for race and age, being Black (P< .001), living in an area of greater deprivation (P = .049), higher perceived stress (P = .008), lower perceived appraisal (P = .040), and less tangible support (P < .001) contributed to greater EH. Worse symptom distress trended toward greater EH (P = .07). CONCLUSIONS: This study emphasizes the importance of incorporating baseline holistic assessment to identify patients most likely to experience EH during early-stage BC treatment.

Predictors of Healthcare Utilization in Family Caregivers of Persons With a Primary Malignant Brain Tumor.

ABSTRACT: BACKGROUND: Negative physical health results from the emotional stress of providing care to a family member with a primary malignant brain tumor; however, the downstream effects on caregivers' healthcare utilization (HCU) are unknown. This analysis examined associations between caregivers' emotional health and markers of HCU during the 6 months after patients' diagnoses. METHODS: Caregivers' self-report HCU data from a longitudinal study with 116 neuro-oncology caregivers were analyzed. Healthcare utilization was operationalized as number of prescription medications, reporting visits to primary care providers (PCPs), nature of PCP visit, number of comorbid conditions, and change in comorbid conditions. Potential predictors were caregivers' depressive symptoms (Center for Epidemiologic Studies-Depression Scale), hours providing care per day, mastery (Pearlin and Schooler), and burden (Caregiver Reaction Assessment). Logistic mixed effects modeling were used. RESULTS : Caregivers with higher levels of depressive symptoms ( P < .01), anxiety ( P = .02), burden related to schedule ( P = .02), and abandonment ( P < .01) were more likely to report worsening comorbid conditions. Those with higher mastery ( P = .02) were less likely to report worsening comorbid conditions. Caregivers who had a PCP visit and reported higher burden related to feelings of self-esteem ( P = .03) were more likely to report an illness-related visit. CONCLUSION : Findings suggest a relationship between neuro-oncology caregivers' emotional health and their HCU. Data highlight the importance of caregivers' PCPs identifying caregivers at risk for deteriorating health and increased HCU and intervene to ensure caregivers' self-care.

Factors Associated with Nurses' Motivation to Provide Care for Patients with Alcohol Use and Alcohol Use-Related Problems.

BACKGROUND: There is a high human and economic cost associated with alcohol use and alcohol use-related problems. Nurses have a pivotal role in addressing the needs of this patient population. Purpose: The study aimed to examine the correlation between nurses' demographics/background characteristics, personal attitudes, professional attitudes, and their motivation to provide care to patients with alcohol use and alcohol use-related problems. METHODS: A descriptive, cross-sectional correlational design was utilized. Nurses were recruited from four Southwestern Pennsylvania hospitals. The study variables were examined using questionnaires that explored nurses' demographic/background characteristics, their personal and professional attitudes, and motivation to care for patients with alcohol use and alcohol use-related problems. RESULTS: The sample included 234 nurses. Demographic/background characteristics were identified as associated with nurse's alcohol use-related motivation, including gender, primary work setting and specialization. Previous personal experience with alcohol use-related problems (nurses themselves or co-workers), familiarity, perceived dangerousness, fear, social distance, personal responsibility beliefs and disease model were also associated with nurses' alcohol use-related motivation to care for these patients. In addition, all professional attitudes were associated with nurses' motivation toward caring for patients with alcohol use and alcohol use-related problems. CONCLUSIONS: The study revealed that certain demographic/background characteristics and personal and professional attitudes were associated with nurses' motivation to provide care to this patient population. This study provides the foundation for future studies aimed at exploring predictors of nurse's motivation to care for patients with alcohol use and alcohol use-related problems.

Cardiorespiratory fitness is associated with hippocampal resting state connectivity in women newly diagnosed with breast cancer.

Background: Breast cancer and its treatment are associated with aberrant patterns of resting state functional connectivity (rsFC) between the hippocampus and several areas of the brain, which may account for poorer cognitive outcomes in patients. Higher cardiorespiratory fitness (CRF) has been associated with enhanced rsFC and cognitive performance; however, these associations have not been well studied in breast cancer. We examined the relationship between CRF, rsFC of the hippocampus, and cognitive performance among women newly diagnosed with breast cancer. Methods: Thirty-four postmenopausal women newly diagnosed with Stage 0-IIIa breast cancer (Mage = 63.59 ± 5.73) were enrolled in a 6-month randomized controlled trial of aerobic exercise vs. usual care. During baseline assessments, participants completed functional brain imaging, a submaximal CRF test, and cognitive testing. Whole-brain, seed-based analyses were used to examine the relationship between CRF and hippocampal rsFC, with age, years of education, and framewise displacement included as covariates. Cognition was measured with a battery of validated neurocognitive measures, reduced to seven composite factors. Results: Higher CRF was positively associated with greater rsFC of the hippocampus to a cluster within the dorsomedial and dorsolateral frontal cortex (z-max = 4.37, p = 0.003, cluster extent = 1,020 voxels). Connectivity within cluster peaks was not significantly related to cognitive factors (all ps > 0.05). Discussion: CRF was positively associated with hippocampal rsFC to frontal cortex structures, comprising a network of regions commonly suppressed in breast cancer. Future longitudinal research is needed to explore whether baseline rsFC predicts long-term cognitive resilience in breast cancer.

The Association between Neighborhood Walkability and Physical Activity in a Behavioral Weight Loss Trial Testing the Addition of Remotely Delivered Feedback Messages to Self-Monitoring.

Adding feedback messages (FB) to self-monitoring (SM) may reinforce behavior change. However, socio-environmental conditions (e.g., limited access to parks or low walkability) may limit one's ability to respond to FB focused on physical activity (PA). In this analysis, we hypothesized that high neighborhood walkability will positively modify the treatment effect of FB on PA, and residents of high walkability neighborhoods will achieve higher PA levels at 12 months than those in low walkability neighborhoods. The study is a secondary analysis of a 12-month behavioral weight-loss trial. Adults with overweight/obesity were randomized to SM + FB (n = 251) or SM alone (n = 251). SM + FB group received smartphone pop-up messages thrice/week tailored to their PA SM data. The assessment included neighborhood walkability via Walk Score (low [<50] vs. high [≥50]), moderate to vigorous PA (MVPA) and step count via Fitbit Charge 2™, and weight via smart scale. We report adjusted linear regression coefficients (b) with standard errors (SE). The analysis included participants who were primarily white, female, and with obesity. In adjusted models, neighborhood walkability did not moderate the effect of treatment assignment on log-transformed (ln) MVPA or steps count over 12 months. The SM + FB group had greater lnMVPA than the SM group, but lnMVPA and steps were similar between walkability groups. There were no significant interactions for group and time or group, time, and walkability. These findings suggest that adding FB to SM had a small but significant positive impact on PA over 12 months, but neighborhood walkability did not moderate the treatment effect of FB on PA.

Machine learning for ECG diagnosis and risk stratification of occlusion myocardial infarction.

Patients with occlusion myocardial infarction (OMI) and no ST-elevation on presenting electrocardiogram (ECG) are increasing in numbers. These patients have a poor prognosis and would benefit from immediate reperfusion therapy, but, currently, there are no accurate tools to identify them during initial triage. Here we report, to our knowledge, the first observational cohort study to develop machine learning models for the ECG diagnosis of OMI. Using 7,313 consecutive patients from multiple clinical sites, we derived and externally validated an intelligent model that outperformed practicing clinicians and other widely used commercial interpretation systems, substantially boosting both precision and sensitivity. Our derived OMI risk score provided enhanced rule-in and rule-out accuracy relevant to routine care, and, when combined with the clinical judgment of trained emergency personnel, it helped correctly reclassify one in three patients with chest pain. ECG features driving our models were validated by clinical experts, providing plausible mechanistic links to myocardial injury.

Comparing American Indian/Alaska Native Adolescent Daughters' and Their Mothers' Awareness, Knowledge, Attitudes, and Behaviors Regarding Risk for Gestational Diabetes: Implications for Mother-Daughter Communication on Reproductive Health.

PURPOSE: The purpose of the study was to describe, compare, and examine associations at baseline of reproductive health awareness, knowledge, health beliefs, communication and behaviors related to gestational diabetes (GDM) and GDM risk reduction in a vulnerable population of both American Indian/Alaska Native (AIAN) adolescent girls and their mothers. METHODS: Descriptive/comparative/correlational analyses examined multitribal baseline data on 149 mother-daughter (M-D) dyads (N = 298; daughter age = 12-24 years) enrolled in a longitudinal study to adapt and evaluate a culturally relevant diabetes preconception counseling (PC) program (Stopping-GDM). The associations between GDM risk reduction awareness, knowledge, health beliefs, and behaviors (eg, daughters' eating, physical activity, reproductive-health [RH] choices/planning, M-D communication, daughters' discussions on PC) were examined. Data collected online from 5 national sites. RESULTS: Many M-D lacked awareness/knowledge of GDM and risk reduction. Both M-D were unaware of the girl's risk for GDM. Mothers' knowledge and beliefs on GDM prevention/RH were significantly higher than daughters. Younger daughters had greater self-efficacy healthy living. Overall sample reported low to moderate scores for both M-D communication and daughters' GDM and RH risk-reduction behaviors. CONCLUSIONS: Knowledge, communication, and behaviors to prevent GDM were low in AIAN M-D, especially daughters. More than daughters, mothers perceive greater risk of GDM for daughters. Early culturally responsive dyadic PC programs could help decrease risk of developing GDM. Implications for M-D communication is compelling.

Relationship between food insecurity and a gestational diabetes risk reduction intervention: outcomes among American Indian and Alaska Native adolescent and young adult females.

American Indian and Alaska Natives (AI/ANs) are disproportionately impacted by gestational diabetes mellitus (GDM), subsequent type 2 diabetes, and food insecurity. It is prudent to decrease risk of GDM prior to pregnancy to decrease the intergenerational cycle of diabetes in AI/AN communities. The purpose of this project is to describe and examine food insecurity, healthy eating self-efficacy, and healthy eating behaviors among AI/AN females (12-24 years old) as related to GDM risk reduction. Methods included: secondary analysis of healthy eating self-efficacy and behaviors, and household-level food insecurity measures from an randomized controlled trial that tested the effect of engagement in a GDM risk reduction educational intervention on knowledge, behavior, and self-efficacy for GDM risk reduction from baseline to 3-month follow-up. Participants were AI/AN daughters (12-24 years old) and their mothers (N = 149 dyads). Researchers found that more than one-third (38.1%) reported food insecurity. At baseline food insecurity was associated with higher levels of eating vegetables and fruit for the full sample (p = .045) and cohabitating dyads (p = .002). By 3 months healthy eating self-efficacy (p = .048) and limiting snacking between meals (p = .031) improved more in the control group than the intervention group only for cohabitating dyads. For the full sample, the intervention group had increases in times eating vegetables (p = .022) and fruit (p = .015), whereas the control group had declines. In the full sample, food insecurity did not moderate the group by time interaction for self-efficacy for healthy eating (p ≥ .05) but did moderate the group by time interaction for times drinking soda (p = .004) and days eating breakfast (p = .013). For cohabitating dyads, food insecurity did moderate self-efficacy for eating 3 meals a day (p = .024) and days eating breakfast (p = .012). These results suggest food insecurity is an important factor regarding the efficacy of interventions designed to reduce GDM risk and offer unique insight on "upstream causes" of GDM health disparities among AI/AN communities.

American Indian and Alaska Native (AI/AN) women are disproportionately impacted by gestational diabetes mellitus (GDM). GDM can cause severe perinatal complications for both mother and baby. Weight management through healthy diet and physical activity are key factors in decreasing risk for GDM. However, there are barriers to healthful eating in many AI/AN communities. Food insecurity, defined as the lack of consistent access to enough food for an active, healthy life, is a risk factor for unwanted weight gain. Living in a food insecure household during preconception and pregnancy may increase risk of greater weight gain. In this paper, we examined the relationship between food insecurity with healthy eating self-efficacy and behaviors among AI/AN adolescents and young adults (AYAs) (n = 149) through secondary analysis of an existing randomized controlled trial dataset. This study offers unique insight regarding "upstream causes" of GDM health disparities among AI/AN communities. Food security had some moderating effects on individual eating behaviors. Additionally, both healthy eating behavior and self-efficacy for healthy eating improved more among the AYA who experienced food insecurity at baseline. Given the intergenerational implications of GDM, it is prudent that the healthcare sector works with AI/AN communities to support healthful eating behaviors and environments to decrease GDM disparities.

Do Individuals Aged 50 or Older View Cognitive Conditions Differently Than Physical Conditions? Evidence From a Pooled Analysis of Illness Perceptions in Type 2 Diabetes and Mild Cognitive Impairment.

Background and Objectives: Type 2 diabetes (T2DM) and mild cognitive impairment (MCI) are common late-life physical and cognitive health conditions. Illness perceptions, an individual's personal beliefs about the conditions, should be explored in the context of disease characteristics (physical or cognitive). This secondary analysis explored illness perceptions with a priori hypotheses about control (perceived controllability) and coherence (perceived understanding) dimensions among persons with T2DM and MCI, treating each as an exemplar of late-life physical and cognitive health conditions. We also explored whether age, education, and comorbid conditions moderate the relationships between T2DM or MCI condition groups and illness perceptions. Research Design and Methods: This cross-sectional, descriptive study examined baseline data collected from 146 T2DM to 90 MCI participants in 2 independent studies. The 9-item Brief Illness Perception Questionnaire was used to identify the similarities and differences in illness perceptions among persons with T2DM and MCI. We performed hierarchical linear regression controlling for identified covariates. Results: We found that T2DM and MCI participants had significantly different illness perceptions, including perceptions of personal control (b = -0.943, p = .009), treatment control (b = -1.619, p < .001), and coherence (b = -1.265, p = .001), after controlling for covariates. The results suggest that persons with MCI were likely to believe that their condition is less controllable (through their own strategies or medical treatment) and less understandable compared with their T2DM counterparts. Such associations remained statistically significant when the interactions were added to the models. Discussion and Implications: As T2DM and MCI are prevalent late-life conditions, health care professionals should consider individuals' subjective perceptions about their conditions in the context of disease characteristics when counseling secondary prevention strategies for disease management. Further research on illness perceptions in other conditions is needed to ensure the replicability of our findings.

The feasibility, acceptability, and preliminary efficacy of a self-advocacy serious game for women with advanced breast or gynecologic cancer.

BACKGROUND: Cancer clinicians and systems aim to provide patient-centered care, but not all patients have the self-advocacy skills necessary to ensure their care reflects their needs and priorities. This study examines the feasibility, acceptability, and preliminary efficacy of a self-advocacy serious game (an educational video game) intervention in women with advanced breast or gynecologic cancer. METHODS: Women with recently diagnosed (<3 months) metastatic breast or advanced gynecologic cancer were randomized 2:1 to receive a tablet-based serious game (Strong Together) (n = 52) or enhanced care as usual (n = 26). Feasibility was based on recruitment, retention, data completion, and intervention engagement. Acceptability was assessed via a postintervention questionnaire and exit interview. Preliminary efficacy was assessed on the basis of change scores from baseline to 3 and 6 months in self-advocacy (Female Self-Advocacy in Cancer Survivorship Scale) using intention-to-treat analysis. RESULTS: Seventy-eight women (55.1% with breast cancer; 44.9% with gynecologic cancer) were enrolled. Feasibility was demonstrated by satisfactory recruitment (69% approach-to-consent rate; 93% enroll-to-randomize rate), retention (90% and 86% at 3 and 6 months, respectively; 85% data completion), and intervention engagement (84% completed ≥75% of the game). Participants endorsed the intervention's (75%) and trial's (87%) acceptability. Participants in the intervention group experienced significant improvements in self-advocacy at 3 and 6 months compared to participants in the control group. CONCLUSIONS: Strong Together is feasible and acceptable among women with advanced breast or gynecologic cancer. This intervention demonstrates promising evidence of clinical efficacy. A future confirmatory trial is warranted to test the efficacy of the intervention for patient and health system outcomes.

Unsupervised machine learning identifies symptoms of indigestion as a predictor of acute decompensation and adverse cardiac events in patients with heart failure presenting to the emergency department.

BACKGROUND: Patients with known heart failure (HF) present to emergency departments (ED) with a plethora of symptoms. Although symptom clusters have been suggested as prognostic features, accurately triaging HF patients is a longstanding challenge. OBJECTIVES: We sought to use machine learning to identify subtle phenotypes of patient symptoms and evaluate their diagnostic and prognostic value among HF patients seeking emergency care. METHODS: This was a secondary analysis of a prospective cohort study of consecutive patients seen in the ED for chest pain or equivalent symptoms. Independent reviewers extracted clinical data from charts, including nine categories of subjective symptoms reported during initial evaluation. The diagnostic outcome was acute HF exacerbation and prognostic outcome was 30-day major adverse cardiac events (MACE). Outcomes were adjudicated by two independent reviewers. K-means clustering was used to derive latent patient symptom clusters, and their associations with outcomes were assessed using multivariate logistic regression. RESULTS: Sample included 438 patients (age 65±14 years; 45% female, 49% Black, 18% HF exacerbation, 32% MACE). K-means clustering identified three presentation phenotypes: patients with dyspnea only (Cluster A, 40%); patients with indigestion, with or without dyspnea (Cluster B, 23%); patients with neither dyspnea nor indigestion (Cluster C, 37%). Compared to Cluster C, indigestion was a significant predictor of acute HF exacerbation (OR=1.8, 95%CI=1.0-3.4) and 30-day MACE (OR=1.8, 95%CI=1.0-3.1), independent of age, sex, race, and other comorbidities. CONCLUSION: Indigestion symptoms in patients with known HF signify excess risk of adverse events, suggesting that these patients should be triaged as high-risk during initial ED evaluation.

Is insomnia severity a moderator of the associations between obstructive sleep apnea severity with mood and diabetes-related distress?

PURPOSE: This study examined insomnia severity as a moderator of the associations between obstructive sleep apnea (OSA) severity with impaired mood and diabetes-related distress in adults with OSA and type 2 diabetes (T2D). METHODS: This secondary analysis used pooled baseline data from two randomized controlled trials that evaluated the efficacy of treatment of OSA or insomnia in adults with T2D. Participants for this analysis had OSA (Apnea Hypopnea Index [AHI] ≥ five events/hour obtained from an in-home sleep apnea testing device) and completed questionnaires on insomnia, mood, and diabetes-related distress. Hierarchical multiple linear regression and multivariate linear regression analyses were used controlling for demographic characteristics and restless leg syndrome. RESULTS: Of 240 participants, mean age was 57.8 ± 10.17, 50% were female, and 35% were non-White. Participants had poorly controlled diabetes (Mean HbA1C = 7.93 ± 1.62), and moderate OSA (Mean AHI = 19.3 ± 16.2). Insomnia severity significantly moderated the association between OSA severity and mood (b = -0.048, p = .017). Although insomnia severity did not moderate the relationship between OSA severity and diabetes-related distress (b = -0.009, p = .458), insomnia severity was independently associated with greater diabetes-related distress (b = 1.133, p < .001). CONCLUSIONS: In adults with T2D and OSA, as insomnia severity increased, increasing OSA severity was associated with lower level of mood disturbances. Insomnia independently increased the level of diabetes-related distress. These findings suggest that comorbid insomnia may be more impactful than OSA on increasing mood disturbances and diabetes-related distress in adults with T2D.

Effect of antenatal milk expression education on lactation outcomes in birthing people with pre-pregnancy body mass index ≥25: protocol for a randomized, controlled trial.

BACKGROUND: Birthing people with pre-pregnancy body mass indices (BMIs) ≥ 25 kg/m2, particularly those without prior breastfeeding experience, are at increased risk for suboptimal lactation outcomes. Antenatal milk expression (AME) may be one way to counteract the negative effects of early infant formula supplementation common in this population. METHODS: This ongoing, randomized controlled trial in the United States evaluates the efficacy of a telelactation-delivered AME education intervention versus an attention control condition on lactation outcomes to 1 year postpartum among 280 nulliparous-to-primiparous, non-diabetic birthing people with pre-pregnancy BMI ≥ 25 kg/m2. The assigned study treatment is delivered via four weekly online video consultations between gestational weeks 37-40. Participants assigned to AME meet with study personnel and a lactation consultant to learn and practice AME. Instructions are provided for home practice of AME between study visits. Control group participants view videos on infant care/development at study visits. Participants complete emailed surveys at enrollment (340/7-366/7 gestational weeks) and 2 weeks, 6 weeks, 12 weeks, 6 months, and 12 months postpartum. Surveys assess lactation and infant feeding practices; breastfeeding self-efficacy, attitudes, and satisfaction; perception of insufficient milk; onset of lactogenesis-II; lactation support and problems; and reasons for breastfeeding cessation. Surveys also assess factors associated with lactation outcomes, including demographic characteristics, health problems, birth trauma, racial discrimination, and weight stigma. Health information and infant feeding data are abstracted from the pregnancy and birth center electronic health record. Milk samples are collected from the intervention group at each study visit and from both groups at each postpartum follow-up for future analyses. Qualitative interviews are conducted at 6 weeks postpartum to understand AME experiences. Primary outcomes of interest are breastfeeding exclusivity and breastfeeding self-efficacy scores at 2 weeks postpartum. Outcomes will be examined longitudinally with generalized linear mixed-effects modeling. DISCUSSION: This is the first adequately powered trial evaluating the effectiveness of AME among U.S. birthing people and within a non-diabetic population with pre-pregnancy BMI ≥ 25 kg/m2. This study will also provide the first evidence of acceptability and effectiveness of telelactation-delivered AME. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04258709.

Perceived and calculated diet quality improvements in a randomized mHealth weight loss trial.

The diet quality of US adults is poor and cross-sectional analyses suggest self-perception of healthful dietary intake may be overestimated. This analysis assessed the concordance between calculated and perceived diet quality and changes in diet quality among adults seeking weight loss and enrolled in a 12-month randomized behavioral trial. Healthy Eating Index-2015 diet quality (HEI) was calculated from self-administered 24-hour recalls. Perceived diet quality (PDQ) was measured on a 100-point scale. Higher scores indicate better diet quality. Concordance was assessed using the concordance correlation coefficient and Bland-Altman plots. The one hundred and five participants with complete dietary data were mostly female and white. There was good agreement between HEI and PDQ scores at 12 months for less than a third of participants. Most of the disagreement arose from PDQ scores being higher than HEI scores. Even fewer participants had good agreement between HEI changes and PDQ changes. Participants perceived greater improvement in diet quality than indicated by HEI score changes. Concordance was low at 12 months and for change in diet quality. Despite the diet quality of adults seeking weight loss being suboptimal and not improving, many perceived their diet quality and diet quality improvements as better than calculated. Future studies might explore the effect of misperceptions on weight loss outcomes.

Postdischarge Nausea and Vomiting and Co-occurring Symptoms in Women Following Breast Cancer Surgery.

PURPOSE: The purpose of this study was to investigate the influence of potential co-occurring symptoms, including fatigue, sleep disturbance, anxiety, depressive symptoms, and pain, on the incidence of postdischarge nausea (PDN) measured two days following discharge to home after surgery for breast cancer. DESIGN: This study used a prospective, cross-sectional, observational design. METHODS: The sample was 334 women aged 27 to 88 years of age. Demographic data were collected from the patient and the medical record before surgery. Symptom data were collected 48 hours following surgery using the Patient Reported Outcome Measurement System (PROMIS) and numerical nausea and pain scales. FINDINGS: Eighty-five (25.4%) of study participants reported some nausea two days after discharge. Study participants who experienced PDN frequently described that it occurred after they left the hospital to drive home following their surgery. Unadjusted odds ratios showed the presence of co-occurring symptoms of anxiety, fatigue, sleep disturbance, and pain were all significantly associated with the presence of nausea 48 hours following surgery. Other significant factors associated with (PDN) were history of motion sickness, history of pregnancy-induced nausea, use of opioids, and type of surgery. CONCLUSIONS: Same-day surgery nurses providing postoperative education for women following surgery for breast cancer should explain to patients that nausea may occur after they are discharged, especially those with known motion sickness. In addition, patients should be informed that other symptoms, especially fatigue, sleep disturbance, and anxiety, may co-occur.

A Real-Time Mobile Intervention to Reduce Sedentary Behavior Before and After Cancer Surgery: Pilot Randomized Controlled Trial.

BACKGROUND: Sedentary behavior (SB) is prevalent after abdominal cancer surgery, and interventions targeting perioperative SB could improve postoperative recovery and outcomes. We conducted a pilot study to evaluate the feasibility and preliminary effects of a real-time mobile intervention that detects and disrupts prolonged SB before and after cancer surgery, relative to a monitoring-only control condition. OBJECTIVE: Our aim was to evaluate the feasibility and preliminary effects of a perioperative SB intervention on objective activity behavior, patient-reported quality of life and symptoms, and 30-day readmissions. METHODS: Patients scheduled for surgery for metastatic gastrointestinal cancer (n=26) were enrolled and randomized to receive either the SB intervention or activity monitoring only. Both groups used a Fitbit smartwatch and companion smartphone app to rate daily symptoms and collect continuous objective activity behavior data starting from at least 10 days before surgery through 30 days post discharge. Participants in the intervention group also received prompts to walk after any SB bout that exceeded a prespecified threshold, with less frequent prompts on days that patients reported more severe symptoms. Participants completed end-of-study ratings of acceptability, and we also examined adherence to assessments and to walking prompts. In addition, we examined effects of the intervention on objective SB and step counts, patient-reported quality of life and depressive and physical symptoms, as well as readmissions. RESULTS: Accrual (74%), retention (88%), and acceptability ratings (mean overall satisfaction 88.5/100, SD 9.1) were relatively high. However, adherence to assessments and engagement with the SB intervention decreased significantly after surgery and did not recover to preoperative levels after postoperative discharge. All participants exhibited significant increases in SB and symptoms and decreases in steps and quality of life after surgery, and participants randomized to the SB intervention unexpectedly had longer maximum SB bouts relative to the control group. No significant benefits of the intervention with regard to activity, quality of life, symptoms, or readmission were observed. CONCLUSIONS: Perioperative patients with metastatic gastrointestinal cancer were interested in a real-time SB intervention and rated the intervention as highly acceptable, but engagement with the intervention and with daily symptom and activity monitoring decreased significantly after surgery. There were no significant effects of the intervention on step counts, patient-reported quality of life or symptoms, and postoperative readmissions, and there was an apparent adverse effect on maximum SB. Results highlight the need for additional work to modify the intervention to make reducing SB and engaging with mobile health technology after abdominal cancer surgery more feasible and beneficial. TRIAL REGISTRATION: ClinicalTrials.gov NCT03211806; https://tinyurl.com/3napwkkt.

Financial Hardship and its Associations with Perceived Sleep Quality in Participants with Type 2 Diabetes and Obstructive Sleep Apnea.

OBJECTIVES: The purpose of this study was to explore social determinants of health (SDoH), and disease severity as predictors of sleep quality in persons with both Obstructive Sleep Apnea (OSA) and type 2 diabetes (T2D). METHODS: Disease severity was measured by Apnea-Hypopnea Index [(AHI) ≥ 5] and HbA1c for glycemic control. SDoH included subjective and objective financial hardship, race, sex, marital status, education, and age. Sleep quality was measured by Pittsburgh Sleep Quality Index (PSQI). RESULTS: The sample (N = 209) was middle-aged (57.6 ± 10.0); 66% White and 34% African American; and 54% men and 46% women. Participants carried a high burden of disease (mean AHI = 20.7 ± 18.1, mean HbA1c = 7.9% ± 1.7%). Disease severity was not significantly associated with sleep quality (all p >.05). Worse sleep quality was associated with both worse subjective (b = -1.54, p = .015) and objective (b = 2.58, p <.001) financial hardship. Characteristics significantly associated with both subjective and objective financial hardship included being African American, female, ≤ 2 years post high school, and of younger ages (all p < .01).Discussion: Financial hardship is a more important predictor of sleep quality than disease severity, age, sex, race, marital status, and educational attainment, in patients with OSA and T2D.

Neighborhood Walkability Is Associated with Physical Activity and Prediabetes in a Behavioral Weight Loss Study: a Secondary Analysis.

BACKGROUND: Socio-environmental factors may affect uptake and utility of behavioral interventions targeting weight loss and cardiometabolic health. To evaluate the relation of neighborhood walkability to physical activity (PA) and glucose control in a sample of adults with overweight/obesity participating in a weight loss study. METHODS: Secondary analysis of a 12-month behavioral weight loss intervention (2011-2015) using one-group pretest-posttest design. Neighborhood walkability was assessed via residential Walk Score (0-100) at study entry. Fasting plasma glucose (FPG) via phlebotomy and PA via waist-worn ActiGraph GT3X were assessed at baseline and end of study. Study variables included neighborhood walkability (car-dependent: Walk Score < 50 vs. walkable: Walk Score ≥ 50), prediabetes (FPG 100-125 mg/dL), and recommended PA (moderate to vigorous PA [MVPA] > 22 min/day). Generalized linear model with logit link results were reported as adjusted odds ratios (AOR) with 95% confidence intervals (CI). RESULTS: The sample (N = 114) was mostly female (88.6%), white (83.3%), college educated (73.7%), and on average 51.4 ± 1.0 years of age. At baseline, persons residing in car-dependent neighborhoods tended to have higher income than those in walkable neighborhoods. Neighborhood walkability interacted with household income at study entry to predict participants' ability to meet the MVPA goal at 12 months (AOR = 13.52, 95% CI: 1.86-119.20). Those from walkable neighborhoods had 67% lower odds of having prediabetes compared to those from car-dependent neighborhoods (AOR = 0.33, 95% CI: 0.10-0.87) at 12 months. CONCLUSION: Our findings corroborate previous research characterizing the relationship between neighborhood walkability, PA, and prediabetes status. Key drivers of this impact warrant further investigation in a study with a larger, more diverse sample.