Publications by authors named "An-Lin Cheng"

76 Publications

Correlation Between Pharmacy Students' Implicit Bias Scores, Explicit Bias Scores, and Responses to Clinical Cases.

Am J Pharm Educ 2021 Jul 22:8587. Epub 2021 Jul 22.

University of Missouri - Kansas City, School of Pharmacy, Kansas City, Missouri.

The purpose of this study is to identify the extent of implicit and explicit bias in a sample of pharmacy students and to determine if there is an association between implicit bias, explicit bias, and responses to clinical cases. Investigators sent links to two online surveys to students. In the first survey, students responded to two clinical cases. Students were presented with a picture of a white or Black patient with each clinical case. Students indicated on the second survey their level of racial implicit bias as assessed by the Harvard Implicit Association Test and their level of racial explicit bias. Pearson's correlation was used to determine the correlation between bias and responses to the clinical cases. Three hundred and fifty-seven first, second, and third year of pharmacy students responded to both surveys (response rate 52%). The students presented with the picture of a Black patient rated the patient's pain and the reliability of the patient's family as higher than students presented with the picture of a white patient. Students had more negative implicit and explicit bias towards Black patients. Neither implicit nor explicit bias correlated with student responses to the clinical cases. Evidence of slight to moderate negative implicit bias and slight negative explicit bias towards Black patients does exist for pharmacy students. Future studies that include a more representative student population and heighten the stakes of the clinical scenario should be done to investigate a possible correlation between bias and clinical behaviors.
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http://dx.doi.org/10.5688/ajpe8587DOI Listing
July 2021

Effectiveness and safety of repeat dexamethasone for bronchopulmonary dysplasia.

J Perinatol 2021 Jun 8. Epub 2021 Jun 8.

Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO, USA.

Objective: To describe effectiveness of repeat dexamethasone for bronchopulmonary dysplasia (BPD) and to evaluate adverse effects on growth.

Study Design: Retrospective study of infants treated with 1 or 2 courses of dexamethasone for BPD. Effectiveness was defined as successful step-down in respiratory support by end of treatment. Adverse effects on growth were analyzed and compared to untreated controls.

Results: A total of 132 dexamethasone-treated infants were identified. In total, 52% (69/132) of infants treated with initial dexamethasone achieved step-down in respiratory support compared to 38% (20/52) of infants with repeat dexamethasone. Growth trajectory did not significantly differ among infants treated with 1 or 2 courses of dexamethasone compared with controls (weight: P = 0.23, length: P = 0.68, and head circumference: P = 0.77).

Conclusions: Repeat dexamethasone for BPD was less effective in weaning respiratory support compared to initial course. Changes in growth parameters to discharge were comparable between controls and infants treated with 1 or 2 dexamethasone courses.
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http://dx.doi.org/10.1038/s41372-021-01125-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184867PMC
June 2021

Platelet-Rich Plasma Centrifugation Changes Leukocyte Ratios.

Cureus 2021 Apr 13;13(4):e14470. Epub 2021 Apr 13.

Biomedical and Health Informatics, University of Missouri Kansas City School of Medicine, Kansas City, USA.

Platelet-rich plasma (PRP) is usually described with respect to its platelet concentration and sometimes the concentration of erythrocytes and leukocytes. In this study, we examined the numbers of leukocyte subtypes in PRPs prepared by five different methods. Single spin PRP methods evaluated resulted in a significant increase in the percentage of lymphocytes and proportional/inverse reduction of the percentage of granulocytes in comparison to those percentages found in whole blood. We propose that the centrifugation process traps the denser granulocytes in the RBC layer more readily than lymphocytes and that this will vary by g force and time. The PRP preparation method may be clinically relevant, because the distribution of leukocytes may affect clinical outcomes.
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http://dx.doi.org/10.7759/cureus.14470DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8115186PMC
April 2021

Sleep among Obstetrics and Gynecology Trainees: Results from a Yoga-Based Wellness Initiative.

Am J Perinatol 2021 May 3. Epub 2021 May 3.

Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri.

Objective:  This study aimed to determine the feasibility of using a wrist-based fitness tracking device to assess sleep among Obstetrics and Gynecology (OBGYN) trainees who engaged in a yoga-based wellness program. We also sought to evaluate the effects of yoga on sleep.

Study Design:  A quality improvement initiative consisting of an 8-week wellness program of weekly yoga classes, nutrition, and physical challenges was implemented for OBGYN residents and Maternal-Fetal Medicine fellows. The Polar A370 fitness tracker device was provided and synced to the Polar Flow for Coach program for inclusion. Data obtained included total and restful sleep from each night the device were worn. Pre- and post-assessment of the Pittsburg Sleep Quality Index (PSQI) were compared. Linear mixed models were used to estimate and test the effect of yoga on sleep while controlling for on-call shifts.

Results:  Of the 15 participants who synced their device, 13 (87%) were included for analysis. Sleep data from 572 nights were analyzed. The mean (SD) total sleep was 434.28 (110.03) minutes over the 8 weeks. A minimum of 7 hours (420 minutes) of total sleep occurred 59.3% of the time. After controlling for Friday or Saturday night on-call, those who attended yoga class had a significantly greater total sleep (yoga: 425.14 minutes [41.89], no yoga: 357.33 [43.04] minutes;  = 0.04). There was no significant change in the mean global PSQI score after the program (pre: 5.0 [1.6], post: 5.1 [2.5],  = 0.35).

Conclusion:  Wearable fitness monitors provide insight into sleep patterns displayed during training and can serve as a tool to identify those who are sleep deprived and assist in the evaluation of trainee wellness. Training programs are encouraged to provide access to yoga and mindfulness interventions to improve sleep and possibly clinical performance.

Key Points: · Yoga improves trainee sleep by approximately 60 minutes.. · Total and restful sleep are reduced during night float rotation.. · Trainees obtained 7 hours of sleep approximately 60% of the time..
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http://dx.doi.org/10.1055/s-0041-1728838DOI Listing
May 2021

Barriers and Challenges to Making Referrals for Treatment and Services for Opioid Misuse in Family Planning Settings.

J Womens Health (Larchmt) 2021 Apr 12. Epub 2021 Apr 12.

School of Nursing and Health Studies, University of Missouri Kansas City, Kansas City, Missouri, USA.

In this opioid overdose epidemic, women are an overlooked group seeing increasing rates of overdose death. Implementation challenges have prevented evidence-based interventions from effectively reaching women who misuse opioids, with gaps in access to effective treatment and services. Family planning clinics could serve as important points of contact for referral to needed treatments and services. The study explores how family planning staff knowledge and attitudes related to opioid misuse serve as potential barriers and challenges in making referrals for evidence-based services and treatments. In 2018, we conducted a national online survey of family planning staff, assessing knowledge and attitudes of treatments and services for opioid misuse. A total of 691 family planning staff completed the survey. Most respondents agreed that opioid misuse was a major problem in their community (86.0%) and identified challenges in responding to it, including a lack of treatment access (70.3%), the absence of in-house behavioral health staff (67.2%), and unfamiliarity with local treatment providers (54.1%). Respondents reported low levels of acceptability for syringe services programs (46.0%), medications such as methadone and buprenorphine (55.4%), and naloxone to reverse opioid overdose (60.1%). Controlling for other factors, race/ethnicity, urbanicity, workplace role, and substance use training were associated with differences in acceptability. Family planning settings could play a critical role in connecting women who misuse opioids to treatment and services. Strategies are needed to increase the acceptability of evidence-based interventions and the feasibility of having family planning staff play a linkage role.
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http://dx.doi.org/10.1089/jwh.2020.8761DOI Listing
April 2021

A Mixed-Methods Assessment of Health Care Providers' Knowledge, Attitudes, and Practices Around Fertility Awareness-Based Methods in Title X Clinics in the United States.

Womens Health Rep (New Rochelle) 2020 15;1(1):354-365. Epub 2020 Sep 15.

School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, USA.

To understand how Title X providers currently engage with fertility awareness-based methods (FABMs) for pregnancy prevention in Title X clinics across the United States. We developed a survey to assess knowledge of fertility for purposes of pregnancy prevention, attitudes toward FABMs use for pregnancy prevention, and practices when patients request FABMs for pregnancy prevention. In total, 329 participants who met all inclusion criteria completed the survey. Respondents were generally highly knowledgeable on fertility, felt neutrally toward FABMs or thought they were a nonviable option for most women, and were likely to respond to patient requests for FABMs for pregnancy prevention by providing information. Qualitative responses included several barriers to provision of FABMs for pregnancy prevention and few successes to provision. Fertility knowledge and discussion of specific methods increased with the number of methods included in the clinic's written materials or with the number of different FABMs someone at that clinic had been trained on. Significant clinician or administrative barriers may exist to offering FABMs to patients. Incorporating up-to-date information on a range of FABMs-rather than treating them as one method-into contraceptive counseling represents an opportunity to increase the contraceptive offering for clients who want them, leading to increased patient satisfaction and successful family planning outcomes.
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http://dx.doi.org/10.1089/whr.2020.0065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7784735PMC
September 2020

The Risk of Primary Uterine and Cervical Cancer After Hysteropexy.

Female Pelvic Med Reconstr Surg 2021 03;27(3):e493-e496

From the University of Missouri Kansas City School of Medicine, Kansas City, MO.

Objective: The aim of the study was to determine the rate of subsequent uterine/cervical cancer after hysteropexy compared with hysterectomy with apical prolapse repair.

Methods: The study used a retrospective cohort of women with uterovaginal prolapse using the Cerner Health Facts database between 2010 and 2018. We identified sacrospinous or uterosacral ligament suspensions or sacral colpopexy/hysteropexy and excluded those with previous hysterectomy. We used the International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes for endometrial cancer/hyperplasia and cervical cancer and then reviewed each case, excluding those whose cancer existed at time of prolapse repair. Given that 0 cancer cases were identified, we used Wilson, Jeffreys, Agresti-Coull, Clopper-Pearson, and Rule of 3 to define 95% confidence intervals to estimate the highest possible rate of cancer in each cohort.

Results: A total of 8,927 patients underwent apical prolapse surgery. Of 4,510 with uterovaginal prolapse, 755 (16.7%) underwent hysteropexy. Seventy one with hysterectomy and 5 with hysteropexy had codes for subsequent gynecologic cancer but were excluded on further review. This left 0 gynecologic cancer cases with the largest 95% confidence interval of 0%-0.61% for hysteropexy versus 0%-0.13% for hysterectomy (P > 0.05). The hysteropexy cohort was older (62.6 years vs 57.3 years, P < 0.0001), more likely to have public insurance (51.0% vs 37.9%, P < 0.0001), and less likely to smoke (4.5% vs 7.6%, P = 0.0026). Median follow-up was longer after hysteropexy (1,480 days vs 1,164 days, P < 0.0009).

Conclusions: We can say with 95% certainty that uterine or cervical cancer will develop after hysteropexy in fewer than 0.61% of women, which was not different if hysterectomy was performed. This should be included in preoperative counseling for hysteropexy. Studying longer follow-up after hysteropexy may capture more cases of subsequent cancer development.
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http://dx.doi.org/10.1097/SPV.0000000000001030DOI Listing
March 2021

Factors Associated with Late-Stage Breast Cancer Diagnosis in an Urban Safety-net Hospital.

J Health Care Poor Underserved 2020 ;31(3):1152-1165

Background: Late diagnosis of breast cancer is associated with lower survival. This study determines the factors associated with late-stage breast cancer diagnosis in an urban safety-net hospital (SNH) with excess late-stage disease.

Study Design: Single-institution retrospective study of all early-stage vs. late-stage breast cancer cases diagnosed or treated at the primary SNH in the Kansas City, Missouri area between January 2011-July 2018. Multiple logistic regression was performed to determine the variables that contributed most to late stage at diagnosis.

Results: The most significant factor associated with late-stage diagnosis was lack of screening mammogram within two years of diagnosis (p<.0001, OR 7.5, CI = 3.6, 15.3). Patients referred from within the SNH compared with those presenting from community health centers were significantly less likely to present with late-stage disease (p=.04, OR 0.50, CI = 0.25, 0.98).

Conclusions: Screening mammography ought to be actively promoted in SNH settings with excess late-stage diagnosis.
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http://dx.doi.org/10.1353/hpu.2020.0087DOI Listing
January 2020

Factors Associated with Late-Stage Breast Cancer Diagnosis in an Urban Safety-net Hospital.

J Health Care Poor Underserved 2020 ;31(3):1152-1165

Background: Late diagnosis of breast cancer is associated with lower survival. This study determines the factors associated with late-stage breast cancer diagnosis in an urban safety-net hospital (SNH) with excess late-stage disease.

Study Design: Single-institution retrospective study of all early-stage vs. late-stage breast cancer cases diagnosed or treated at the primary SNH in the Kansas City, Missouri area between January 2011-July 2018. Multiple logistic regression was performed to determine the variables that contributed most to late stage at diagnosis.

Results: The most significant factor associated with late-stage diagnosis was lack of screening mammogram within two years of diagnosis (p<.0001, OR 7.5, CI = 3.6, 15.3). Patients referred from within the SNH compared with those presenting from community health centers were significantly less likely to present with late-stage disease (p=.04, OR 0.50, CI = 0.25, 0.98).

Conclusions: Screening mammography ought to be actively promoted in SNH settings with excess late-stage diagnosis.
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http://dx.doi.org/10.1353/hpu.2020.0087DOI Listing
January 2020

Dextrose Prolotherapy Versus Lidocaine Injection for Temporomandibular Dysfunction: A Pragmatic Randomized Controlled Trial.

J Altern Complement Med 2020 Nov 11;26(11):1064-1073. Epub 2020 Aug 11.

Department of Family and Community Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA.

Several intraarticular injections, including dextrose and lidocaine, are reported to reduce pain and dysfunction in temporomandibular dysfunction (TMD) and increase maximal jaw opening; our goal was to determine whether dextrose/lidocaine outperforms sterile water/lidocaine for TMD. Pragmatic randomized controlled trial. Outpatient clinic. Chronic (≥3 months) of moderate-to-severe (≥6/10) jaw or facial pain meeting research-specific TMD criteria. Blinded intraarticular dextrose prolotherapy (DPT) (20% dextrose/0.2% lidocaine) versus intraarticular lidocaine (0.2% lidocaine in sterile water) at 0, 1, and 2 months. Participants were then unblinded and offered DPT by request for 9 additional months. Primary: Numerical Rating Scale (0-10 points) score for facial pain and jaw dysfunction; percentage achieving ≥50% improvement in pain and dysfunction (0, 3, and 12 months). Secondary: Maximal interincisal opening (MIO; 0 and 3 months). Intention-to-treat analysis was by joint using mixed-model regression. Randomization of 29 participants (25 female, 47 ± 17 years, 43 joints) produced similar groups. Three-month pain and dysfunction improvements were similar, but more DPT-treated joints improved by ≥50% in pain (17/22 vs. 6/21;  = 0.028). The MIO improved in both groups (5.6 ± 5.8 mm vs. 5.1 ± 7.0 mm;  = 0.70). From 3 to 12 months, minimal DPT was received by original DPT and lidocaine recipients, 0.5 ± 0.9 and 0.6 ± 1.5 injections, respectively, with only 2 out of 21 joints in the original lidocaine group receiving more than 1 dextrose injection after 3 months. Twelve-month analysis revealed that joints in the original DPT group improved more in jaw pain (4.8 ± 2.4 points vs. 2.6 ± 2.9 points;  = 0.026) and jaw dysfunction (5.3 ± 2.6 points vs. 2.7 ± 2.3 points;  = 0.013). More DPT than lidocaine-treated joints improved by ≥50% in both pain (19/22 vs. 5/21;  = 0.003) and dysfunction (17/22 vs. 7/21;  = 0.040). There were no adverse events; satisfaction was high. Intraarticular DPT resulted in clinically important and statistically significant improvement in pain and dysfunction at 12 months compared to lidocaine injection (ClinicalTrials.gov identifier NCT01617356).
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http://dx.doi.org/10.1089/acm.2020.0207DOI Listing
November 2020

Impact of Phone-Call and Access-Enhancing Intervention on Mammography Uptake among Primary Care Patients at an Urban Safety-Net Hospital: A Randomized Controlled Study.

Ann Surg Oncol 2020 Nov 21;27(12):4643-4649. Epub 2020 Jul 21.

Truman Medical Centers, Kansas City, MO, USA.

Background: Our urban safety-net hospital (SNH) has very low screening mammogram rates within its primary care clinics. Despite Commission on Cancer (CoC) accreditation, we see ~ 3 × more late-stage breast cancer diagnoses than other CoC sites across the country, and recently showed this to be strongly associated with lack of screening (Ahmadiyeh et al. in J Health Care Poor Underserved, in press, 2020). Here we study whether a two-step intervention (phone calls and assistance scheduling mammograms) increases uptake over usual care.

Patients And Methods: Randomized controlled study of 890 women aged 50-65 years who were due for biennial screening mammograms and who were established within one of five primary care clinics at an urban SNH. Each patient in the intervention group was called with overdue status (up to three times, voicemail left if needed) and offered assistance scheduling mammogram appointment. Mammography uptake at 3 and 6 months was analyzed.

Results: Intervention significantly increased uptake compared with usual care at both timepoints (18% versus 6% at 3 months; χ = 27.597, p < 0.0001; 23% versus 12% at 6 months; χ = 18.0, p < 0.0001), with scheduling component driving effectiveness. Of those who were successfully contacted, uptake was significantly greater among those who scheduled appointments versus those who did not (47% versus 9%, χ = 95, p < 0.0001), and uptake was no different between contacted but not scheduled patients and usual care controls.

Conclusions: Phone call with access-enhancing intervention (facilitating mammogram appointments) increased screening mammogram uptake among primary care patients in an urban safety-net setting and may be applicable to other urban SNHs around the country.
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http://dx.doi.org/10.1245/s10434-020-08884-xDOI Listing
November 2020

Variability in Price of Generic Antipsychotic Medications at Community Pharmacies.

Psychiatr Serv 2020 10 24;71(10):1005-1010. Epub 2020 Jun 24.

Division of Pharmacy Practice and Administration, School of Pharmacy (Kriz, Nelson, Sommi), and Department of Biomedical and Health Informatics, School of Medicine (Kriz, Venkitachalam, Allsworth, Cheng), University of Missouri-Kansas City, Kansas City; American Heart Association, Kansas City, Missouri (Venkitachalam).

Objective: This study aimed to examine variability in pricing of generic antipsychotic medications in a diverse metropolitan area and to determine whether prices varied by pharmacy type.

Methods: A cross-sectional survey was conducted of pharmacy-level variability in retail cash prices for a 30-day supply of one first-generation and five generically available second-generation antipsychotic medications at community pharmacies in the Kansas City metropolitan area. All community pharmacies in the area were identified (N=281), and 94% (N=265, with 147 in Missouri and 118 in Kansas) responded to phone queries between April 25 and May 25, 2017, requesting the cash price of a 30-day supply of each of the six antipsychotics. All included pharmacies were categorized as a nationwide chain (N=182), grocery store (N=53), or independent pharmacy (N=30).

Results: Retail cash prices varied for all antipsychotic medications, with significant differences in price by pharmacy type. Price variation across all pharmacy types was lowest for haloperidol ($20-$102.99) and highest for aripiprazole ($29.99-$1,345.00). Pairwise comparisons showed that chain pharmacies had higher prices, compared with independent pharmacies, for all medications except haloperidol. Overall, chain pharmacies had the highest prices, with prices at grocery store pharmacies averaging $180 lower than chain pharmacies, and independent pharmacies averaging $415 lower than chain pharmacies.

Conclusions: This report is the first on pharmacy-level variability in the costs of generic antipsychotic treatment options for schizophrenia. Appreciable differences were found in the costs of generic antipsychotics. Understanding variability in antipsychotic pricing may be important for providers serving uninsured patients.
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http://dx.doi.org/10.1176/appi.ps.201900319DOI Listing
October 2020

Online couples mindfulness-based intervention for young breast cancer survivors and their partners: A randomized-control trial.

J Psychosoc Oncol 2020 Sep-Oct;38(5):592-611. Epub 2020 Jun 19.

Department of Psychological Sciences, University of Missouri, Columbia, Missouri, USA.

Purpose: Young breast cancer survivors (YBCS) face unique challenges in coping with disease, distress, and relationship concerns. The purposes of this study were to understand the acceptability and feasibility of an online Mindfulness-Based Intervention (MBI) for YBCS and their partners (i.e., Couples Mindfulness-Based Intervention: C-MBI) and to compare the effectiveness of the C-MBI to a closely-matched control, an online MBI for individuals (I-MBI).

Methods: YBCS and their partners were recruited. Couples were randomly assigned to an 8-week C-MBI (couples = 41) or to I-MBI (couples = 36), which included one-hour video modules, a manual, and guided-meditation audios. Both couple members participated in the C-MBI; only the YBCS participated in the control I-MBI. Participants answered surveys about individual- and couple-level functioning at baseline and post-intervention.

Results: Online delivery was shown to be feasible and acceptable. For YBCS and their partners, levels of perceived stress, anxiety, depression, and fatigue were lower after the intervention, in both conditions. Unexpectedly, however, participating in the C-MBI appeared to have detrimental effects on dyadic adjustment and relationship quality.

Conclusion: Although YBCS and their partners reported online delivery was acceptable and benefited well-being, for couple-based MBIs to have benefits for relationship functioning, it may be necessary for couples to have the support of other couples and an instructor. Online delivery may be particularly acceptable and effective for clinical populations, including YBCS. Medical professionals may be more likely to recommend online-MBI programs to cancer survivors, because the programs are of little or no cost.
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http://dx.doi.org/10.1080/07347332.2020.1778150DOI Listing
June 2021

Risk Factors for Returning to the Operating Room for a Second Surgery After Midurethral Sling for Stress Urinary Incontinence.

Female Pelvic Med Reconstr Surg 2020 07;26(7):443-446

From the Department of Obstetrics and Gynecology, School of Medicine, University of Missouri Kansas City, Kansas City, MO.

Objectives: The objective of this study was to identify risk factors for having to return to the operating room for a second surgery after midurethral sling (MUS).

Methods: We used a case-control design. Cases return to operating room were a composite of 6 surgical complications or recurrent stress urinary incontinence because we believed that women would consider return to the operating room (OR) a similar MUS-related complication regardless of indication. Cases were obtained from Cerner Health Facts database, including 213 hospitals, using current procedural technology codes 57288 (repeat sling), 57287 (sling revision), and 53500 (urethrolysis) for procedures after index MUS. Controls no return to OR were randomly selected in 4:1 ratio from the remaining slings without these procedures. Multivariable regression analysis included all variables with P < 0.10 on univariable analysis.

Results: Between January 1, 2010, and December 31, 2016, 1247 patients returned to the OR of 17,953 patients who underwent initial MUS (6.9%). After adjusting for confounders, white race (OR, 1.47 [1.20-1.81]), lack of concomitant prolapse surgery (OR, 1.37 [1.18-1.59]), immunosuppressant drugs (OR, 1.27 [1.12-1.45]), and blood thinner use (OR, 1.38 [1.18-1.62]) significantly impacted the odds for returning to the OR. Anticholinergic use and smoking tobacco or marijuana, although significant on univariable analysis, were no longer significant after adjusting for confounders.

Conclusions: The rate of a second surgery after MUS using a composite outcome, over a 7-year period including multiple diagnoses, is 6.9%. White race, using immunosuppressant drugs, using blood thinners, and not having concomitant prolapse surgery are all risk factors for having second surgery after MUS.
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http://dx.doi.org/10.1097/SPV.0000000000000804DOI Listing
July 2020

Preoperative imaging characteristics predict poor survival and inadequate resection for left-sided pancreatic adenocarcinoma: a multi-institutional analysis.

HPB (Oxford) 2020 08 11;22(8):1216-1221. Epub 2020 Jan 11.

Virginia Mason Medical Center, Department of Surgery, 1100 9th Ave, Seattle, WA, 98101, USA.

Background: Optimal treatment of pancreatic ductal adenocarcinoma of the neck, body and tail (PDAC-NBT) necessitates R0 surgical resection. Preoperative radiographic identification of patients likely to achieve successful oncologic resection remains difficult. This study seeks to identify preoperative imaging characteristics predictive of non-R0 resections or impaired survival for PDAC-NBT.

Methods: Patients at five high-volume centers who underwent resection for PDAC-NBT were retrospectively analyzed. The most immediate preoperative cross-sectional scan was assessed along with outcome measures of overall survival and margin status.

Results: 330 patients were treated between 2001 and 2016. Margin status included 247 R0 (78.2%), 67 R1 (21.2%), and 2 R2 (0.6%). A non-R0 resection predicted worse survival (p = 0.0002). On preoperative imaging, patients with tumors greater than 20 mm, tumor attenuation greater than 70 Hounsfield units, or who demonstrated pancreatic atrophy and/or calcifications also had worse survival (p = 0.010, p = 0.036, p = 0.025 respectively). Patients with tumors interfacing with the splenic artery or vein or extending posteriorly achieved fewer R0 resections (p = 0.0006, p = 0.0004, p = 0.001, respectively).

Conclusion: Preoperative cross-sectional imaging can identify tumor characteristics associated with poor survival and non-R0 resection. Further investigation is needed to identify the appropriate surgical and treatment modifications necessary to clinically benefit this subset of patients.
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http://dx.doi.org/10.1016/j.hpb.2019.12.012DOI Listing
August 2020

Platelet yield and yield consistency for six single-spin methods of platelet rich plasma preparation.

Platelets 2020 Jul 9;31(5):661-666. Epub 2019 Sep 9.

Private Practice Physical Medicine and Rehabilitation , Roeland Park, Kansas, USA.

Single-spin methods of preparation of platelet-rich plasma are used widely in private practice, yet they have not been extensively studied and compared. The use of platelet-rich plasma (PRP) by the private practitioner can be facilitated by efficient and predictable PRP preparation. The primary purpose of this study was to study common methods of single-spin PRP preparation to determine their efficiency and variability. Six single-spin methods of PRP production from whole blood were analyzed. The primary measures were mean yield and standard deviation as the quotient of total platelet count in PRP produced divided by total platelet count in whole blood utilized. Each sample was analyzed in triplicate and the results were averaged. Secondary measures included red blood cell count (RBC) and white blood cell count (WBC), concentration ratio, and variable cost per million platelets produced. Sixty-four volunteers provided samples from 30 June 2017 to 30 September 2018. Seventeen to twenty six samples were utilized to assess each method. Yields for the six preparation methods (PMs) varied from 53(±18)% to 72(±13)%. Differences were observed for WBC count (1.8 to 14), Hematocrit (0.8 to 32), platelet concentration (568 to 1062), and variable cost per billion platelets produced ($1.55 to $44.31). All six methods evaluated provided a platelet yield of more than 50%, although two methods were less efficient than the others. Two methods were able to produce leukocyte-poor PRP. Variability was moderate across all methods, suggesting that estimation of platelet yield should be feasible from a baseline platelet count for all methods.
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http://dx.doi.org/10.1080/09537104.2019.1663808DOI Listing
July 2020

Leveraging the Electronic Medical Record to Identify Predictors of Nonattendance to a Diabetes Self-Management Education and Support Program.

Diabetes Educ 2019 10 5;45(5):544-552. Epub 2019 Sep 5.

Department of Internal Medicine and Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.

Purpose: The purpose of this study is to identify patient-specific factors, easily obtainable from the electronic medical record (EMR), that are associated with nonattendance to a group Diabetes Self-Management Education and Support (DSMES) program among an adult population with type 2 diabetes.

Methods: This study used a retrospective cohort design, with attendance to a group DSMES session as the primary outcome. The study included adult patients with diagnosed type 2 diabetes who were scheduled for a group DSMES session between March 1, 2013, and June 30, 2017. Patients who were pregnant or who had other types of diabetes (eg, type 1 diabetes, prediabetes, gestational diabetes) were excluded.

Results: A higher A1C, required copay for DSMES, low socioeconomic status, increased number of diabetes medications prescribed, the presence of a prescription for any insulin, and a higher calculated total daily dose of insulin were all associated with a decreased likelihood of attendance. Only older age was associated with an increased likelihood of attendance.

Conclusion: Using the EMR to identify patients who need more intensive intervention strategies can help programs direct resources to those who need them most. Having identified these at-risk individuals, a targeted communication and outreach strategy can be developed to assist these individuals with overcoming barriers to attending DSMES.
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http://dx.doi.org/10.1177/0145721719873066DOI Listing
October 2019

Peers Keep It Real: Re-engaging Adults in HIV Care.

J Int Assoc Provid AIDS Care 2019 Jan-Dec;18:2325958219838858

8 KU Medical Center, Kansas City, KS, USA.

Background: After diagnosis, a substantial number of people with HIV disease fall out of care. Effective interventions are needed for this priority population.

Methods: The "Peers Keep It Real" study aimed to help adults who were disengaged from HIV treatment. Peers, lay individuals living with HIV, facilitated intervention sessions. Participants were randomized to immediately receive the peer-facilitated intervention or were wait-listed.

Results: Considerable attrition occurred in the control group. Pre-/postanalyses showed that among participants (n = 23) who received the intervention, 65% had viral load suppression and 100% remained in care at 12 months postintervention. Impact on viral load was significant ( P = .0326), suggesting that peers are effective change agents who positively impacted outcomes for individuals struggling with adherence to HIV treatment.

Conclusion: Future endeavors should consider providing all individuals from this priority population with an active peer intervention from the onset to enhance retention and adherence.
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http://dx.doi.org/10.1177/2325958219838858DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748541PMC
June 2020

Treatment of Temporomandibular Dysfunction With Hypertonic Dextrose Injection (Prolotherapy): A Randomized Controlled Trial With Long-term Partial Crossover.

Mayo Clin Proc 2019 05 14;94(5):820-832. Epub 2019 Mar 14.

Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Objective: To assess the efficacy and longer-term effectiveness of dextrose prolotherapy injections in participants with temporomandibular dysfunction.

Patients And Methods: A randomized controlled trial with masked allocation was conducted from January 14, 2013, through December 19, 2015. Forty-two participants (with 54 joints) meeting temporomandibular dysfunction criteria were randomized (1:1) to 3 monthly intra-articular injections (20% dextrose/0.2% lidocaine or 0.2% lidocaine) followed by as-needed dextrose/0.2% lidocaine injections through 1 year. Primary and secondary outcome measures included a 0 to 10 Numerical Rating Scale score for facial pain and jaw dysfunction; maximal interincisal opening (MIO) measured in millimeters, percentage of joints with 50% or more change (improvement) in pain and function, and satisfaction.

Results: Randomization produced a control group with more female participants (P=.03), longer pain duration (P=.01), and less MIO (P=.01). Upon 3-month analysis, including pertinent covariates, dextrose group participants reported decreased jaw pain (4.3±2.9 points vs 1.8±2.7 points; P=.02), jaw dysfunction (3.5±2.8 points vs 1.0±2.1 points; P=.008), and improved MIO (1.5±4.1 mm vs -1.8±5.1 mm; P=.006). Control group participants received dextrose injections beginning at 3 months. No between-group differences were noted at 12 months; pooled data suggested that jaw pain, jaw function, and MIO improved by 5.2±2.7 points (68%), 4.1±2.8 points (64%), and 2.1±5.5 mm, respectively. Pain and dysfunction improved by at least 50% in 38 of 54 (70%) and 39 of 54 (72%) jaws, respectively.

Conclusion: Intra-articular dextrose injection (prolotherapy) resulted in substantial improvement in jaw pain, function, and MIO compared with masked control injection at 3 months; clinical improvements endured to 12 months. Satisfaction was high.

Trial Registration: clinicaltrials.gov Identifier: NCT01706172.
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http://dx.doi.org/10.1016/j.mayocp.2018.07.023DOI Listing
May 2019

Perceived Social Support Among Adults Struggling With Adherence to HIV Care and Treatment.

J Assoc Nurses AIDS Care 2019 May-Jun;30(3):362-371

Few studies have examined perceived social support among the subgroup of the HIV population that struggles with adherence to HIV care and treatment. A secondary analysis from 2 HIV medication adherence intervention studies was conducted using a mixed method design. Participants were not taking HIV medications as prescribed or had fallen out of HIV care. Two major themes emerged from the qualitative data analysis: extreme isolation and constant turmoil. Overall social support scores were low, as measured by the Medical Outcomes Study Social Support Survey. Convergent qualitative data excerpt corresponded with low scores on every dimension of the Medical Outcomes Study Social Support Survey. Findings from our study indicate that adults living with HIV who struggled with taking HIV medications lacked social support in many areas of their lives. Interventions that focus on perceptions of available social support may be helpful for individuals with ongoing HIV medication adherence challenges.
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http://dx.doi.org/10.1097/JNC.0000000000000059DOI Listing
June 2020

Serum Albumin Trend Is a Predictor of Mortality in ICU Patients With Sepsis.

Biol Res Nurs 2019 05 5;21(3):237-244. Epub 2019 Feb 5.

2 Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.

Introduction: Patients admitted to the hospital with sepsis are 8 times more likely to die than patients with other diagnoses. There is no diagnostic test that clearly identifies the presence of the dysregulated host response that is central to sepsis. Researchers have identified serum albumin as a possible predictor of mortality in a number of critically ill patient populations. However, these studies primarily focus on the levels on admission, neglecting the clinically significant decrease that occurs subsequently. The purpose of this study was to examine the relationship between the trend of serum albumin over time and mortality in adults admitted to the intensive care unit (ICU) with sepsis.

Methods: This retrospective, correlational study used existing medical record data. All patients admitted to the ICU at a Midwestern regional medical center with a primary sepsis diagnosis were included in the initial sample. Logistic regression analysis was used to assess the ability of serum albumin to predict mortality.

Results: Serum albumin trend, admission serum albumin level, and lowest serum albumin level were significant unique predictors of mortality. The probability of survival decreases by 70.6% when there is a strong negative trend in serum albumin level, by 63.4% when admission serum albumin is ≤2.45 g/dl, and by 76.4% when the lowest serum albumin is ≤1.45 g/dl.

Conclusion: Clinicians are encouraged to measure serum albumin levels in patients with sepsis. Low serum albumin levels and a strong negative trend in serial measurements should instigate aggressive monitoring and treatment in this population.
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http://dx.doi.org/10.1177/1099800419827600DOI Listing
May 2019

The Jonas Hypertension Program: An Academic-Community Partnership to Address Hypertension in Four Dominican Bateyes.

Hisp Health Care Int 2019 03 27;17(1):11-17. Epub 2018 Dec 27.

2 Dominican Republic Medical Partnership, Prairie Village, KS, USA.

Introduction: Adults living in bateyes (i.e., sugarcane plantation villages) in the Dominican Republic have minimal access to health care services. Hypertension (HTN) is a serious and often unrecognized health problem among batey residents. The Jonas Batey Hypertension Program was built on existing social networks to address the detection and treatment of HTN.

Methods: An ongoing community-based participatory research endeavor involves a partnership among three organizations and collaboration with promotoras who engage their batey communities in a mobile HTN screening and treatment program. Adults are screened and, if indicated, are treated with antihypertensive medications. Data collection includes project documentation, participant observation, demographic data, blood pressure (BP) measurements, and pill counts.

Results: To date, 243 adults have received HTN treatment in four batey communities. A within-group, as-treated, repeated-measures, pre-/postanalysis showed that among participants who had been receiving antihypertensive treatment for 12 months ( n = 70), there was a significant decrease in BP ( p < .005).

Conclusion: Results of an interim data analysis indicate that the program model has been implemented successfully and is making a positive impact on BP control. Evaluation is ongoing with regard to the long-term HTN-related health outcomes of batey residents. Ensuring program sustainability is an important consideration for the future.
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http://dx.doi.org/10.1177/1540415318819487DOI Listing
March 2019

Testing the efficacy of a scaffolded writing intervention with online degree-completion nursing students: A quasi-experimental design.

Nurse Educ Pract 2018 Sep 26;32:115-121. Epub 2018 Jun 26.

University of Missouri Kansas City School of Nursing and Health Studies, 2464 Charlotte St, Kansas City, MO, 64108, USA. Electronic address:

Writing should receive dedicated time in the nursing classroom for students to become competent writers, offering practical experiences for them to critically think and organize their ideas into meaningful messages. The purpose of this pre-post quasi-experimental study was to compare implementation of a scaffolded sequence of writing assignments (intervention) to typical writing assignments (comparison) in final coursework for baccalaureate nursing (BSN) completion students. Student writing self-efficacy and writing competency were measured pre and post coursework using the Post Secondary Writerly Self-Efficacy Scale, 6 + 1 Trait scale and Holistic scale. A convenience sample of 78 BSN-completion students at two Midwestern universities in the US were recruited to participate. The sample was primarily female (83%) and Caucasian (81%). There were no significant differences between the two groups on self-efficacy scores (p = 0.594). Significant group differences were noted on writing competency as assessed by the 6 + 1 Trait scale (p = 0.004) but not the Holistic scale (p = 0.024). No significant correlation between writing self-efficacy scores and writing competency were apparent (Holistic scale, p = 0.601; 6 + 1 Trait scale, p = 0.615). Writing skill-building needs attention to assure student competency. Educational interventions implemented in BSN education must be tested for efficacy and effectiveness.
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http://dx.doi.org/10.1016/j.nepr.2018.06.011DOI Listing
September 2018

High prevalence of comorbid autoimmune diseases in adults with type 1 diabetes from the HealthFacts database.

J Diabetes 2019 Apr 4;11(4):273-279. Epub 2018 Nov 4.

Department of Medicine, University of Missouri, Kansas City School of Medicine, Kansas City, Missouri.

Background: Patients with type 1 diabetes (T1D) are at risk for other autoimmune diseases (ie, polyautoimmunity). The prevalence and risk factors of this phenomenon have been underreported in adults and ethnic minorities, and data are lacking regarding non-endocrine autoimmune diseases.

Methods: Study population data were gathered from HealthFacts, a deidentified patient database compiled from electronic medical records systems in the US. Patients with an International Classification of Diseases diagnosis code specifying T1D were included in the study, whereas those with a diagnosis of type 2 diabetes were excluded.

Results: The cross-sectional study cohort comprised 158 865 adults with T1D (mean [±SD] age 51.4 ± 18.9 years, 52.5% female). The most common autoimmune diseases were thyroid disease (20.1%), systemic rheumatic diseases (3.4%), rheumatoid arthritis specifically (2.0%), and gastrointestinal autoimmune diseases (1.4%). Most of the autoimmune diseases were more common in women (eg hypothyroidism, hyperthyroidism, celiac disease, rheumatoid arthritis, lupus, and Sjögren syndrome). Caucasians were more likely than other ethnicities to have an additional autoimmune disease. The prevalence of autoimmune diseases increased with increasing age, significantly in women, such that 38.5% of women over 80 years of age had an additional autoimmune disease, compared with 17.9% of women aged ≤29 years.

Conclusions: Additional autoimmunity represents a significant comorbidity in patients with T1D. Autoimmune diseases are more common in Caucasians and in women, and increase with age. Clinicians treating patients with T1D should be aware of the risk factors for additional autoimmune diseases.
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http://dx.doi.org/10.1111/1753-0407.12856DOI Listing
April 2019

Analgesic Effect and Potential Cumulative Benefit from Caudal Epidural D5W in Consecutive Participants with Chronic Low-Back and Buttock/Leg Pain.

J Altern Complement Med 2018 Dec 8;24(12):1189-1196. Epub 2018 Jun 8.

Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI.

Chronic low-back pain (CLBP) participants in a prior controlled study reported short-term pain relief after caudal epidural injection of 5% dextrose (D5W). This study assessed whether repeated caudal epidural injections of D5W results in serial short-term diminution of CLBP and progressive long-term decrease in pain and disability. Prospective uncontrolled study. Outpatient pain clinic. Adults with CLBP with radiation to gluteal or leg areas. Caudal epidural injection of 10 mL of D5W (without anesthetic) every 2 weeks for four treatments and then as needed for 1 year. Numerical Rating Scale (NRS, pain, 0-10 points), Oswestry Disability Index (ODI, disability, %), and fraction of participants with ≥50% reduction in NRS score. Analysis by intention to treat. Participants ( = 32, 55 ± 9.8 years old, nine female) had moderate-to-severe CLBP (6.5 ± 1.2 NRS points) for 11.1 ± 10.8 years. They received 5.5 ± 2.9 caudal D5W injections through 12 months of follow-up. The data capture rate for analysis was 94% at 12 months for NRS and ODI outcome measures, with 6% carried forward by intention to treat. A consistent pattern of analgesia was demonstrated after D5W injection. Compared with baseline status, NRS and ODI scores improved by 3.4 ± 2.3 (52%) and 18.2 ± 16.4% (42%) points, respectively. The fraction of participants with 50% reduction in NRS-based pain was 21/32 (66%). Epidural D5W injection, in the absence of anesthetic, resulted in consistent postinjection analgesia and clinically significant improvement in pain and disability through 12 months for most participants. The consistent pattern postinjection analgesia suggests a potential sensorineural effect of dextrose on neurogenic pain.
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http://dx.doi.org/10.1089/acm.2018.0085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6308281PMC
December 2018

Transition from Deep Regional Blocks toward Deep Nerve Hydrodissection in the Upper Body and Torso: Method Description and Results from a Retrospective Chart Review of the Analgesic Effect of 5% Dextrose Water as the Primary Hydrodissection Injectate to Enhance Safety.

Biomed Res Int 2017 1;2017:7920438. Epub 2017 Oct 1.

Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.

Deep nerve hydrodissection uses fluid injection under pressure to purposely separate nerves from areas of suspected fascial compression, which are increasingly viewed as potential perpetuating factors in recalcitrant neuropathic pain/complex regional pain. The usage of 5% dextrose water (D5W) as a primary injectate for hydrodissection, with or without low dose anesthetic, could limit anesthetic-related toxicity. An analgesic effect of 5% dextrose water (D5W) upon perineural injection in patients with chronic neuropathic pain has recently been described. Here we describe ultrasound-guided methods for hydrodissection of deep nerve structures in the upper torso, including the stellate ganglion, brachial plexus, cervical nerve roots, and paravertebral spaces. We retrospectively reviewed the outcomes of 100 hydrodissection treatments in 26 consecutive cases with a neuropathic pain duration of 16 ± 12.2 months and the mean Numeric Pain Rating Scale (NPRS) 0-10 pain level of 8.3 ± 1.3. The mean percentage of analgesia during each treatment session involving D5W injection without anesthetic was 88.1%  ±  9.8%. The pretreatment Numeric Pain Rating Scale score of 8.3 ± 1.3 improved to 1.9 ± 0.9 at 2 months after the last treatment. Patients received 3.8 ± 2.6 treatments over 9.7 ± 7.8 months from the first treatment to the 2-month posttreatment follow-up. Pain improvement exceeded 50% in all cases and 75% in half. Our results confirm the analgesic effect of D5W injection and suggest that hydrodissection using D5W provides cumulative pain reduction.
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http://dx.doi.org/10.1155/2017/7920438DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684526PMC
July 2018

Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial.

Anesth Pain Med 2017 Feb 6;7(1):e42550. Epub 2016 Dec 6.

Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Court, Madison, Wisconsin, U.S A. 53715.

Background: Hypertonic dextrose injection (prolotherapy) is reported to reduce pain including non-surgical chronic low back pain (CLBP), and subcutaneous injection of 5% dextrose is reported to reduce neurogenic pain, hyperalgesia and allodynia. The mechanism in both cases is unclear, though a direct effect of dextrose on neurogenic pain has been proposed. This study assessed the short-term analgesic effects of epidural 5% dextrose injection compared with saline for non-surgical CLBP.

Methods: Randomized double-blind (injector, participant) controlled trial. Adults with moderate-to-severe non-surgical low back pain with radiation to gluteal or leg areas for at least 6 months received a single epidurogram-confirmed epidural injection of 10 mL of 5% dextrose or 0.9% saline using a published vertical caudal injection technique. The primary outcome was change in a numerical rating scale (NRS, 0 - 10 points) pain score between baseline and 15 minutes; and 2, 4, and 48 hours and 2 weeks post-injection. The secondary outcome was percentage of participants achieving 50% or more pain improvement at 4 hours.

Results And Conclusions: No baseline differences existed between groups; 35 participants (54 ± 10.7 years old; 11 female) with moderate-to-severe CLBP (6.7 ± 1.3 points) for 10.6 ± 10.5 years. Dextrose participants reported greater NRS pain score change at 15 minutes (4.4 ± 1.7 vs 2.4 ± 2.8 points; P = 0.015), 2 hours (4.6 ± 1.9 vs 1.8 ± 2.8 points; P = 0.001), 4 hours (4.6 ± 2.0 vs 1.4 ± 2.3 points; P < 0.001), and 48 hours (3.0 ± 2.3 vs 1.0 ± 2.1 points; P = 0.012), but not at 2 weeks (2.1 ± 2.9 vs 1.2 ± 2.4 points; P = 0.217). Eighty four percent (16/19) of dextrose recipients and 19% (3/16) of saline recipients reported ≥ 50% pain reduction at 4 hours (P < 0.001). These findings suggest a neurogenic effect of 5% dextrose on pain at the dorsal root level; waning pain control at 2 weeks suggests the need to assess the effect of serial dextrose epidural injections in a long-term study with robust outcome assessment.
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http://dx.doi.org/10.5812/aapm.42550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5554430PMC
February 2017

Resilience in Families of Children With Autism and Sleep Problems Using Mixed Methods.

J Pediatr Nurs 2017 Nov - Dec;37:e2-e9. Epub 2017 Sep 12.

University of Missouri-Kansas City, Kansas City, MO, USA. Electronic address:

Purpose: About 80% of children with autism spectrum disorder (ASD) have sleep problems that may disrupt optimal family functioning. We explored the impact of sleep problems on families' resilience.

Design And Methods: An explanatory sequential mixed methods design was used to discern whether resilience differed between families whose children with ASD have or do not have sleep problems, to seek predictors for family hardiness/resilience, and to determine whether narrative findings support, expand, or conflict quantitative findings.

Results: Seventy complete surveys were returned from parents of children with ASD to compare sleep and family functioning. Fifty-seven children had sleep problems and six interviews regarding eight of these children were conducted. Parents of children with ASD and sleep problems had lower levels of resilience than those who slept well. Predictors of hardiness were social support, coping-coherence (stress management), and lower strain scores. Qualitative content analysis revealed a journey analogy with themes: finding the trailhead, dual pathways, crossing paths and choosing travel companions, forging new paths, resting along the way, and seeing the vistas.

Conclusions: Qualitative findings supported quantitative findings regarding the impact of sleep problems but also expanded them by illustrating how families' resilience and children's socialization improved over time. Social support predicted family hardiness. Parents revealed that sleep issues contributed to family strains and described their progression to resilience and embracing their child.

Practice Implications: Findings support the need for community and provider advocacy and implicates a need for development of sleep interventions on behalf of families and children with ASD.
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http://dx.doi.org/10.1016/j.pedn.2017.08.030DOI Listing
July 2018
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