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Wound infection is the most serious cause of delayed healing for patients with pressure injuries. The wound microbiota, which plays a crucial role in delayed healing, forms by bacterial dissemination from the peri-wound skin. To manage the bioburden, wound and peri-wound skin care has been implemented; however, how the microbiota at these sites contribute to delayed healing is unclear. Therefore, we investigated the relationship between healing status and microbial dissimilarity in wound and peri-wound skin.A prospective cohort study was conducted at a long-term care hospital. The outcome was healing status assessed using the DESIGN-R® tool, a wound assessment tool to monitor the wound healing process. Bacterial DNA was extracted from the wound and peri-wound swabs, and microbiota composition was analyzed using 16S rRNA gene analysis. To evaluate microbial similarity, the weighted UniFrac dissimilarity index between wound and peri-wound microbiota was calculated.Twenty-two pressure injuries (7 deep and 15 superficial wounds) were included in the study. For deep wounds, the predominant bacteria in wound and peri-wound skin were the same in the healing wounds, whereas they were different in all cases of hard-to-heal wounds. Analysis based on the weighted UniFrac dissimilarity index, there was no significant difference for healing wounds (p = 0.639), while a significant difference was found for hard-to-heal wounds (p = 0.047).Delayed healing is possibly associated with formation of wound microbiota that is different in composition from that of the skin commensal microbiota. This study provides a new perspective for assessing wound bioburden.

We report an international collaborative project to develop the first Doctor of Nursing Practice (DNP) program in Japan. We described the development and implementation of the first DNP program at the St. Luke's International University in Tokyo and the collaboration with the University of North Carolina at Chapel Hill in the United States. Faculty perceptions in both parties gradually evolved from the traditional perspective of international collaboration to the transitional and the beginning of the holistic partnership perspectives. The collaboration resulted in an innovative DNP program that directly addressed the gap between nursing education programs and Japan's clinical needs. The collaborative project cultivated a holistic international partnership. Rather than reporting a manual for international collaboration, we present our reflections and outcomes as narratives that others could use to achieve a holistic global partnership.

Background: Increased local skin temperature (hotspot) on a callus site as detected by thermography is a well-known precursor of diabetic foot ulcers. This study aimed to determine the factors associated with callus hotspots in order to predict the risk of callus hotspots and then provide information for specific interventions. Methods: In this cross-sectional study, 1,007 patients’ data from a diabetic foot prevention clinic between April 2008 and March 2020 were used. Data regarding patients’ characteristics, foot calluses, and callus hotspots were collected and analyzed. Callus and callus hotspot were confirmed from foot photos and thermographs, respectively. A callus hotspot was defined as a relative increase in temperature compared to the skin surrounding the callus on the thermograph. Plantar pressure was measured with a pressure distribution measurement system. A generalized linear mixed model was used to identify the factors associated with callus hotspots. Results: Among the 2,014 feet, 28.5% had calluses, and 18.5% of feet with calluses had callus hotspots. The factors associated with callus hotspots were number of calluses (Adjusted odds ratio (aOR): 1.540, P = .003), static forefoot peak plantar pressure (SFPPP) (aOR: 1.008, P = .001), and body mass index (aOR: 0.912, P = .029). Conclusions: Patients with a higher SFPPP were more likely to have callus hotspots suggesting that SFPPP might contribute to callus inflammation. SFPPP has the potential to be a useful predictor of callus hotspots in people with diabetes and at the same time provide information for off-loading interventions to prevent callus hotspots.

The COVID-19 pandemic has led to disruptions in health care in the perinatal period and women's childbirth experiences. Organizations that represent health care professionals have responded with general practice guidelines for pregnant women, but limited attention has been devoted to mental health in the perinatal period during a pandemic. Evidence suggests that in this context, significant psychological distress may have the potential for long-term psychological harm for mothers and infants. For infants, this risk may extend into early childhood. In this commentary, we present recommendations for practice, research, and policy related to mental health in the perinatal period. These recommendations include the use of a trauma-informed framework to promote social support and infant attachment, use of technology and telehealth, and assessment for mental health needs and experiences of violence.

Physical activity (PA) naturally declines during pregnancy and its effects on infant size are unclear, especially in overweight or obese pregnancies, a low-active subpopulation that tends deliver heavier infants. The objective of this study was to evaluate changes in prenatal PA and infant birthweight in a group of overweight or obese pregnant women. We employed a prospective analysis using data from a randomized controlled exercise trial (2001 to 2006) in sedentary, overweight or obese pregnant women in Michigan. Women with complete data on peak oxygen consumption, daily PA (via pedometers) and birthweight were included in the analyses. Change in PA was estimated via repeated measures analyses, and then its influence on infant birthweight was assessed via linear regression. Eighty-nine pregnant women were included and considered low-active (6,579.91 ± 2379.17 steps/day). PA declined from months 4 to 8 (−399.73 ± 371.38 steps∙day(−1)∙month(−1)). Analyses showed that the decline in PA (β= −0.28 g, 95%CI: −0.70, 0.25 g, p=0.35) was not associated with birthweight. The findings of this study demonstrated that the decline in maternal PA during mid- to late-pregnancy, in overweight or obese women, was unrelated to infant birthweight. Future investigations should employ rigorous measurements of PA and infant anthropometry in this subpopulation.

Background: Existing evidence on the effects of race and ethnicity on pregnancy outcomes is restricted to individual studies done within specific countries and health systems. We aimed to assess the impact of race and ethnicity on perinatal outcomes in high-income and upper-middle-income countries, and to ascertain whether the magnitude of disparities, if any, varied across geographical regions. Methods: For this individual participant data (IPD) meta-analysis we used data from the International Prediction of Pregnancy Complications (IPPIC) Network of studies on pregnancy complications; the full dataset comprised 94 studies, 53 countries, and 4 539 640 pregnancies. We included studies that reported perinatal outcomes (neonatal death, stillbirth, preterm birth, and small-for-gestational-age babies) in at least two racial or ethnic groups (White, Black, south Asian, Hispanic, or other). For our two-step random-effects IPD meta-analysis, we did multiple imputations for confounder variables (maternal age, BMI, parity, and level of maternal education) selected with a directed acyclic graph. The primary outcomes were neonatal mortality and stillbirth. Secondary outcomes were preterm birth and a small-for-gestational-age baby. We estimated the association of race and ethnicity with perinatal outcomes using a multivariate logistic regression model and reported this association with odds ratios (ORs) and 95% CIs. We also did a subgroup analysis of studies by geographical region. Findings: 51 studies from 20 high-income and upper-middle-income countries, comprising 2 198 655 pregnancies, were eligible for inclusion in this IPD meta-analysis. Neonatal death was twice as likely in babies born to Black women than in babies born to White women (OR 2·00, 95% CI 1·44–2·78), as was stillbirth (2·16, 1·46–3·19), and babies born to Black women were at increased risk of preterm birth (1·65, 1·46–1·88) and being small for gestational age (1·39, 1·13–1·72). Babies of women categorised as Hispanic had a three-times increased risk of neonatal death (OR 3·34, 95% CI 2·77–4·02) than did those born to White women, and those born to south Asian women were at increased risk of preterm birth (OR 1·26, 95% CI 1·07–1·48) and being small for gestational age (1·61, 1·32–1·95). The effects of race and ethnicity on preterm birth and small-for-gestational-age babies did not vary across regions. Interpretation: Globally, among underserved groups, babies born to Black women had consistently poorer perinatal outcomes than White women after adjusting for maternal characteristics, although the risks varied for other groups. The effects of race and ethnicity on adverse perinatal outcomes did not vary by region. Funding: National Institute for Health and Care Research, Wellbeing of Women.

There is a lack of knowledge on the intersection between prematurity, small for gestational age, and hypertensive disorders of pregnancy (HDP). Therefore, the aim of this systematic review was to examine the outcomes of preterm infants who were small for gestational age born to women with HDP. Searches were conducted with no date restriction through the final search date of May 13, 2020, in the following databases: PubMed, Web of Science Core Collection, Cumulative Index of Nursing and Allied Health Literature Plus with Full Text (EBSCOhost), and Embase (Elsevier). A total of 6 studies were eligible for this review. The adjusted odds of mortality and necrotizing enterocolitis were significantly lower in the pregnancy-induced hypertension (PIH)/HDP group than in the non-PIH/HDP group. There was no significant difference in the odds of respiratory distress syndrome, bronchopulmonary dysplasia, and intraventricular hemorrhage between PIH/HDP and non-PIH/HDP groups. There was no significant difference between PIH/HDP and non-PIH/HDP groups in cystic periventricular leukomalacia, retinopathy of prematurity, late-onset sepsis, patent ductus arteriosus, length of hospital stays, duration of supplemental oxygen use, duration of mechanical ventilation, and continuous airway pressure. The studies included in this systematic review demonstrated that PIH/HDP is associated with lower infant mortality and necrotizing enterocolitis.

Yoga is a mind and body practice that includes relaxation, meditation, breathing exercises, and body postures. It can be effective in enhancing the functioning of several body systems, including the lower urinary tract. Normal lower urinary tract functioning depends in part on the coordination of the bladder, urethra, pelvic floor and other muscles, and the nerves that control them. Lower urinary tract dysfunction can lead to symptoms, that is, stress urinary incontinence (UI), urinary frequency, nocturia, urinary urgency with and without incontinence, and mixed UI. Recent evidence suggests that yoga can improve lower urinary tract symptoms (LUTS). Thus, we performed a scoping review of the literature with regard to the evidence for the effects of yoga on LUTS and factors that may mediate yoga's effects on LUTS with the goal to identify gaps in knowledge regarding the relationship between yoga practice and LUTS.The authors employed the PRISMA extension for Scoping Reviews (PRISMA-ScR) methodological approach, proposed by Tricco et al., by searching the electronic databases, PubMed, Embase, and PsycINFO, for articles using the following keywords: yoga, urinary incontinence, urinary tract, bladder, and urethra. We assessed the quality of the studies using the Joanna Briggs Institute Critical Appraisal Checklist.Of the 172 articles we found, 8 articles met the inclusion criteria and were reviewed. We found that, despite the use of different protocols, yoga may reduce certain LUTS by increasing the strength of pelvic floor muscle and/or regulating the autonomic nervous system and activating the central nervous system.Yoga is a noninvasive practice that may improve some LUTS. Rigorous studies are needed to determine the specific mechanisms through which yoga may affect LUTS.

Background Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk is needed to plan management. Objectives To assess the performance of existing pre-eclampsia prediction models and to develop and validate models for pre-eclampsia using individual participant data meta-analysis. We also estimated the prognostic value of individual markers. Design This was an individual participant data meta-analysis of cohort studies. Setting Source data from secondary and tertiary care. Predictors We identified predictors from systematic reviews, and prioritised for importance in an international survey. Primary outcomes Early-onset (delivery at Analysis We externally validated existing prediction models in UK cohorts and reported their performance in terms of discrimination and calibration. We developed and validated 12 new models based on clinical characteristics, clinical characteristics and biochemical markers, and clinical characteristics and ultrasound markers in the first and second trimesters. We summarised the data set-specific performance of each model using a random-effects meta-analysis. Discrimination was considered promising for C-statistics of ≥ 0.7, and calibration was considered good if the slope was near 1 and calibration-in-the-large was near 0. Heterogeneity was quantified using I 2 and τ2. A decision curve analysis was undertaken to determine the clinical utility (net benefit) of the models. We reported the unadjusted prognostic value of individual predictors for pre-eclampsia as odds ratios with 95% confidence and prediction intervals. Results The International Prediction of Pregnancy Complications network comprised 78 studies (3,570,993 singleton pregnancies) identified from systematic reviews of tests to predict pre-eclampsia. Twenty-four of the 131 published prediction models could be validated in 11 UK cohorts. Summary C-statistics were between 0.6 and 0.7 for most models, and calibration was generally poor owing to large between-study heterogeneity, suggesting model overfitting. The clinical utility of the models varied between showing net harm to showing minimal or no net benefit. The average discrimination for IPPIC models ranged between 0.68 and 0.83. This was highest for the second-trimester clinical characteristics and biochemical markers model to predict early-onset pre-eclampsia, and lowest for the first-trimester clinical characteristics models to predict any pre-eclampsia. Calibration performance was heterogeneous across studies. Net benefit was observed for International Prediction of Pregnancy Complications first and second-trimester clinical characteristics and clinical characteristics and biochemical markers models predicting any pre-eclampsia, when validated in singleton nulliparous women managed in the UK NHS. History of hypertension, parity, smoking, mode of conception, placental growth factor and uterine artery pulsatility index had the strongest unadjusted associations with pre-eclampsia. Limitations Variations in study population characteristics, type of predictors reported, too few events in some validation cohorts and the type of measurements contributed to heterogeneity in performance of the International Prediction of Pregnancy Complications models. Some published models were not validated because model predictors were unavailable in the individual participant data. Conclusion For models that could be validated, predictive performance was generally poor across data sets. Although the International Prediction of Pregnancy Complications models show good predictive performance on average, and in the singleton nulliparous population, heterogeneity in calibration performance is likely across settings. Future work Recalibration of model parameters within populations may improve calibration performance. Additional strong predictors need to be identified to improve model performance and consistency. Validation, including examination of calibration heterogeneity, is required for the models we could not validate. Study registration This study is registered as PROSPERO CRD42015029349. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 72. See the NIHR Journals Library website for further project information.

Background Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk during pregnancy is required to plan management. Although there are many published prediction models for pre-eclampsia, few have been validated in external data. Our objective was to externally validate published prediction models for pre-eclampsia using individual participant data (IPD) from UK studies, to evaluate whether any of the models can accurately predict the condition when used within the UK healthcare setting. Methods IPD from 11 UK cohort studies (217,415 pregnant women) within the International Prediction of Pregnancy Complications (IPPIC) pre-eclampsia network contributed to external validation of published prediction models, identified by systematic review. Cohorts that measured all predictor variables in at least one of the identified models and reported pre-eclampsia as an outcome were included for validation. We reported the model predictive performance as discrimination (C-statistic), calibration (calibration plots, calibration slope, calibration-in-the-large), and net benefit. Performance measures were estimated separately in each available study and then, where possible, combined across studies in a random-effects meta-analysis. Results Of 131 published models, 67 provided the full model equation and 24 could be validated in 11 UK cohorts. Most of the models showed modest discrimination with summary C-statistics between 0.6 and 0.7. The calibration of the predicted compared to observed risk was generally poor for most models with observed calibration slopes less than 1, indicating that predictions were generally too extreme, although confidence intervals were wide. There was large between-study heterogeneity in each model’s calibration-in-the-large, suggesting poor calibration of the predicted overall risk across populations. In a subset of models, the net benefit of using the models to inform clinical decisions appeared small and limited to probability thresholds between 5 and 7%. Conclusions The evaluated models had modest predictive performance, with key limitations such as poor calibration (likely due to overfitting in the original development datasets), substantial heterogeneity, and small net benefit across settings. The evidence to support the use of these prediction models for pre-eclampsia in clinical decision-making is limited. Any models that we could not validate should be examined in terms of their predictive performance, net benefit, and heterogeneity across multiple UK settings before consideration for use in practice. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Background: Chronic hypertension complicates birth outcomes. This secondary analysis of data from the North Carolina 2009-2011 Pregnancy Risks Assessment Monitoring System (PRAMS) examined factors associated with infant outcomes (preterm birth and small for gestational age) among women with hypertension before pregnancy to determine if the maternal age and race/ethnicity moderated the effect of preexisting hypertension on preterm birth and small for gestational age infants.Methods: We performed logistic regression to determine whether hypertension before pregnancy (HTN, n=292; non-HTN controls, n=2625), maternal age and race/ethnicity (Black vs Non-Black) and their interactions with hypertension before pregnancy predicted preterm birth and small for gestational age infants compared to normotensive women. Results: Results indicated that women with hypertension before pregnancy had significantly higher rates of preterm birth (29.8% vs. 21.3%) and small for gestational infants (23.0% vs. 17.9%) compared to non-HTN controls without adjusting for covariates. HTN had an effect on preterm birth that was independent of other maternal risk factors (aOR= 1.31) after adjusting for covariates . Being Black was associated with a greater likelihood of preterm birth (aOR=1.55). Conclusion: Hypertension before pregnancy is more likely to be associated Black race and with adverse birth outcomes. Black women are especially likely to experience poor birth outcomes. Continuous education to encourage all women and especially women of color and women with chronic illness to access preconception care is needed

BACKGROUND Previous studies have demonstrated that arterial stiffness is associated with lumbar flexibility (LF). Stretching exercise targeted to improve LF may have a beneficial effect on reducing arterial stiffness. OBJECTIVES We examined the effects of a single bout of a structured, static stretching exercise on arterial stiffness, LF, peripheral and central blood pressure (BP), and heart rate (HR) and tested the association between LF and central arterial stiffness. METHOD The study had a pretest-posttest design without a control group. Thirty healthy women followed a video demonstration of a 30-minute whole-body stretching exercise. Carotid-femoral pulse wave velocity (cf-PWV), augmentation index, LF, peripheral and central BP, and HR were measured before and after the stretching exercise. RESULTS One bout of a static stretching exercise significantly reduced cf-PWV (t29 = 2.708, P = .011) and HR (t29 = 7.160, P = .000) and increased LF (t29 = 12.248, P < .000). Augmentation index and peripheral and central BP also decreased but did not reach statistical significance. Despite no association found between cf-PWV and LF, the larger increase in LF the subjects had, the larger decrease in cf-PWV they had after exercise (r = 0.500, P = .005). CONCLUSIONS Study findings highlight the potential benefit of a static stretching exercise on central arterial stiffness, an independent predictor of cardiovascular morbidity. Static stretching exercise conducted in the sitting position may be used as an effective intervention to reduce cardiovascular risk after a cardiac event or for patients whose sympathetic function should not be overly activated or whose gaits are not stable.

Only a small proportion of research-tested interventions translate into broad-scale implementation in real world practice, and when they do, it often takes many years. Partnering with national and regional organizations is one strategies that researchers may apply to speed the translation of interventions into real-world practice. Through these partnerships, researchers can promote and distribute interventions to the audiences they want their interventions to reach. In this paper, we describe five nurse scientists' programs of research and their partnerships with networks of national, regional, and local organizations, including their initial formative work, activities to engage multi-level network partners, and lessons learned about partnership approaches to speeding broad-scale implementation.

Aim Trials on diet and physical activity in pregnancy report on various outcomes. We aimed to assess the variations in outcomes reported and their quality in trials on lifestyle interventions in pregnancy. Methods We searched major databases without language restrictions for randomized controlled trials on diet and physical activity-based interventions in pregnancy up to March 2015. Two independent reviewers undertook study selection and data extraction. We estimated the percentage of papers reporting ‘critically important’ and ‘important’ outcomes. We defined the quality of reporting as a proportion using a six-item questionnaire. Regression analysis was used to identify factors affecting this quality. Results Sixty-six randomized controlled trials were published in 78 papers (66 main, 12 secondary). Gestational diabetes (57.6%, 38/66), preterm birth (48.5%, 32/66) and cesarian section (60.6%, 40/66), were the commonly reported ‘critically important’ outcomes. Gestational weight gain (84.5%, 56/66) and birth weight (87.9%, 58/66) were reported in most papers, although not considered critically important. The median quality of reporting was 0.60 (interquartile range 0.25, 0.83) for a maximum score of one. Study and journal characteristics did not affect quality. Conclusion Many studies on lifestyle interventions in pregnancy do not report critically important outcomes, highlighting the need for core outcome set development.

Background Little evidence exists for effects of low-intensity exercises such as stretching on cardiovascular health in pregnant women. Aim Our aim was to evaluate the effect of a 20-minute stretching exercise on heart rate variability (HRV), blood pressure (BP), and heart rate (HR) in healthy pregnant women. Methods In 15 pregnant women with a mean (SD) age of 29.47 (4.07) years and mean (SD) gestational weeks of 26.53 (8.35), HRV, and BP were measured before and after the 20-minute stretching exercise. Results Compared with before the stretching exercise, standard deviation of the normal-to-normal intervals, total variability of heart rate, increased by 7.40 milliseconds (t = -2.31, P = .04) and root mean square of successive differences, a surrogate measure of parasympathetic outflow, also increased by 11.68 milliseconds (Z = -2.04, P = .04) after the stretching exercise. Diastolic BP and HR decreased by 2.13 mm Hg (t = 1.93, P = .07) and 3.31 bpm (t = 2.17, P = .05), respectively, but they did not reach statistical significance. Discussion These preliminary data suggest that 20 minutes of stretching exercise may promote cardiovascular health by attenuating the loss of parasympathetic tone associated with pregnancy.

Summary Lifestyle interventions targeting gestational weight gain (GWG) report varying degrees of success. To better understand factors influencing efficacy, we reviewed randomized trials specifically among obese and overweight pregnant women. Methods We conducted a systematic review and a meta-analysis of 32 studies with a pooled population of 5,869 overweight or obese pregnant women. Random effects models were fit to compute the weighted mean difference (WMD) in GWG between groups across studies. Subgroup analyses were conducted to compare intervention efficacy in overweight vs. obese pregnant women, and interventions delivered by prenatal care providers (PCPs) vs. non-PCPs during pregnancy. Moderator analyses ensured. Results Nine (28%) of 32 studies reported significant reductions in GWG in response to intervention. Of these, six (66%) of nine were delivered by PCPs. Overall, the WMD in GWG was −1.71 (95% confidence interval [CI]: −2.55, −0.86) kg. However, interventions delivered by PCPs yielded a significantly greater reduction in GWG compared to interventions delivered by non-PCPs (WMD = −3.88 kg; 95% CI: −7.01, −0.75 vs. -0.80 kg; 95% CI: −1.32, −0.28; p for difference = 0.005). Conclusion When PCPs counsel nutrition and physical activity, obese and overweight pregnant women have greater success meeting GWG targets and may be more motivated to modify their behaviour than with other modes of intervention deliveries.

ObjectivesTo identify if maternal educational attainment is a prognostic factor for gestational weight gain (GWG), and to determine the differential effects of lifestyle interventions (diet based, physical activity based or mixed approach) on GWG, stratified by educational attainment.DesignIndividual participant data meta-analysis using the previously established International Weight Management in Pregnancy (i-WIP) Collaborative Group database (https://iwipgroup.wixsite.com/collaboration). Preferred Reporting Items for Systematic reviews and Meta-Analysis of Individual Participant Data Statement guidelines were followed.Data sourcesMajor electronic databases, from inception to February 2017.Eligibility criteriaRandomised controlled trials on diet and physical activity-based interventions in pregnancy. Maternal educational attainment was required for inclusion and was categorised as higher education (≥tertiary) or lower education (≤secondary).Risk of biasCochrane risk of bias tool was used.Data synthesisPrinciple measures of effect were OR and regression coefficient.ResultsOf the 36 randomised controlled trials in the i-WIP database, 21 trials and 5183 pregnant women were included. Women with lower educational attainment had an increased risk of excessive (OR 1.182; 95% CI 1.008 to 1.385, p =0.039) and inadequate weight gain (OR 1.284; 95% CI 1.045 to 1.577, p =0.017). Among women with lower education, diet basedinterventions reduced risk of excessive weight gain (OR 0.515; 95% CI 0.339 to 0.785, p = 0.002) and inadequate weight gain (OR 0.504; 95% CI 0.288 to 0.884, p=0.017), and reduced kg/week gain (B −0.055; 95% CI −0.098 to −0.012, p=0.012). Mixed interventions reduced risk of excessive weight gain for women with lower education (OR 0.735; 95% CI 0.561 to 0.963, p=0.026). Among women with high education, diet based interventions reduced risk of excessive weight gain (OR 0.609; 95% CI 0.437 to 0.849, p=0.003), and mixed interventions reduced kg/week gain (B −0.053; 95% CI −0.069 to −0.037,pConclusionsPregnant women with lower education are at an increased risk of excessive and inadequate GWG. Diet based interventions seem the most appropriate choice for these women, and additional support through mixed interventions may also be beneficial.

Introduction The necessity of culturally competent Internet Cancer Support Groups (ICSGs) for ethnic minorities has recently been highlighted in order to increase its attractiveness and usage. The purpose of this study was to determine the preliminary efficacy of a culturally tailored registered-nurse-moderated ICSG for Asian American breast cancer survivors in enhancing the women’s breast cancer survivorship experience. Methods The study included two phases: (a) a usability test and an expert review; and (b) a randomized controlled pilot intervention study. The usability test was conducted among five Asian American breast cancer survivors using a one-month online forum, and the expert review was conducted among five experts using the Cognitive Walkthrough method. The randomized controlled pilot intervention study (a pre-test and post-test design) was conducted among 65 Asian American breast cancer survivors. The data were analysed using content analysis and descriptive and inferential statistics including the repeated ANOVA. Results All users and experts positively evaluated the program and provided their suggestions for the display, educational contents, and user-friendly structure. There were significant positive changes in the support care needs and physical and psychological symptoms ( p Discussion The findings supported the positive effects of ICSGs on support care needs, psychological and physical symptoms, and quality of life.

The purpose of this paper is to identify practical issues in Internet recruitment of racial/ethnic minorities by analyzing an Internet intervention study conducted with Asian American breast cancer survivors, and to propose directions for recruitment of racial/ethnic minorities for future Internet research. Six practical issues were identified: (a) a relatively fewer number of Internet communities/groups; (b) hindrances in establishing authenticity; (c) difficulties in gaining entrée from the webmasters or website owners of Internet communities/groups; (d) the necessity of racially/ethnically matched research team members; (e) flexibility required in recruitment strategies; and (f) strategies to overcome the low response rate.

Objective To examine health departments' (HD) capacity to adapt and implement an intervention to prevent excessive gestational weight gain. Design and Sample Seventy-seven stakeholders (nurses, nutritionists, social workers, health educators, health directors, and multilingual service providers) in nine HDs participated. A descriptive mixed methods approach was used to collect data at workshops held onsite to introduce the evidence-based intervention (EBI) and discuss its adaptation. Measures A survey was administered to assess the intervention's fit with the HDs context. Generalized logit mixed models were used to analyze the survey data. The discussions of adaptation were audiotaped and thematically analyzed to identify factors influencing implementation. Results The majority of stakeholders desired to participate in the training portion of the EBI, but they were reluctant to adopt it, and noted a lack of adequate resources. From the audiotaped narratives, three themes emerged: (1) Patient needs and resources, (2) Perception about adaptability of the EBI, and (3) The complexity of the EBI for pregnant populations. Conclusion Although the EBI was effective for low-income nonpregnant populations in southeastern regions, pregnancy and complex antenatal services make this intervention unrealistic to be adapted as a part of prenatal care at HDs.

Objective To develop maternal, fetal, and neonatal composite outcomes relevant to the evaluation of diet and lifestyle interventions in pregnancy by individual patient data (IPD) meta-analysis. Design Delphi survey. Setting The International Weight Management in Pregnancy (i-WIP) collaborative network. Sample Twenty-six researchers from the i-WIP collaborative network from 11 countries. Methods A two-generational Delphi survey involving members of the i-WIP collaborative network (26 members in 11 countries) was undertaken to prioritise the individual outcomes for their importance in clinical care. The final components of the composite outcomes were identified using pre-specified criteria. Main outcome measures Composite outcomes considered to be important for the evaluation of the effect of diet and lifestyle in pregnancy. Results Of the 36 maternal outcomes, nine were prioritised and the following were included in the final composite: pre-eclampsia or pregnancy-induced hypertension, gestational diabetes mellitus (GDM), elective or emergency caesarean section, and preterm delivery. Of the 27 fetal and neonatal outcomes, nine were further evaluated, with the final composite consisting of intrauterine death, small for gestational age, large for gestational age, and admission to a neonatal intensive care unit (NICU). Conclusions Our work has identified the components of maternal, fetal, and neonatal composite outcomes required for the assessment of diet and lifestyle interventions in pregnancy by IPD meta-analysis. Tweetable abstract Composite outcomes in IPD meta-analysis on diet and lifestyle in pregnancy. Tweetable abstract Composite outcomes in IPD meta-analysis on diet and lifestyle in pregnancy. This article includes Author Insights, a video abstract available at https://vimeo.com/148890226

Background: Preeclampsia is a leading cause of maternal morbidity and perinatal mortality. Manifestations include hypertension, proteinuria, and end-organ dysfunction in the latter half of pregnancy. The United States Preventive Services Task Force recommends low-dose aspirin as a modestly effective preventive treatment; however, no conclusive prevention is currently available. Moderate to vigorous physical activity is reported to reduce preeclampsia risk, but is increasingly difficult by the 3 rd trimester. Further, intense exercise may stimulate sympathetic overactivation, a precursor of late-onset (≥34 weeks gestation) preeclampsia associated with maternal obesity. Stretching exercise may be a feasible alternative to intense exercise, and more readily adopted by obese women at risk of late-onset preeclampsia. We hypothesized that stretching exercise would suppress sympathetic overactivity and enhance parasympathetic tone in pregnant women. Methods: Gravid women were recruited with informed consent for stretching exercise and cardiovascular testing during the 2 nd to 3 rd trimester of pregnancy. Exercises were standardized by video demonstration, and targeted 14 major muscle groups in the lower and upper extremities. Each muscle group was stretched for 20 seconds in 3 repetitions. Blood pressure, carotid-femoral pulse wave velocity (PWV), and heart rate variability (HRV) were acquired before and after stretching, with baseline values preceded by a 15 minute rest. Heart rate and HRV were averaged over 10 minute acquisitions. Total HRV variance was stratified into low frequency (LF; < 0.15 Hz) and high frequency (HF; ≥ 0 .15 Hz) domains, with HF reflecting parasympathetic nerve activity and LF dominated by sympathetic activity. Sympathovagal balance was estimated by the LF/HF ratio. Pre- and post-exercise measurements were compared by paired t-tests. Results: A total of 20 women consented to enrollment; all completed stretching exercise and cardiovascular testing without complications. On average, study participants were 32 years old, 27 weeks pregnant, and had a BMI of 29 kg/m 2 . Over a third (35%) had a BMI > 30 kg/m 2 . Significant reductions between pre- and post-exercise were observed for mean diastolic blood pressure (60 vs. 57 mmHg; p=0.02) and heart rate (78 vs. 75 bpm; p Conclusion: This pilot study demonstrates stretching exercise is well-tolerated by pregnant women in the 2 nd or 3 rd trimester, and may be a feasible prevention for obese women at risk of late-onset preeclampsia. A randomized controlled trial investigating outcomes of routine stretching exercise in pregnancy is warranted.

Background and objectives With an increasing number of racial/ethnic minorities in the U.S., nursing research frequently involves the use of multiple languages, especially to promote the understanding of educational materials related to nursing care. Furthermore, with a recent emphasis on innovation in health-related research, the use of technology is prominent in nursing research. However, practical issues in the use of multiple languages, especially in technology-based intervention studies, have rarely been reported and/or discussed in nursing literature. The purpose of this paper is to identify practical issues in conducting a technology-based intervention study using multiple languages among Asian American breast cancer survivors. Methods In a large-scale technology-based breast cancer intervention study, research team members wrote memos on issues in translation process and plausible reasons for the issues. Then, the memos and written records were analyzed using a content analysis. By using individual words as the unit of analysis, line-by-line coding was done, and idea categories representing practical issues were extracted from the codes. Results Six themes representing the practical issues were extracted. Issues were found in recruiting and retaining bilingual research team members; maintaining consistency in translation process; keeping cultural and conceptual equivalence; repeating IRB protocol modifications; finding and using existing translated versions; and arranging technological aspects related to electronic multiple-language versions. Conclusion The use of multiple languages in a technology-based intervention study is feasible. However, it is necessary to effectively manage unforeseen challenges through various strategies.

Introduction: Large-artery stiffness (i.e., aortic stiffness) is an independent predictor of hypertension which is a leading cause of excess cardiovascular morbidity and mortality. Carotid-femoral pulse wave velocity (cf-PWV) is considered the ‘gold-standard’ measure of arterial stiffness because it measures along the aorto-iliac pathway, which buffers blood pressure (BP) the most. While there is well-documented evidence on the health benefits of aerobic and resistance exercise, the information for the effect of stretching on aortic stiffness is limited. Previous studies have shown that arterial stiffness is associated with trunk flexibility. Stretching exercise targeted to improve flexibility may exert a beneficial effect on reducing aortic stiffness. Objectives: This study aimed to examine effects of a single bout of a structured static stretching exercise on aortic stiffness as well as trunk flexibility, blood pressure (BP), and heart rate (HR). Method: This study has a pretest-postest design without a control group. Thirty healthy women from the community were instructed to follow a video demonstration of a structured whole-body static stretching lasting 30 minutes. Each stretching was designed to improve range of motion and enhance flexibility in 10 body areas, and all stretching motions were performed in the sitting position. Aortic stiffness was measured by cf-PWV using the SphygmoCor system (AtCor medical, AU). Trunk Flexibility was measured by the sit and reach method. BP and HR were measured using the WelchAllyn Monitor (WelchAllyn, USA). Results: After stretching exercise, cf-PWV (m/s) was significantly reduced (M=6.93, SD=1.54 vs M=6.29, SD=1.17; t(29)=2.708, p =.011). In addition, HR (bpm) was significantly decreased (M=64.88, SD=6.29 vs M=61.77, SD=6.29; t(29) = 7.170, p=.000). A significant increase of lumbar flexibility (inches) was also detected (M=13.37, SD=4.3 vs M=16.45, SD=4.79; t(29) = 12.248, p=.000). Systolic BP and diastolic BP (mmHg) were decreased after stretching exercise from M=107.87 (SD 10.75) to M=106.82 (SD 12.48), from M=63.37 (SD 6.71) to M=61.88 (SD 6.47), respectively; however, the differences did not reach the statistical significance. Conclusions: Findings of the current study highlight the potential benefit of static stretching exercise on aortic stiffness independent of BP. The results also demonstrate that HR was significantly decreased after the stretching exercise. Given no sign of over-activity of sympathetic function, a structured static stretching exercise may be prescribed as an effective intervention to reduce aortic stiffness for the people with high risk of cardiac events. In addition, stretching motions that were conducted in the sitting position can be cautiously utilized as an effective intervention for stroke patients, post-surgery patients, and people who have unsteady walking.

Introduction: Large-artery stiffness is an independent predictor of hypertension which is a leading cause of excess cardiovascular morbidity and mortality. Carotid-femoral pulse wave velocity (cf-PWV) is considered the ‘gold-standard’ measure of arterial stiffness because it measures along the aorto-iliac pathway, which makes the largest contribution to the arterial buffering function. While there is well-documented evidence on the health benefits of aerobic and resistance exercise, the information for the effect of stretching on arterial stiffness is limited. Previous studies have shown that arterial stiffness is associated with trunk flexibility. Stretching exercise targeted to improve flexibility may exert a beneficial effect on reducing arterial stiffness. Purpose: This study aimed (1) to determine the association between trunk flexibility and arterial stiffness and (2) to examine whether one bout of stretching exercise will increase trunk flexibility and decrease arterial stiffness. Methods: Thirty healthy women (mean age = 44.37 years) were instructed to follow a 20-minute DVD demonstration of whole-body stretching. Before and after stretching, cf-PWV and trunk flexibility were measured by using the SphygmoCor system and by sit-and-reach test, respectively, as well as systolic and diastolic blood pressure (SBP and DBP) and heart rate (HR) by using a Welch Allyn Monitor. All data were measured after taking a 10-minute rest in a supine position. Results: cf-PWV was not related to trunk flexibility, however, cf-PWV was significantly decreased after stretching compared with before stretching (mean difference [MD]=.63, , p=.01). Trunk flexibility was also significantly increased after stretching (MD=-3.08, p=.00). Furthermore, while SBP and DBP did not change significantly, HR was significantly reduced after stretching compared with before stretching (MD=3.12, p=.00). Conclusions: Our results showed that one bout of stretching exercise had significant effects on reducing arterial stiffness and heart rate. Further testing of long-term effects of stretching exercise is warranted for development of preventative interventions to reduce arterial stiffness, an important subclinical biomarker of cardiovascular disease.

BackgroundDiet- and physical activity-based interventions in pregnancy have the potential to alter maternal and child outcomes.ObjectivesTo assess whether or not the effects of diet and lifestyle interventions vary in subgroups of women, based on maternal body mass index (BMI), age, parity, Caucasian ethnicity and underlying medical condition(s), by undertaking an individual patient data (IPD) meta-analysis. We also evaluated the association of gestational weight gain (GWG) with adverse pregnancy outcomes and assessed the cost-effectiveness of the interventions.Data sourcesMEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment database were searched from October 2013 to March 2015 (to update a previous search).Review methodsResearchers from the International Weight Management in Pregnancy Collaborative Network shared the primary data. For each intervention type and outcome, we performed a two-step IPD random-effects meta-analysis, for all women (except underweight) combined and for each subgroup of interest, to obtain summary estimates of effects and 95% confidence intervals (CIs), and synthesised the differences in effects between subgroups. In the first stage, we fitted a linear regression adjusted for baseline (for continuous outcomes) or a logistic regression model (for binary outcomes) in each study separately; estimates were combined across studies using random-effects meta-analysis models. We quantified the relationship between weight gain and complications, and undertook a decision-analytic model-based economic evaluation to assess the cost-effectiveness of the interventions.ResultsDiet and lifestyle interventions reduced GWG by an average of 0.70 kg (95% CI –0.92 to –0.48 kg; 33 studies, 9320 women). The effects on composite maternal outcome [summary odds ratio (OR) 0.90, 95% CI 0.79 to 1.03; 24 studies, 8852 women] and composite fetal/neonatal outcome (summary OR 0.94, 95% CI 0.83 to 1.08; 18 studies, 7981 women) were not significant. The effect did not vary with baseline BMI, age, ethnicity, parity or underlying medical conditions for GWG, and composite maternal and fetal outcomes. Lifestyle interventions reduce Caesarean sections (OR 0.91, 95% CI 0.83 to 0.99), but not other individual maternal outcomes such as gestational diabetes mellitus (OR 0.89, 95% CI 0.72 to 1.10), pre-eclampsia or pregnancy-induced hypertension (OR 0.95, 95% CI 0.78 to 1.16) and preterm birth (OR 0.94, 95% CI 0.78 to 1.13). There was no significant effect on fetal outcomes. The interventions were not cost-effective. GWG, including adherence to the Institute of Medicine-recommended targets, was not associated with a reduction in complications. Predictors of GWG were maternal age (summary estimate –0.10 kg, 95% CI –0.14 to –0.06 kg) and multiparity (summary estimate –0.73 kg, 95% CI –1.24 to –0.23 kg).LimitationsThe findings were limited by the lack of standardisation in the components of intervention, residual heterogeneity in effects across studies for most analyses and the unavailability of IPD in some studies.ConclusionDiet and lifestyle interventions in pregnancy are clinically effective in reducing GWG irrespective of risk factors, with no effects on composite maternal and fetal outcomes.Future workThe differential effects of lifestyle interventions on individual pregnancy outcomes need evaluation.Study registrationThis study is registered as PROSPERO CRD42013003804.FundingThe National Institute for Health Research Health Technology Assessment programme.

Chronic diseases continue to be disproportionately higher in Black women in comparison with other ethnic groups, with physical inactivity being linked to the growing incidences of many of these diseases. The review of the literature indicates that attitude which is shaped by beliefs, self-efficacy, and cultural factors is a key variable in promoting physical activity (PA) in Black adolescent girls. Specific aims of this review were to identify PA interventions designed specifically for adolescent girls, with an emphasis on Black adolescent girls, and to identify what factor promotes PA in this group. The long-term goal is to use the information from this review to design effective PA programs aimed at Black adolescent girls. Physical activity and fitness were improved in four of the interventions in this review that focused on enhanced self-efficacy, goal setting, social support, and measures aimed at changing attitudes. Overall, this review shows that more effective interventions targeting Black adolescent girls are needed that consider the cultural factors (beliefs, self-efficacy, and family dynamics) that shape one’s attitude toward being physically active.

Low-income women are at risk for excessive gestational weight gain. Inactive lifestyle and lack of regular moderate exercise may contribute to the risk of weight gain. This study was conducted to (1) determine the rate and characteristics of low-income pregnant women who exercised regularly and met the American College of Obstetricians and Gynecologists recommendation and (2) describe how these women spent time for other physical activities compared with those who did not exercise regularly. Medicaid-recipient or uninsured pregnant women (n = 816) were asked to complete a physical activity questionnaire at rural and urban county health departments located in North Carolina. Twenty percent of low-income women met the American College of Obstetricians and Gynecologists recommendation for moderate exercise (≥10 METs-h/wk [metabolic equivalent task-hours per week]). The women who met the recommendation spent 3 hours 45 minutes per week walking as exercise, whereas those who did not meet the recommendation spent 1 hour per week (P < .0001). Women who exercised regularly spent longer hours at work (4.25 vs. 1.75 hours per day; P = .019) and on household tasks (5.25 vs. 4.0 hours per day; P = .002) than women who did not exercise regularly. Time spent on domestic and occupation activities does not seem to prohibit low-income women from engaging in moderate exercise on a regular basis.

Objective To assess the psychometric properties of the Pregnancy Physical Activity Questionnaire (PPAQ) for women who read and speak Japanese. Design This longitudinal study used a self-report questionnaire and quantitative biometric and instrumental measurements (actigraph) to assess the reliability and criterion validity. Setting A university hospital in Tokyo, Japan. Participants Sixty-nine pregnant women living in Tokyo and its suburbs were recruited. Methods The test–retest reliability of the Japanese version of the Pregnancy Physical Activity Questionnaire (PPAQ-J) was evaluated through intraclass correlation coefficients (ICCs) between PPAQ-J results administered three times (at recruitment, 7 and 14 days later). Criterion validity was assessed by comparing results to actigraph measures using Spearman's correlation coefficients. Participants wore the actigraph over the 2-week research period. Data from 58 participants were analyzed for test–retest reliability. The data of 54 participants were used to analyze criterion validity. Results The ICCs for the first and second and for the first and third PPAQ-J questionnaires were ≥0.56 for total activity and activities broken down by intensity and type (in metabolic equivalents [METs] × hours/day). To evaluate criterion validity, Spearman's correlation coefficients were calculated between the first measurement of the PPAQ-J and three published cut-points used to classify actigraph data (minutes/day); correlations ranged from .02 to .35 for total activity, −.21 to −.25 for vigorous activity, −.09 to .38 for moderate activity, and .01 to .28 for light activity. Conclusion The PPAQ-J is a psychometrically sound and comprehensive measure of physical activity in pregnant Japanese women.

A high total homocysteine (tHcy) level during pregnancy is a risk factor for adverse perinatal outcomes, such as fetal growth restriction and preeclampsia. Caffeine is assumed to increase tHcy levels by acting as a vitamin B6 antagonist. The objective of this study was to examine a relationship between circulating tHcy levels and dietary caffeine and vitamin B6 intakes in pregnant Japanese women. A total of 321 healthy women with singleton pregnancies were recruited in metropolitan Tokyo, from June to December 2008, resulting in the final number included in the study as 254. Dietary caffeine intakes did not correlate with plasma tHcy levels. When we analyzed the data according to caffeinated beverages, caffeinated tea consumption was positively associated with plasma tHcy levels only among the women with a high intake of vitamin B6, after controlling for confounding factors (P = 0.029). No correlation between coffee consumption and plasma tHcy levels was found. Pregnant Japanese women might need to cut down the consumption of caffeinated tea as well as take sufficient vitamin B6 in order to prevent the tHcy levels from increasing.

Background and Objective: There is controversy on the psychological effects of postpartum exer- cise. The study aimed to evaluate the effective- ness of a postpartum exercise program on health- related quality of life and psychological well- being. Methods: We conducted a randomized controlled trial in Tokyo, Japan. The intervention groups participated in ball-exercise classes (week- ly exercise of 90 minutes for four weeks) at three months postpartum. The exercise class included the following: 1) greeting and warm-up; 2) aero- bic exercise involving bouncing on an exercise ball 55 or 65 cm in diameter; 3) rest and self- introduction; 4) stretching and cooling down. The primary outcome measure was health-relat- ed Quality of Life (QOL) assessed using the MOS Short-Form 36-Item Health Survey (SF-36v2). The secondary outcome measures were Rosen- berg Self-Esteem Scale (RSES) and Edinburgh Postnatal Depression Scale (EPDS) scores. The intervention group was compared to the control group at four months postpartum. Results: Of the 120 women screened, 110 women met the study criteria. Nine could not be included and the remaining 101 were allocated randomly into intervention and control groups (50 and 51 par- ticipants respectively). Analysis of covariance adjusting for baseline values indicated that the SF36 subscales of physical functioning (p = 0.018) and vitality (p = 0.016) significantly im- proved in the intervention group compared to the control group, although there were no signi- ficant differences between the groups in the SF36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. The RSES increased in the intervention group (p = 0.020) compared to the control group. No signi- ficant group differences were observed in EPDS scores. Conclusions: The postpartum exercise class program provided to healthy postpartum women appears to have contributed to promo- ting health-related QOL and self-esteem.

Objective: The primary research question for this study was: Do symptoms during pregnancy relate to the amount of physical activity undertaken by women at heightened risk for preeclampsia? Study Design: This is a secondary data analysis of prospective data collected from a randomized intervention study. Background: Physical activity during pregnancy reduces health risks, yet the majority of pregnant women are sedentary. Physical symptoms during pregnancy may be a barrier to activity. Given the ubiquity of symptoms in pregnancy, we identifi ed a need for more information regarding the link between symptoms and physical activity. Methods and Measures: The original study looked at the impact of 2 exercise routines on the incidence of preeclampsia: walking (n 64) and stretching (n 60). Our primary analysis evaluated the connection between self-reported symptoms and physical activity as measured by steps per day.

This double cohort study aimed to evaluate the effect of tailored dietary guidance for pregnant women on dietary intake, nutritional status, and infant birth weight. Healthy pregnant women were recruited at an antenatal clinic during two phases over 2 years. The historical controls were analyzed a year prior to the intervention group. In both groups, data were collected at 19-26 gestational weeks (baseline) and at 34-37 gestational weeks (outcome measurement). The intervention included the following: (a) assessments of maternal dietary nutritional intake using the brief self-administered diet history questionnaire, (b) individual feedback based on the assessments of maternal nutritional status, (c) tailored guidance for a healthy diet, (d) original cooking recipes, and (e) goal sharing. Mann-Whitney U test was used to compare the outcome data between the groups. Of the 378 eligible women, 309 women had follow-up questionnaire data. Blood samples were obtained from 202 women. Despite a lack of improvement in reported dietary intake, plasma eicosapentaenoic acid (p = .002), docosahexaenoic acid (p < .001), arachidonic acid (p < .001), and dihomo-gamma-linolenic acid (p < .001) concentrations as well as maternal weight gain (p = .019) were significantly higher in the intervention group. However, serum folate (p = .031) concentration was significantly lower in the intervention group, and there were no significant differences between the groups in 25-hydroxy vitamin D levels, blood count, average birth weight, and rate of low birth weight infants. Assessment-based tailored guidance individualized to maternal dietary intake might partially contribute to improved nutrition in pregnant women.