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Nursing's economic value is presently framed within the dominant "outcomes-over-cost" value framework. Within this context, organizations employing nurses often use nursing budget reductions as a cost-minimization strategy, with the intent of retaining high quality outcomes. However, persistent issues such as nurse understaffing, burnout, and turnover threaten healthcare systems' capacity to deliver the quality, equitable, affordable patient care that the public requires. In this paper, we propose a new conceptual model and definition of nursing's economic value. The model development is guided by the convergence of three classic economic frameworks: human capital theory, production theory, and value theory. Grounded in these theories, we envision nursing as a value-adding human capital asset and explicitly link nursing staff characteristics and allocation to the production of healthcare services and organizational financial outcomes. We redefine nursing's economic value as the return on investment (ROI) in nursing human capital reflected in the improvement of consumer, nurse, and organizational outcomes. This new conceptual model, termed the Nursing Human Capital Value Model, presents a cycle of value creation that starts with investments in growing, developing and sustaining an organization's nursing human capital. Nurses, as a human capital asset, deliver nursing care-a foundational ingredient to the production of healthcare services and consumer outcomes. Improved outcomes, subsequently, drive organizational revenue growth. Finally, the accrued revenue is reinvested in nursing, further propelling the cycle's continuation. This innovative model, which is applicable across health systems financed through both governmental and private/non-governmental payor sources, highlights that investment in nursing human capital development is essential for sustainable value generation, identifying opportunities for optimizing nurses' contributions to the value cycle. By directly incorporating economic theories of human capital, production, and value, our model paves the way for future research on the dynamic scope of nursing's economic contribution within healthcare organizations and systems and underscores its necessity for the long-term sustainability and growth of the nursing profession. Tweetable abstract: The economic value of nursing lies in the return on investment in nursing human capital. #nurses #ROI #healthcare., Competing Interests: Declaration of Competing Interest The author is an Editorial Board Member/Editor-in-Chief/Associate Editor/Guest Editor for The International Journal of Nursing Studies and was not involved in the editorial review or the decision to publish this article. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Olga Yakusheva and Marianne Weiss were commissioned by the American Nurses Association and its subsidiaries, American Nurses Credentialing Center and American Nurses Foundation; together known as the American Nurses Association Enterprise (“ANA Enterprise”). The authors are solely responsible for the content of this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Rationale: Organizing ICU interprofessional teams is a high priority because of workforce needs, but the role of interprofessional familiarity remains unexplored. Objectives: Determine if mechanically ventilated patients cared for by teams with greater familiarity have improved outcomes, such as lower mortality, shorter duration of mechanical ventilation (MV), and greater spontaneous breathing trial (SBT) implementation. Methods: We used electronic health records data of five ICUs in an academic medical center to map interprofessional teams and their ICU networks, measuring team familiarity as network coreness and mean team value. We used patient-level regression models to link team familiarity with patient outcomes, accounting for patient and unit factors. We also performed a split-sample analysis by using 2018 team familiarity data to predict 2019 outcomes. Measurements and Main Results: Team familiarity was measured as the average number of patients shared by each clinician with all other clinicians in the ICU (i.e., coreness) and the average number of patients shared by any two members of the team (i.e., mean team value). Among 4,485 encounters, unadjusted mortality was 12.9%, average duration of MV was 2.32 days, and SBT implementation was 89%; average team coreness was 467.2 (standard deviation [SD], 96.15), and average mean team value was 87.02 (SD, 42.42). A 1-SD increase in team coreness was significantly associated with a 4.5% greater probability of SBT implementation, 23% shorter MV duration, and 3.8% lower probability of dying; the mean team value was significantly associated with lower mortality. Split-sample results were attenuated but congruent in direction and interpretation. Conclusions: Interprofessional familiarity was associated with improved outcomes; assignment models that prioritize familiarity might be a novel solution.

Background: Home health care (HHC) services following hospital discharge provide essential continuity of care to mitigate risks of posthospitalization adverse outcomes and readmissions, yet patients from racial and ethnic minority groups are less likely to receive HHC visits., Objective: To examine how the association of nurse assessments of patients' readiness for discharge with referral to HHC services at the time of hospital discharge differs by race and ethnic minority group., Research Design: Secondary data analysis from a multisite study of the implementation of discharge readiness assessments in 31 US hospitals (READI Randomized Clinical Trial: 09/15/2014-03/31/2017), using linear and logistic models adjusted for patient demographic/clinical characteristics and hospital fixed effects., Subjects: All Medicare patients in the study's intervention arm (n=14,684)., Measures: Patient's race/ethnicity and discharge disposition code for referral to HHC (vs. home) from electronic health records. Patient's Readiness for Hospital Discharge Scale (RHDS) score (0-10 scale) assessed by the discharging nurse on the day of discharge., Results: Adjusted RHDS scores were similar for non-Hispanic White (8.21; 95% CI: 8.18-8.24), non-Hispanic Black (8.20; 95% CI: 8.12-8.28), Hispanic (7.92; 95% CI: 7.81-8.02), and other race/ethnicity patients (8.09; 95% CI: 8.01-8.17). Non-Hispanic Black patients with low RHDS scores (6 or less) were less likely than non-Hispanic White patients to be discharged with an HHC referral (Black: 26.8%, 95% CI: 23.3-30.3; White: 32.6%, 95% CI: 31.1-34.1)., Conclusions: Despite similar RHDS scores, Black patients were less likely to be discharged with HHC. A better understanding of root causes is needed to address systemic structural injustice in health care settings., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Due to the nature of fatigue, a brief reliable measure of fatigue severity is needed. Thus, the aim of our study was to evaluate a short version of the Lee Fatigue Scale (LFS) in the Norwegian general population., Methods: This cross-sectional survey consists of a representative sample from the Norwegian population drawn by The National Population Register in Norway. The study is part of a larger study (NORPOP) aimed at collecting normative data from several questionnaires focused on health in adults living in Norway. Registered citizens between 18 and 94 years of age were randomly selected stratified by age, sex and geographic region. Of the 4971 respondents eligible for the study, 1792 (36%) responded to the survey. In addition to age and sex, we collected responses on a 5-item version of the LFS measuring current fatige severity. The psychometric properties focusing on internal structure and precision of the LFS items were analyzed by a Rasch rating scale model., Results: Complete LFS scores for analyses were available for 1767 adults. Women had higher LFS-scores than men, and adults < 55 years old had higher scores than older respondents. Our analysis of the LFS showed that the average category on each item advanced monotonically. Two of the five items demonstrated misfit, while the three other items demonstrated goodness-of-fit to the model and uni-dimensionality. Items #1 and #4 (tired and fatigue respectively) showed differential item functioning (DIF) by sex, but no items showed DIFs in relation to age. The separation index of the LFS 3-item scale showed that the sample could be separated into three different groups according to the respondents' fatigue levels. The LFS-3 raw scores correlated strongly with the Rasch measure from the three items. The core dimensions in these individual items were very similarly expressed in the Norwegian language version and this may be a threat to the cultural-related or language validity of a short version of the LFS using these particular items., Conclusions: The study provides validation of a short LFS 3-item version for estimating fatigue in the general population., (© 2023. The Author(s).)

Study Objectives: To describe changes in sleep quality and associated sleep symptoms as women begin menopausal transition compared with premenopausal controls., Methods: In a repeated-measures design, we analyzed data collected every 2-6 months from a community-based sample of 223 women aged 40-50 (45.6 ± 2.3) years old over a 2-year period. Each 6-month visit included urinary follicle-stimulating hormone (FSH) as a marker of ovarian function and the Pittsburgh Sleep Quality Index (PSQI) and other questionnaires (Center for Epidemiological Studies-Depression Scale; Perceived Stress Scale). Menstrual cycle and vasomotor symptoms (Seattle Women's Health Symptom Checklist) were tracked every 2 months by phone. For women entering menopausal transition (n = 68) we used data from the two consecutive visits prior to their FSH rise and the next two visits. Data from the last four consecutive visits were used for controls remaining premenopausal (n = 155)., Results: The transition group did not differ from controls on age, vasomotor symptoms (hot flashes/night sweats), stress, or depression but did have a higher body mass index. Measures were stable over time for controls. However, the transition group experienced an increase in PSQI scores (initial PSQI = 5.7 ± 3.2 and final PSQI = 6.3 ± 3.8; P = .030) and frequency of trouble sleeping because of feeling too hot ( P = .016), which lagged the FSH rise by 6 months with no notable change in report of hot flashes/night sweats., Conclusions: Trouble sleeping because of feeling too hot, distinct from awareness of vasomotor symptoms, was the only uniform contribution to higher PSQI scores after the initial FSH increase and may signal the onset of the menopausal transition., Citation: Zak R, Zitser J, Jones HJ, Gilliss CL, Lee KA. Sleep symptoms signaling the menopausal transition. J Clin Sleep Med . 2023;19(8):1513-1521., (© 2023 American Academy of Sleep Medicine.)

Study Objectives: To describe the association between preoperative sleep disruption and postoperative delirium., Methods: Prospective cohort study with six time points (3 nights pre-hospitalization and 3 nights post-surgery). The sample included 180 English-speaking patients ≥65 years old scheduled for major non-cardiac surgery and anticipated minimum hospital stay of 3 days. Six days of wrist actigraphy recorded continuous movement to estimate wake and sleep minutes during the night from 22:00 to 05:59. Postoperative delirium was measured by a structured interview using the Confusion Assessment Method. Sleep variables for patients with (n = 32) and without (n = 148) postoperative delirium were compared using multivariate logistic regression., Results: Participants had a mean age of 72 ± 5 years (range 65-95 years). The incidence of postoperative delirium during any of the three postoperative days was 17.8%. Postoperative delirium was significantly associated with surgery duration (OR = 1.49, 95% CI 1.24-1.83) and sleep loss >15% on the night before surgery (OR = 2.64, 95% CI 1.10-6.62). Preoperative symptoms of pain, anxiety and depression were unrelated to preoperative sleep loss., Conclusions: In this study of adults ≥65 years of age, short sleep duration was more severe preoperatively in the patients who experienced postoperative delirium as evidenced by sleep loss >15% of their normal night's sleep. However, we were unable to identify potential reasons for this sleep loss. Further investigation should include additional factors that may be associated with preoperative sleep loss to inform potential intervention strategies to mitigate preoperative sleep loss and reduce risk of postoperative delirium., Competing Interests: Declaration of competing interest All authors have seen and approved the manuscript and attest that there are no conflicts of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Health care executives and policymakers have raised concerns about the adequacy of the US nursing workforce to meet service demands. Workforce concerns have risen given the SARS-CoV-2 pandemic and chronically poor working conditions. There are few recent studies that directly survey nurses on their work plans to inform possible remedies., Methods: In March 2022, 9150 nurses with a Michigan license completed a survey on their plans to leave their current nursing position, reduce their hours, or pursue travel nursing. Another 1224 nurses who left their nursing position within the past 2 years also reported their reasons for departure. Logistic regression models with backward selection procedures estimated the effects of age, workplace concerns, and workplace factors on the intent to leave, hour reduction, pursuit of travel nursing (all within the next year), or departure from practice within the past 2 years., Results: Among practicing nurses surveyed, 39% intended to leave their position in the next year, 28% planned to reduce their clinical hours, and 18% planned to pursue travel nursing. Top-ranked workplace concerns among nurses were adequate staffing, patient safety, and staff safety. The majority of practicing nurses (84%) met the threshold for emotional exhaustion. Consistent factors associated with adverse job outcomes include inadequate staffing and resource adequacy, exhaustion, unfavorable practice environments, and workplace violence events. Frequent use of mandatory overtime was associated with a higher likelihood of departure from the practice in the past 2 years (Odds Ratio 1.72, 95% CI 1.40-2.11)., Conclusions: The factors associated with adverse job outcomes among nurses-intent to leave, reduced clinical hours, travel nursing, or recent departure-consistently align with issues that predated the pandemic. Few nurses cite COVID as the primary cause for their planned or actual departure. To maintain an adequate nursing workforce in the United States, health systems should enact urgent efforts to reduce overtime use, strengthen work environments, implement anti-violence protocols, and ensure adequate staffing to meet patient care needs., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Main Objective: Systematically review and synthesize preoperative and intraoperative factors associated with pain after total knee arthroplasty (TKA) in patients with osteoarthritis., Methods: Based on a peer-reviewed protocol, we searched Medline, Embase, CINAHL, Cochrane Library, and PEDro for prospective observational studies (January 2000 to February 2023) investigating factors associated with pain after TKA. The primary outcome was pain twelve months after TKA. Pain at three and six months were secondary outcomes. Multivariate random-effects meta-analyses were used to estimate mean correlation (95% CIs) between factors and pain. Sensitivity analysis was performed for each risk of bias domain and certainty of evidence was assessed., Results: Of 13,640 studies, 29 reports of 10,360 patients and 61 factors were analysed. The mean correlation between preoperative factors and more severe pain at twelve months was estimated to be 0.36 (95% CI, 0.24, 0.47; P < .000; moderate-certainty evidence) for more catastrophizing, 0.15 (95% CI; 0.08, 0.23; P < .001; moderate-certainty evidence) for more symptomatic joints, 0.13 (95% CI, 0.06, 0.19; P < .001; very low-certainty evidence) for more preoperative pain. Mean correlation between more severe radiographic osteoarthritis and less pain was -0.15 (95% CI; -0.23, -0.08; P < .001; low-certainty evidence). In sensitivity analysis, the estimated correlation coefficient for pain catastrophizing factor increased to 0.38 (95% CI 0.04, 0.64). At six and three months, more severe preoperative pain was associated with more pain. Better preoperative mental health was associated with less pain at six months., Conclusion and Relevance: More pain catastrophizing, more symptomatic joints and more pain preoperatively were correlated with more pain, while more severe osteoarthritis was correlated with less pain one year after TKA. More preoperative pain was correlated with more pain, and better mental health with less pain at six and three months. These findings should be further tested in predictive models to gain knowledge which may improve TKA outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Olsen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To describe sleep characteristics in the third trimester of pregnancy for women who had a prior pregnancy loss compared to women with no history of loss., Design: Descriptive comparison of baseline data prior to randomization for a clinical trial., Setting: Participants' homes., Participants: Eligible women recruited from childbirth education classes during third trimester were over 18 years old, in partnered relationships, spoke English, did not work nightshift or have a diagnosed sleep disorder, and had no current complications or prior pregnancy loss (n = 140). Women with prior miscarriage or stillbirth were offered enrollment in an ancillary study (n = 20)., Measurements: Sleep was assessed with the Pittsburgh Sleep Quality Index (PSQI) and wrist actigraphy. Other measures included relationship satisfaction, perceived stress, and depressive symptoms. For this analysis, only third trimester data prior to randomization were compared., Results: Both groups had similar actigraphy-recorded sleep duration (7.1 ± 1.1 hours) and sleep efficiency (83.7 ± 7.9%). However, the pregnancy loss group had significantly (p = .050) worse PSQI scores (7.8 ± 2.6) than controls (6.7 ± 3.1), resulting primarily from the sleep disturbance component (p = .003), specifically bad dreams (p = .030) and legs twitching/jerking (p = .071). Controlling for demographic and health factors in multivariate analyses, prior pregnancy loss was significant for sleep disturbance (p = .047), bad dreams (p = .018), and partner-reported leg twitching/jerking (p = .048)., Conclusions: Long after the acute grief of a pregnancy loss, perceived sleep quality can be problematic during the next pregnancy. Whether poor sleep quality is present prior to the pregnancy loss or reflects long-term maternal sleep characteristics require further research., (Copyright © 2022 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Non-Hispanic Black individuals may be less likely to receive a diagnosis of dementia compared to non-Hispanic White individuals. These findings raise important questions regarding which factors may explain this observed association and any differences in the time to which disparities emerge following dementia onset., Methods: We conducted a retrospective cohort study using survey data from the 1995 to 2016 Health and Retirement Study linked with Medicare fee-for-service claims. Using the Hurd algorithm (a regression-based approach), we identified dementia onset among older adult respondents (age ≥65 years) from the Telephone Interview for Cognitive Status and proxy respondents. We determined date from dementia onset to diagnosis using Medicare data up to 3 years following onset using a list of established diagnosis codes. Cox Proportional Hazards modeling was used to examine the association between an individual's reported race and likelihood of diagnosis after accounting for sociodemographic characteristics, income, education, functional status, and healthcare use., Results: We identified 3435 older adults who experienced a new onset of dementia. Among them, 30.1% received a diagnosis within 36 months of onset. In unadjusted analyses, the difference in cumulative proportion diagnosed by race continued to increase across time following onset, p-value <0.001. 23.8% of non-Hispanic Black versus 31.4% of non-Hispanic White participants were diagnosed within 36 months of dementia onset, Hazard Ratio = 0.73 (95% CI: 0.61, 0.88). The association persisted after adjustment for functional status and healthcare use; however, these factors had less of an impact on the strength of the association than income and level of education., Conclusion: Lower diagnosis rates of dementia among non-Hispanic Black individuals persists after adjustment for sociodemographic characteristics, functional status, and healthcare use. Further understanding of barriers to diagnosis that may be related to social determinants of health is needed to improve dementia-related outcomes among non-Hispanic Black Americans., (© 2022 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: Validity of the Pittsburgh Sleep Quality Index (PSQI) has not been established for midlife women before menopause, and evidence suggests that two-factor or three-factor models may be more informative than the PSQI global score derived from its seven components. We hypothesized that the PSQI and its factor structure would be valid in premenopausal women. Materials and Methods: We performed a validation study of the PSQI against wrist actigraphy in a community-based convenience sample of 71 healthy premenopausal women (aged 40-50 years). For convergent validity, PSQI and its component scores were compared with homologous actigraphy measures. For discriminant validity, characteristics known to affect sleep quality were compared, including body mass index, exercise, menopausal status, menopausal symptoms, and depressive symptoms measured with the Center for Epidemiological Studies-Depression (CES-D) Scale. Results: The PSQI global score and Components 1 (quality) and 5 (disturbance) were correlated ( p  < 0.05) with actigraphy-measured wake after sleep onset. The PSQI global score and Components 1 (quality) and 7 (daytime dysfunction) were correlated with CES-D scores. PSQI Components 2 (onset latency) and 4 (efficiency) were not congruent with homologous actigraphy measures, while component 3 (duration) was congruent with actigraphy duration. The single-factor PSQI global score had a higher McDonald's omega (0.705) and Cronbach's alpha (0.702) than the two-factor or three-factor models. Conclusions: The PSQI global score is a valid measure of sleep quality in healthy midlife women, performing better than two-factor or three-factor models. However, overlapping CES-D and PSQI scores warrant further clinical assessment and research to better differentiate poor sleep quality from depression.

The purpose was to examine the degree to which perceived risk for diabetes differed by race and ethnicity among U.S. adults with undiagnosed prediabetes. The study was a cross-sectional analysis of data from 4005 participants (aged ≥20 years) in the National Health and Nutrition Examination Survey (NHANES) program between 2011 and 2018. Individuals with prediabetes were identified using glycohemoglobin (HbA 1c ) data. Logistic regression was used to estimate the association between race and ethnicity and perceived risk of diabetes while adjusting for age and sex, educational level, family history of diabetes, BMI, and healthcare factors (health insurance coverage and routine place to go for healthcare). Nearly three-quarters (71.8%) of adults with undiagnosed prediabetes reported no perceived risk for diabetes. Rates of perceived risk for diabetes did not change significantly in any racial and ethnic groups from 2011 to 12 to 2017-18. In models adjusted for individual characteristics, identifying as Non-Hispanic Black was associated with a 34% higher likelihood of reporting no perceived risk compared to identifying as Non-Hispanic White (OR 1.34, 95% CI:1.03-1.74). Identifying as Hispanic was associated with a 29% higher likelihood of reporting no perceived risk compared to identifying as Non-Hispanic White (OR 1.29, 95% CI: 1.01, 1.66). Healthcare factors may have less influence on diabetes risk perception. Future public health efforts should improve diabetes risk communication efforts across racial and ethnic groups, emphasizing Non-Hispanic Black and Hispanic populations., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To increase the percentage of women who attend postpartum visits and decrease the number of days to the first postpartum visit by implementing a scheduling change., Design: Quality improvement project., Setting/local Problem: A small nurse practitioner maternity care clinic in an academic health center at which only 74% of the women who attended two or more prenatal visits attended postpartum clinic visits., Participants: A diverse sample of 25 publicly insured women who gave birth during the 5-month implementation period., Intervention/measurements: We added a 2- to 3-week postpartum appointment to our standard 6-week postpartum appointment. The measurable outcomes were the percentage of women who attended postpartum clinic visits and the number of days to the first postpartum visit., Results: During the first 4 months of the 5-month project implementation phase, 14 of the 20 (70%) women who gave birth attended postpartum visits. The attendance at postpartum visits in the last month of the project was 100% (all five women). Days to first postpartum visit decreased from a mean of 40.7 in the baseline year to a mean of 21.8 by the last month of project implementation., Conclusion: Despite the small scope of this project, our outcomes support continuing the practice of scheduling an earlier postpartum clinic appointment. The timing for when to preschedule postpartum appointments and contextual factors, such as the availability and use of telehealth technology and COVID-19 pandemic challenges, should be considered when implementing similar projects in other settings., Competing Interests: Conflict of Interest The authors report no conflicts of interest or relevant financial relationships., (Copyright © 2022. Published by Elsevier Inc.)

We present a 74-year-old gentleman, who presented with foot ischaemia requiring bilateral amputation in the absence of radiological signs of occlusive peripheral arterial disease. He was found to have COVID-19 pneumonitis and concurrent arterial and venous thromboemboli despite no initial respiratory symptoms or signs, nor pre-existing risk factors for cardiovascular disease. Patients who present with foot ischaemia with or without respiratory symptoms or signs warrant a high index of suspicion for COVID-19 infection, particularly in those with no predisposing risk factors.

Objective: To describe correlates of fatigue and lack of energy symptoms in adults living with HIV., Methods: Adults living with HIV were recruited if they were ≥45 years old, unemployed, and reported either fatigue or lack of energy in the past week. HIV-associated correlates included CD4 cell count, viral load, and hemoglobin. Daytime correlates included physical activity, daytime sleepiness, napping behavior, and symptoms of anxiety and depression. Nighttime correlates included use of sleep medication, sleep duration, and sleep quality. Outcomes included physical and cognitive function., Results: Most (70%) of the 53 participants were male. The mean age was 56.7 ± 6.7 years and participants had been living with HIV for a mean of 22 ± 6.4 years. Controlling for all other factors, African Americans reported less fatigue and more energy than other racial/ethnic groups. Lack of energy was associated with daytime napping and cognitive function. Fatigue was associated with shorter nighttime sleep duration, anxiety, and both physical and cognitive function., Discussion: Findings highlight potential differences between lack of energy and fatigue that could influence intervention outcomes. Avoiding daytime naps and encouraging longer nighttime sleep may improve fatigue as well as physical and cognitive function in this chronic illness population.

Citation: Zak RS, Lee KA. The glass is half full: gender diversity in sleep medicine award recognition. J Clin Sleep Med. 2021;17(8):1517-1518., (© 2021 American Academy of Sleep Medicine.)

Objective: To determine whether selected genes and plasma markers involved in energy homeostasis are associated with sleep disruption or duration in adults with HIV/AIDS., Methods: A sample of 289 adults with HIV/AIDS wore a wrist actigraph for 72 h to estimate total sleep time (TST) and wake after sleep onset (WASO). Twenty-three single nucleotide polymorphisms (SNP) spanning 5 energy homeostasis genes (adiponectin [ADIPOQ], ghrelin [GHRL], leptin [LEP], peroxisome proliferator-activated receptor-alpha [PPARA], and -gamma [PPARG]) were genotyped using a custom array. Plasma markers of energy homeostasis (adiponectin, ghrelin, leptin) were measured by commercial multiplex assay., Results: After adjusting for demographic and clinical characteristics (race/ethnicity, gender, CD4 cell count, waist circumference, medications), both WASO and TST were associated with SNPs in ADIPOQ (rs182052), LEP (rs10244329, rs3828942), PPARA (rs135551, rs4253655), and PPARG (rs709151). Additional SNPs in ADIPOQ were associated with WASO (rs1501299, rs3821799, rs6773957) and TST (rs2241766). TST was also associated with SNPs in GHRL (rs26802), LEP (rs11760956), PPARA (rs135547, rs8138102, rs4253776), and PPARG (rs12490265, rs796313). Many covariate-adjusted associations involved a significant interaction with markers of HIV (viral load, years since diagnosis). Among plasma markers, higher adiponectin was associated with less WASO, higher ghrelin and glucose levels with shorter TST, and higher leptin with longer TST., Conclusions: Replication of SNPs in all five genes and three plasma markers of energy homeostasis were associated with objective sleep measures. HIV disease influenced many of the associations. Findings strengthen evidence for associations between energy homeostasis genetics and poor sleep, and provide direction for pharmacological intervention research., (Copyright © 2020. Published by Elsevier B.V.)

Introduction: One in five patients undergoing total knee arthroplasty (TKA) experience unchanged or worse pain and physical function 1 year after surgery. Identifying risk factors for unfavourable outcomes is necessary to develop tailored interventions to minimise risk. There is a need to review more current literature with updated methodology that addresses the limitations of earlier systematic reviews and meta-analyses. We present a Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols compliant protocol for a systematic review and meta-analysis of predictors of chronic pain and impaired function after TKA., Methods and Analysis: This review will include prospective longitudinal observational studies, or randomised trials (including cluster and crossover designs) that report arm-wise predictors of chronic postsurgical pain or impaired physical function at 3 months, 6 months or 12 months. A comprehensive literature search of studies published between 2000 and 2019 will be performed in Medline, Embase, CINAHL, Cochrane Library and PEDro. Blinded assessment with consensus agreement will be applied for inclusion of studies, data extraction and assessment of bias risk (Quality in Prognosis Studies tool). The co-primary outcomes, pain and impaired function, at 12 months after TKA will be analysed separately. Estimates of association between each outcome and any preoperative or intraoperative factor that may predict chronic pain or impaired physical function will be extracted from the included studies, where possible. For randomised studies, results will only be extracted from TKA arms (or the first period of crossover trials). Estimates of association from the primary evidence will be synthesised narratively, and quantitatively using multivariate meta-analysis to provide 'pooled' estimates of association. Subgroup and sensitivity analyses will be performed. Certainty of evidence for each predictor will be derived from the Grading of Recommendations Assessment, Development and Evaluation framework., Ethics and Dissemination: No ethical issues are associated with this project. The results from this review will be published in peer-reviewed journals and presented at international conferences., Prospero Registration Number: CRD42018079069., Competing Interests: Competing interests: CJR reports personal fees from Oncolmmunity AS. He has a patent and patent application with no relevance to this study., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Fatigue is a common symptom associated with a wide range of diseases and needs to be more thoroughly studied. To minimise patient burden and to enhance response rates in research studies, patient-reported outcome measures (PROM) need to be as short as possible, without sacrificing reliability and validity. It is also important to have a generic measure that can be used for comparisons across different patient populations. Thus, the aim of this secondary analysis was to evaluate the psychometric properties of the Norwegian 5-item version of the Lee Fatigue Scale (LFS) in two distinct patient populations., Methods: The sample was obtained from two different Norwegian studies and included patients 4-6 weeks after stroke (n = 322) and patients with osteoarthritis on a waiting list for total knee arthroplasty (n = 203). Fatigue severity was rated by five items from the Norwegian version of the LFS, rating each item on a numeric rating scale from 1 to 10. Rasch analysis was used to evaluate the psychometric properties of the 5-item scale across the two patient samples., Results: Three of the five LFS items ("tired", "fatigued" and "worn out") showed acceptable internal scale validity as they met the set criterion for goodness-of-fit after removal of two items with unacceptable goodness-of-fit to the Rasch model. The 3-item LFS explained 81.6% of the variance, demonstrated acceptable unidimensionality, could separate the fatigue responses into three distinct severity groups and had no differential functioning with regard to disease group. The 3-item version of the LFS had a higher separation index and better internal consistency reliability than the 5-item version., Conclusions: A 3-item version of the LFS demonstrated acceptable psychometric properties in two distinct samples of patients, suggesting it may be useful as a brief generic measure of fatigue severity., Trial Registration: Clinicaltrials.gov: NCT02338869; registered 10/04/2014 (stroke study).

Background: Nocturnal bladder symptoms and sleep disruption commonly coexist in middle-aged and older women. Although sleep disruption is often attributed to nocturnal bladder symptoms in women with overactive bladder syndrome, nonbladder factors also may influence sleep in this population. Many women with overactive bladder are eager to identify nonpharmacologic strategies for both bladder symptoms and sleep disruption, given the potential adverse effects of sedative and anticholinergic bladder medications in this population., Objectives: To provide greater insight into the complex relationship between nighttime overactive bladder symptoms and sleep disruption, and to evaluate the effects of a guided slow-paced respiration intervention on sleep outcomes in women with overactive bladder., Study Design: We conducted an ancillary study within a randomized trial of slow-paced respiration in women with overactive bladder symptoms. Ambulatory community-dwelling women who reported ≥3 episodes/day of urgency-associated voiding or incontinence were randomized to use either a portable biofeedback device (RESPeRATE; Intercure, Ltd) to practice guided slow-paced respiration exercises daily for 12 weeks (N=79) or an identical-appearing device programmed to play nonrhythmic music without guiding breathing (N=82). At baseline and after 12 weeks, bladder symptoms were assessed by voiding diary, sleep duration, and disruption were assessed by sleep diary corroborated by wrist actigraphy, and poor sleep quality was determined by a Pittsburgh Sleep Quality Index global score >5., Results: Of the 161 women randomized, 31% reported at least twice-nightly nocturia, 26% nocturnal incontinence, and 70% poor sleep quality at baseline. Of the 123 reporting any nighttime awakenings, 89% averaged 1 or more nighttime awakenings, and 83% attributed at least half of awakenings to using the bathroom. Self-reported wake time after sleep onset increased with increasing frequency of nocturnal bladder symptoms (P=.01 for linear trend). However, even among women without nocturia, average sleep quality was poor (Pittsburg Sleep Quality Index global score mean of 7.3; 95% confidence interval, 6.0-8.6). Over 12 weeks, women assigned to slow-paced respiration (N=79) experienced modest improvements in mean nocturnal voiding frequency (0.4 fewer voids/night), sleep quality (1.1 point score decrease), and sleep disruption (1.5% decreased wake time after sleep onset). However, similar improvements were detected in the music control group (N=81), without significant between-group differences., Conclusions: Many women with overactive bladder syndrome experience disrupted sleep, but not all nocturnal awakenings are attributable to bladder symptoms, and average sleep quality tends to be poor even in women without nocturia. Findings suggest that clinicians should not assume that poor sleep in women with overactive bladder syndrome is primarily caused by nocturnal bladder symptoms. Guided slow-paced respiration was associated with modest improvements in nocturia frequency and sleep quality in this trial, but the results do not support clinician recommendation to use this technique over other behavioral relaxation techniques for improving sleep., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: It is unclear if the relationship between depression and physical health problems in women is related to age, reproductive stage, obesity or socio-demographic risk factors., Methods: Longitudinal data were obtained every 6 months for 36 months in 264 midlife African American, Caucasian and Latina women who began the study as healthy regularly menstruating 40 to 50-year-olds; 75 transitioned to peri- or post-menopause by 36 months. Scores of 16 or higher on the Center for Epidemiologic Studies-Depression (CES-D) scale were used to estimate depression risk., Results: Depression risk was 28% at study initiation and 25% at 36 months. Significantly more women at risk for depression were unemployed, obese, or hypertensive. Women at risk were more likely to become peri- or post-menopausal during the study period. A higher percentage (38%) of overweight and obese women had CES-D scores ≥ 16 compared to normal weight women (23%; p < .001). Over half (58%) of the 73 women at higher depression risk at the initial visit reported a health problem or chronic illness at 36 months, compared to only 36% of the 191 women with CES-D scores <16 (p = .001)., Limitations: This was a secondary analysis of data from a relatively healthy sample of women in the decade before menopause. Chronic illness was self-reported and the CES-D is a screening tool for depressive symptoms rather than a clinical diagnostic tool., Conclusions: Health care providers may be underestimating the impact of unemployment on depressive symptoms, obesity and chronic health problems in midlife women., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: The objective of this study was to examine the association between high risk of obstructive sleep apnea (OSA) and subclinical atherosclerosis among South Asians in the United States., Design: A secondary analysis of cross-sectional data., Setting/participants: A community-based cohort of 906 men and women participating in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study., Measurements: The Berlin Questionnaire was used to screen for OSA risk. Coronary artery calcium (CAC), common carotid artery intima-media thickness (IMT), and internal carotid artery IMT were used as measures of subclinical atherosclerosis., Results: The majority of participants (59%) with high OSA risk had CAC scores >0 compared with only 41% of participants with low OSA risk (P <.001). The high OSA risk group was older (P =.005), male (P =.04), had higher body mass index (P <.001) and had greater common carotid artery IMT (0.96 ± 0.27 mm) and internal carotid artery IMT (1.33 ± 0.42 mm) measurements. Snoring, sleep-disordered breathing (SDB), and high OSA risk were associated with subclinical atherosclerosis. However, only high OSA risk remained significant in multivariable models after controlling for demographic and clinical factors that included hypertension (HTN), obesity, diabetes, and dyslipidemia., Conclusions: High OSA risk, which includes overlapping comorbidities of HTN and obesity, was not associated with the time living in the US but was associated with subclinical atherosclerosis markers. These cardiovascular disease risk factors should include evaluation of the spectrum of SDB among all adults, including South Asian men and women., (Copyright © 2019 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Fatigue is a prevalent symptom for adults living with HIV infection. The purpose of this randomized clinical trial was to pilot test a behavioral-educational intervention to reduce fatigue. The intervention included education about daytime behaviors as well as nighttime sleep behaviors. Participants were HIV-positive, between 45 and 75 years old, unemployed, and experiencing fatigue. They were randomized to intervention (n = 25) or control (n = 26) after obtaining baseline measures, administered the intervention or attention control, and followed with monthly assessments for 3 months. Primary outcome measures included the Fatigue Severity Scale (FSS) and fatigue symptom burden using the four-dimension structure of the Memorial Symptom Assessment Scale that includes occurrence, frequency, severity, and distress of a symptom. Other measures included the International Physical Activity Questionnaire, step counts with a Fitbit Flex, Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index, and Sleep Behavior Rating Scale. Compared with attention controls, the intervention group had significantly (p < .05) lower FSS scores and fatigue symptom burden over time, particularly in the frequency dimension. Secondary outcomes for reducing daytime naps and improving sleep quality were also significant (p < .05). This intervention, focused on both daytime and nighttime behaviors, demonstrated promising effects for reducing fatigue among adults living with HIV. Results provide useful direction for larger clinical trials to reduce fatigue in adults living with other types of chronic illness., (© 2019 Wiley Periodicals, Inc.)

Study Objectives: To compare causes of sleep disturbance and to compare self-reported sleep duration among groups of late premenopausal women and early perimenopausal women., Methods: In a longitudinal study of a community-based sample of healthy women 40 to 50 years of age, menstrual cycle and symptom data were collected every 2 months; anthropometric measures, a urine sample for follicle stimulating hormone (FSH), and the Pittsburgh Sleep Quality Index (PSQI) measures were collected every 6 months., Results: At 12 to 18 months, 206 women remained premenopausal and 69 women became perimenopausal. Poor sleep quality (PSQI score > 5) was experienced by 42% of the total cohort. Awakening to use the bathroom was the most frequent reason (81%) for sleep disturbance in the entire cohort, followed by feeling too hot (26%). However, premenopausal women were significantly more likely to awaken to use the bathroom than perimenopausal women ( P = .047), and perimenopausal women were more likely than premenopausal women to awaken because of feeling too hot ( P = .002). Women in early perimenopause reported shorter sleep duration ( P = .007) and worse sleep quality ( P = .05) than premenopausal women of similar age., Conclusions: Sleep disturbance is a significant issue for midlife women regardless of age or reproductive stage. Identification of salient factors that disrupt sleep, such as nocturia prior to menopausal transition or feeling too hot early in menopausal transition, will provide direction for developing tailored intervention strategies to improve sleep and quality of life., Commentary: A commentary on this article appears in this issue on page 1095., (© 2018 American Academy of Sleep Medicine.)

Aims: To examine the association between glycaemia status and the risk for obstructive sleep apnoea (OSA) in a cohort of South Asians living in the United States., Methods: A secondary analysis of a community based cohort of 899 participants from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. The Berlin Questionnaire was used to screen for OSA., Results: Almost one in four (24%) South Asians was at high risk for OSA. Compared to the normal glucose tolerance group (18%), high risk of OSA was significantly more likely in the prediabetes (24%) and diabetes (32%) groups ( p = .007). More men (28%) than women (18%) were at high risk of OSA. Risk for OSA was also associated with higher haemoglobin A1c values, hypertension, large waist circumference, and BMI > 27.5 kg/m 2 . In a multivariate regression analysis, sleep disordered breathing (SDB) remained significantly associated with higher haemoglobin A1c values, even after controlling for waist circumference and other demographic and clinical factors., Conclusions: The risk for SDB and OSA was high among South Asian men and women. Given the association between dysglycaemia and risk for OSA, these health issues require simultaneous clinical assessment. Future studies using objective sleep measures such as polysomnography are warranted in the diagnosis and treatment of OSA in the South Asian adult population already at high risk for dysglycaemia., Competing Interests: Conflict of Interest Statement: Dr. Deol, Dr. Lee, Dr. Kanaya, and Dr. Kandula have no conflicts of interest to declare. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or any other funders.

The mechanisms by which intake of dietary protein is regulated are poorly understood despite their potential involvement in determining food choice and appetite. In particular, it is unclear whether protein deficiency results in a specific appetite for protein and whether influences on diet are immediate or develop over time. To determine the effects of protein restriction on consumption, preference, and palatability for protein we assessed patterns of intake for casein (protein) and maltodextrin (carbohydrate) solutions in adult rats. To induce a state of protein restriction, rats were maintained on a low protein diet (5% casein) and compared to control rats on non-restricted diet (20% casein). Under these dietary conditions, relative to control rats, protein-restricted rats exhibited hyperphagia without weight gain. After two weeks, on alternate conditioning days, rats were given access to either isocaloric casein or maltodextrin solutions that were saccharin-sweetened and distinctly flavored whilst consumption and licking patterns were recorded. This allowed rats to learn about the post-ingestive nutritional consequences of the two different solutions. Subsequently, during a preference test when rats had access to both solutions, we found that protein-restricted rats exhibited a preference for casein over carbohydrate whereas non-restricted rats did not. Analysis of lick microstructure revealed that this preference was associated with an increase in cluster size and number, reflective of an increase in palatability. In conclusion, protein-restriction induced a conditioned preference for protein, relative to carbohydrate, and this was associated with increased palatability., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Study Objectives: To evaluate feasibility and efficacy of a hospital-based protocol for improving sleep in high- risk antepartum patients., Methods: Sleep measures were compared during 1 week of hospitalization before and after implementing a Sleep Improvement Protocol for Antepartum Patients (SIP-AP). A non-randomized convenience sample of usual care controls was compared to a subsequent intervention sample after the protocol was implemented. Women were eligible if they spoke English, were medically stable, pregnant for at least 20 weeks, and hospitalized at least 24 hours; 25 pregnant women had sufficient data for analyses (11 controls, 14 intervention). Sleep was assessed in 3 ways: the Pittsburgh Sleep Quality Index was completed after obtaining consent to estimate sleep quality prior to hospital admission; sleep diary completed each hospital day; and General Sleep Disturbance Scale completed at 7 days or prior to hospital discharge. Symptoms that could affect sleep were assessed with the Memorial Symptom Assessment Scale., Results: Both groups recorded similar sleep duration (7 hours) but the intervention group had fewer symptoms and significantly ( P = .015) lower sleep disturbance scores (53.1 ± 14.5) than controls (71.9 ± 18.8). Participant feedback about the intervention was positive, although adherence to components of the intervention protocol was variable., Conclusions: This pilot study provides evidence of the feasibility and preliminary efficacy of the SIP-AP intervention for reducing symptoms and improving sleep of antepartum patients during hospitalization. Further detailed evaluation of specific components of this protocol is warranted, and other types of hospitalized patients may benefit from unit-based modifications to this SIP-AP protocol., (© 2017 American Academy of Sleep Medicine)

Background: Biomass fuel smoke is a leading risk factor for the burden of disease worldwide. International campaigns are promoting the widespread adoption of liquefied petroleum gas (LPG) in resource-limited settings. However, it is unclear if the introduction and use of LPG stoves, in settings where biomass fuels are used daily, reduces pollution concentration exposure, improves health outcomes, or how cultural and social barriers influence the exclusive adoption of LPG stoves., Methods: We will conduct a randomized controlled, field intervention trial of LPG stoves and fuel distribution in rural Puno, Peru, in which we will enroll 180 female participants aged 25-64 years and follow them for 2 years. After enrollment, we will collect information on sociodemographic characteristics, household characteristics, and cooking practices. During the first year of the study, LPG stoves and fuel tanks will be delivered to the homes of 90 intervention participants. During the second year, participants in the intervention arm will keep their LPG stoves, but the gas supply will stop. Control participants will receive LPG stoves and vouchers to obtain free fuel from distributors at the beginning of the second year, but gas will not be delivered. Starting at baseline, we will collect longitudinal measurements of respiratory symptoms, pulmonary function, blood pressure, endothelial function, carotid artery intima-media thickness, 24-h dietary recalls, exhaled carbon monoxide, quality-of-life indicators, and stove-use behaviors. Environmental exposure assessments will occur six times over the 2-year follow-up period, consisting of 48-h personal exposure and kitchen concentration measurements of fine particulate matter and carbon monoxide, and 48-h kitchen concentrations of nitrogen dioxide for a subset of 100 participants., Discussion: Findings from this study will allow us to better understand behavioral patterns, environmental exposures, and cardiovascular and pulmonary outcomes resulting from the adoption of LPG stoves. If this trial indicates that LPG stoves are a feasible and effective way to reduce household air pollution and improve health, it will provide important information to support widespread adoption of LPG fuel as a strategy to reduce the global burden of disease., Trial Registration: ClinicalTrials.gov, ID: NCT02994680 , Cardiopulmonary Outcomes and Household Air Pollution (CHAP) Trial. Registered on 28 November 2016.

Objective: To compare symptoms of depression, maternal adjustment, and perceived stress in late adolescent and young adult mothers and to examine the patterns of these symptoms during the first 3 months after birth., Design: Secondary analysis of existing longitudinal data., Setting: San Francisco Bay Area, with participants in their home environments., Participants: Ethnically diverse women expecting their first infants recruited during the third trimester from childbirth education classes and antenatal clinics. The final sample included 34 participants in the late adolescent group (18-20 years) and 48 participants in the young adult group (21-24 years)., Methods: The Center for Epidemiologic Studies Depression Scale was used to assess depression symptoms, the Maternal Adjustment and Maternal Attitudes Scale was used to assess maternal adjustment, and the 10-item Perceived Stress Scale was used to assess perceived stress. Repeated-measures analyses of variance were used to examine changes over time in depression, maternal adjustment, and perceived stress scores., Results: Compared with young adult participants, late adolescent participants had greater mean depression scores (F (1, 61)  = 8.02, p = .006) and perceived stress scores (F (1, 62)  = 9.45, p = .003) at all time points. Scores for maternal adjustment could not be compared because of the low internal validity of the instrument., Conclusion: Our results indicated that late adolescent mothers may have more symptoms of depression and stress in late pregnancy and the early postpartum period than young adult mothers. Clinicians in maternity and pediatric settings should be vigilant in screening for depression and stress in this vulnerable population during their transitions to motherhood., (Copyright © 2017 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Thoracic outlet syndrome (TOS) poses a difficult diagnostic entity with varied etiology and clinical presentation. We present a 35-year-old gentleman with unilateral long thoracic nerve palsy and contralateral subscapular paralysis caused by aberrant scalenus medius anatomy. TOS ought to be considered in patients presenting with isolated nerve palsies., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To compare leukocyte telomere length (LTL) by race and describe demographic, health, and psychosocial factors associated with LTL in postmenopausal women., Design: Descriptive study with comparative analyses and correlations., Setting: Data were collected at the University of California-San Francisco, San Francisco Clinical and Translational Science Institute., Participants: Thirty-nine African American and White postmenopausal women between 58 and 65 years of age (mean age = 61.3 ± 1.83 years)., Methods: Measures included demographics, blood pressure, anthropometrics, scores on the Perceived Stress Scale and the Center for Epidemiologic Studies-Depression, and blood samples for LTL., Results: African American women (n = 14) had greater PSS-10 and CES-D scores, greater blood pressure, and greater body mass index than White women (n = 25; p < .05), but LTL did not significantly differ between the two groups. Age was inversely related to LTL (r = -.355, p < .05). After age and race were controlled, fewer children (p = .005) and greater perceived stress (p = .036) were related to shorter LTL., Conclusion: Findings from this small sample support the association between age and LTL. The association between perceived stress, number of children, and shorter LTL in postmenopausal women requires further research and replication of findings in a larger, more diverse sample., (Copyright © 2017 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the frequency, severity, distress, and correlates of common and rare symptoms reported by nulliparous women during the last month of pregnancy., Design: Secondary cross-sectional analysis of data obtained in a larger randomized clinical trial., Setting: San Francisco Bay area., Participants: Nulliparous, ethnically diverse, predominantly low-income pregnant women 18 to 47 years of age (N = 151)., Methods: Participants at or beyond 36 weeks gestation used the Memorial Symptom Assessment Scale (MSAS) to provide self-reports of general symptom experience. Other symptom measures were also completed for comparison. Demographic characteristics, including gestational weight gain, were also collected. Gestational weight gain was categorized in relation to the Institute of Medicine's 2009 recommendations for weight gain during pregnancy., Results: Women endorsed an average of 10.6 ± 5.6 symptoms on the MSAS. Prevalent symptoms (reported by at least half the sample) included lack of energy, pain, difficulty sleeping, worrying, irritability, drowsiness, shortness of breath, and nervousness. Among the women who reported these symptoms, relatively few described them as occurring with high frequency or severity or as causing much distress. One of the most prevalent symptoms (reported by 68% of women) was difficulty sleeping, which also had among the greatest ratings for frequency, severity, and distress. Although few maternal characteristics were associated with symptom experience, women who gained more weight than the Institute of Medicine's recommendation had worse MSAS total scores than women who gained the recommended amount or less., Conclusion: In nulliparas, symptom frequency, severity, and distress varied and were related to excessive gestational weight gain., (Copyright © 2017 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Objective: Yoga may improve physical function and reduce disease symptoms in adults with rheumatoid arthritis (RA). However, little is known about how patients with RA are practicing yoga in the community. The objective of this qualitative study was to explore community yoga practice characteristics and thoughts about yoga practice for adults with RA., Design: Participants completed a semi-structured telephone interview with open-ended questions. Thematic analysis was used to analyze interview transcripts., Participants: A convenience sample of 17 adults with rheumatologist-diagnosed RA who had participated in yoga within the past year were asked about the decision to start, continue, and stop yoga; the perceived benefits of yoga; components of yoga sessions; and general thoughts about yoga as it relates to RA., Results: Although eight different styles of yoga were practiced, commonalities in yoga class components (such as stretching, strengthening, deep breathing, meditation, and positive messaging from the instructor) reveal examples of preferred types of yoga for patients with RA. Three main themes emerged, each with multiple subthemes: (1) motivators (physical fitness, influence of others, reduced price), (2) barriers (cost, symptom burden, class difficulty), and (3) benefits of yoga practice (mind-body, a tool for coping, pride/achievement, social, and "yoga meets you where you are")., Conclusion: In this study, patients with RA described how yoga practice helped improve physical and psychosocial symptoms related to their disease. Yoga practice, a dynamic exercise, encompassing many different styles, can provide many benefits for adults with RA; however, yoga may not be beneficial for every adult with RA.

Background: Poor sleep during pregnancy has been associated with poorer birth outcomes. High body mass index (BMI) is often associated with poor sleep, but little is known about the relationship between gestational weight gain and sleep in late pregnancy. The purpose of this study was to evaluate the relationships of both gestational weight gain and pre-pregnancy BMI to objective and subjective measures of sleep during late pregnancy., Methods: Pregnant women (n=128) were recruited from prenatal clinics and childbirth classes primarily serving low-income women. Their sleep (disruption and duration) was objectively assessed in their last month of pregnancy with 72 hours of wrist actigraphy monitoring. Their perceived sleep quality was assessed with the Pittsburgh Sleep Quality Index. Pre-pregnancy and late pregnancy height and weight were assessed by self-report and used to calculate BMI and gestational weight gain, which were then grouped into standardized categories., Results: Mean Pittsburgh Sleep Quality Index score was 6.8 ± 3.1 (range 2-16). Sixty percent had excess gestational weight gain and it was associated with poorer perceived sleep quality, but was unrelated to objective measures of sleep duration and disruption. Pre-pregnancy BMI was unrelated to all sleep parameters. However, analyses of the interaction of pre-pregnancy BMI and gestational weight gain indicated that excess weight gain was associated with shorter sleep duration and more sleep disruption, but only among women who were overweight before pregnancy., Conclusion: Pregnancy is an opportunity to promote long-term women's health with a better understanding of the relationship between weight management and healthy sleep habits., (© 2017 Wiley Periodicals, Inc.)

Context: Patients with breast cancer receiving chemotherapy (CTX) experience multiple concurrent symptoms, but little is known about how symptoms change during and after treatment. Knowledge of the identity and trajectory of symptom clusters (SCs) would enhance measurement and management., Objectives: We aimed to identify SCs and their change over time from baseline to completion of breast cancer CTX., Methods: SCs were identified and assessed for change in 219 women from Nebraska at four times: baseline, during cycles #3 and #4 of CTX, and one month after finishing CTX. Ten symptoms were measured: two using the Hospital Anxiety and Depression Scale and eight using the Symptom Experience Scale. Exploratory factor analysis was conducted at each time point, then changes in SCs were evaluated at different times., Results: Two SCs were identified before and after initiating CTX: gastrointestinal and treatment-related. The number and type of symptoms in each cluster differed over time. Clusters were dynamic during CTX with changes in the number and type of symptoms. Only one treatment-related SC, which consisted of fatigue, pain, and sleep disturbance, was identified after CTX completion., Conclusion: SCs during CTX appear to be dynamic, changing over time from before until after CTX completion. Repeated assessments of SCs reveal symptoms that are present and when patients are most burdened and in need of additional support., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective/background: Daytime napping longer than one hour has been associated with an increased risk for all-cause mortality. Associations between cytokine polymorphisms and daytime napping in chronic illnesses such as HIV, however, have not been well described. The purpose of this study was to examine cytokine polymorphisms associated with long daytime napping in adults living with HIV., Methods: A cross-sectional analysis was conducted using a convenience sample of 257 adults living with HIV. Daytime napping was assessed with wrist actigraphy data collected over three days. Participants categorized as long nappers (≥60 min) were compared to short nappers and non-nappers (<60 min). Single nucleotide polymorphisms (SNPs) for 15 candidate genes involved in cytokine signaling were analyzed. Genes included: interferon-gamma (IFNG), IFNG receptor 1 (IFNGR1), interleukins (IL1B, IL1R, IL1R2, IL2, IL4, IL6, IL8, IL10, IL13, IL17A), nuclear factors of kappa light polypeptide gene enhancer in B cells (NFKB1 and NFKB2), and tumor necrosis factor alpha (TNFA)., Results: After adjusting for relevant demographic and clinical characteristics, long daytime napping was associated with 12 SNPs from seven genes: 1) IFNG rs2069728; 2) IL1B rs1143642, rs1143627, and rs16944; 3) IL2 rs2069763; 4) IL6 rs4719714, rs1554606, and rs2069845; 5) IL17A rs3819024 and rs8193036; 6) NFKB1 rs4648110; and 7) NFKB2 rs1056890., Conclusions: Cytokine genetic variations may have a role in physiological regulation of daytime napping as well as nocturnal sleep. Cytokine polymorphisms associated with long daytime napping could help identify adults with HIV who may benefit from targeted therapeutic interventions., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To evaluate the feasibility and efficacy of a home-based cognitive-behavioral training program for sleep during late pregnancy., Methods: A nonrandomized quasiexperimental sample of nulliparous women who received the intervention during pregnancy (n=25) was compared with two control groups (n=76 and n=48) from other intervention studies at similar postintervention time points: approximately 1 month before childbirth and 1-2 months after childbirth. The home-based Sleep Enhancement Training System for Pregnancy consisted of 4 weeks of sound-enhanced audio relaxation programs, readings, and daily sleep diaries. Both control groups received dietary recommendations for improving sleep. Sleep duration (total sleep time) and sleep disruption (wake after sleep onset) were measured using wrist actigraphy for a minimum of 48 hours on consecutive weekdays., Results: The intervention group had significantly longer sleep duration and less sleep disruption than both control groups, particularly at the postpartum assessment. Intervention participants slept an average of 430 (95% confidence interval [CI] 397-464) minutes during pregnancy compared with 420 (95% CI 403-438) and 417 (95% CI 395-439) minutes for the two control groups. At the postpartum assessment, the intervention group slept 446 (95% CI 415-478) minutes compared with 390 (95% CI 373-408) and 370 (95% CI 348-393) minutes for those in the control groups. In terms of sleep disruption, women in the intervention group had 16.1% (95% CI 11.9-20.2%) wake after sleep onset during pregnancy, whereas women in the control groups had 13.4% (95% CI 11.2-15.5%) and 20.4% (95% CI 17.7-23.0%). Postpartum, the intervention group had 20.3% (95% CI 16.4-24.1%) wake after sleep onset compared with 26.6% (95% CI 24.5-28.8%) and 28.7% (95% CI 26.0-31.5%) among women in the control groups. Participant feedback about the intervention was generally positive, although intervention adherence was variable., Conclusion: This study provides evidence of the feasibility and efficacy of the Sleep Enhancement Training System for Pregnancy intervention for enhancing sleep that typically worsens during late pregnancy and after childbirth., Competing Interests: Financial Disclosure: The other authors did not report any potential conflicts of interest.

Objectives: The International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events (InterLACE) project is a global research collaboration that aims to advance understanding of women's reproductive health in relation to chronic disease risk by pooling individual participant data from several cohort and cross-sectional studies. The aim of this paper is to describe the characteristics of contributing studies and to present the distribution of demographic and reproductive factors and chronic disease outcomes in InterLACE., Study Design: InterLACE is an individual-level pooled study of 20 observational studies (12 of which are longitudinal) from ten countries. Variables were harmonized across studies to create a new and systematic synthesis of life-course data., Main Outcome Measures: Harmonized data were derived in three domains: 1) socio-demographic and lifestyle factors, 2) female reproductive characteristics, and 3) chronic disease outcomes (cardiovascular disease (CVD) and diabetes)., Results: InterLACE pooled data from 229,054 mid-aged women. Overall, 76% of the women were Caucasian and 22% Japanese; other ethnicities (of 300 or more participants) included Hispanic/Latin American (0.2%), Chinese (0.2%), Middle Eastern (0.3%), African/black (0.5%), and Other (1.0%). The median age at baseline was 47 years (Inter-quartile range (IQR): 41-53), and that at the last follow-up was 56 years (IQR: 48-64). Regarding reproductive characteristics, half of the women (49.8%) had their first menstruation (menarche) at 12-13 years of age. The distribution of menopausal status and the prevalence of chronic disease varied considerably among studies. At baseline, most women (57%) were pre- or peri-menopausal, 20% reported a natural menopause (range 0.8-55.6%) and the remainder had surgery or were taking hormones. By the end of follow-up, the prevalence rates of CVD and diabetes were 7.2% (range 0.9-24.6%) and 5.1% (range 1.3-13.2%), respectively., Conclusions: The scale and heterogeneity of InterLACE data provide an opportunity to strengthen evidence concerning the relationships between reproductive health through life and subsequent risks of chronic disease, including cross-cultural comparisons., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Medication adherence is linked to health outcomes among adults with HIV infection. Transgender women living with HIV (TWLWH) in the US report suboptimal adherence to medications and are found to have difficulty integrating HIV medication into their daily routine, but few studies explore the factors associated with medication adherence among transgender women. Thus, the purpose of this paper is to examine demographic and clinical factors related to self-reported medication adherence among transgender women. This secondary analysis is based on data collected from the Symptom and Genetic Study that included a convenience sample of 22 self-identified transgender women, 201 non-transgender men, and 72 non-transgender women recruited in northern California. Self-reported medication adherence was assessed using the AIDS Clinical Trials Group Adherence Questionnaire. Gender differences in demographic and clinical variables were assessed, as were differences between transgender women reporting high and low adherence. Transgender women had lower adherence to medications compared to non-transgender males and non-transgender females (p = .028) and were less likely to achieve viral suppression (p = .039). Within the transgender group, Black/African-Americans reported better adherence than participants who were Whites/Caucasian or other races (p = .009). Adherence among transgender women was unrelated to medication count and estrogen therapy, but consistent with other reports on the HIV population as a whole; transgender women with high adherence were more likely to achieve viral suppression compared to the transgender women with low adherence. Despite the high incidence of HIV infection in the transgender population, few studies focus on TWLWH, either in regard to their adherence to antiretroviral therapies or to their healthcare in general. To address ongoing health disparities, more studies are needed focusing on the transgender population's continuum of care in HIV therapies.

African-American women suffer from disproportionate adverse health outcomes compared to women of other ethnicities living in the United States. It is suggested in the literature that chron- ic stress can be an antecedent to health disparity. The purpose of this study was to evaluate changes in perceived stress from late pre-menopause to post-menopause and to identify significant life stressors perceived by a cohort of African-American women. Retrospective and current data were used to evaluate perceived stress over time, sources of stress, and resources in a cohort of 15 African-American women. Mixed methodologies were utilized. Perceived stress scores were consistent over time. Six themes were identified in responses about stress: finances, caringforfamily members, relationships, personal health and aging, race and discrimination, and raising children. Understanding the role that unique life stressors play in the lives of African-American women is essential in anticipating the need for assistance and in implementing preventive strategies.

Context: To accurately investigate diurnal variations in fatigue, a measure needs to be psychometrically sound and demonstrate stable item function in relationship to time of day. Rasch analysis is a modern psychometric approach that can be used to evaluate these characteristics., Objectives: To evaluate, using Rasch analysis, the psychometric properties of the Lee Fatigue Scale (LFS) in a sample of oncology patients., Methods: The sample comprised 587 patients (mean age 57.3 ± 11.9 years, 80% women) undergoing chemotherapy for breast, gastrointestinal, gynecological, or lung cancer. Patients completed the 13-item LFS within 30 minutes of awakening (i.e., morning fatigue) and before going to bed (i.e., evening fatigue). Rasch analysis was used to assess validity and reliability., Results: In initial analyses of differential item function, eight of the 13 items functioned differently depending on whether the LFS was completed in the morning or in the evening. Subsequent analyses were conducted separately for the morning and evening fatigue assessments. Nine of the morning fatigue items and 10 of the evening fatigue items demonstrated acceptable goodness-of-fit to the Rasch model. Principal components analyses indicated that both morning and evening assessments demonstrated unidimensionality. Person-separation indices indicated that both morning and evening fatigue scales were able to distinguish four distinct strata of fatigue severity., Conclusion: Excluding four items from the morning fatigue scale and three items from the evening fatigue scale improved the psychometric properties of the LFS for assessing diurnal variations in fatigue severity in oncology patients., (Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Psychosocial and behavioural interventions that address suicidal thoughts and behaviour during treatment (direct interventions) might be more effective in preventing suicide and suicide attempts than indirect interventions that address symptoms associated with suicidal behaviour only (eg, hopelessness, depression, anxiety, quality of life). To test this hypothesis, we did a systematic review and meta-analysis of psychosocial and behavioural interventions aimed at preventing suicide and suicide attempts., Methods: For this systematic review and meta-analysis, we searched MEDLINE and PsycINFO from inception to Dec 25, 2015, for randomised controlled trials that reported suicides or suicide attempts as an outcome, irrespective of participants' diagnoses or the publication language. We excluded studies with pharmacological or device-based interventions, those that targeted communities or clinicians, primary prevention trials, and trials that reported events of non-suicidal self-injury as suicide attempts. Trials that had no suicides or suicide attempts in both groups were also excluded. Data were extracted by one investigator and independently verified by a second investigator. We used random-effects models of the odds ratio (OR) based on a pooled measure of suicides and the number of individuals who attempted suicide, immediately post-treatment and at longer-term follow-up., Findings: Of 2024 unique abstracts screened, 53 articles met eligibility criteria and reported on 44 studies; 31 studies provided post-treatment data with 6658 intervention group participants and 6711 control group participants at baseline, and 29 studies provided follow-up data. The post-treatment difference between direct interventions and indirect interventions did not reach statistical significance at the 0·05 level (OR 0·62 [95% CI 0·45-0·87] vs 0·93 [0·77-1·12], p=0·06) and represented a large effect size (Cohen's d=0·77). At longer-term follow-up, the difference was not significant (OR 0·65 [0·46-0·91] vs 0·82 [0·70-0·96], p=0·25) but still represented a medium effect size (Cohen's d=0·47). These effect sizes emphasise the clinical importance of direct interventions. Post-hoc subgroup and sensitivity analyses showed that our results are robust and unlikely to be notably affected by between-study heterogeneity or publication bias., Interpretation: Psychosocial and behavioural interventions that directly address suicidal thoughts and behaviour are effective immediately post-treatment and long term, whereas treatments indirectly addressing these components are only effective long term. Moreover, although the differences shown between direct and indirect strategies were non-significant, the difference in favour of direct interventions represented a large post-treatment improvement and medium improvement at longer-term follow-up. On the basis of these findings, clinicians working with patients at risk of suicide should address suicidal thoughts and behaviours with the patient directly. Although direct interventions are effective, they are not sufficient, and additional efforts are needed to further reduce death by suicide and suicide attempts. Continued patient contact might be necessary to retain long-term effectiveness., Funding: National Institute of Nursing Research., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Purpose: Bladder symptoms are common in women and result in use of healthcare resources and poor quality of life. Bladder symptoms have been linked to age and menopause, but debate exists in the literature. This article examines factors associated with bladder symptoms and compares women in late reproductive stage with those in menopausal transition., Materials and Methods: We analyzed cross-sectional data from a prospective cohort study of midlife women (mean age, 48; range, 44-54 years) in northern California. The sample consisted of 158 women in late reproductive stage or menopause transition. Assessments included anthropometrics, menstrual cycle lengths and symptoms, urine samples for follicle-stimulating hormone level, and self-reported health perception and depressive symptoms. Analyses included descriptive bivariate statistics, group comparisons, and regression models., Results: The most common bladder symptoms were nocturia (72%) at least once per night and urinary incontinence (50%) at least once per week. Incontinence was less prevalent in African American women compared to European Americans and Latinas (p = 0.001) and more prevalent in late reproductive stage than in menopause transition (p = 0.024). Controlling for age, women in late reproductive stage were more likely to report nocturia compared to those in menopause transition. Reproductive stage (p = 0.016), higher body mass index (p = 0.007), and race (p = 0.017) contributed to the variance in weekly nighttime urinary frequency., Conclusion: Bladder symptoms were associated with reproductive stage. Women in late reproductive stage were more likely to experience nocturia and incontinence than those in menopause transition. The higher rates of nocturia and incontinence in late reproductive stage are intriguing. Future studies should include analysis of pelvic organ prolapse degree and other structural differences.

For mothers with breastfeeding difficulties, pumping can be recommended to help establish milk production. However, pumping may present some barriers to successful breastfeeding. Mothers with milk supply concern may be at higher risk of barriers to successful breastfeeding. No previous studies have described experiences of pumping among mothers with milk supply concern. We conducted 10 focus groups of 56 mothers who had milk supply concern in the first month after birth. A paid, trained facilitator led groups in a semi-structured approach. Sessions were audiorecorded and transcribed verbatim. The transcripts were coded independently by two investigators and analysed using grounded theory. We identified five themes related to the experience of pumping among mothers with milk supply concern: (1) additional control over breastfeeding from pumping: 'I would feed and then give him … whatever I could manage to pump to him'. (2) Painful experience: 'The first time I pumped my boobs hurt so bad'. (3) Pumped volume affected milk supply concern: 'Pump and there was hardly anything coming out that's when I started to worry'. (4) Pumping interfered with other nurturing activities: 'While you're pumping, you can't touch the baby'. (5) Frustration from inconsistent provider advice: 'They told me to pump … and then said, "That's going to cause your milk to increase too much" '. Mothers had positive and negative experiences with pumping. Clinicians should assess a mother's experience shortly after she initiates pumping, as further management and counselling may be necessary to avoid barriers to successful breastfeeding., (© 2014 John Wiley & Sons Ltd.)