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Publication Who Listens to Our Advice? A Secondary Analysis of Data From a Clinical Trial Testing an Intervention Designed to Decrease Delay in Seeking Treatment for Acute Coronary Syndrome(2011-11-01) Riegel, Barbara; Elmi, Angelo; Moser, Debra K; McKinley, Sharon; Meischke, Hendricka; Doering, Lynn V; Davidson, Patricia; Pelter, Michele; Baker, Heather; Dracup, KathleenObjective Prolonged prehospital delay in persons experiencing acute coronary syndrome (ACS) remains a problem. Understanding which patients respond best to particular interventions designed to decrease delay time would provide mechanistic insights into the process by which interventions work. Methods In the PROMOTION trial, 3522 at-risk patients were enrolled from 5 sites in the United States (56.4%), Australia and New Zealand; 490 (N = 272 intervention, N = 218 control) had an acute event within 2 years. Focusing on these 490, we (1) identified predictors of a rapid response to symptoms, (2) identified intervention group subjects with a change in these predictors over 3 months of follow-up, and (3) compared intervention group participants with and without the favorable response pattern. Hypothesized predictors of rapid response were increased perceived control and decreased anxiety. Knowledge, attitudes, and beliefs were hypothesized to differ between responders and non-responders. Results Contrary to hypothesis, responders had low anxiety and low perceived control. Only 73 (26.8%) subjects showed this pattern 3 months following the intervention. No differences in ACS knowledge, attitudes, or beliefs were found. Conclusion The results of this study challenge existing beliefs. Practice implications New intervention approaches that focus on a realistic decrease in anxiety and perceived control are needed.Publication Characteristics and Outcomes of Serious Traumatic Injury in Older Adults(2002-02-01) Richmond, Therese S; Kauder, Donald R; Strumpf, Neville; Meredith, TammyObjectives: The aims were to: 1) describe the seriously injured older adult; 2) characterize and compare the differences in injury characteristics and outcomes in three subgroups of seriously injured older adults: 65-74 years, 75-84 years, and >85 years of age; 3) identify risk factors for death, complications, and discharge placement at hospital discharge. Design: A retrospective secondary analysis of a statewide trauma data set from 1988-1997. Setting: Data submitted from all designated trauma centers in Pennsylvania. Participants: The data set yielded 38,707 patients with a mean age of 77.5 years with serious injury (mean number of injuries = 3.6, mean number of body systems involved = 2). Measurements: Key outcomes were mortality, complications, and discharge placement. Abbreviated Injury Score categorized injuries and Injury Severity Score (ISS) quantified anatomic severity of injury. Results: Mortality was 10%. Mean length of stay 11.5 days. 52.2% of survivors were discharged home and 25.4% to a skilled nursing facility. Injury severity, total number of injuries, complications and increasing age were predictors of mortality (p<.01). The presence of pre-existing co-morbid medical conditions increased the odds of experiencing a complication over three-fold. Increasing age, total number of injuries, injury to extremities or abdominal contents, injuries due to falls, and lower functional level predicted discharge to a skilled nursing facility (p<.01). Conclusions: Traumatic injury in older adults are typically multisystem, life-threatening, and affects older adults of all ages. The standard ISS does not fully capture the potential for mortality in older adults and does not predict discharge placement. The majority of older adults survive multisystem injury. Our findings indicate the need to examine outcomes beyond mortality and to make the identification and management of co-morbid conditions a priority. A geriatric consultation service could be an important additional to the interdisciplinary trauma team.Publication Modifiable Factors Associated With Sleep Dysfunction in Adults With Heart Failure(2012-12-01) Riegel, BarbaraBackground: Sleep dysfunction contributes to poor quality of life in adults with heart failure (HF). The purpose of this study was to identify factors associated with sleep dysfunction that may be modifiable. Methods: Data were collected from 266 subjects enrolled from three sites in the U.S. Sleep dysfunction was measured over the past month with the Pittsburgh Sleep Quality Index, using a score > 10 to indicate sleep dysfunction. Potentially modifiable clinical, behavioral, and psychological factors thought to be associated with sleep dysfunction were analyzed with hierarchical logistic regression analysis. Results: When covariates of age, gender, race, data collection site, and New York Heart Association (NYHA) functional class were entered on the first step, only NYHA was a significant correlate of sleep dysfunction. When the clinical, behavioral, and psychological factors were entered, correlates of sleep dysfunction were the number of drugs known to cause daytime somnolence (OR = 2.08), depression (OR = 1.83), worse overall perceived health (OR = 1.64), and better sleep hygiene (OR = 1.40). Although most (54%) subjects had sleep disordered breathing (SDB), SDB was not a significant predictor of sleep dysfunction. Discussion: Factors associated with sleep dysfunction in HF include medications with sleepiness as a side-effect, depression, poorer health perceptions, and better sleep hygiene. Sleep dysfunction may motivate HF patients to address sleep hygiene. Eliminating medications with sleepiness as a side-effect, treating depression and perceptions of poor health may improve sleep quality in HF patients.Publication The Case for Enhanced Data Collection of Gun Type(2004-01-01) Richmond, Therese S; Branas, Charles; Cheney, Rose Ann; Schwab, C WilliamBackground: National surveillance systems have differentiated long guns into rifles and shotguns but fail to do so for handgun type. We sought to determine whether specific gun type data could be collected and whether knowledge of specific gun types (rifle, shotgun, pistol, revolver) could be used to distinguish gun homicide victims with respect to important injury parameters such as number of wounds. Methods: Data on gun fatalities over a 5-year period in three communities were abstracted from medical examiner/coroner, police, and crime laboratory records. Results: Gun type was obtained for 92% of 490 guns linked to 405 gun homicides. Handguns were associated with more wounds per gun than long guns (p = 0.001) and more entry wounds per gun than long guns (p = 0.002). Among handguns, pistols were associated with more wounds per gun (p < 0.001) and entry wounds per gun (p = 0.001) than revolvers. These same associations were not found among specific long gun types (i.e., rifles and shotguns). Conclusion: Our findings demonstrate that information about gun type can be obtained and that significant differences exist in wounds per gun between long guns and handguns and between pistols and revolvers. Classification of long guns into rifles and shotguns and handguns into pistols and revolvers should be included in local, regional, and national data collection systems.Publication Design and Rationale of Safe Pediatric Euglycemia After Cardiac Surgery (SPECS): A Randomized Controlled Trial of Tight Glycemic Control After Pediatric Cardiac Surgery(2013-02-01) Gaies, Michael G; Langer, Monica; Alexander, Jamin; Steil, Garry M; Ware, Janice; Wypij, David; Laussen, Peter C; Newburger, Jane W; Goldberg, Caren S; Pigula, Frank A; Shukla, Avinash C; Duggan, Christopher P; Agus, Michael S D; Curley, Martha A. Q.Objectives: To describe the design of a clinical trial testing the hypothesis that children randomized to tight glycemic control with intensive insulin therapy after cardiac surgery will have improved clinical outcomes compared to children randomized to conventional blood glucose management. Design: Two-center, randomized controlled trial. Setting: Cardiac ICUs at two large academic pediatric centers. Patients: Children from birth to those aged 36 months recovering in the cardiac ICU after surgery with cardiopulmonary bypass. Interventions: Subjects in the tight glycemic control (intervention) group receive an intravenous insulin infusion titrated to achieve normoglycemia (target blood glucose range of 80–110 mg/dL; 4.4–6.1 mmol/L). The intervention begins at admission to the cardiac ICU from the operating room and terminates when the patient is ready for discharge from the ICU. Continuous glucose monitoring is performed during insulin infusion to minimize the risks of hypoglycemia. The standard care group has no target blood glucose range. Measurements and Main Results: The primary outcome is the development of any nosocomial infection (bloodstream, urinary tract, and surgical site infection or nosocomial pneumonia). Secondary outcomes include mortality, measures of cardiorespiratory function and recovery, laboratory indices of nutritional balance, immunologic, endocrinologic, and neurologic function, cardiac ICU and hospital length of stay, and neurodevelopmental outcome at 1 and 3 yrs of age. A total of 980 subjects will be enrolled (490 in each treatment arm) for sufficient power to show a 50% reduction in the prevalence of the primary outcome. Conclusions: Pediatric cardiac surgery patients may recognize great benefit from tight glycemic control in the postoperative period, particularly with regard to reduction of nosocomial infections. The Safe Pediatric Euglycemia after Cardiac Surgery trial is designed to provide an unbiased answer to the question of whether this therapy is indeed beneficial and to define the associated risks of therapy.Publication Mentoring for Nursing Research: Students' Perspectives and Experiences(2008-01-29) Persichilli, Joseph M; Daniels, Tammy VThis paper explores the connection between nursing research and mentorship. The importance of nursing research and the concept of mentoring are discussed based on a review of the literature. Using personal experiences of undergraduate research assistants, positive outcomes of mentorship are explained. Outcomes cited include collaborative effort on projects, future aspirations, preparedness for evidence-based practice, improved patient care, personal and professional development, and increased exposure and awareness of research. The relevance of mentoring to current and future nursing research is described.Publication Using Growth Mixture Modeling to Identify Classes of Sodium Adherence in Adults with Heart Failure(2014-05-01) Masterson-Creber, Ruth; Lee, Christopher S; Lennie, Terry A; Topaz, Maxim; Riegel, BarbaraBACKGROUND: The prevention of fluid retention is important to reduce hospitalizations in patients with heart failure (HF). Following a low-sodium diet helps to reduce fluid retention. OBJECTIVE: The primary objective of this study was to use growth mixture modeling to identify distinct classes of sodium adherence-characterized by shared growth trajectories of objectively measured dietary sodium. The secondary objective was to identify patient-level determinants of the nonadherent trajectory. METHODS: This was a secondary analysis of data collected from a prospective longitudinal study of 279 community-dwelling adults with previously or currently symptomatic HF. Growth mixture modeling was used to identify distinct trajectories of change in 24-hour urinary sodium excretion measured at 3 time points over 6 months. Logistic modeling was used to predict membership in observed trajectories. RESULTS: The sample was predominantly male (64%), had a mean age of 62 years, was functionally compromised (59% New York Heart Association class III), and had nonischemic HF etiology. Two distinct trajectories of sodium intake were identified and labeled adherent (66%) and nonadherent (34%) to low-sodium diet recommendations. Three predictors of the nonadherent trajectory were identified, confirming our previous mixed-effect analysis. Compared with being normal weight (body mass index/m2), being overweight and obese was associated with a 4-fold incremental increase in the likelihood of being in the nonadherent trajectory (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.66-12.91; P < .002). Being younger than 65 years (OR, 4.66; 95% CI, 1.04-20.81; P = .044) or having diabetes (OR, 4.15; 95% CI, 1.29-13.40; P = .016) were both associated with more than 4 times the odds of being in the nonadherent urine sodium trajectory compared with being older than 65 years or not having diabetes, respectively. CONCLUSIONS: Two distinct trajectories of sodium intake were identified in patients with HF. The nonadherent trajectory was characterized by an elevated pattern of dietary sodium intake shown by others to be associated with adverse outcomes in HF. Predictors of the nonadherent trajectory included higher body mass index, younger age, and diabetes.Publication Motivational Interviewing to Improve Self-Care for Patients with Chronic Heart Failure: MITI-HF Randomized Controlled Trial(2016-02-01) Masterson-Creber, Ruth; Patey, Megan; Lee, Christopher S; Kuan, Amy; Jurgens, Corrine Y; Riegel, BarbaraOBJECTIVE: The purpose of this study was to test the efficacy of a tailored motivational interviewing (MI) intervention versus usual care for improving HF self-care behaviors, physical HF symptoms and quality of life. METHODS: This is a single-center, randomized controlled trial. Participants were enrolled in the hospital. Immediately after discharge, those in the intervention group received a single home visit and 3-4 follow-up phone calls by a nurse over 90 days. RESULTS: A total of 67 participants completed the study (mean age 62±12.8 years), of which 54% were African American, 30% were female, 84% had class III/IV symptoms, and 63% were educated at a high school level or less. There were no differences between the groups in self-care maintenance, self-care confidence, physical HF symptoms, or quality of life at 90 days. CONCLUSION: Patients who received the MI intervention had significant and clinically meaningful improvements in HF self-care maintenance over 90 days that exceeded that of usual care. PRACTICE IMPLICATIONS: These data support the use of a nurse-led MI intervention for improving HF self-care. Identifying methods to improve HF self-care may lead to improved clinical outcomes.Publication The Effect of Early Psychological Symptom Severity on Long-term Functional Recovery: A Secondary Analysis of Data from a Cohort Study of Minor Injury Patients(2017-01-01) Jacoby, Sara Fredricka; Shults, Justine; Richmond, Therese SBackground: The mental health consequences of injuries can interfere with recovery to pre-injury levels of function and long term wellbeing. Objectives: The purpose of this study was to explore the relationship between psychological symptoms after minor injury and long-term functional recovery and disability. Design: This exploratory study uses secondary data derived from a longitudinal cohort study of psychological outcomes after minor injury. Setting: Participants were recruited from the Emergency Department of an urban hospital in the United States. Participants: A cohort of 275 patients was randomly selected from 1100 consecutive emergency department admissions for minor injury. Potential participants were identified as having sustained minor injury by the combination of three standard criteria including: presentation to the emergency department for medical care within 24 h of a physical injury, evidence of anatomical injury defined as minor by an injury severity score between 2 and 8 and normal physiology as defined by a triage-Revised Trauma Score of 12. Patients with central nervous system injuries, injury requiring medical care in the past 2 years and/or resulting from domestic violence, and those diagnosed with major depression or psychotic disorders were excluded. Methods: Psychological symptom severity was assessed within 2 weeks of injury, and outcome measures for functional limitations and disability were collected at 3, 6 and 12 months. A quasi-least squares approach was used to examine the relationship between psychological symptom scores at intake and work performance and requirement for bed rest in the year after injury. Results: Adjusting for demographic and injury covariates, depression symptoms at the time of injury predicted (p ≤ 0.05) both poorer work performance and increased number of days in bed due to health in the year after injury. Anxiety symptoms predicted (p ≤ 0.05) bed days at 3, 6, and 12 months and work performance at 3 months. Conclusions: Depression and anxiety soon after minor injury may help predict important markers of long-term recovery. With further research, simple assessment tools for psychological symptoms may be useful to screen for patients who are at higher risk for poor long-term recoveries and who may benefit from targeted interventions.Publication Identifying Distinct Risk Profiles to Predict Adverse Events among Community-Dwelling Older Adults(2017-05-04) O'Connor, Melissa; Hanlon, Alexandra; Mauer, Elizabeth; Meghani, Salimah; Masterson-Creber, Ruth; Marcantonio, Sherry; Coburn, Ken; Van Cleave, Janet; Davitt, Joan; Riegel, Barbara; Bowles, Kathryn H; Keim, Susan; Greenberg, Sherry A; Sefcik, Justine S; Topaz, Maxim; Kong, Dexia; Naylor, MaryPreventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community-dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles. The Vuong-Lo-Mendell-Rubin Likelihood Ratio Test demonstrated optimal fit for three risk profiles (High, Medium, and Low Risk). The High Risk profile had significantly shorter time to hospitalization, ED visit, and death (p < 0.001 for each). These findings provide a road map for generating risk profiles that could enable more effective targeting of interventions and be instrumental in reducing health care costs for subgroups of chronically ill community-dwelling older adults.