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Parents (N = 599) of 6-month-old to 10-year-old children were given a handbook intervention that educates about healthy discipline in a pediatric clinic serving low-income families in Nashville, Tennessee. A research assistant spent approximately 1 minute introducing the intervention. A total of 440 parents (73.4%) responded to a follow-up survey 2 to 4 months later. Most parents (88%) who completed the follow-up survey had read at least part of the handbook. Of parents who received the handbook, 63% reported that the handbook helped them discipline their children. Half of parents reported specific changes they made because of the handbook. The most frequently reported changes were more talking/explaining/communicating (25%), more redirecting (7.8%), more patience/listening (6.0%), less anger/yelling (10.8%), and less spanking (7.5%). 42% of parents reported that they shared the handbook with other caregivers, friends, relatives, and children. A brief clinic intervention improves parents' discipline practices and reaches other caregivers. [ABSTRACT FROM AUTHOR]

Background and Objectives The World Health Organization created the Age-Friendly Environment (AFE) framework to design communities that support healthy aging and equitable decision making. This framework's resource domains may account for disparately lower advance care planning (ACP) among older adults with limited incomes compared to those with high incomes. We aimed to describe and examine associations of AFE factors with ACP. Research Design and Methods We recruited and conducted cross-sectional surveys among older adults with limited incomes in 7 community-based settings in Nashville, TN. ACP and AFE item scales were dichotomized and analyzed with unadjusted phi correlation coefficients. Results Survey participants (N  = 100) included 59 women, 70 Black/African American, and 70 ≥60 years old. Most participants agreed that their community was age friendly (≥58%) and varied in ACP participation (22%–67%). Participants who perceived easy travel and service access and sufficient social isolation outreach were more likely to have had family or doctor quality-of-life discussions (phi = 0.22–0.29, p  < .05). Having a healthcare decision maker was positively associated with age-friendly travel, housing, and meet-up places (phi = 0.20–0.26, p  < .05). Discussion and Implications The AFE framework is useful for exploring the environmental factors of ACP, but further research is warranted to identify specific and immediate resources to support successful ACP among populations with socioeconomic disadvantage. [ABSTRACT FROM AUTHOR]

Introduction The Maternal Infant Health Outreach Worker (MIHOW) program is a home visiting program, utilizing peer mentors to improve maternal/child health outcomes in underserved communities. Findings are presented from a randomized clinical trial (RCT) testing the efficacy of the MIHOW model in a sample of Hispanic women in Tennessee. We hypothesized maternal and infant outcomes would be better in women assigned to MIHOW than women assigned to the minimal education intervention (MEI) group (receipt of educational materials). Methods Women entered the study during pregnancy (< 26 weeks gestation) and were followed through 6 months postpartum. A total of 188 women were enrolled and randomly assigned (MEI = 94; MIHOW = 94), with 178 women completing the study (MEI = 87; MIHOW = 91). Results Positive and statistically significant (p < 0.01) effects of MIHOW were observed on breastfeeding self-efficacy and exclusivity, levels of depressive symptoms and parenting stress, safe sleep practices, and infant stimulation in the home. No statistically significant differences were noted in number of prenatal visits. Discussion Results expand limited empiric evidence and provide strong support of the effectiveness of MIHOW on improving health outcomes in this sample of Hispanic mothers and their infants. MIHOW is a viable option for providing culturally sensitive services to immigrant and underserved families. [ABSTRACT FROM AUTHOR]

To address manpower shortages, health care leaders recommend technology, including robots, to facilitate and augment processes for delivery of efficient, safe care. Little is known regarding older adults' perceptions of socially assistive robots (SARs). Using the Unified Theory of Acceptance and Use Technology framework, a survey was developed and tested for capturing older adults' likelihood to use SARs. The Robot Acceptance Survey (RAS) comprises three subscales: Performance Expectancy, Eff ort Expectancy, and Attitude. Older adults completed the RAS pre- and post-experimental procedure with a SAR. Cronbach's alpha coefficients for the subscales ranged from 0.77 to 0.89. Subscales were sensitive to change, with more positive reactions after exposure to SAR activities. Future studies must identify robotic programming capable of providing cognitive, physical, and social assistance, as well as person-, activity-, situation-, and robot-specific factors that will influence older adults' acceptance of SARs. [ABSTRACT FROM AUTHOR]

Purpose/Objectives: To measure the effect of clinical decision support (CDS) on oncology nurse evidence-based practice (EBP). Design: Longitudinal cluster-randomized design. Setting: Four distinctly separate oncology clinics associated with an academic medical center. Sample: The study sample was comprised of randomly selected data elements from the nursing documentation software. The data elements were patient-reported symptoms and the associated nurse interventions. The total sample observations were 600, derived from a baseline, posteducation, and postintervention sample of 200 each (100 in the intervention group and 100 in the control group for each sample). Methods: The cluster design was used to support randomization of the study intervention at the clinic level rather than the individual participant level to reduce possible diffusion of the study intervention. An elongated data collection cycle (11 weeks) controlled for temporary increases in nurse EBP related to the education or CDS intervention. Main Research Variables: The dependent variable was the nurse evidence-based documentation rate, calculated from the nurse-documented interventions. The independent variable was the CDS added to the nursing documentation software. Findings: The average EBP rate at baseline for the control and intervention groups was 27%. After education, the average EBP rate increased to 37%, and then decreased to 26% in the postintervention sample. Mixed-model linear statistical analysis revealed no significant interaction of group by sample. The CDS intervention did not result in an increase in nurse EBP. Conclusions: EBP education increased nurse EBP documentation rates significantly but only temporarily. Nurses may have used evidence in practice but may not have documented their interventions. Implications for Nursing: More research is needed to understand the complex relationship between CDS, nursing practice, and nursing EBP intervention documentation. CDS may have a different effect on nurse EBP, physician EBP, and other medical professional EBP. [ABSTRACT FROM AUTHOR]

This study examined participation factors in a study of families ( N = 84) within 1 year of a child's cancer-related death. Specific aims were to examine associations between: (a) recruitment variables (number of phone calls made to eligible families, number of calls answered by eligible families) and participation rates (study agreement and refusal) and (b) characteristics of deceased children (gender, age, length of illness, time since death) and participation rates. Characteristics of deceased children did not differ between participating and non-participating families. Researchers made significantly fewer calls to participating versus refusing families. Participating families most often agreed during the first successful call connection, and more calls did not mean more recruitment success. Thus, it is reasonable to limit the number of calls made to bereaved families. Despite recruitment challenges, many bereaved parents and siblings are willing and interested to participate in grief research. [ABSTRACT FROM AUTHOR]

Delineating etiologic mechanisms of adolescent-onset depressive disorders has implications for advances in depression recognition and prevention. Two cognitive processes, namely brooding and reflection, may be instrumental in the development of depressive symptoms. Study aims were to (1) examine the relationships among brooding, reflection, dysfunctional attitudes, negative inferential style, stressful life events, and depressive symptoms and (2) determine the unique contributions of brooding and reflection to depressive symptoms in adolescents who are experiencing stressful life events. A secondary data analysis was conducted using cross-sectional data gathered via a web-based survey ( N = 111) of 12-15 year olds. Descriptive statistics, Pearson's correlations, and hierarchical linear regression modeling were used to evaluate study aims. The final regression model explained approximately 73% of the variance in depressive symptoms (Multiple R = 0.85, p < .001). After controlling for each of the study variables, both brooding ( beta = .48, p < .001) and reflection ( beta = .33, p < .001) demonstrated unique contributions to the prevalence of depressive symptoms. Our findings suggest that brooding and reflection are significant contributors to depressive symptoms in young adolescents experiencing stressful life events. With this knowledge, nurses are better equipped to identify adolescents at high risk for depressive symptoms and implement appropriate levels of intervention. [ABSTRACT FROM AUTHOR]

Aim One condition associated with severe end-of-life pain that can lead to a poor quality of death is cancer. Cancer pain in people with dementia is of particular concern because of communication problems that occur with worsening disease. The aim of the current pilot study was to examine the association between hospice enrolment, dementia severity and pain among nursing home residents who died from advanced cancer. Methods Between-groups cross-sectional chart audits of 55 nursing home residents with dementia who died from cancer were carried out. Results A total of 45% of residents were in hospice at the end-of-life. Residents in hospice were more likely to receive an opioid (80% vs 43%, P = 0.005); but less likely to show severe cognitive impairment (20% vs 50%, P = 0.050). Enrolment in hospice was associated with an increased likelihood of receiving an opioid after controlling for level of cognitive impairment (OR = 3.9, 95% CI = 1.1-14.0, P = 0.037). Lower levels of cognitive functioning were associated with a decreased likelihood of receiving an opioid after controlling for enrolment in hospice (OR = 0.3, 95% CI = 0.1-0.8, P = 0.030). Notably, 40% of nursing home residents with dementia who died from cancer did not receive any opioid during this time. Conclusions Preliminary results suggest that hospice enrolment might be influenced by the facility or region of this particular country. Hospice enrolment predicts more opioid pain treatment in residents with dementia and terminal cancer; however, no resident with very severe dementia and terminal cancer was placed in hospice care. Severely cognitively impaired nursing home residents requiring opioids are at great risk of suffering from untreated advanced cancer pain. New methods are urgently required to improve end-of-life palliative care for nursing home residents with terminal cancer and severe dementia. Geriatr Gerontol Int 2013; 13: 1018-1025. [ABSTRACT FROM AUTHOR]

Consecutive English- or Spanish-speaking caregivers of 1- to 5-year-old children were randomized to view a multimedia program (approximately 5-10 minutes) in a pediatric primary care clinic. After the clinic visit, 258/259 caregivers participated in a brief personal interview. In the multivariate logistic model, caregivers were more likely to have been assisted in their plans to discipline if they had had a discussion about discipline with their physician (odds ratio [OR] = 4.93; 95% confidence interval [CI] = 1.08-22.46), viewed the multimedia program (OR = 259.29; 95% CI = 56.56-1188.61), or viewed the multimedia program and had had a discussion with their physician (OR = 507.05; 95% CI = 86.81-2961.45) than if they had had no discussion and had not viewed the multimedia program. In addition to face-to-face discussions, routinely viewed educational material may help teach caregivers about discipline. The results have implications for improving primary care services, child abuse prevention, and violence prevention. [ABSTRACT FROM PUBLISHER]

Background: The purpose of this descriptive, correlational study was to explore associations of maternal psychosocial factors with beliefs and practices related to infant feeding in a sample of young, first-time mothers. Methods: Data were collected from 67 mothers (ages 15-22 years) to assess maternal attributes of self-esteem, depressive symptoms, social support, and beliefs and practices related to infant feeding. Results: Significant multivariate associations were found among the variables of interest with mothers' reports of feeding infants at set times, concern the infant was eating too much, and concern about the infant becoming overweight. Maternal depressive symptoms and social support were found to uniquely contribute to the practice of feeding at set times, while depressive symptoms contributed to concern of the infant eating too much. Conclusions: The findings of this study add to the understanding of young, first-time, mothers' infant feeding beliefs and practices and the particular psychosocial factors, which are associated with them. [ABSTRACT FROM AUTHOR]

Background: Alcoholics Anonymous (AA) members represent an important and relatively understudied population for improving our understanding of alcohol dependence recovery as over 1 million Americans participate in the program. Further insight into coffee and cigarette use by these individuals is necessary given AA members’ apparent widespread consumption and the recognized health consequences and psychopharmacological actions of these substances. Methods: Volunteers were sought from all open-AA meetings in Nashville, TN during the summer of 2007 to complete a questionnaire ( n = 289, completion rate = 94.1%) including timeline followback for coffee, cigarette, and alcohol consumption; the Alcoholics Anonymous Affiliation Scale; coffee consumption and effects questions; the Fagerstrom Test for Nicotine Dependence (FTND); and the Smoking Effects Questionnaire. Results: Mean (±SD) age of onset of alcohol consumption was 15.4 ± 4.2 years and mean lifetime alcohol consumption was 1026.0 ± 772.8 kg ethanol. Median declared alcohol abstinence was 2.1 years (range: 0 days to 41.1 years) and median lifetime AA attendance was 1000.0 meetings (range: 4 to 44,209 meetings); average AA affiliation score was 7.6 ± 1.5. Most (88.5%) individuals consumed coffee and approximately 33% of coffee consumers drank more than 4 cups per day (M = 3.9 ± 3.9). The most common self-reported reasons for coffee consumption and coffee-associated behavioral changes were related to stimulatory effects. More than half (56.9%) of individuals in AA smoked cigarettes. Of those who smoked, 78.7% consumed at least half a pack of cigarettes per day (M = 21.8 ± 12.3). Smokers’ FTND scores were 5.8 ± 2.4; over 60% of smokers were highly or very highly dependent. Reduced negative affect was the most important subjective effect of smoking. Conclusions: A greater proportion of AA participants drink coffee and smoke cigarettes in larger per capita amounts than observed in general U.S. populations. The effects of these products as described by AA participants suggest significant stimulation and negative affect reduction. Fundamental knowledge of the quantitative and qualitative aspects of coffee and cigarette consumption among AA members will enable future research to discern their impact on alcohol abstinence and recovery. [ABSTRACT FROM AUTHOR]

Objective: To examine the effects of a total body recumbent stepper exercise program on blood pressure, strength and walking speed in elderly, assisted-living residents. Design: A non-experimental (longitudinal) pre-post-test descriptive design was used to determine changes in physical performance measures after 13 weeks of recumbent stepper exercising. Setting: Morningside Assisted-Living Communities in Middle Tennessee Participants: Thirty-nine volunteer, assisted living residents with mean age of 85.5 ± 6.6 years, height of 1.6 ± .1m, and weight of 63.6 ± 9.6 kg. Interventions: Recumbent Stepper exercise program. The residents were classified into two groups based on the total time of exercise logged over the test period. One group exercised less than an average of nine minutes per week while the other group averaged nine or more minutes of exercise per week. Main Outcomes Measures: The residents were tested on physical characteristics, sitting and standing blood pressure, mobility (15.2 meter timed walk), and six strength measurements on a hydraulic exercise machine. Results: Statistically significant differences pre- and post-intervention were found on several measures of blood pressure, strength, and mobility. while residents exercising less than nine minutes per week tended to remain stable of show changes in adverse directions on these measures (e.g., decreased Shoulder Press strength, p < .05), residents exercising at least nine minutes per week demonstrated positive improvements (e.g., Knee Flexion and Back Pulldown, p < .01), as well as increased mobility (p < .01). Statistically significant decreases were also found for measures of sitting and standing blood pressure (p < .05). Conclusions: The results of this study revealed that assisted-living residents who exercised on a recumbent stepper as little as nine minutes per week decreased blood pressure and increased strength and walking speed. This effect holds true even in the oldest-old individuals. [ABSTRACT FROM PUBLISHER]

Discusses home economics education at George Peabody College for Teachers in Nashville, Tennessee, between 1914 and 1938. Origins of the college's home economics department; Transformation of home economics from a reform program to a training course in domestic skills; Members of the college's home economics faculty; Emphasis of home economics education; Role of vocational education legislation in shaping home economics courses.

Purpose/Objectives: To compare available grading and staging scales that measure external lymphedema in patients with head and neck cancer (HNC) and to assess problems and gaps related to these tools.Design: Cross-sectional.Setting: A comprehensive cancer center in Tennessee.Sample: 103 participants post-HNC treatment.Methods: Four scales were used to evaluate study participant external lymphedema status, including the Common Terminology Criteria for Adverse Events (CTCAE) Lymphedema Scale (version 3.0), American Cancer Society Lymphedema Scale, Stages of Lymphedema (Földi's Scale), and the CTCAE Fibrosis Scale (version 3.0).Main Research Variables: Occurrence rate, severity of lymphedema, and components and descriptors of each scale.Findings: The prevalence and severity of external lymphedema differed based on the tools. Each tool had an identified limitation. Current theory postulates a continuum between lymphedema and fibrosis, but only the Földi's Scale adequately reflected that concept.Conclusions: None of the available scales clearly captured all the important characteristics of external lymphedema in patients with HNC. A need exists to develop a clearly defined and validated scale of external lymphedema in the HNC population.Implications for Nursing: Oncology nurses should take an active role in addressing issues related to lymphedema assessment in patients post-HNC treatment; however, new assessment tools need to be developed for clinical use.Knowledge Translation: Early identification and accurate documentation of head and neck lymphedema are critically important to prevent lymphedema progress. However, existing grading criteria failed to capture important characteristics of external head and neck lymphedema. More research efforts need to be made to address this under-recognized issue. [ABSTRACT FROM AUTHOR]

Breast cancer survivors with lymphedema experience physical, psychosocial, and quality-of-life difficulties. Cancer treatment-related lymphedema often is viewed as a disabling condition, and that assumption has fostered an environment in which oncology nurses are not actively involved in the care of patients with lymphedema. Little is known about how breast cancer survivors with lymphedema structure their daily lives. This article describes an effort to determine whether lymphedema truly is a disabling condition by collecting symptom data and self-generated narratives from breast cancer survivors with lymphedema regarding their eating habits, daily activities, substance use, and future plans. Although the sample experienced multiple symptoms, lymphedema duration and degree of extracellular arm fluid did not appear to influence those symptoms. In addition, participants led full, rich, busy lives. The findings do not support the notion that patients with lymphedema live as disabled people. A disability model may not be optimal to guide research design or patient care; rather, a symptom management model better explains the findings and implies that active involvement by nurses in lymphedema patient care and education is indicated. [ABSTRACT FROM AUTHOR]

Objectives: (1) To compare changes in vulnerability after hospital discharge among older patients with cardiovascular disease who were discharged home with self-care versus a home healthcare (HHC) referral and (2) to examine factors associated with changes in vulnerability in this period., Design: Secondary analysis of longitudinal data from a cohort study., Participants and Setting: 834 older (≥65 years) patients hospitalised for acute coronary syndromes and/or acute decompensated heart failure who were discharged home with self-care (n=713) or an HHC referral (n=121)., Outcome: Vulnerability was measured using Vulnerable Elders Survey 13 (VES-13) at baseline (prior to hospital admission) and 30 days and/or 90 days after hospital discharge. Effects of HHC referral on postdischarge change in vulnerability were examined using three linear regression approaches, with potential confounding on HHC referral adjusted by propensity score matching., Results: Overall, 44.4% of the participants were vulnerable at prehospitalisation baseline and 34.4% were vulnerable at 90 days after hospital discharge. Compared with self-care patients, HHC-referred patients were more vulnerable at baseline (66.9% vs 40.3%), had more increase (worsening) in VES-13 score change (B=-1.34(-2.07, -0.61), p<0.001) in the initial 30 days and more decrease (improvement) in VES-13 score change (B=0.83(0.20, 1.45), p=0.01) from 30 to 90 days after hospital discharge. Baseline vulnerability and the HHC referral attributed to 14%-16% of the variance in vulnerability change during the 90 postdischarge days, and 6% was attributed by patient age, race (African-American), depressive symptoms, and outpatient visits and hospitalisations in the past year., Conclusion: After adjusting for preceding vulnerability and covariates, older hospitalised patients with cardiovascular disease referred to HHC had delayed recovery in vulnerability in first initial 30 days after hospital discharge and greater improvement in vulnerability from 30 to 90 days after hospital discharge. HHC seemed to facilitate improvement in vulnerability among older patients with cardiovascular disease from 30 to 90 days after hospital discharge., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The growing incidence of elderly patients injured from falls, combined with a growing understanding of the contribution of cognition and frailty to mortality, prompted this work. Our objective was to develop a clinical risk prediction model for prognosticating disability and mortality among injured older adults 1 year after hospitalization., Methods: Secondary analysis of prospective longitudinal data from an urban Level 1 trauma center. A proportional odds regression model was used to model mortality and functional status as ordinal outcomes. Death was treated as the lowest functional status, and 3 ordered groups of the Barthel Index were treated as higher functional status. 188 patients aged 65 and older who were admitted through the emergency department from 2013 to 2014 with a primary injury diagnosis comprised the prospective cohort. Follow-up assessments were performed at 30-days, 90-days, 6-months, and 1-year. Predictors in the model included: baseline physical function, baseline cognition, two physical frailty measures, age, injury severity, a comorbidity index, gender, living location, mechanism of injury, and hospital admitting service., Results: The full model yielded an R 2 of 0.45, and Life Space Assessment, Vulnerable Elders Survey, and Injury Severity were the most influential predictors. Approximated models (to encourage clinical use) yielded an R 2 of 0.86. Calibration assessment (i.e., accuracy) demonstrated a mean squared error <0.003 at all 3 intercepts., Conclusions: A moderate statistical signal was discovered that contributed to a highly accurate clinical prediction model. Approximated models and nomograms could be used by clinicians, patients, and families in shared decision making during hospitalization., (Published by Elsevier B.V.)

Background: The purpose of this study was to determine the prevalence and nature of internal, external, and combined lymphedema and fibrosis in patients with head and neck cancer (HNC)., Materials and Methods: We obtained consent from 100 patients newly diagnosed with having cancer of the head and neck for a 4-year, prospective, longitudinal descriptive study. Recruitment began in August 23, 2010, and the study was completed in April 24, 2014. Eighty-three were evaluated at regular intervals from preradiation therapy to 18 months post-treatment. Percentage developing external, internal, or both types of lymphedema and/or fibrosis and trajectories of the severity of external, internal, or both types of lymphedema and/or fibrosis were determined., Results: Before treatment, lymphedema rates were the following: external: 62.7%, internal: 41.7%, or combined: 29.2%, and/or fibrosis: 42.2%. Ranges of lymphedema late-effect rates were even higher: external: 81.9%-90.1%, internal: 80.4%-89.4%, combined: 70.6%-80.9%, and fibrosis: 66.7%-77.4%. Approximately 75% had a late-effect trajectory characterized by moderate to severe external or internal lymphedema; ∼47% had moderate to severe fibrosis., Conclusion: Lymphatic and soft tissue complications of HNC occur not only post-treatment but also before treatment. They are ubiquitous throughout the first 18 months post-treatment, with greater than 90% of patients in our study experiencing some form of internal, external, or combined lymphedema, and over half of those patients developing fibrosis. Further research regarding these conditions is indicated., Competing Interests: Author Disclosure Statement No competing financial interests exist.

Background: Participants were consecutive English or Spanish speaking parents of 1- to 5-year-old children presenting for a well-child visit. Parents viewed a 5- to 10-minute intervention that teaches appropriate discipline strategies. The participation rate was 99% (129/130). Thirty-six percent (46/129) reported they had a discussion about discipline with their pediatrician. Of the parents who had a discussion, 93% (43/46) agreed or strongly agreed that the intervention program helped with a discussion about discipline. One hundred percent (19/19) of Hispanic parents reported that the program was helpful compared with 86% (12/14) of Black parents and 91% (10/11) of White parents. Parents' qualitative responses revealed that the intervention helped by facilitating communication with their physician and/or by providing information. Brief interventions, integrated into the primary care visit can help parents have discussions about discipline with their physician. The results have implications for improving pediatric primary care services, violence prevention, and child abuse prevention., (© The Author(s) 2015.)

Context: Because surgery, radiation, and/or chemotherapy disrupt lymphatic structures, damage soft tissue leading to scar tissue formation and fibrosis, and further affect lymphatic function, patients with head and neck cancer may be at high risk for developing secondary lymphedema. Yet, no published data are available regarding the prevalence of secondary lymphedema after head and neck cancer treatment., Objectives: The aim of this study was to examine prevalence of secondary lymphedema in patients with head and neck cancer., Methods: The study included 81 patients with head and neck cancer who were three months or more post-treatment. External lymphedema was staged using Foldi's lymphedema scale. Internal lymphedema was identified through a flexible fiber-optic endoscopic or mirror examination. Patterson's scale was used to grade degrees of internal lymphedema., Results: Of the 81 patients, 75.3% (61 of 81) had some form of late-effect lymphedema. Of those, 9.8% (6 of 61) only had external, 39.4% (24 of 61) only had internal, and 50.8% (31 of 61) had both types., Conclusion: Lymphedema is a common late effect in patients with head and neck cancer, and it develops in multiple external and internal anatomical locations. During physical examination and endoscopic procedures, clinicians should assess patients with head and neck cancer for late-effect lymphedema. Referral for treatment should be considered when lymphedema is noted. Research is needed to examine risk factors of lymphedema in patients with head and neck cancer and its effects on patients' symptoms, function, and quality of life., (Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Objective: This study explores the interactions among phases of team coordination, patient-related information, decision-making levels, and role holders in intensive care units (ICUs)., Background: The effects of communication improvement initiatives on adverse patient events or improved outcomes have been difficult to establish. Conceptual inconsistencies and methodological shortcomings suggest insufficient understanding about clinical communication and care coordination., Method: Data were collected by shadowing a charge nurse, fellow, resident, and nurse in each of eight ICUs and recording each of their conversations during 12 hrs (32 role holders during 350 hrs)., Results: Hierarchical log linear analyses show statistically significant three-way interactions between the patient information, phases of team coordination, and decision levels, chi2(df = 75) = 212, p < .0001; between roles, phases of team coordination, and decision levels, chi2(df = 60) = 109, p < .0001; and between roles, patient information, and decision levels, chi2(df = 60) = 155, p < .0001. Differences among levels of the variables were evaluated with the use of standardized parameter estimates and 95% confidence intervals., Conclusion: ICU communication and care coordination involve complex decision structures and role interactions across two information spaces. Different role holders mediate vertical and lateral process flows with goals and directions representing an important conceptual transition. However, lateral isolation within decision levels (charge nurses) and information overload (residents) are potential communication and care coordination vulnerabilities. Results are consistent with and extend the findings of previous studies., Application: The profile of ICU communication and care coordination provides a systemic framework that may inform future interventions and research.

Objective: Establish the time required to perform cochlear implantation (CI) in academic settings., Study Design: Historical cohort study., Setting: German and American academic centers., Patients: A total of 2639 patients underwent CI (1997-2007). We excluded patients receiving an experimental device or technique and those with abnormal cochlear anatomy or incomplete charts, leaving 2253 for analysis., Intervention: Unilateral, bilateral, and revision CI with devices approved in the U.S. and Europe., Main Outcome Measures: Mean surgical time (ST) and total operating room time (TORT)., Results: Mixed model analysis was used; estimated marginal means were calculated in minutes after adjusting for random effect of individual surgeon. There were no differences between unilateral (ST = 171, TORT = 245) and revision CI (ST = 160, TORT = 232), but bilateral procedures were longer (ST = 295, TORT = 377, P < 0.001). In unilateral surgeries, Cochlear Limited (CL) devices were implanted faster (ST = 165, TORT = 225) than Advanced Bionics (ABC) (ST = 183, P = 0.001; TORT = 240, P = 0.023) or MedEl (ST = 193, P < 0.001; TORT = 253, P = 0.002) devices. There were no differences for unilateral CI between ABC and MedEl devices. For revision CI, ABC devices (ST = 141, TORT = 219) were implanted faster than CL devices (ST = 181, P = 0.001; TORT = 266, P < 0.001). There were no differences by age group or between Germany and the U.S. ST and TORT were shorter for 575 CIs performed in the final two years of the study (unilateral CI: ST = 145, TORT = 209; bilateral CI: ST = 259, TORT = 330; revision CI: ST = 138, TORT = 205). For unilateral CI, ST and TORT decreased yearly (linear regression, P < 0.001) and inversely correlated with surgeon experience (linear regression, P < 0.01)., Conclusions: We report the time required to perform CI in academic settings-data that are vital for cost-benefit analyses and assessing new CI techniques., (Copyright 2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

Background and Research Objective: Worksite health promotion programs use health risk appraisal (HRA) surveys to identify employees at increased risk, then provide a range of interventions to encourage high-risk individuals to improve their health. Our objective was to determine how the intensity of intervention after HRA affected cardiovascular risk after 1 year, comparing individual follow-up counseling with environmental supports., Subjects and Methods: 133 employees of Vanderbilt University with cardiovascular risk factors were randomly assigned to worksite HRA plus targeted disease management (DM group) or HRA plus information about worksite health promotion programs (HRA group). The DM group received longitudinal individualized counseling for risk reduction, whereas the HRA group members received one feedback session about their risk factors and information about free worksite health promotion programs. The main outcome measure was the difference between groups in the change in average Framingham risk score from baseline to 1 year., Results: There was no significant baseline difference between groups in the Framingham risk score. Among DM participants, the mean (SD) Framingham risk score decreased by 22.6%; among HRA participants, the mean score rose by 4.3% (P = .017 for the difference between groups)., Conclusions: In this study of employees with cardiovascular risk factors, HRA followed by individual counseling was more effective than providing information about free worksite health promotion programs.

Objective: To determine if health literacy is associated with knowledge of colorectal cancer (CRC) and CRC screening tests, with perceived benefits and barriers to CRC screening, with perceived risk of CRC, with reported self-efficacy for completing CRC screening and with receipt of CRC tests., Methods: A convenience sample of 99 subjects completed a health literacy assessment, the Rapid Estimate of Adult Literacy in Medicine (REALM) and a structured interview., Results: Limited or inadequate health literacy was significantly associated with less knowledge about CRC and CRC screening and with more reported barriers to completing fecal occult blood testing (FOBT) and colonoscopy in multivariate analysis. Health literacy was not associated with perceived benefits or reported self-efficacy for completing FOBT or colonoscopy, with perceived risk of developing CRC or with completing CRC tests. However, our small sample size limited our power to detect differences., Conclusions: Patients with limited health literacy have less knowledge about CRC and CRC screening and report more barriers to completing FOBT and colonoscopy. Interventions to improve CRC screening should consider the health literacy of patients, especially when addressing barriers to screening. Future studies are needed to better define the role of health literacy in CRC screening.

Background: Little is known about the morbidity and mortality among older adults with asthma requiring hospital care., Objectives: To determine whether an initial hospital visit for asthma was associated with an increase in use of inhaled corticosteroids (CCS) at discharge, and to identify risk factors for recurrent asthma hospital visits and death., Methods: A retrospective cohort analysis identified 93,174 persons 65 years and older enrolled in the Tennessee Medicaid program for at least 1 year and free of asthma hospital visits during that year; 510 survived a single hospital visit for asthma in 1992 and comprised the study population. Main outcome measures included recurrent hospital visit for asthma and all-cause mortality during the year after an asthma hospital visit., Results: Among the 510 study subjects, 10% were on inhaled CCS at admission compared with 11% at discharge. Twenty-three percent of the population had recurrent asthma hospital visits and 12% died during 1-year followup. Asthma severity was the strongest independent risk factor for both a recurrent hospital visit [relative risk for moderate to severe disease 1.92 (1.01 to 3.66), and for near-fatal disease 2.28 (1.01 to 5.13), respectively] and death [relative risk for moderate to severe disease 2.99 (1.07 to 8.32) and for near-fatal disease 4.44 (1.34 to 4.69), respectively]., Conclusions: In this population, older adults with an exacerbation of asthma requiring hospital care experienced significant morbidity and mortality. An acute hospital visit for an asthma exacerbation did not result in initiation of inhaled CCS therapy. Asthma severity predicted both recurrent hospital visits and all-cause mortality among older adults with asthma requiring hospital care.