Better Nurse Practitioner Primary Care Practice Environments Reduce Hospitalization Disparities Among Dually-Enrolled Patients.

BACKGROUND: Over 12 million Americans are dually enrolled in Medicare and Medicaid. These individuals experience over twice as many hospitalizations for chronic diseases such as coronary artery disease and diabetes compared with Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address the care needs of dually-enrolled patients, yet NPs often work in unsupportive clinical practice environments. The purpose of this study was to examine the association between the NP primary care practice environment and hospitalization disparities between dually-enrolled and Medicare-only patients with chronic diseases. METHODS: Using secondary cross-sectional data from the Nurse Practitioner Primary Care Organizational Climate Questionnaire and Medicare claims files, we examined 135,648 patients with coronary artery disease and/or diabetes (20.0% dually-eligible, 80.0% Medicare-only), cared for in 450 practices employing NPs across 4 states (PA, NJ, CA, FL) in 2015. We compared dually-enrolled patients' odds of being hospitalized when cared for in practice environments characterized as poor, mixed, and good based on practice-level Nurse Practitioner Primary Care Organizational Climate Questionnaire scores. RESULTS: After adjusting for patient and practice characteristics, dually-enrolled patients in poor practice environments had the highest odds of being hospitalized compared with their Medicare-only counterparts [odds ratio (OR): 1.48, CI: 1.37, 1.60]. In mixed environments, dually-enrolled patients had 27% higher odds of a hospitalization (OR: 1.27, CI: 1.12, 1.45). However, in the best practice environments, hospitalization differences were nonsignificant (OR: 1.02, CI: 0.85, 1.23). CONCLUSIONS: As policymakers look to improve outcomes for dually-enrolled patients, addressing a modifiable aspect of care delivery in NPs' clinical practice environment is a key opportunity to reduce hospitalization disparities.

Percutaneous Management of Dialysis Access Steal Syndrome: Interventions and Outcomes from a Single Institution's 20-Year Experience.

PURPOSE: To determine safety and effectiveness of percutaneous interventions performed by interventional radiologists at a single institution over 2 decades in patients with dialysis access steal syndrome (DASS). MATERIALS AND METHODS: A retrospective review of fistulograms from 2001 to 2021 (N = 11,658) was performed. In total, 286 fistulograms in 212 patients with surgically created dialysis accesses met inclusion criterion of fistulography for suspected DASS. Chart review collected data regarding patient demographics, comorbidities, access characteristics, fistulography findings, intervention(s) performed, and outcomes. Procedures with and without DASS intervention were compared. Odds ratios (ORs), adjusted for age, sex, comorbidities, access characteristics, and multiple within-patient events, were calculated using logistic regression to determine associations between steal intervention status and outcome variables: (a) major adverse events, (b) access preservation, and (c) follow-up surgery. A percutaneously treatable cause of DASS was present in 128 cases (45%). Treatment of DASS lesions was performed in 118 cases. Fifteen embolizations were also performed in patients without DASS lesions. RESULTS: Technical success of DASS interventions, defined by the Society of Interventional Radiology (SIR) reporting standards, was 94%; 54% of interventions resulted in DASS symptom improvement at a median follow-up of 15 days. Patients with steal intervention had 60% lower odds of follow-up surgery (OR, 0.4; P = .007). There was no difference in major adverse events (P = .98) or access preservation (P = .13) between groups. CONCLUSIONS: In this retrospective cohort study, approximately half of DASS fistulograms revealed a percutaneously treatable cause of steal. Over half of DASS interventions resulted in symptomatic relief. Percutaneous intervention was associated with lower odds of follow-up surgery without compromising access preservation.

Anesthesia and Sedation Exposure and Neurodevelopmental Outcomes in Infants Undergoing Congenital Cardiac Surgery: A Retrospective Cohort Study.

BACKGROUND: Children undergoing complex cardiac surgery are exposed to substantial cumulative doses of sedative medications and volatile anesthetics and are more frequently anesthetized with ketamine, compared with healthy children. This study hypothesized that greater exposure to sedation and anesthesia in this population is associated with lower neurodevelopmental scores at 18 months of age. METHODS: A secondary analysis was conducted of infants with congenital heart disease who participated in a prospective observational study of environmental exposures and neurodevelopmental outcomes to assess the impact of cumulative volatile anesthetic agents and sedative medications. Cumulative minimum alveolar concentration hours of exposure to volatile anesthetic agents and all operating room and intensive care unit exposures to sedative and anesthesia medications were collected before administration of Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley III), at 18 months of age. RESULTS: The study cohort included 41 (37%) single-ventricle and 69 (63%) two-ventricle patients. Exposures to volatile anesthetic agents, opioids, benzodiazepines, and dexmedetomidine were not associated with abnormal Bayley III scores. At 18-month follow-up, after adjusting for confounders, each mg/kg increase in ketamine exposure was associated with a 0.34 (95% CI, -0.64 to -0.05) point decrease in Bayley III motor scores (P = 0.024). CONCLUSIONS: Total cumulative exposures to volatile anesthetic agents were not associated with neurodevelopmental impairment in infants with congenital heart disease undergoing various imaging studies and procedures, whereas higher ketamine doses were associated with poorer motor performance.

Telehealth utilization in gynecologic oncology clinical trials.

OBJECTIVE: Prior to the COVID-19 pandemic, telehealth visits and remote clinical trial operations (such as local collection of laboratory tests or imaging studies) were underutilized in gynecologic oncology clinical trials. Current literature on these operational changes provides anecdotal experience and expert opinion with few studies describing patient-level safety data. We aimed to evaluate the safety and feasibility of telehealth and remote clinical trial operations during the COVID-19 Pandemic. METHODS: Gynecologic oncology patients enrolled and actively receiving treatment on a clinical trial at a single, academic institution during the designated pre-Telehealth and Telehealth periods were identified. Patients with at least 1 provider or research coordinator telehealth visit were included. Patient demographics, health system encounters, adverse events, and protocol deviations were collected. Pairwise comparisons were performed between the pre-Telehealth and Telehealth period with each patient serving as their own control. RESULTS: Thirty-one patients met inclusion criteria. Virtual provider visits and off-site laboratory testing increased during the Telehealth period. Delays in provider visits, imaging, and laboratory testing did not differ between time periods. Total and minor protocol deviations increased in incidence during the Telehealth period and were due to documentation of telehealth and deferment of non-therapeutic testing. Major protocol deviations, emergency department visits, admissions, and severe adverse events were of low incidence and did not differ between time periods. CONCLUSIONS: Telehealth and remote clinical trial operations appeared safe and did not compromise clinical trial protocols in a small, single institutional study. Larger scale evaluations of such trial adaptations should be performed to determine continued utility following the Pandemic.

Comparison of Transthoracic Contrast Echocardiography with High-Resolution Chest CT after Embolization of Pulmonary Arteriovenous Malformation.

PURPOSE: To compare postembolotherapy follow-up graded transthoracic contrast echocardiography (TTCE) and high-resolution computed tomography (CT) of the chest and to evaluate the use of graded TTCE in the early postembolic period. MATERIALS AND METHODS: Thirty-five patients (6 men and 29 women; mean age, 56 years; range, 27-78 years) presenting for postembolotherapy follow-up between 2017 and 2021 with concurrent high-resolution CT and graded TTCE were analyzed retrospectively. Untreated pulmonary arteriovenous malformations (PAVMs) with a feeding artery of ≥2 mm were considered treatable. RESULTS: Ninety-four percent of patients (33 of 35) did not have treatable PAVMs on high-resolution CT. TTCE was negative for shunts (Grade 0) in 34% of patients (n = 12). Of patients with a TTCE positive for shunts (23 of 35, 66%), 83% had a Grade 1 shunt, 13% had a Grade 2 shunt, and 4% had a Grade 3 shunt. No patient with a Grade 0 or 1 shunt had a treatable PAVM on high-resolution CT. Of the 2 patients with PAVMs requiring treatment, one had a Grade 2 shunt and one had a Grade 3 shunt. TTCE grade was significantly associated with the presence of a treatable PAVM on high-resolution CT (P < .01). CONCLUSIONS: Graded TTCE predicts the need for repeat embolotherapy and does so reliably in the early postembolotherapy period. This suggests that graded TTCE can be utilized in the postembolotherapy period for surveillance, which has the potential to lead to a decrease in cumulative radiation in this patient population.

Development of the perceived miscommunication measure in the pediatric intensive care unit.

PURPOSE: Miscommunication between parents and healthcare providers in the Pediatric Intensive Care Unit (PICU) can affect family-provider relationships and outcomes. This paper reports on the development and psychometric testing of a measure for parent perceived miscommunication, defined as the failure to communicate clearly as perceived by relevant stakeholders in the PICU. DESIGN AND METHODS: Miscommunication items were identified through a review of the literature with interdisciplinary experts. In a cross-sectional quantitative survey, the scale was tested with 200 parents of children discharged from a PICU at a large Northeastern Level 1 Pediatric hospital. The psychometric properties of a 6-item miscommunication measure were assessed using exploratory factor analysis and internal consistency reliability. RESULTS: Exploratory factor analysis yielded one factor explaining 66.09% of the variance. Internal consistency reliability in the PICU sample was α = 0.89. As hypothesized, there was a significant correlation between parental stress, trust, and perceived miscommunication in the PICU (p < .001). Confirmatory factor analysis supported good fit indices in testing the measurement model (χ2/df = 2.57, Goodness of Fit Index (GFI) = 0.979, Confirmatory Fit Index (CFI) =0.993 and Standardized Mean Residual (SMR) = 0.0136). CONCLUSIONS: This new six-item miscommunication measure shows promising psychometric properties including content and construct validity, which can be further tested and refined in future studies of miscommunication and outcomes in PICU. PRACTICE IMPLICATIONS: Awareness of perceived miscommunication in the PICU can benefit stakeholders within the clinical environment by recognizing the importance of clear and effective communication and how language affects the parent-child-provider relationship.

Nurse, Provider, and Emergency Department Technician: Perceptions and Experiences of Violence and Aggression in the Emergency Department.

INTRODUCTION: Patient/visitor violence and aggression (V&A) in the emergency department occurs daily. Few interventions exist to decrease V&A. Research describing prevalence, severity, and perceived safety among ED clinicians is limited. METHODS: A descriptive survey explored V&A against ED clinicians in one urban emergency department. A sample of nurses, ED technicians, physicians and advanced practice providers participated. Participants completed a demographic survey, Personal Workplace Safety Instrument for Emergency Nurses (PWSI-EN), and ENA V&A frequency checklist. Analysis of Variance (ANOVA) for unadjusted and Analysis of Covariance (ANCOVA) for adjusted associations were used to assess differences in the PWSI-EN survey composite score and "feeling safe in the ED" among ED roles. ANCOVA was adjusted for potential confounders: sex, race, years working in emergency department, and shift worked. RESULTS: Sixty-five (46.4%) of the 140 ED clinicians returned surveys, which were almost evenly distributed between ED clinician roles and sex. Mean age was 37.2 (range: 21-64) years. All (100%) nurses and providers reported being verbally abused. More nurses reported physical violence (n = 21, 87.5%) than providers (n = 7, 36.8%) and ED technicians (n = 11, 55%). Nurses and ED technicians reported experiencing greater prevalence of physical violence than providers (P < .05). Nurses (mean 3.29, range 2.95 to 3.63) were more fearful for their personal safety than ED technicians (mean 3.88, range 3.48 to 4.28) (P < .03). DISCUSSION: V&A are common creating a fearful environment. However, little research regarding clinician perceptions exists. Our study aids in identifying areas for clinician-targeted strategies to prevent ED V&A.

Access to post-acute care services reduces emergency department utilisation among individuals insured by Medicaid: An observational study.

AIMS AND OBJECTIVES: We examined whether access to post-acute care services differed between individuals insured by Medicaid and commercial insurers and whether those differences explained emergency department utilisation 30 days post-hospitalisation. BACKGROUND: Timely follow-up to community-based providers is a strategy to improve post-hospitalisation outcomes. However, little is known regarding the influence of post-acute care services on the likelihood of emergency department use post-hospitalisation for individuals insured by Medicaid. DESIGN: We conducted a retrospective observational study of electronic health record data from an academic medical centre in a large northeastern urban setting. The STROBE checklist was used in reporting this observational study. METHODS: Our analysis included adults insured by Medicaid or commercial insurers who were discharged from medical services between 1 August-31 October 2017 (n = 785). Logistic regression models were used to examine the effects of post-acute care services (primary care, home health, specialty care) on the odds of an emergency department visit. RESULTS: Post-hospitalisation, 12% (n = 59) of individuals insured by Medicaid experienced an emergency department visit compared to 4.2% (n = 13) of individuals commercially insured. Having Medicaid insurance was associated with higher odds of emergency department visits post-hospitalisation (OR = 3.24). Having a home care visit or specialty care visit within 30 days post-discharge were significant predictors of lower odds of emergency department visits. Specific to specialty care visits, Medicaid was no longer a significant predictor of emergency department visits with specialty care being more influential (OR = 0.01). CONCLUSIONS: Improving connections to appropriate post-acute care services, specifically specialty care, may improve outcomes among individuals insured by Medicaid. RELEVANCE TO CLINICAL PRACTICE: Hospital-based nurses, including those in direct care, case management and discharge planning, play an important role in facilitating referrals and scheduling appointments prior to discharge. Individuals insured by Medicaid may require additional support in accessing these services and nurses are well-positioned to facilitate care continuity.

Role alteration predicts anxiety and depressive symptoms in parents of infants with congenital heart disease: a pilot study.

BACKGROUND: Parents of infants born with critical congenital heart disease are at risk for adverse mental health symptoms. The purpose of this study was to identify infant-, parent-, and environmental-based stressors for mothers and fathers after their infants' cardiac surgery, and to explore relationships between stressors and mental health symptoms of anxiety and depression. METHODS: This study enrolled 28 biological mother-father dyads from families admitted to the paediatric cardiac intensive care unit for cardiac surgery at one free-standing children's hospital in the Northeast. Paired t-tests were used to examine group differences between mothers and fathers on perceived stressors and mental health symptoms, while linear mixed effects modelling was used to explore the predictive relationship between perceived stressors, personal factors, and mental health symptoms. RESULTS: Mothers reported higher perceived stressor scores of parental role alteration (t = 4.03, p < 0.01) and infant appearance and behaviour (t = 2.61, p = 0.02), and total perceived stress (t = 2.29 p = 0.03), compared to fathers. Mothers also reported higher anxiety (t = 2.47, p = 0.02) and depressive symptoms (t = 3.25, p < 0.01) than fathers. In multivariable analysis, parental role alteration significantly predicted anxiety (t = 5.20, p < 0.01, d = 0.77) and depressive symptoms (t = 7.09, p < 0.01, d = 1.05) for mothers and fathers. The consensus subscale of the Dyadic Adjustment Scale also significantly predicted depressive symptoms (t = -2.42, p = 0.02, d = 0.04). CONCLUSION: Parents were distressed during their infant's admission for surgical repair for critical congenital heart disease. Parental role alteration was significantly associated with parental anxiety and depressive symptoms, while poor relationship quality was associated with depressive symptoms, highlighting areas for potential nursing-led psychosocial led interventions.

Disparities in Nurse Job Dissatisfaction and Intent to Leave: Implications for Retaining a Diverse Workforce.

OBJECTIVE: To determine if Black nurses are more likely to report job dissatisfaction and whether factors related to dissatisfaction influence differences in intent to leave. BACKGROUND: Minority nurses report higher job dissatisfaction and intent to leave, yet little is known about factors associated with these differences in community settings. METHOD: Cross-sectional analysis of 11 778 nurses working in community-based settings was conducted. Logistic regression was used to estimate the association among race, job satisfaction, and intent to leave. RESULTS: Black nurses were more likely to report job dissatisfaction and intent to leave. Black nurses' intent to leave decreased in adjusted models that accounted for dissatisfaction with aspects of their jobs including salary, advancement opportunities, autonomy, and tuition benefits. CONCLUSION: Nurse administrators may find opportunities to decrease intent to leave among Black nurses through focused efforts to target areas of dissatisfaction.

Group-randomized trial of tailored brief shared decision-making to improve asthma control in urban black adults.

AIMS: To assess the intervention effects of BREATHE (BRief intervention to Evaluate Asthma THErapy), a novel brief shared decision-making intervention and evaluate feasibility and acceptability of intervention procedures. DESIGN: Group-randomized longitudinal pilot study. METHODS: In total, 80 adults with uncontrolled persistent asthma participated in a trial comparing BREATHE (N = 40) to a dose-matched attention control intervention (N = 40). BREATHE is a one-time shared decision-making intervention delivered by clinicians during routine office visits. Ten clinicians were randomized and trained on BREATHE or the control condition. Participants were followed monthly for 3 months post-intervention. Data were collected from December 2017 - May 2019 and included surveys, lung function tests, and interviews. RESULTS: Participants were Black/multiracial (100%) mostly female (83%) adults (mean age 45). BREATHE clinicians delivered BREATHE to all 40 participants with fidelity based on expert review of audiorecordings. While the control group reported improvements in asthma control at 1-month and 3-month follow-up, only BREATHE participants had better asthma control at each timepoint (ß = 0.77; standard error (SE)[0.17]; p ≤ 0.0001; ß = 0.71; SE[0.16]; p ≤ 0.0001; ß = 0.54; SE[0.15]; p = .0004), exceeding the minimally important difference. BREATHE participants also perceived greater shared decision-making occurred during the intervention visit (ß = 7.39; SE[3.51]; p = .03) and fewer symptoms at follow-up (e.g., fewer nights woken, less shortness of breath and less severity of symptoms) than the controls. Both groups reported improved adherence and fewer erroneous medication beliefs. CONCLUSION: BREATHE is a promising brief tailored intervention that can be integrated into office visits using clinicians as interventionists. Thus, BREATHE offers a pragmatic approach to improving asthma outcomes and shared decision-making in a health disparity population. IMPACT: The study addressed the important problem of uncontrolled asthma in a high-risk vulnerable population. Compared with the dose-matched attention control condition, participants receiving the novel brief tailored shared decision-making intervention had significant improvements in asthma outcomes and greater perceived engagement in shared decision-making. Brief interventions integrated into office visits and delivered by clinicians may offer a pragmatic approach to narrowing health disparity gaps. Future studies where other team members (e.g., office nurses, social workers) are trained in shared decision-making may address important implementation science challenges as it relates to adoption, maintenance, and dissemination. TRAIL REGISTRATION: clinicaltrials.gov # NCT03300752.

Spontaneous Dislodgement of Tunneled Dialysis Catheters after De Novo versus Over-The-Wire-Exchange Placement.

PURPOSE: To evaluate dislodgement of tunneled dialysis catheters (TDCs) in de novo (DN) placement with ultrasound versus over-the-wire exchange (OTWE). MATERIALS AND METHODS: Data were collected retrospectively on all TDC placements at this institution from 2001 to 2019 and were excluded if no removal date was recorded or if dwell time was more than 365 days. Information on TDC brand, placement, insertion/removal, and removal reason were collected. Multiple logistic regression evaluated factors associated with TDC dislodgement. DN placement and OTWE were compared for rate of dislodgement (generalized estimating equations method) and TDC dwell time (survival analysis). RESULTS: In total, 5328 TDCs were included with 66% (3522) placed DN and 32% (1727) via OTWE. Mean dwell time was 65 ± 72 days, and dislodgement occurred in 4% (224). TDC dislodgement rates in the DN and OTWE groups were 0.48 and 0.93 per 1000 catheter days, respectively. Brand (Ash Split vs. VectorFlow), placement technique (OTWE vs. DN), laterality (left vs. right), and site (left vs. right internal jugular vein) were significant predictors of dislodgement. OTWE placement exhibited 1.7 times the odds of dislodgement (95% confidence interval, 1.2-2.6; P = .004) compared to DN and had significantly higher probability of dislodgement across time (hazard ratio = 2.0; P < .001) compared to DN. Dislodgement rates for OTWE vs. DN were 8% vs. 3% (3 months), 13% vs. 6% (6 months), and 38% vs. 17% (1 year). CONCLUSIONS: TDC spontaneous dislodgement rates were significantly and consistently higher after OTWE compared to DN placement. These data support more careful attention to catheter fixation after OTWE placement.

Prevalence and Characterization of Interaction of Retrievable Inferior Vena Cava Filters with the Spine in Patients Undergoing Complex Filter Removal.

PURPOSE: To examine spinal interaction types and prevalence of inferior vena cava (IVC) filters in patients presenting for complex filter removal. MATERIALS AND METHODS: The records of 447 patients presenting for complex removal of IVC filters were reviewed, including patient demographics, IVC filter dwell time, filter fracture status, and computed tomography (CT) evidence of filter interaction with the spine. Spinal interaction was defined as a filter strut touching or penetrating into the vertebral body or disc. Patients with evidence of filter penetration and spinal interaction had abdominal CT that preceded filter removal assessed by 2 interventional radiologists to categorize the type of spinal interaction, including bony reaction and osteophyte formation. RESULTS: CT evidence of spinal interaction by the filter was found in 18% of patients (80/447). Interaction with the spine was more common in single point of fixation filters than filters with rails (P = .007) and was more likely in filters with round wires than flat wires (P = .0007). Patients with interaction had longer dwell times (mean [SD] 5.7 [4.46] y) compared with patients without interaction (mean [SD] 3.2 [3.85] y); this relationship was significant (P < .0001). Women were more likely than men to experience filter/spine interaction (P = .04). Filters with spinal interaction were more likely to be fractured (P = .001). Filter interaction was found in 38% (30/78) of patients with symptoms, including chest and back pain, compared with 14% (50/369) of patients without symptoms (P < .0001, odds ratio 3.99). CONCLUSIONS: Retrievable IVC filters may interact with the spine. These interactions are associated with longer filter dwell times, female sex, and round wire filter construction.

Skin-to-Skin Care Is a Safe and Effective Comfort Measure for Infants Before and After Neonatal Cardiac Surgery.

OBJECTIVES: To determine the effect of skin-to-skin care on stress, pain, behavioral organization, and physiologic stability of infants with critical congenital heart disease before and after neonatal cardiac surgery. DESIGN: A baseline response-paired design was used, with infants acting as their own controls before, during, and after skin-to-skin care at two distinct time points: once in the preoperative period (T1) and once in the postoperative period (T2). SETTING: Cardiac ICU and step-down unit in a large metropolitan freestanding children's hospital. SUBJECTS: Convenience sample of 30 infants admitted preoperatively for critical congenital heart disease. INTERVENTIONS: Eligible infants were placed into skin-to-skin care for 1 hour with their biological mothers once each at T1 and T2. MEASUREMENTS AND MAIN RESULTS: Measurements of stress (salivary cortisol), pain and behavior state (COMFORT scale), and physiologic stability (vital signs) were assessed immediately before skin-to-skin care, 30 minutes into skin-to-skin care, and 30 minutes after skin-to-skin care ended.At both T1 and T2, infant pain scores were significantly decreased (p < 0.0001) and infants moved into a calmer behavior state (p < 0.0001) during skin-to-skin care as compared to baseline. At T1, infants also had significantly reduced heart rate (p = 0.002) and respiratory rate (p < 0.0001) and increased systolic blood pressure (p = 0.033) during skin-to-skin care. At both T1 and T2, infant cortisol remained stable and unchanged from pre-skin-to-skin care to during skin-to-skin care (p = 0.096 and p = 0.356, respectively), and significantly increased from during skin-to-skin care to post-skin-to-skin care (p = 0.001 and p = 0.023, respectively). Exploratory analysis revealed differences in cortisol reactivity for infants with higher baseline cortisol (> 0.3 µg/dL) versus lower (≤ 0.3 µg/dL) prior to skin-to-skin care. Infants with higher baseline cortisol at T2 experienced significantly reduced cortisol during skin-to-skin care (p = 0.025). No significant differences in demographics or baseline variables were found between infants in either group. CONCLUSIONS: Skin-to-skin care is a low-cost, low-risk intervention that promotes comfort and supports physiologic stability in infants before and after neonatal cardiac surgery.

Caloric compensation and appetite control in children of different weight status and predisposition to obesity.

To prevent childhood obesity it is critical to identify behavioral phenotypes for overeating, especially among children who are predisposed to obesity. We examined caloric compensation and appetite control in 212 normal-weight (NW) and obese (OB) children, ages 7 to 9, who were at high risk (HR) or low risk (LR) for obesity based on maternal obesity. In a within-subjects crossover design, children ate breakfast, lunch, dinner, and snacks in the laboratory once a week for two weeks. Children's percentage compensation index (%COMPX) was computed at breakfast. Twenty-five minutes before breakfast, children received one of two compulsory preloads, which varied in energy density (ED) and caloric content [Low ED (LED): 1.00 kcal/g; 100 kcal; High ED (HED): 1.60 kcal/g; 160 kcal]. Children's appetite was measured hourly using Visual Analog Scales, which were used to compute 3-h post-prandial area under the curve (AUCs) after breakfast and the satiety quotient (SQ), which allows between-group comparisons of a fixed amount of a food's potency to reduce appetite sensations per unit of intake. There were no significant differences in %COMPX, SQ, or AUC among LR-NW, HR-NW, and HR-OB children (P > 0.10). SQs for Hunger and Prospective Consumption were higher and SQ for Fullness lower after consuming the LED compared to the HED preload (P < 0.009). Further, the SQ and AUC for Desire to Eat and AUC for Prospective Consumption significantly predicted energy intake during the remainder of the day (P < 0.03). In this study, HR-NW children did not differ from LR-NW or HR-OB children in their caloric compensation or appetite control. Foods with a high satiating effect may facilitate appetite control and help to moderate daily energy intake in all children, including at-risk children.

Both Race and Insurance Type Independently Predict the Selection of Oral Opioids Prescribed to Cancer Outpatients.

BACKGROUND: Previous research suggests that racial disparities in patients' reported analgesic adverse effects are partially mediated by the type of opioid prescribed to African Americans despite the presence of certain comorbidities, such as renal disease. AIMS: We aimed to identify independent predictors of the type of opioid prescribed to cancer outpatients and determine if race and chronic kidney disease independently predict prescription type, adjusting for relevant sociodemographic and clinical confounders. DESIGN: We conducted a secondary analysis of a 3-month observational study. SETTING: Outpatient oncology clinics of an academic medical center. PARTICIPANTS/SUBJECTS: Patients were older than 18 years of age, self-identified as African American or White, and had an analgesic prescription for cancer pain. METHODS: Cancer patients (N = 241) were recruited from outpatient oncology clinics within a large mid-Atlantic healthcare system. RESULTS: Consistent with published literature, most patients (75.5%) were prescribed either morphine or oxycodone preparations as oral opioid therapy for cancer pain. When compared with Whites, African Americans were significantly more likely to be prescribed morphine (33% vs 14%) and less likely to be prescribed oxycodone (38% vs 64%) (p < .001). The estimated odds for African Americans to receive morphine were 2.573 times that for Whites (95% confidence interval 1.077-6.134) after controlling for insurance type, income, and pain levels. In addition, the presence of private health insurance was negatively associated with the prescription of morphine and positively associated with prescription of oxycodone in separate multivariable models. The presence of chronic kidney disease did not predict type of analgesic prescribed. CONCLUSIONS: Both race and insurance type independently predict type of opioid selection for cancer outpatients. Larger clinical studies are needed to fully understand the sources and clinical consequences of racial differences in opioid selection for cancer pain.

Patient Trade-Offs Related to Analgesic Use for Cancer Pain: A MaxDiff Analysis Study.

PURPOSE: Many patients with cancer pain deviate from prescribed analgesic regimens. Our aim was to elicit the trade-offs patients make based on their beliefs about analgesic use and rank utilities (importance scores) using maximum difference (MaxDiff) scaling. We also investigated if there were unique clusters of patients based on their analgesic beliefs. METHODS: This was a secondary analysis of a three-month, prospective observational study. Patients (N = 207) were self-identified African Americans and Whites, >18 years, diagnosed with multiple myeloma or solid tumor, and were prescribed at least one around-the-clock analgesic for cancer pain. MaxDiff analysis allowed us to identify patients utilities. Second, a cluster analysis assisted in ranking how analgesic beliefs differed by groups. Third, clusters were described by comparing key sociodemographic and clinical variables. RESULTS: Participants' beliefs were a significant factor in choices related to analgesic use (chi-square = 498.145, p < .0001). The belief, 'Pain meds keep you from knowing what is going on in your body', had the highest patient endorsement. Two distinct clusters of patients based on analgesic beliefs were identified; 'knowing body' was ranked as top priority for both clusters. The belief that cancer patients become addicted to analgesics was moderately important for both clusters. Severity of side effects was the only key variable significantly different between clusters (p = .043). CONCLUSIONS: Our findings support tailored pain management interventions that attend to individual beliefs about cancer pain and analgesic use. Future research should explore the relationship between analgesic utilities, actual analgesic taking behaviors, and how they impact patients' cancer pain outcomes.

Leveraging Electronic Health Records and Machine Learning to Tailor Nursing Care for Patients at High Risk for Readmissions.

BACKGROUND: Electronic health record-derived data and novel analytics, such as machine learning, offer promising approaches to identify high-risk patients and inform nursing practice. PURPOSE: The aim was to identify patients at risk for readmissions by applying a machine-learning technique, Classification and Regression Tree, to electronic health record data from our 300-bed hospital. METHODS: We conducted a retrospective analysis of 2165 clinical encounters from August to October 2017 using data from our health system's data store. Classification and Regression Tree was employed to determine patient profiles predicting 30-day readmission. RESULTS: The 30-day readmission rate was 11.2% (n = 242). Classification and Regression Tree analysis revealed highest risk for readmission among patients who visited the emergency department, had 9 or more comorbidities, were insured through Medicaid, and were 65 years of age and older. CONCLUSIONS: Leveraging information through the electronic health record and Classification and Regression Tree offers a useful way to identify high-risk patients. Findings from our algorithm may be used to improve the quality of nursing care delivery for patients at highest readmission risk.

Relationship of Weight Outcomes, Co-Occurring Conditions, and Severity of Autism Spectrum Disorder in the Study to Explore Early Development.

OBJECTIVE: To assess contributing factors to increased obesity risk, by comparing children with autism spectrum disorder (ASD), developmental delays/disorders, and general population controls in weight status, and to examine associations between weight status and presence of co-occurring medical, behavioral, developmental, or psychiatric conditions across groups and ASD severity among children with ASD. STUDY DESIGN: The Study to Explore Early Development is a multisite cross-sectional study of children, 2-5 years of age, classified as children with ASD (n = 668), children with developmental delays/disorders (n = 914), or general population controls (n = 884). Using an observational cohort design, we compared the 3 groups. Children's heights and weights were measured during a clinical visit. Co-occurring conditions (medical, behavioral, developmental/psychiatric) were derived from medical records, interviews, and questionnaires. ASD severity was measured by the Ohio State University Global Severity Scale for Autism. RESULTS: The odds of overweight/obesity were 1.57 times (95% CI 1.24-2.00) higher in children with ASD than general population controls and 1.38 times (95% CI 1.10-1.72) higher in children with developmental delays/disorders than general population controls. The aORs were elevated for children with ASD after controlling for child co-occurring conditions (ASD vs general population controls: aOR = 1.51; 95% CI 1.14-2.00). Among children with ASD, those with severe ASD symptoms were 1.7 times (95% CI 1.1-2.8) more likely to be classified as overweight/obese compared with children with mild ASD symptoms. CONCLUSIONS: Prevention of excess weight gain in children with ASD, especially those with severe symptoms, and in children with developmental delays/disorders represents an important target for intervention.

Pharmacokinetics and Pharmacodynamics of Inorganic Nitrate in Heart Failure With Preserved Ejection Fraction.

RATIONALE: Nitrate-rich beetroot juice has been shown to improve exercise capacity in heart failure with preserved ejection fraction, but studies using pharmacological preparations of inorganic nitrate are lacking. OBJECTIVES: To determine (1) the dose-response effect of potassium nitrate (KNO3) on exercise capacity; (2) the population-specific pharmacokinetic and safety profile of KNO3 in heart failure with preserved ejection fraction. METHODS AND RESULTS: We randomized 12 subjects with heart failure with preserved ejection fraction to oral KNO3 (n=9) or potassium chloride (n=3). Subjects received 6 mmol twice daily during week 1, followed by 6 mmol thrice daily during week 2. Supine cycle ergometry was performed at baseline (visit 1) and after each week (visits 2 and 3). Quality of life was assessed with the Kansas City Cardiomyopathy Questionnaire. The primary efficacy outcome, peak O2-uptake, did not significantly improve (P=0.13). Exploratory outcomes included exercise duration and quality of life. Exercise duration increased significantly with KNO3 (visit 1: 9.87, 95% confidence interval [CI] 9.31-10.43 minutes; visit 2: 10.73, 95% CI 10.13-11.33 minute; visit 3: 11.61, 95% CI 11.05-12.17 minutes; P=0.002). Improvements in the Kansas City Cardiomyopathy Questionnaire total symptom (visit 1: 58.0, 95% CI 52.5-63.5; visit 2: 66.8, 95% CI 61.3-72.3; visit 3: 70.8, 95% CI 65.3-76.3; P=0.016) and functional status scores (visit 1: 62.2, 95% CI 58.5-66.0; visit 2: 68.6, 95% CI 64.9-72.3; visit 3: 71.1, 95% CI 67.3-74.8; P=0.01) were seen after KNO3. Pronounced elevations in trough levels of nitric oxide metabolites occurred with KNO3 (visit 2: 199.5, 95% CI 98.7-300.2 µmol/L; visit 3: 471.8, 95% CI 377.8-565.8 µmol/L) versus baseline (visit 1: 38.0, 95% CI 0.00-132.0 µmol/L; P<0.001). KNO3 did not lead to clinically significant hypotension or methemoglobinemia. After 6 mmol of KNO3, systolic blood pressure was reduced by a maximum of 17.9 (95% CI -28.3 to -7.6) mm Hg 3.75 hours later. Peak nitric oxide metabolites concentrations were 259.3 (95% CI 176.2-342.4) µmol/L 3.5 hours after ingestion, and the median half-life was 73.0 (interquartile range 33.4-232.0) minutes. CONCLUSIONS: KNO3 is potentially well tolerated and improves exercise duration and quality of life in heart failure with preserved ejection fraction. This study reinforces the efficacy of KNO3 and suggests that larger randomized trials are warranted. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02256345.