Search

Background: Professional self-concept consists of one's judgments, attitudes about oneself professionally, and one's own perception as a professional. A positive professional self-concept can support students and new nurses throughout their nursing careers., Objective: To describe levels of self-concept among pre-licensure undergraduate students., Participants/setting: The participants were nursing students in a Bachelor of Science in Nursing program in the United States., Design/methods: This is a cross-sectional correlational study with self-report instruments, including demographics and the Professional Self-Concept of Nurses Instrument. Data (N = 103) were analyzed with SPSS/WIN 29.0. Descriptive statistics and professional self-concept scores were examined with independent t-tests, ANOVA, and Pearson's correlations., Results: Most participants were female (n = 90), with a mean age of 20 years (SD = 1). The mean professional self-concept of nurses score was 78 (SD = 7), ranging from 27 to 108, and professional self-concept was positively correlated with receiving tutoring through the university's program, working as a tutor for nursing students or students in prerequisite classes, transferring into the nursing program, and participating in campus nursing organizations. Professional self-concept was negatively correlated with advancement in semesters of the nursing program, being a first-generation college student, having a family member who is a nurse, GPA, and having clinical-related work experience in healthcare., Conclusions: Higher levels of exposure to nursing may be related to lower professional self-concept. This is important to recognize and it may generalize to other nursing schools and health-related departments. Schools of nursing should enhance students' resilience by promoting self-concept. Our findings also shade light on self-care and the mental health of healthcare professionals., Competing Interests: Declaration of competing interest Nothing to disclose., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: It has been shown that AI models can learn race on medical images, leading to algorithmic bias. Our aim in this study was to enhance the fairness of medical image models by eliminating bias related to race, age, and sex. We hypothesise models may be learning demographics via shortcut learning and combat this using image augmentation., Methods: This study included 44,953 patients who identified as Asian, Black, or White (mean age, 60.68 years ±18.21; 23,499 women) for a total of 194,359 chest X-rays (CXRs) from MIMIC-CXR database. The included CheXpert images comprised 45,095 patients (mean age 63.10 years ±18.14; 20,437 women) for a total of 134,300 CXRs were used for external validation. We also collected 1195 3D brain magnetic resonance imaging (MRI) data from the ADNI database, which included 273 participants with an average age of 76.97 years ±14.22, and 142 females. DL models were trained on either non-augmented or augmented images and assessed using disparity metrics. The features learned by the models were analysed using task transfer experiments and model visualisation techniques., Findings: In the detection of radiological findings, training a model using augmented CXR images was shown to reduce disparities in error rate among racial groups (-5.45%), age groups (-13.94%), and sex (-22.22%). For AD detection, the model trained with augmented MRI images was shown 53.11% and 31.01% reduction of disparities in error rate among age and sex groups, respectively. Image augmentation led to a reduction in the model's ability to identify demographic attributes and resulted in the model trained for clinical purposes incorporating fewer demographic features., Interpretation: The model trained using the augmented images was less likely to be influenced by demographic information in detecting image labels. These results demonstrate that the proposed augmentation scheme could enhance the fairness of interpretations by DL models when dealing with data from patients with different demographic backgrounds., Funding: National Science and Technology Council (Taiwan), National Institutes of Health., Competing Interests: Declaration of interests L.A.C. reports consulting fees from Philips, payment or honoraria for lectures, presentations, speakers bureaus from Stanford University, University of California San Francisco, University of Toronto (visiting professor), and Taipei Medical University. L.A.C. reports support for attending meetings from Australia New Zealand College of Intensive Care Medicine, University of Bergen, University Medical Center Amsterdam, Académie Nationale de Médecine, Doris Duke Foundation. L.A.C. reports leadership or fiduciary role in other boards, society, committee or advocacy group, paid or unpaid from PLOS Digital Health and Lancet Digital Health. L.A.C. reports cloud compute credits from Oracle. R.W., P.C.K, L.C.C., and K.P.S, have nothing to declare., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Acute kidney injury (AKI) is a severe postoperative complication associated with poor clinical outcomes, including the development of chronic kidney disease (CKD) and death. This study aimed to investigate the incidence and determinants of AKI following elective surgeries for degenerative lumbar spine disease., Methods: All patient data were extracted from the US Nationwide Inpatient Sample database. After surgery, AKI's incidence and risk factors were identified for lumbar degenerative disease. ICD-9 and ICD-10 codes defined lumbar spine degenerative disease, fusion, decompression, and AKI. The study cohort was categorized by type of surgery, that is, decompression alone or spinal fusion. Regression analysis was used to identify associations between AKI and risk factors organized by surgery type., Results: The incidence of AKI after decompression or fusion was 1.1% and 1.8%, respectively. However, the incidence of AKI in the United States is rising. The strongest predictor of AKI was underlying CKD, which was associated with an 9.0- to 12.9-fold more significant risk of AKI than in subjects without comorbid CKD. In this setting, older age, congestive heart failure, anemia, obesity, coagulopathy and hospital-acquired infections were also strong predictors of AKI. In contrast, long-term aspirin/anticoagulant usage was associated with lowered AKI risk., Conclusion: Findings of this study inform risk stratification for AKI and may help to optimize treatment decisions and care planning after elective surgery for lumbar degenerative disease., Competing Interests: Conflicts of interest: The authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article., (Copyright © 2024, the Chinese Medical Association.)

Introduction: We aimed to investigate the prognostic determinants of life-threatening and fatal complications in patients <80 and ≥ 20 years of age and those ≥80 years who were undergoing surgery for spinal metastases., Materials and Methods: Based on data between 2005 and 2018 extracted from National Inpatient Sample as the largest longitudinal hospital inpatient databases in the United States, statistical analyses were performed to identify prognostic factors (age, sex, household income, insurance status, major comorbidities, primary site of malignancy, types of surgery, surgical approaches, types of hospital admission, and hospital-related characteristics) for major and fatal perioperative complications among older adult patients., Results: A total of 31,925 patients aged ≥ 20y who were undergoing surgery for spinal metastasis were identified (< 80 y: n = 28,448; ≥ 80 y: n = 35,37). After adjustment, age ≥80 y was significantly associated with greater risk of perioperative cardiac arrest (adjusted odds ratio [aOR]: 1.34, 95% confidence interval [CI]: 1.03-1.73) and acute kidney injury (AKI) (aOR: 1.23, 95% CI: 1.07-1.41) but lower risk of venous thromboembolic event (VTE) (aOR: 0.80, 95% CI: 0.66-0.96) than <80y. Factors predicting life-threatening complications among patients ≥ 80y were: male sex (<80 y: aOR = 1.14; ≥ 80 y: aOR = 1.35), higher score on Charlson Comorbidity Index (CCI) (80 y, aOR = 1.21-2.67; ≥ 80 y: aOR = 1.25-2.55), open surgery (<80 y: aOR = 1.24; ≥ 80 y: aOR = 1.35), and greater Metastatic Spinal Tumor Frailty Index (MSTFI) (<80 y: aOR = 2.48-10.03; ≥ 80 y: aOR = 2.69-11.21). Among patients <80y, factors predicting life-threatening complications were: male sex, Black race, greater CCI score, primary tumor at kidney, hematologic cancer, other/unspecified primary site, certain surgical procedures, open surgery, greater MSTFI, emergent admission, and low hospital volume., Discussion: This study identifies a list of independent risk factors for the presence of life-threatening complications among patients <80 and ≥ 80y who were undergoing surgery for spinal metastasis. The findings contribute to the development of clinical strategies for the surgical management of spinal metastasis, especially for octogenarians, and lower the risk of unfavorable inpatient outcomes., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2023. Published by Elsevier Ltd.)

Novel hormonal agents (NHAs) have significantly improved outcomes in men with advanced prostate cancer. However, it remains unclear whether NHAs are associated with subsequent cognitive impairment. Thus, we sought to perform a network meta-analysis to compare the risk of cognitive impairment across NHA types. Databases (PubMed, Embase, Scopus, and Web of Science), trial registries (Clinicaltrial.gov), the European Medicines Agency, and the US Food and Drug Administration drug safety reports were searched from inception through July 30, 2021. Eligible studies were clinical trials evaluating the risk of cognitive impairment between NHAs and placebo/standard care. Two independent investigators extracted the data and performed quality assessments using the Cochrane Risk of Bias Tool and ROBINS-I. We estimated the risk ratios by the frequentist approach and calculated the ranking probabilities of all treatments with the surface under the cumulative ranking probabilities. The primary outcome and secondary outcome were odds ratio (OR) and incidence rate ratio of cognitive impairment, respectively. We identified 15 trials with 14,723 participants comparing HNAs with placebo/standard care. Treatments associated with cognitive impairment, from the most to the least, were enzalutamide (OR, 3.66; 95% confidence interval [CI], 2.84-4.73), apalutamide (OR, 1.76; 95% CI, 1.08-2.87), abiraterone acetate (OR, 1.64; 95% CI, 1.01-2.45), and darolutamide (OR, 1.11 95% CI, 0.51-2.39). After adjustment of treatment time duration, enzalutamide still had the highest risk of cognitive impairment with an incidence rate ratio of 2.17 (95% CI, 1.65-2.78). These findings suggest that NHAs, especially enzalutamide, may increase the risk of cognitive impairment compared with placebo/standard care., (© 2022 The Authors. Clinical and Translational Science published by Wiley Periodicals LLC on behalf of American Society for Clinical Pharmacology and Therapeutics.)

Objective: To assess healthcare resource utilization and costs for female patients diagnosed with stress or mixed urinary incontinence (SUI/MUI) compared to a matched cohort of patients without SUI/MUI., Methods: We conducted a retrospective matched cohort study of women using the IBM MarketScan research database. Women diagnosed with SUI/MUI between July 1, 2014 and June 30, 2016 were identified using International Classification of Diseases 9 and 10 codes for SUI or MUI with the date of first diagnosis as the index date from which 2-year postindex healthcare resource use and direct cost data were derived from claims, examined, and compared 1:1 with patients without a SUI/MUI diagnosis, matched by age and Charlson's Comorbidity Index., Results: A total of 68 636 women with SUI/MUI were matched 1:1 with controls. In the 2-year postindex date, a significantly higher proportion of SUI/MUI patients had ≥1 inpatient visit and ≥1 outpatient visit compared to the control group (inpatient: 18.89% vs. 12.10%, p < 0.0001; outpatient: 88.44% vs. 73.23%, p < 0.0001). Mean primary care visits were significantly higher in SUI/MUI patients compared to controls (7.33 vs. 5.53; p < 0.0001) as were specialist visits (1.2 vs. 0.08; p < 0.0001). Mean all-cause outpatient costs were higher in SUI/MUI patients compared to controls ($7032.10 vs. $3348.50; p < 0.0001), as were inpatient costs ($3990.70 vs. $2313.70; p < 0.0001)., Conclusion: Women with SUI/MUI consume significantly higher medical resources and incur higher costs to payers, compared to women without SUI/MUI. While reasons for this are not fully understood, improved and standardized treatment for women with SUI/MUI may positively affect cost and outcomes., (© 2022 Renovia Inc. Neurourology and Urodynamics published by Wiley Periodicals LLC.)

Since the spread of tobacco from the Americas hundreds of years ago, tobacco cigarettes and, more recently, alternative tobacco products have become global products of nicotine addiction. Within the evolving alternative tobacco product space, electronic cigarette (e-cigarette) vaping has surpassed conventional cigarette smoking among adolescents and young adults in the United States and beyond. This review describes the experimental and clinical evidence of e-cigarette toxicity and deleterious health effects. Adverse health effects related to e-cigarette aerosols are influenced by several factors, including e-liquid components, physical device factors, chemical changes related to heating, and health of the e-cigarette user (e.g., asthmatic). Federal, state, and local regulations have attempted to govern e-cigarette flavors, manufacturing, distribution, and availability, particularly to underaged youths. However, the evolving e-cigarette landscape continues to impede timely toxicological studies and hinder progress made toward our understanding of the long-term health consequence of e-cigarettes.

Aims: Physical activity may be an important modifiable risk factor for atrial fibrillation (AF), but associations have been variable and generally based on self-reported activity., Methods and Results: We analysed 93 669 participants of the UK Biobank prospective cohort study without prevalent AF who wore a wrist-based accelerometer for 1 week. We categorized whether measured activity met the standard recommendations of the European Society of Cardiology, American Heart Association, and World Health Organization [moderate-to-vigorous physical activity (MVPA) ≥150 min/week]. We tested associations between guideline-adherent activity and incident AF (primary) and stroke (secondary) using Cox proportional hazards models adjusted for age, sex, and each component of the Cohorts for Heart and Aging Research in Genomic Epidemiology AF (CHARGE-AF) risk score. We also assessed correlation between accelerometer-derived and self-reported activity. The mean age was 62 ± 8 years and 57% were women. Over a median of 5.2 years, 2338 incident AF events occurred. In multivariable adjusted models, guideline-adherent activity was associated with lower risks of AF [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.75-0.89; incidence 3.5/1000 person-years, 95% CI 3.3-3.8 vs. 6.5/1000 person-years, 95% CI 6.1-6.8] and stroke (HR 0.76, 95% CI 0.64-0.90; incidence 1.0/1000 person-years, 95% CI 0.9-1.1 vs. 1.8/1000 person-years, 95% CI 1.6-2.0). Correlation between accelerometer-derived and self-reported MVPA was weak (Spearman r = 0.16, 95% CI 0.16-0.17). Self-reported activity was not associated with incident AF or stroke., Conclusions: Greater accelerometer-derived physical activity is associated with lower risks of AF and stroke. Future preventive efforts to reduce AF risk may be most effective when targeting adherence to objective activity thresholds., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

The Trans-Omics for Precision Medicine (TOPMed) programme seeks to elucidate the genetic architecture and biology of heart, lung, blood and sleep disorders, with the ultimate goal of improving diagnosis, treatment and prevention of these diseases. The initial phases of the programme focused on whole-genome sequencing of individuals with rich phenotypic data and diverse backgrounds. Here we describe the TOPMed goals and design as well as the available resources and early insights obtained from the sequence data. The resources include a variant browser, a genotype imputation server, and genomic and phenotypic data that are available through dbGaP (Database of Genotypes and Phenotypes) 1 . In the first 53,831 TOPMed samples, we detected more than 400 million single-nucleotide and insertion or deletion variants after alignment with the reference genome. Additional previously undescribed variants were detected through assembly of unmapped reads and customized analysis in highly variable loci. Among the more than 400 million detected variants, 97% have frequencies of less than 1% and 46% are singletons that are present in only one individual (53% among unrelated individuals). These rare variants provide insights into mutational processes and recent human evolutionary history. The extensive catalogue of genetic variation in TOPMed studies provides unique opportunities for exploring the contributions of rare and noncoding sequence variants to phenotypic variation. Furthermore, combining TOPMed haplotypes with modern imputation methods improves the power and reach of genome-wide association studies to include variants down to a frequency of approximately 0.01%.

Objective: The optimal adjuvant therapy for stage III endometrial cancer is unknown. Studies have suggested that combination therapy with chemotherapy and radiation is associated with improved survival. We examined early and late-term toxicities associated with chemotherapy (CT), external beam radiotherapy (RT), or combination chemoradiotherapy for stage III uterine cancer., Methods: The SEER-Medicare database was used to identify women age ≥ 65 years with stage III uterine cancer who received adjuvant CT, RT, or chemoradiotherapy from 2000 to 2015. The associations between therapy and early and late-term toxicities identified with billing claims, hospitalizations and emergency department visits were examined using multivariable regression models., Results: A total of 2185 patients were identified including 574 (26.3%) who received CT, 636 (29.1%) who received RT, and 975 (44.6%) who received chemoradiotherapy. The proportion of patients receiving chemoradiotherapy or CT increased over time. During the first 6 and 12 months of adjuvant therapy, RT was associated with a lower risk of early-term toxicity compared to chemoradiotherapy (aRR = 0.59, 95%CI 0.49-0.70 and aRR = 0.76, 95%CI 0.67-0.86, respectively) while CT shared a similar risk of early toxicities as chemoradiotherapy. CT and RT shared a similar risk of late-term toxicities compared to chemoradiotherapy. CT and RT alone were associated with a higher hazard for overall mortality than chemoradiotherapy (aHR = 1.27, 95% CI 1.10-1.47 and aHR = 1.25, 95% CI 1.08-1.44, respectively)., Conclusion: Chemoradiotherapy is associated with lower mortality compared to single modality therapy and has a similar risk of early and late term toxicities compared to CT, though higher risk of early toxicities compared to RT., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Atrial fibrillation (AF) may occur after an acute precipitant and subsequently resolve. Management guidelines for AF in these settings are unclear as the risk of recurrent AF and related morbidity is poorly understood. We examined the relations between acute precipitants of AF and long-term recurrence of AF in a clinical setting., Methods: From a multi-institutional longitudinal electronic medical record database, we identified patients with newly diagnosed AF between 2000 and 2014. We developed algorithms to identify acute AF precipitants (surgery, sepsis, pneumonia, pneumothorax, respiratory failure, myocardial infarction, thyrotoxicosis, alcohol, pericarditis, pulmonary embolism, and myocarditis). We assessed risks of AF recurrence in individuals with and without a precipitant and the relations between AF recurrence and heart failure, stroke, and mortality., Results: Among 10 723 patients with newly diagnosed AF (67.9±9.9 years, 41% women), 19% had an acute AF precipitant, the most common of which were cardiac surgery (22%), pneumonia (20%), and noncardiothoracic surgery (15%). The cumulative incidence of AF recurrence at 5 years was 41% among individuals with a precipitant compared with 52% in those without a precipitant (adjusted hazard ratio [HR], 0.75 [95% CI, 0.69-0.81]; P <0.001). The lowest risk of recurrence among those with precipitants occurred with postoperative AF (5-year incidence 32% in cardiac surgery and 39% in noncardiothoracic surgery). Regardless of the presence of an initial precipitant, recurrent AF was associated with increased adjusted risks of heart failure (hazard ratio, 2.74 [95% CI, 2.39-3.15]; P <0.001), stroke (hazard ratio, 1.57 [95% CI, 1.30-1.90]; P <0.001), and mortality (hazard ratio, 2.96 [95% CI, 2.70-3.24]; P <0.001)., Conclusions: AF after an acute precipitant frequently recurs, although the risk of recurrence is lower than among individuals without an acute precipitant. Recurrence is associated with substantial long-term morbidity and mortality. Future studies should address surveillance and management after newly diagnosed AF in the setting of an acute precipitant.

Background: The popularity of electronic cigarettes (E-cigarettes) has risen considerably. Several studies have suggested that nicotine may affect insulin resistance, however, the impact of E-cigarette exposure on insulin resistance, an early measure of cardiometabolic risk, is not known., Methods and Results: Using experimental animals and human data obtained from 3,989 participants of the United States National Health and Nutrition Examination Survey (NHANES), respectively, we assessed the association between E-cigarette and conventional cigarette exposures and insulin resistance, as modelled using the homeostatic model assessment of insulin resistance (HOMA-IR) and glucose tolerance tests (GTT). C57BL6/J mice (on standard chow diet) exposed to E-cigarette aerosol or mainstream cigarette smoke (MCS) for 12 weeks showed HOMA-IR and GTT levels comparable with filtered air-exposed controls. In the NHANES cohort, there was no significant association between defined tobacco product use categories (non-users; sole E-cigarette users; cigarette smokers and dual users) and insulin resistance. Compared with non-users of e-cigarettes/conventional cigarettes, sole E-cigarette users showed no significant difference in HOMA-IR or GTT levels following adjustment for age, sex, race, physical activity, alcohol use and BMI., Conclusion: E-cigarettes do not appear to be linked with insulin resistance. Our findings may inform future studies assessing potential cardiometabolic harms associated with E-cigarette use., Competing Interests: The authors have declared that no competing interests exist.

Most genome-wide association and fine-mapping studies to date have been conducted in individuals of European descent, and genetic studies of populations of Hispanic/Latino and African ancestry are limited. In addition, these populations have more complex linkage disequilibrium structure. In order to better define the genetic architecture of these understudied populations, we leveraged >100,000 phased sequences available from deep-coverage whole genome sequencing through the multi-ethnic NHLBI Trans-Omics for Precision Medicine (TOPMed) program to impute genotypes into admixed African and Hispanic/Latino samples with genome-wide genotyping array data. We demonstrated that using TOPMed sequencing data as the imputation reference panel improves genotype imputation quality in these populations, which subsequently enhanced gene-mapping power for complex traits. For rare variants with minor allele frequency (MAF) < 0.5%, we observed a 2.3- to 6.1-fold increase in the number of well-imputed variants, with 11-34% improvement in average imputation quality, compared to the state-of-the-art 1000 Genomes Project Phase 3 and Haplotype Reference Consortium reference panels. Impressively, even for extremely rare variants with minor allele count <10 (including singletons) in the imputation target samples, average information content rescued was >86%. Subsequent association analyses of TOPMed reference panel-imputed genotype data with hematological traits (hemoglobin (HGB), hematocrit (HCT), and white blood cell count (WBC)) in ~21,600 African-ancestry and ~21,700 Hispanic/Latino individuals identified associations with two rare variants in the HBB gene (rs33930165 with higher WBC [p = 8.8x10-15] in African populations, rs11549407 with lower HGB [p = 1.5x10-12] and HCT [p = 8.8x10-10] in Hispanics/Latinos). By comparison, neither variant would have been genome-wide significant if either 1000 Genomes Project Phase 3 or Haplotype Reference Consortium reference panels had been used for imputation. Our findings highlight the utility of the TOPMed imputation reference panel for identification of novel rare variant associations not previously detected in similarly sized genome-wide studies of under-represented African and Hispanic/Latino populations., Competing Interests: Edwin K Silverman and Michael H Cho have received grant support from GSK, MHC has received consulting fees from Genentech. Scott T. Weiss and Kathleen C. Barnes received royalties from UpToDate. Patrick T. Ellinor is supported by a grant from Bayer AG to the Broad Institute focused on the genetics and therapeutics of cardiovascular diseases, and has also served on advisory boards or consulted for Bayer AG, Quest Diagnostics and Novartis. Steven A Lubitz receives sponsored research support from Bristol Myers Squibb / Pfizer, Bayer HealthCare, and Boehringer Ingelheim, and has consulted for Abbott, Quest Diagnostics, Bristol Myers Squibb / Pfizer. Other authors declared no conflicts of interest.

Background: Many patients with atrial fibrillation (AF) and elevated stroke risk are not prescribed oral anticoagulation (OAC) despite evidence of benefit. Identification of factors associated with OAC non-prescription could lead to improvements in care., Methods and Results: Using NCDR PINNACLE, a United States-based ambulatory cardiology registry, we examined factors associated with OAC non-prescription in patients with non-valvular AF at elevated stroke risk (CHA 2 DS 2 -VASc ≥2) between January 5, 2008 and December 31, 2014. Among 674,841 patients, 57% were treated with OAC (67% of whom were treated with warfarin). OAC prescription varied widely (28%-75%) across preselected strata of age, stroke risk (CHA 2 DS 2 -VASc), and bleeding risk (HAS-BLED), generally indicating that older patients at high stroke and low bleeding risk are commonly treated with OAC. Other factors associated with OAC non-prescription included reversible AF etiology; female sex; liver, renal, or vascular disease; and physician versus non-physician provider. Antiplatelet use was common (57%) and associated with the greatest risk of OAC non-prescription (odds ratio [OR] 4.44, 95% confidence interval [CI] 4.39-4.49)., Conclusions: In this registry of AF patients, older patients at elevated stroke and low bleeding risk were commonly treated with OAC. However, a variety of factors were associated with OAC non-prescription. Specifically, antiplatelet use was prevalent and associated with the highest likelihood of OAC non-prescription. Future studies are warranted to understand provider and patient rationale that may underlie observed associations with OAC non-prescription., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The long-term probability of developing atrial fibrillation (AF) considering genetic predisposition and clinical risk factor burden is unknown., Methods: We estimated the lifetime risk of AF in individuals from the community-based Framingham Heart Study. Polygenic risk for AF was derived using a score of ≈1000 AF-associated single-nucleotide polymorphisms. Clinical risk factor burden was calculated for each individual using a validated risk score for incident AF comprised of height, weight, systolic and diastolic blood pressure, current smoking status, antihypertensive medication use, diabetes mellitus, history of myocardial infarction, and history of heart failure. We estimated the lifetime risk of AF within tertiles of polygenic and clinical risk., Results: Among 4606 participants without AF at 55 years of age, 580 developed incident AF (median follow-up, 9.4 years; 25th-75th percentile, 4.4-14.3 years). The lifetime risk of AF >55 years of age was 37.1% and was substantially influenced by both polygenic and clinical risk factor burden. Among individuals free of AF at 55 years of age, those in low-polygenic and clinical risk tertiles had a lifetime risk of AF of 22.3% (95% confidence interval, 15.4-9.1), whereas those in high-risk tertiles had a risk of 48.2% (95% confidence interval, 41.3-55.1). A lower clinical risk factor burden was associated with later AF onset after adjusting for genetic predisposition ( P <0.001)., Conclusions: In our community-based cohort, the lifetime risk of AF was 37%. Estimation of polygenic AF risk is feasible and together with clinical risk factor burden explains a substantial gradient in long-term AF risk., (© 2018 American Heart Association, Inc.)

Objective: Previous studies have identified common genetic variants in 4 chromosomal regions that together account for 14% to 15% of the variance in circulating levels of protein C. To further characterize the genetic architecture of protein C, we obtained denser coverage at some loci, extended investigation of protein C to low-frequency and rare variants, and searched for new associations in genes known to influence protein C., Approach and Results: Genetic associations with protein C antigen level were evaluated in ≤10 778 European and 3190 black participants aged 45 to 64 years. Analyses included >26 million autosomal variants available after imputation to the 1000 Genomes reference panel along with additional low-frequency and rare variants directly genotyped using the Illumina ITMAT-Broad-CARe chip and Illumina HumanExome BeadChip. Genome-wide significant associations ( P <5×10 -8 ) were found for common variants in the GCKR , PROC , BAZ1B , and PROCR-EDEM2 regions in whites and PROC and PROCR-EDEM2 regions in blacks, confirming earlier findings. In a novel finding, the low-density lipoprotein cholesterol-lowering allele of rs12740374, located in the CELSR2-PSRC1-SORT1 region, was associated with lower protein C level in both whites and blacks, reaching genome-wide significance in a meta-analysis combining results from both groups ( P =1.4×10 -9 ). To further investigate a possible link between lipid metabolism and protein C level, we conducted Mendelian randomization analyses using 185 lipid-related genetic variants as instrumental variables. The results indicated that triglycerides, and possibly low-density lipoprotein cholesterol, influence protein C levels., Conclusions: Discovery of variants influencing circulating protein C levels in the CELSR2-PSRC1-SORT1 region may indicate a novel genetic link between lipoprotein metabolism and hemostasis., (© 2017 American Heart Association, Inc.)

Objective: The recommendations of the American Institute of Medicine (IOM) were revised recently in order to enhance maternal and neonatal health. The aim of our study was to investigate the risk of low birth weight (LBW) among women who follow the IOM recommendations., Materials and Methods: Gestational weight gain (GWG) and rate of weight gain (RWG) across the different periods of pregnancy among women who delivered LBW fetuses were analyzed retrospectively. The logistic regression was used to analyze the risk of LBW and to identify recommendations., Results: From January 2008 to December 2009, 117 out of 4924 (2.4%) women delivered term LBW fetuses. After exclusions, 88 LBW and 91 control subjects were enrolled into the study. There was increased risk of cesarean delivery [odds ratio (OR) with 95% confidence interval (CI): 2.53 (1.33-4.83)] and neonatal asphyxia within 7 days of birth [OR 95% CI: 5.71 (1.21-26.83)] for the LBW group compared with the control group. Normal weight women [body mass index (BMI): 18.5-24.9 kg/m(2)] who followed the GWG and RWG recommendations of the IOM had no increased risk of LBW. However, there was a two-to three-fold increased LBW risk among normal weight women who followed the IOM guidelines when, during the 2(nd) trimester, their GWG was ≤7 kg [OR 95% CI: 2.21 (1.28-6.49)] or their RWG was ≤0.45 kg/week [OR 95% CI: 3.14 (1.32-7.47)]. Among underweight women (BMI < 18.5 kg/m(2)), if, during the 2(nd) and 3(rd) trimesters, they followed the lower range of the GWG and RWG recommendations of the IOM there was a five-fold increased risk of LBW if the GWG was ≤13 kg [OR 95% CI: 5.29 (1.61-25.51)]; or the RWG was ≤0.45 kg/week [OR 95% CI: 5.35 (1.61-24.66)]., Conclusion: For underweight women, it is suggested that they follow the upper range of the IOM recommendation in order to avoid LBW. For normal weight women, although the IOM guidelines provide a good basis, it is suggested that they carefully follow the recommended GWG and the RWG values during the 2(nd) trimester, which is a very important period for fetal growth., (Copyright © 2014. Published by Elsevier B.V.)

Filipina nurses represent the majority of all internationally educated nurses recruited to work in the US. Although the hiring of Filipina nurses is not a new practice in US hospitals, very few studies have detailed how these nurses have adjusted to US nursing practices. This study examines how Filipina nurses transition into their role as nurses and adapt to nursing practice in the US. Following a qualitative approach, 31 Filipina nurses were interviewed as participants. The data were audio-taped and transcribed verbatim, using the method of constant comparison. Analysis revealed that transitioning from Philippine to US nursing practice formed the basis of the social adaptation process, which occurred in three stages: pre-arrival, early adaptation, and late adaptation. Participant-recommended strategies to address adaptation needs experienced at each of these stages are shared. All participants experienced challenges while adjusting to the US healthcare system and cultural landscape.

Particulate matter (PM*), an ambient air criteria pollutant, is a complex mixture of chemical components; particle sizes range from nanometer-sized molecular clusters to dust particles that are too large to be aspirated into the lungs. Although particle composition is believed to affect health risks from PM exposure, our current health-based air quality standards for PM are limited to (1) the mass concentrations of PM2.5 (particles 2.5 microm or smaller in aerodynamic diameter), which are largely attributable to combustion products; and (2) PM10 (10 microm or smaller), which includes larger-sized mechanically generated dusts. Both of these particle size fractions are regulated under the National Ambient Air Quality Standards (NAAQS) and both have been associated with excess mortality and morbidity. We conducted four studies as part of HEI's integrated National Particle Component Toxicity (NPACT) Initiative research program. Since 1999, the Chemical Speciation Network (CSN), managed by the U.S. Environmental Protection Agency (U.S; EPA), has routinely gathered air monitoring data every third or sixth day for the concentrations of numerous components of PM2.5. Data from the CSN enabled us to conduct a limited time-series epidemiologic study of short-term morbidity and mortality (Ito study); and a study of the associations between long-term average pollutant concentrations and annual mortality (Thurston study). Both have illuminated the roles of PM2.5 chemical components and source-related mixtures as potentially causal agents. We also conducted a series of 6-month subchronic inhalation exposure studies (6 hours/day, 5 days/week) of PM2.5 concentrated (nominally) 10 x from ambient air (CAPs) with apolipoprotein E-deficient (ApoE(-/-)) mice (a mouse model of atherosclerosis) (Chen study). The CAPs studies were conducted in five different U.S. airsheds; we measured the daily mass concentrations of PM2.5, black carbon (BC), and 16 elemental components in order to identify their sources and their roles in eliciting both short- and long-term health-related responses. In addition, from the same five air-sheds we collected samples of coarse (PM10-2.5), fine (PM2.5-0.2), and ultrafine (PM0.2) particles. Aliquots of these samples were administered to cells in vitro and to mouse lungs in vivo (by aspiration) in order to determine their comparative acute effects (Gordon Study). The results of these four complementary studies, and the overall integrative analyses, provide a basis for guiding future research and for helping to determine more targeted emission controls for the PM components most hazardous to acute and chronic health. Application of the knowledge gained in this work may therefore contribute to an optimization of the public health benefits of future PM emission controls. The design of each NPACT study conducted at NYU was guided by our scientific hypotheses, which were based on our reviews of the background literature and our experience in conducting studies of associations between ambient PM and health-related responses. These hypotheses guided the development and conduct of the four studies. Hypothesis 1. Coarse, fine, and ultrafine PM are each capable of producing acute health effects of public health concern, but the effects may differ according to particle size and composition. (Applies to all studies.) Hypothesis 2. Long-term PM2.5 exposures are closely associated with chronic health effects. (Applies to studies 1 and 4.) Hypothesis 3. The source-apportionment techniques that we have developed and refined in recent years provide a useful basis for identifying major categories of sources of PM in ambient air and specific chemical components that have the greatest impacts on a variety of acute and chronic health effects. (Applies to all studies.) Hypothesis 4. The health effects due to ambient PM exposures can best be seen in sensitive subgroups within overall human populations and in animal models of such populations. (Applies to studies 1, 3, and 4.) Overall, the studies have demonstrated that the toxicity of PM is driven by a complex interaction of particle size range, geographic location, source category, and season. These findings suggest that the components of PM--associated with certain categories of sources--are responsible for the observed adverse health effects. Most importantly, the responsible components and source categories vary with the health-related endpoints being assessed. Across all studies, fossil-fuel combustion source categories were most consistently associated with both short- and long-term adverse effects of PM2.5 exposure. The components that originate from the Residual Oil Combustion and Traffic source categories were most closely associated with short-term effects; and components from the Coal Combustion category were more closely associated with long-term effects.

Objective: Telehealthcare has been used to provide healthcare service, and information technology infrastructure appears to be essential while providing telehealthcare service. Insufficiencies have been identified, such as lack of integration, need of accommodation of diverse biometric sensors, and accessing diverse networks as different houses have varying facilities, which challenge the promotion of telehealthcare. This study designs an information technology framework to strengthen telehealthcare delivery., Materials and Methods: The proposed framework consists of a system architecture design and a network transmission design. The aim of the framework is to integrate data from existing information systems, to adopt medical informatics standards, to integrate diverse biometric sensors, and to provide different data transmission networks to support a patient's house network despite the facilities. The proposed framework has been evaluated with a case study of two telehealthcare programs, with and without the adoption of the framework., Results: The proposed framework facilitates the functionality of the program and enables steady patient enrollments. The overall patient participations are increased, and the patient outcomes appear positive. The attitudes toward the service and self-improvement also are positive., Conclusions: The findings of this study add up to the construction of a telehealthcare system. Implementing the proposed framework further assists the functionality of the service and enhances the availability of the service and patient acceptances.

Nursing shortages in the United States have underscored the need for foreign nurse recruitment. The major population of foreign nurse recruits has long been Asian. When employing foreign nurses, fair employment practices and quality of care must be ensured; however, few empirical studies were found on this topic. Thus, the purpose of this article is to synthesize the extant literature about Asian nurses' work experiences in and adaptation to the U.S. health care system. The author searched four major bibliographic databases, as well as the ProQuest Dissertation and Thesis Database and analyzed eight empirical studies based on four predetermined inclusion criteria. The major themes identified in the selected scholarly works were: (a) overcoming language barriers, (b) dealing with discrimination, (c) adopting U.S. nursing practices, (d) adjusting to U.S. social customs, (e) becoming accustomed to U.S. culture, and (f) reconciling work ethics. Additional research studies, using both quantitative and qualitative approaches, are necessary to gain in-depth knowledge related to this phenomenon.

Aim: The purpose of this paper is to compare and contrast the systems of risk management between a hospital in the USA and a hospital in Taiwan., Background: By comparing both systems, nurses and managers will have a better understanding of risk management improvements and be in a better position to protect their patients and themselves., Evaluation: Two interviews were conducted and literature were collected and reviewed by the author to support the argument. The gathered information was analysed to demonstrate the strengths and weaknesses of both hospital systems., Key Issues: Although risk management is not difficult to understand, nurses and managers usually pay insufficient attention to it., Conclusion: Health care providers should work as a team to complete risk assessment and management in their workplaces. There are weaknesses to be improved and strengths to be continued and addressed in Taiwan and in the USA.

Lack of consistency among definitions of undernutrition used for different public health purposes in the United States hinders an effective diagnosis of the problem and the design of interventions to prevent and treat undernutrition. No single-case definition of undernutrition is appropriate for all purposes. These purposes include surveillance of the prevalence of undernutrition in the population, epidemiological research on risk factors and consequences of undernutrition within population subgroups and communities, and screening, monitoring and evaluation of nutritional programs. We recommend that a cut-off of -2.0 SD (2.3 percentile) for weight-for-age, height-for-age, and weight-for-height on National Center for Health Statistics (NCHS) reference growth charts be used to estimate and monitor the prevalence of undernutrition in the United States, in accordance with guidelines of the World Health Organization. Epidemiological research on population-based risk factors for undernutrition and its functional consequences is required to identify the appropriate nutritional indicator and cut-off for screening and monitoring and evaluation of interventions.