Prostate cancer is the most commonly diagnosed malignancy among US men. Men diagnosed with LPC, or cancer confined to the organ, are presented with many equally efficacious treatment options, such as radical prostatectomy surgery or radiation treatments, all with specific benefits and side effects. Clinicians often, respecting autonomy in decision making, provide information but do not prescribe therapy, leaving treatment decision-making to patients and families. Understanding these factors and conflicts can help clinicians better guide patient treatment decisions. The aims of this study are to: (1) summarize the specific factors men take into consideration when making the LPC treatment decision, and (2) to identify inherent conflicts of this decision-making process. Methodology included a content, conceptual, secondary data analysis of transcribed interviews from primary study of LPC decision-making.3 Concept categories were established through review of literature. Assessment of interview text using previously established translation rules ascertained factors and conflicts in LPC treatment decision process. These were summarized and corroborated with expert review. For the purpose of this study, factors have been categorized into absolute and relative factors. Analysis reveals that several inherent, multifaceted conflicts persist among these men. The conflicts that surfaced during secondary analysis of 31 individual interviews were thematically categorized into (1) fear of a reduction in quality of life, (2) time urgency, and (3) lack of trust in the physician. Interestingly, if men have had experiences with traumatic family medical histories, especially non-prostate cancer, they were particularly fearful of cancer spread, and some even expressed inaccurate perceptions about prostate cancer treatments. The most prominent conflict appeared to be a lack of trust in the physician and healthcare system, which is categorized further into four subthemes. Many of these conflicts stem from profound past experiences that may require a more comprehensive assessment by clinicians then what is done in a typical doctor visit. Future studies should focus on discovering realistic, cost-effective methods to address patient conflicts and fears. If clinicians wish to individualize care, knowing men heavily rely on personal factors, they must understand the uniqueness of a mans life experience will undoubtedly influence decision-making.

As the HIV/AIDS epidemic has entered the third decade, a gap remains regarding the uniqueness of women with disease. Although the course of HIV disease management has changed with the development of antiretroviral medications women were not initially in these medication trials. Therefore, much of what is known regarding womens adherence to these medications has been based upon research and clinical trials with HIV positive men. The purpose of this research was to examine selected psychological factors (depressive symptomatology, social support, and perceived stigma) and selected physiological factors (CD-4, viral load, HIV disease symptoms, and physical well-being) as predictors of self-reported adherence among women with HIV who were prescribed antiretroviral medications. In addition, this study examined the mediating effect of self-efficacy on the relationships between the selected psychological and physiological variables and self-reported adherence to antiretroviral medications. This convenience sample consisted of 44 HIV positive women. White subjects (55%) were women living in rural areas of eastern Ohio or western Pennsylvania. Approximately 80% of the women had a high school education or its equivalent; 30% of the women were married or in a significant relationship, 80% of the women reported their insurance as coming from public assistance, and most identified her disease exposure as being through heterosexual contact. Standard measures were used for data collection and a demographic measure. Within the larger study, a sample of ten women used the electronic event monitor (MEMS cap) for a period of 29 days. There were significant relationships between depressive symptomatology, perceived stigma, CD 4, HIV disease symptoms, and self-reported adherence. Self-efficacy beliefs had a mediating effect for depressive symptoms and CD 4 and self-reported adherence to antiretroviral medications. This study is one of the first to explore the relationship between perceived stigma and self-reported adherence to antiretroviral medications in women. For this study, ones self-efficacy beliefs mediated self-reported adherence to antiretroviral medications for women with depressive symptomatology.

Often considered the big little problem, postoperative nausea and vomiting (PONV) is a common surgical complication. Treatment of pain with opioids is the primary cause of PONV although other risk factors include female gender, non smoking status and history of PONV or motion sickness. Research has focused on medications to prevent or treat PONV, and risk factors that contribute to PONV. Genetics may also play a role. The purpose of this study was to explore the association of CYP2D6 and mu-opioid receptor genotypes with PONV in patients with single extremity fractures. Subjects (n=143), aged 18-70 were recruited for this exploratory, descriptive study. Informed consent was obtained. PONV was collected by self-report and chart audit. Saliva samples were collected for DNA extraction. Results of Taqman® allele discrimination were used to assign a CYP2D6 classification of poor metabolizer (PM), intermediate metabolizer (IM) extensive metabolizer (EM) and ultrarapid metabolizer (UM). Two SNPS of the mu-opioid receptor gene were analyzed, A118G and C17T by Polymerace Chain Reaction (PCR). Due to genetic differences within ethnic groups, only Caucasians (n=112) were included in the CYP2D6 analysis. The incidence of PONV in the PACU was 38%, increasing to 50% when assessed for 48 hours. CYP2D6 classification results were: 7 (6%) PM group; 34 (30%) IM group; 71 (63%), EM group; and no ultrarapid metabolizers. Gender and history of PONV were significant risk factors in this study (p<.05). There was a trend for age (p=.071), but smoking was not significant (p=.505). The CYP2D6 EM group served as the reference for binary logistic regression analysis which revealed a significant difference with the CYP2D6 PM group for presence of PONV (p =.003). The sample size for the mu-opioid receptor genotype analysis was 82, the genotype distribution was 58 (70%) AA or CC (wild type) and 24 (30%) polymorphism (AG, GG, CT, or TT were combined). No statistical differences were found in the mu-opioid receptor genotype groups for PONV. Ultimately personalized medicine will allow health care providers to treat all patients individually, so it is important for clinical genetic research to identify those risks that may lead to a negative outcome.

Obesity prevalence remains high for U.S. adults. Standardized behavioral treatment (SBT) has been demonstrated to be efficacious in achieving weight loss. Yet, an evaluation of the effectiveness of each behavioral strategy used in SBT is needed to optimize SBT and achieve improved long-term outcomes. This secondary analysis used baseline and 12-month data from a randomized clinical trial testing the effect of three different self-monitoring approaches (paper record [PR], personal digital assistant [PDA], and PDA with daily tailored feedback messages [PDA+FB]) on weight loss. Observed variable path analysis was used to examine the mediation effects of social problem solving and adherence to self-monitoring of diet and exercise in this trial. The group effect was evaluated considering two comparisons: 1) PDAs vs. PR, and 2) daily tailored feedback (DTF) vs. none. Self-monitoring adherence was measured by the proportion of weeks that participants adhered to dietary/exercise self-monitoring. Social problem solving was measured by the Social Problem Solving Inventory-Revised (SPSI-R). Cardiometabolic risk factors considered were waist circumference, systolic blood pressure [SBP], diastolic blood pressure [DBP], high-density lipoprotein [HDL], low-density lipoprotein [LDL], total cholesterol, triglycerides, and fasting glucose. The sample was predominantly white (78%) and female (85%). Adherence to self-monitoring of diet and exercise partially mediated the group effect (PDAs vs PR) on weight loss. Self-monitoring adherence also fully mediated the group effect (DTF vs none) on changes in weight, waist circumference, SBP, DBP, total cholesterol, HDL, LDL, and triglycerides. Social problem solving did not mediate any group effect. Weight loss mediated the effect of social problem solving and self-monitoring adherence on changes in cardiometabolic risk factors. In addition, psychometric analysis revealed that the SPSI-R had high internal consistency reliability and convergent and concurrent validity in our sample. Age, income, education, mental health, perceived stress, and barriers to healthy eating were associated with social problem solving. Future research examining the mechanism of social problem solving, adherence to self-monitoring of diet and exercise, and other behavioral factors used in SBT for obesity with longer follow-up in a larger sample is warranted to provide scientific evidence for optimizing SBT for the long-term.

Background: Haptoglobin (Hp) binds hemoglobin (Hgb), thereby inhibiting free radical production. It is presumed that Hp 2-2 genotype is associated with worse functional outcome after aneurysmal subarachnoid hemorrhage (aSAH) related to the weaker affinity for Hgb binding, decreased clearance of hemoglobin from the site of hemorrhage, and an associated increase in secondary injury with the alpha-2 allele. Objective: The objective is to describe the relationship between Hp genotype and mortality and gross functional outcome after aSAH. Methods: A total sample of 268 subjects was narrowed down to a sample of 193 Caucasian subjects (due to differences in allele frequency distribution among races), age 18-75 with a diagnosis of aSAH, Fisher Grade greater than or equal to 2, DNA and outcome data available and without pre-existing chronic neurologic disease/deficit were enrolled into an ongoing study (NR004339). Demographic and medical condition variables were extracted from medical records. Modified Rankin Score (MRS) and Glasgow Outcome Score (GOS) were assessed at 3, 6, 12, and 24 months after aSAH. Data analysis included univariate analysis as well as multivariate logistic regression analysis, controlling for covariates including age, sex, and severity of hemorrhage (Fisher grade). Results: The sample was primarily female (n=138; 71.5%) and Caucasian (n=237; 88.4%) with a mean age of 54.45 years. This sample was further narrowed down to include only subjects of Caucasian race due to differences in allele frequency distribution among other races previously published in literature. Haptoglobin 2-2 genotype was significantly correlated with MRS at 3 months post aSAH during univariate analysis (p=.04) and at 3 months after controlling for covariates in the multivariate logistic regression analysis (p=.05). Univariate analysis produced a significant (p=.02) relationship between subjects whose genotypes yielded at least one alpha-2 allele and development of cerebral vasospasm (CV). Subjects whose genotypes had only one alpha-2 allele were significantly (p=.01) associated with Fisher grade. Fisher grade and Hunt and Hess score were both significantly associated with poor outcomes on MRS at all four time periods. Age was significantly (p=.01) correlated with Hp 1-1 and Hp 1-2 genotypes; specifically, these patients were younger than those with Hp 2-2 genotype. After controlling for covariates, Fisher grade was the only covariate that maintained significance in predicting outcomes after aSAH at all four time periods. Conclusions: Subjects whose genotypes contain at least one alpha-2 allele more often had poor outcomes on MRS at 3 months post aSAH and were more likely to develop CV. Additionally, haptoglobin genotype can be used as predictor of gross functional outcome when measured using MRS at 3 months after aSAH. The Fisher grading scale and Hunt and Hess scoring system are both significantly useful for predicting outcomes (GOS, MRS, mortality) at all four time periods after aSAH.

Anxiety and agitation are experienced by critically ill patients frequently and produce management challenges for clinicians. The purpose of this study was to describe critically ill patients behaviors classified as anxious or agitated, clinician interpretation of these behavioral cues, and choice of interventions based on those interpretations. This qualitative secondary analysis used existing longitudinal data (observations, interviews, and medical records) from an ethnographic study of 30 critically ill patients who were weaning from prolonged mechanical ventilation, patient families and clinicians who cared for them. Each event of anxiety or agitation was analyzed using dimensional analysis techniques. Exploration of relationships of resulting themes and patterns using graphic displays led to development of the Anxiety Agitation in Critical Illness Model which describes patient physiological, behavioral and psychological responses to stimuli of anxiety and agitation; clinician assessment of symptoms of anxiety and agitation, and management strategies chosen by clinicians. Interaction was identified as the core process in which patients appraised the threat of stimuli. Clinician assessment of patient interaction guided assessment and management of anxiety and agitation. Clinicians observed and interpreted patient responses to stimuli using knowing the patient and attributions about anxiety and agitation. Two opposing or dialectic attributions were revealed: discrimination vs. generalization and anxiety as an expected response vs. a character flaw. Interventions were designed to modify the stimulus of anxiety or agitation and included physical comfort measures, distraction, supportive verbal strategies, and music. Withholding presence and withholding information was described by clinicians as strategies used when patient anxiety was associated with ventilator weaning. These interventions were called out of sight, out of mind and sneaking the wean. These were new and unexpected psychosocial interactions not described previously in the literature. Sedation was used to modify appraisal of or response to the stimulus. Sedation management was inconsistent and variable especially when anxiety was associated with ventilator weaning. This study provides a foundation for practice improvement by offering a comprehensive model and alternative considerations for interpretation and management of symptoms in the ICU. It suggests areas for additional study, specifically, social support, sedation and withholding information or presence.

The purpose of this study was to use the Leader-Member Exchange (LMX) perspective to examine the association of leadership with safety climate and adverse care outcomes. LMX posits that leaders engage in differentiated dyadic relationships with staff (members) and the quality of these relationships is an important predictor of employee attitudes, beliefs, and thus outcomes. Data for this multi-level cross-sectional study were obtained from 34 unit directors and their associated staff members (n=711) in a large academic medical center. Measures were the Agency for Healthcare Research Hospital Survey on Patient Safety Culture (safety climate), Leader-Member Exchange tool (differentiated relationship), staff characteristics and unit level data (characteristics and adverse outcomes) obtained from hospital information systems. Differentiated relationships were found between nursing leaders and their respective staff (p<.0001). LMX scores demonstrated significant variability both within (p<.0001) and among units (p=.004). Positive associations were observed with each safety climate dimension and LMX (p<.0001). Furthermore, a multivariate model of supervisor expectations and actions promoting safety (p<.0001), organizational learning-continuous improvement (p=0.54), unit teamwork (p=.001), and feedback and communication about error (p =.001) together predicted LMX. Significant differences in safety climate (p=.002) were found between units with high and low LMX scores in multivariate analysis, irrespective of patient care mix. Supervisor expectations and actions promoting safety (p<.001), organizational learning-continuous improvement (p=.034), communication openness (p=.027), feedback and communication about error (p=.012), and nonpunitive response to error (p=.005) were significant in univariate analysis. No associations were found between safety climate, staff member/unit level characteristics, LMX scores or adverse outcomes or for any interrelationships of these variables. These findings indicate high quality LMX relationships were associated with positive staff perceptions of safety behaviors. The observation of positive findings in all patient care units demonstrates LMX's potential applicability to broadly impact safety climate. High scoring units can be identified and used as exemplars. Future studies should test this concept in additional settings to confirm findings and examine how to develop and use LMX as a model to improve staff attitudes, safety behaviors, and patient care outcomes.

Background: Enrollment in cardiac rehabilitation programs (CR) is used to help patients with coronary artery disease alone (CAD) and diabetes mellitus plus coronary artery disease (T2DM+CAD) regain function after coronary artery bypass grafting (CABG), but T2DM+CAD patients show less functional improvement and lower CR adherence for unknown reasons. The Patient-by-Treatment Context Interaction in Disease Model may provide a framework for explaining how disease and intrapersonal factors impact outcomes of these patients. Objective: To explore potential differences in patient profiles and illness contextual factors between CAD and T2DM+CAD subjects at CR entry, and in adherence and outcomes at CR conclusion. Methods: This prospective descriptive pilot study recruited 51 CR subjects (27 CAD; 24 T2DM+CAD) and measured patient profiles (socio-demographics, personality traits, locus of control, coping, social support, exercise efficacy) and illness contextual factors (specific disease stage, illness severity, treatment complexity, comorbidities) at CR entry, and appointment and medication adherence, functional status and illness severity at CR conclusion, using questionnaires, point-of-care testing, and medical record information. Results: There were no statistically significant differences in patient profiles and illness contextual factors between the CAD and T2DM+CAD cohorts, but there were clinically meaningful trends regarding age and gender (T2DM+CAD younger and more female), profiles (CAD more conscientious; T2DM+CAD more adaptive coping, less exercise efficacy) and illness severity (T2DM+CAD fewer bypasses but lower ejection fraction, many CAD subjects were pre-diabetic). There were no statistically significant differences between cohorts in attendance, medication adherence and functional outcomes at CR conclusion, but the T2DM+CAD cohort reported need for more functional assistance at both time points; neither cohort improved their illness severity. Conclusions: Although patient profiles and illness contextual factors of CAD and T2DM+CAD subjects in a CR program were statistically similar, some clinically meaningful trends were noted that are worthy of future investigation to inform CR care.

Purpose: The purpose of this pilot study is to describe characteristics of hospitalized patients who experience a Medical Emergency Team activation in the Radiology Department (RD-MET) and their outcomes post RD-MET intervention. In addition, the study will compare the incidence of RD-MET to the incidence of MET activations occurring on general in-patient units of the same facility for the same time period. Theoretical Rationale: Failure-to-Rescue (FTR) or death of hospitalized patients following a complication is one hospital quality measure. Patient, nursing and organizational characteristics contribute to FTR. Patient instability always precedes FTR. Medical Emergency Teams (MET) activation can deploy critical-care providers to the unstable patients bedside, but nurses ability to detect instability and call the MET early improves outcomes. Particularly at risk for undetected instability are patients who require transport to the Radiology Department (RD). Little is known about the characteristics of patients who require MET activation while in the RD (RD-MET), factors associated with their nursing surveillance, and outcomes. Once known, modifiable characteristics could undergo intervention to improve outcomes. Methods: A descriptive comparative survey design pilot study will be conducted. We will 1) describe RD-MET patients in regard to their a) non-modifiable patient characteristics, b) modifiable patient characteristics, and c) modifiable surveillance characteristics, 2) determine differences in the characteristic profiles of patients who have poor outcomes post RD-MET (FTR [death before discharge], require higher care level post-MET) and patients with good outcomes (survive to discharge, return to same care level post-MET) and 3) compare the incidence of RD-MET to MET incidence on in-patient units in the same interval. Data will be obtained from the electronic medical record, Medical Emergency Database, and RD documentation. Analyses: The detailed descriptive analyses of the data, using standard descriptive summaries (e.g., means, standard deviation, percentiles, ranges and frequencies) and graphical techniques (e.g., histograms, scatter plots) will be used to describe the non-modifiable patient characteristics, modifiable patient characteristics and modifiable surveillance characteristics. The Student t-test, nonparametric test and/or chi-square test will be used as appropriate to compare the patient characteristics profile between two groups (patients with good outcome and patients with bad outcome). Logistic regression will be performed to identify predictors of patient at risk for poor outcomes post MET activation in the RD. The ratio of occurrence in the RD will be measured by the number of MET activations in the RD during the study period per 1000 RD in-patient admissions (procedures) during the study period. The ratio of occurrence in the general hospital population will be measured as the number of MET activations per 1000 hospital admissions. The chi-square test will be used to compare the difference of incidence rate between RD and general in-patient unit. Implications: Prospective identification of risk for instability and poor RD-MET outcomes will lead to development of targeted surveillance and educational interventions to improve safety and decrease FTR in the RD.

The purpose of this study was to develop and evaluate a comprehensive intervention fidelity monitoring plan for a web-based symptom management intervention for women with recurrent ovarian cancer, the nurse-delivered WRITE Symptoms intervention. Because the intervention was designed to be flexible and dynamic to meet the individual needs of each participant, a comprehensive monitoring plan was necessary to ensure internal validity of the trial evaluating the efficacy of WRITE Symptoms. The first phase of this study was the development of a fidelity instrument. The instrument development began with a review of fidelity literature and the underlying intervention theory to guide item selection and scaling. An iterative process was used to identify, develop, and refine the items for the instrument and the interventionist manual. Several rounds of expert review and item revision resulted in a preliminary instrument to be used in the initial evaluation process. A sample of five mock intervention sessions was used to evaluate inter-rater reliability for the instrument. Modifications were made to items with low reliability. The revised instrument contained 13 subscales with 54 items. The revised instrument was then evaluated using twenty completed interventions from the WRITE Symptoms RCT. Analyses included inter-rater reliability and two week intra-rater reliability. The instrument demonstrated acceptable psychometric properties. Inter-rater reliability based on weighted Kappa range from 0.47 to 1.00 and percentage of agreement (POA) range from 85 to 100 for each individual item. Intra-rater reliability was also good with weighted Kappa of 0.48 to 1.00 and POA of 85 to 100 for each individual item. An intervention fidelity-manual was developed to address two topics: (1) how to use the instrument to monitor fidelity of the nurse-delivered WRITE Symptoms intervention and (2) how to train raters to use the instrument. Finally, an analytic plan was proposed for understanding the influence of fidelity on intervention outcomes. Further research should address two questions: (1) is intervention fidelity a predictor of intervention outcomes and (2) what is the active ingredient of the nurse-delivered WRITE Symptoms intervention?