Publications

BACKGROUND: Hypotensive episodes detected by 24-hour ambulatory blood pressure (BP) monitoring capture daily cumulative hypotensive stress and could be clinically relevant to cognitive impairment, but this relationship remains unclear.

METHODS: We included participants from the Systolic Blood Pressure Intervention Trial (receiving intensive or standard BP treatment) who had 24-hour ambulatory BP monitoring measured near the 27-month visit and subsequent biannual cognitive assessments. We evaluated the associations of hypotensive episodes (defined as systolic BP drops of ≥20 mm Hg between 2 consecutive measurements that reached <100 mm Hg) and hypotensive duration (cumulative time of systolic BP <100 mm Hg) with subsequent cognitive function using adjusted linear mixed models. We further assessed 24-hour average BP and variability.

RESULTS: Among 842 participants with treated hypertension (mean age, 71±9 years; 29% women), the presence (versus absence) of recurrent hypotensive episodes (11%) was associated with lower digit symbol coding scores (difference in Z scores, -0.249 [95% CI, -0.380 to -0.119]) and faster declines (difference in Z score changes, -0.128 [95% CI, -0.231 to -0.026]). A consistent dose-response association was also observed for longer hypotensive duration with worse Montreal Cognitive Assessment and digit symbol coding scores. The association with digit symbol coding scores remained significant after further adjusting for 24-hour average BP and variability and was not observed for hypotension defined by clinic, orthostatic, or 24-hour average BP. Intensive BP treatment increased 24-hour hypotensive episodes and modified its association with the decline in digit symbol coding score.

CONCLUSION: Twenty-four-hour hypotensive episodes were associated with worse cognitive function, especially in processing speed, and could be a novel marker for optimal BP control and dementia prevention.

AIMS: The purpose of this integrative review was to identify effective diabetes self-management education and support for increasing adult primary care referrals, participation rates and improving health outcomes for persons with diabetes.

DESIGN: Integrative review.

METHODS: A systematic literature search of PubMed/MEDLINE, Embase and CINAHL was performed by applying the PRISMA guidelines. Following Whittemore and Knafl's method, 11 papers were included for review.

RESULTS: Integration of diabetes self-management education and support in primary care clinics and a multifaceted approach resulted in improved referral and participation rates, ameliorated glycated haemoglobin A1C and boosted patient, provider and staff satisfaction.

CONCLUSION: Patient-centred multifaceted interventions can boost current diabetes self-management education referrals and participation rates and enhance health outcomes for persons with diabetes. Nurses in their role as primary care providers, diabetes educators and clinic staff are well-positioned to undertake this intervention. Further investigation is needed to explore the impact of these interventions among individuals with type 1 diabetes, gestational diabetes and those living across various global regions.

IMPLICATIONS FOR PATIENT CARE: Along with other healthcare providers, nurses are qualified to advocate for, and lead programmes that increase referrals for persons with diabetes to improve health outcomes. Additionally, as primary care providers, nurse practitioners are well placed to positively impact the outcomes of individuals with diabetes by referring them to diabetes self-management education. Nurses, as diabetes educators, are well positioned to implement diabetes self-management education which can improve patient outcomes.

IMPACT: Improved referral of persons with diabetes to diabetes self-management education and increased participation have the propensity to contribute to the achievement of positive health outcomes for individuals living with Type 2 Diabetes.

PATIENT OR PUBLIC CONTRIBUTION: There is no patient or public contribution for this review.

RATIONALE: The chronic kidney disease (CKD) burden in the US varies by race/ethnicity. It was unclear whether nativity status influences these disparities. This study compared CKD prevalence by nativity status, race and ethnicity, and length of US residence.

STUDY DESIGN: Cross-sectional analysis.

SETTING/PARTICIPANTS: We drew a weighted sample of 13,636 adults representing 155,147,141 Hispanic, White, Black, and Asian adults from the pooled 2011-March 2020 National Health and Nutrition Examination Survey (NHANES), which included 155,147,141 US- and foreign-born adults.

EXPOSURES: Nativity (US- or foreign-born), race/ethnicity, and length of US residence.

OUTCOME: We defined CKD as eGFR <60mL/min/1.73m2 or a urinary albumin-to-creatinine ratio ≥30 mg/g.

ANALYTICAL APPROACH: Survey-weighted multivariable Poisson models estimated associations among nativity status, race, and ethnicity, length of US residence, and CKD, adjusting for covariates.

RESULTS: The prevalence of CKD among US-born adults was 14.0%, vs. 11.5% of foreign-born. Foreign-born adults were less likely to have CKD (prevalence rate ratio [PRR]: 0.75, 95% CI 0.60-0.93) than US-born adults, adjusting for age, sex, and socioeconomic factors. Black adults were more likely to have CKD than White adults (PRR: 1.44, 95% CI 1.23-1.68); this difference was greater among US-born adults (PRR: 1.48, 95% CI 1.25-1.76). Among Hispanic and Asian adults, age- and sex-adjusted prevalence of CKD increased with longer length of residence in the US.

CONCLUSIONS: There are clear CKD disparities related to nativity location and length of US residence, and these vary by race/ethnicity. Interventions addressing the unique challenges faced by populations most at risk for CKD, such as access to healthcare barriers and socioeconomic disparities, may help mitigate the burden of CKD and promote health equity.

BACKGROUND AND OBJECTIVES: Care partners are critical for making treatment decisions in persons living with dementia. However, identifying them is challenging, hindering the broader use of interventions, such as those using digital technologies. We aimed to (i) assess the feasibility of identifying and contacting care partners using electronic health record (EHR) systems, and (ii) elicit their perspectives on electronic interventions for deprescribing.

RESEARCH DESIGN AND METHODS: We systematically identified care partners of persons living with dementia ≥65 years of age via structured EHR data in a large healthcare system. Eligible care partners were contacted by patient portal (if they were an established proxy), mail, and phone to complete a survey.

RESULTS: Of 4,138 eligible persons living with dementia identified, 1,084 (26%) had a care partner name recorded in the EHR. Out of 259 (6%) with sufficient care partner contact information for outreach, 74 (29%) completed the survey. Among care partners, 62 (84%) reported being confident in managing dementia medications, 59 (80%) were willing to stop ≥1 medications, and 43 (58%) were very/extremely interested in using digital tools for decision-making.

DISCUSSION AND IMPLICATIONS: Despite the low percentage of care partners with sufficient contact information, reach rates were high for contacted care partners, suggesting feasibility for pragmatic system-level interventions. Most care partners showed great interest in using digital health tools for decision-making and managing medications. Therefore, electronic tools could help with identifying care partners and engaging them. However, scaling up interventions requires better care partner documentation or extracting information from free text.

OBJECTIVE: Breast cancer over-screening is common in older women. Messaging about breast cancer screening cessation may reduce over-screening but the broader informational environment often emphasizes screening continuation. We aimed to examine the effect of receiving consistent messages about breast cancer screening cessation versus conflicting messages (i.e., receiving messages about screening cessation and screening continuation from different sources).

METHODS: In a two-wave survey experiment with 3809 women 65 + years from a U.S. population-based online panel, we randomized participants to a) no messages, b) consistent messages promoting screening cessation, or c) conflicting messages - a message promoting screening continuation followed by a message promoting screening cessation.

RESULTS: The conflicting message group had significantly lower support for screening cessation in a hypothetical older woman (mean 3.87 [SD 2.00] on 7-point scale, 95 % CI 3.76-3.97) compared with the consistent message group (mean 4.17 [SD 1.99], 95 % CI 4.08-4.28), but was still significantly higher than the control group (mean 2.68 [SD 1.87], 95 % CI 2.54-2.82, p's < 0.001). Message effects on self-screening intentions were similar. Participants reported low rates of confusion, distrust or ambivalence.

CONCLUSIONS: Messaging about screening cessation can significantly increase older women's support for screening cessation, with low rates of negative reactions, even if there are competing messages on continued screening.

PRACTICE IMPLICATIONS: Messaging about screening cessation can be incorporated into clinical discussions or used in conjunction with other interventions aimed at reducing over-screening.

OBJECTIVE: Although the adverse effects of excessive alcohol consumption are well established, the association between light to moderate alcohol consumption (≤30 g ethanol per day) and risk of type 2 diabetes (T2D) remains controversial and holds substantial public health implications. We aimed to examine the association of total alcohol intake and drinking pattern with T2D among three cohorts, Nurses' Health Study (NHS), Nurses' Health Study II (NHSII), and Health Professionals Follow-up Study (HPFS).

RESEARCH DESIGN AND METHODS: Former regular drinkers were excluded from baseline nondrinkers. Hazard ratios (HRs) and 95% CIs were estimated by Cox models.

RESULTS: Over 3 decades of follow-up, 20,551 T2D cases were documented among 200,969 participants. Total alcohol intake was associated with a lower risk of T2D, either using nondrinkers or 0.1-4.9 g/day as the reference. The association was robust to extended latency periods and alternative modeling of exposure. Drinking frequency was associated with a lower T2D risk. For example, compared with drinking 1-2 days per week, the HRs (95% CIs) for drinking 5-6 days were 0.73 (0.65, 0.83), 0.73 (0.62, 0.86), and 0.76 (0.67, 0.86) in the NHS, NHSII, and HPFS cohorts, respectively. When modeled jointly, the lower risk of T2D among drinkers was primarily driven by the drinking frequency. The inverse association began at drinking 1-2 days per week in women and 3-4 days per week in men and was strongest for ≥5 days per week, regardless of drinking <10 g or ≥30 g per drinking day.

CONCLUSIONS: Light to moderate alcohol consumption, especially regular light drinking, was associated with a lower risk of T2D in both men and women.

BACKGROUND: Bedside whiteboards are ubiquitous fixtures in hospitalized patients' rooms and present unique, low-cost opportunities to improve patient care. Specifically, bedside whiteboards may enhance communication practices, safety standards, and patient education. Despite their commonality at the bedside, the direct impact of whiteboards on patient care remains unclear.

OBJECTIVE: To perform a scoping review of medical literature to synthesize available evidence and identify gaps regarding the impact of bedside whiteboards on patient communication, safety, and education.

ELIGIBILITY CRITERIA: Published articles evaluating the impact of physical, patient-facing whiteboards on patient communication, safety, and education for adult patients hospitalized on medical-surgical floors and intensive care units.

SOURCES OF EVIDENCE: MEDLINE via PubMed, Google Scholar, Embase, Web of Science, and CINAHL databases.

CHARTING METHODS: We performed a scoping review using Mak and Thomas' Steps for Conducting a Scoping Review and PRISMA-ScR guidelines. Two reviewers independently performed database searches on relevant publications that evaluated the impact of whiteboard-based interventions on communication practices, safety standards, and patient education.

RESULTS: Thirteen articles were included in the final analysis. Studies were conducted on general medicine-specific units (n = 9, 69%) or medicine-surgery inpatient units (n = 3, 23%). Twelve of the 13 studies evaluated patient communication metrics, including provider identification (n = 9), patient engagement in care plan (n = 6), patient-provider communication (n = 3), interprofessional communication (n = 1), and discharge date estimation (n = 4). Six of these studies showed a statistically significant improvement in some aspect of patient communication. Patient safety metrics and education efforts were rarely included in whiteboard-based interventions, with only 2 studies exploring each aspect, respectively.

CONCLUSIONS: Most studies focused on whiteboards to facilitate patient communication, with 4 studies showing 6 statistically significant improvements. Our scoping review highlights a paucity of research evaluating how whiteboard-based interventions could enhance patient safety and education, and future studies are necessary to explore this potential.

OBJECTIVE: Neurosurgery is regarded as a meaningful career. However, there is no assessment of how many neurosurgeons hold this belief, factors that affect it, or the consequences that follow when neurosurgeons cannot practice in ways they find meaningful. We sought to quantify the neurosurgical experience of meaningful work, evaluate the impact of administrative burden, and relate meaningful work to physician attrition.

METHODS: An online survey investigating meaningful work, administrative burden, organizational commitment, and practice patterns was emailed to attending neurosurgeon members of the Congress of Neurological Surgeons.

RESULTS: 308 neurosurgeons completed the survey. 85.1% of neurosurgeons reported that they found their career to be meaningful; however, most also reported their administrative burden as excessive (59.4%). Over the past 10 years, 17.2% of neurosurgeons left a position due to excessive administrative burden. On multivariable analysis, increased burnout score correlated with increases in administrative hours outside of work (p = 0.0042), perception of excessive administrative burden (p = 0.0267), and willingness to leave a current position of employment (p = 0.0006). Rising administrative burden trended towards reduced experience of meaningful work (p = 0.062). A positive working relationship with their neurosurgical department enhanced meaningful work (p < 0.0017) and willingness to remain at place of employment (p = 0.0027).

CONCLUSION: The majority of neurosurgeons find neurosurgery to be a meaningful career. Critical to meaningful work is maintaining a good departmental working relationship and reducing administrative tasks. When neurosurgeons cannot practice their work meaningfully, they risk burnout. Organizations that do not invest in reducing their neurosurgical administrative burdens are at high risk for neurosurgeon attrition.

Circulating non-esterified fatty acids (NEFAs) have toxic effects on a variety of organs central to cardiometabolic disease and can cross the blood-brain barrier. Whether NEFAs associate with cognitive decline or dementia remains unknown. Circulating total NEFA levels were measured in 3242 participants without dementia among older adults of the Cardiovascular Health Study (CHS) and related to adjudicated dementia over 6 years (n = 456 cases) and annually assessed cognitive decline. For confirmation, we related circulating NEFAs to cognition assessed 10 years later among 4361 participants in the Multi-Ethnic Study of Atherosclerosis (MESA). In CHS participants, each SD higher NEFA levels were associated with a hazard ratio (HR) for all-cause dementia of 1.11 (95 % CI: 1.01; 1.22). Baseline NEFA levels were also associated with more rapid decline in cognition over 6 years of follow-up. In MESA, circulating NEFA measurements were associated with lower cognitive scores measured 10 years later.'