Publications by authors named "Christine M Schubert"

49 Publications

The Relationship between Pet Ownership, Social Support, and Internalizing Symptoms in Students from the First to Fourth Year of College.

Appl Dev Sci 2020 24;24(3):279-293. Epub 2018 Jul 24.

Departments of Psychology, African American Studies, and Human and Molecular Genetics, Virginia Commonwealth University.

Internalizing symptoms are prevalent in students as they enter and complete college. Considering research suggesting mental health benefits of pet ownership, this study explores the relationship between pet ownership, social support (SS), and internalizing symptoms (IS) in a cohort of students across their 4-year college experience. With no differences at college entry, students growing up with pets had greater IS through the fourth year, and greater SS through the third year, than those without pets. Currently living with a pet, gender, SS and personality predicted IS in the fourth year. Females experiencing higher IS in their first year are more likely to live with pets in their fourth year, and fourth year females living with pets or greatly missing absent pets have higher IS than females without pets or missing pets less. Findings suggest a unique relationship between IS in female students and their pet relationships not seen in males.
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http://dx.doi.org/10.1080/10888691.2018.1476148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394412PMC
July 2018

Author Response: Sacral Pressure Injury Study Commentary.

AORN J 2019 10;110(4):358

Georgia Baptist College of Nursing of Mercer University, Atlanta, GA.

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http://dx.doi.org/10.1002/aorn.12826DOI Listing
October 2019

Choosing between the BP and BN sequential strategies.

Pharm Stat 2019 10 8;18(5):533-545. Epub 2019 May 8.

Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Ohio.

Cost and burden of diagnostic testing may be reduced if fewer tests can be applied. Sequential testing involves selecting a sequence of tests, but only administering subsequent tests dependent on results of previous tests. This research provides guidance to choosing between single tests or the believe the positive (BP) and believe the negative (BN) sequential testing strategies, using accuracy (as measured by the Youden Index) as the primary determinant. Approximately 75% of the parameter combinations examined resulted in either BP or BN being recommended based on a higher accuracy at the optimal point. In about half of the scenarios BP was preferred, and the other half, BN, with the choice often a function of the value of the ratio of standard deviations of those without and with disease (b). Large values of b for the first test of the sequence tended to be associated with preference for BN as opposed to BP, while small values of b appear to favor BP. When there was no preference between sequences and/or single tests based on the Youden Index, cost of the sequence was considered. In this case, disease prevalence plays a large role in the selection of strategies, with lower values favoring BN and sometimes higher values favoring BP. The cost threshold for the sequential strategy to be preferred over a single, more accurate test, was often quite high. It appears that while sequential strategies most often increase diagnostic accuracy over a single test, sequential strategies are not always preferred.
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http://dx.doi.org/10.1002/pst.1945DOI Listing
October 2019

OR Time and Sacral Pressure Injuries in Critically Ill Surgical Patients.

AORN J 2019 02;109(2):229-239

Critically ill patients are at risk for developing pressure injuries during operative and other invasive procedures. The purpose of this secondary analysis was to explore the relationship of OR time to sacral pressure injuries in critically ill patients using high frequency ultrasound as a method of assessment. The 41 participants examined in this study had both time in the OR and up to eight days of pressure injury data. The multivariable model containing OR bed time, body mass index, and Braden Scale score produced the best prediction of pressure injury (area under the curve = 0.859). A higher body mass index (P = .09), shorter OR bed time (P = .01), and lower Braden Scale score (P = .05) were associated with a greater chance of pressure injury. These results suggest that use of high frequency ultrasound may identify tissue changes before observable skin changes, leading to earlier pressure injury prevention strategies.
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http://dx.doi.org/10.1002/aorn.12583DOI Listing
February 2019

Lack of Association of High Backrest With Sacral Tissue Changes in Adults Receiving Mechanical Ventilation.

Am J Crit Care 2018 03;27(2):104-113

Mary Jo Grap is Nursing Alumni Distinguished Professor and Ruth S. Burk is an assistant professor, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, Virginia Commonwealth University, Richmond, Virginia. Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University Health System, Richmond, Virginia. Cindy L. Munro is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio.

Background: Although higher backrest elevation may be a theoretical risk for integrity of sacral tissues, few data support use of high backrest elevation.

Objective: To describe the effect of backrest elevation on the integrity of sacral tissue in critically ill adults receiving mechanical ventilation.

Methods: Patients from 3 critical care units (surgical trauma, medical respiratory, and neuroscience) who were expected to have mechanical ventilation for at least 24 hours were intubated and mechanical ventilation was started. Participants were enrolled in the study within 24 hours of intubation. Backrest elevation was continuously measured by using mechanical system- based accelerometers. Integrity of sacral tissue was evaluated by using high-frequency sonography.

Results: Data for 84 patients who had measurements of both backrest elevation and skin integrity were available for analysis. General linear models indicated no significant difference among the proportions of time spent at less than 20° ( values: .57 the first 24 hours, .17 the first 48 hours, .81 the first 72 hours), 20° to 30° ( values: .25 the first 24 hours, .08 the first 48 hours, .25 the first 72 hours), or greater than 30° ( values: .62 the first 24 hours, .28 the first 48 hours, .68 the first 72 hours) among participants with no injury, no change in injury, improvement in injury, or injury that worsened.

Conclusions: Level of backrest elevation is not associated with changes in tissue integrity. Body positioning in critically ill patients receiving mechanical ventilation may not be as important or as effective as once thought.
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http://dx.doi.org/10.4037/ajcc2018419DOI Listing
March 2018

High-Frequency Ultrasound: Obtaining Optimal Images and the Effect of Image Artifacts on Image Quality.

Adv Wound Care (New Rochelle) 2017 Nov;6(11):383-391

Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio.

High-frequency ultrasound (HFUS) images are being researched for use in the prevention, detection, and monitoring of pressure injuries in patients at risk. This seminal longitudinal study in mechanically ventilated adults describes image quality, the incidence of image artifacts, and their effect on image quality in critically ill subjects. Mechanically ventilated subjects from three adult intensive care units were enrolled, and multiple sacral images from each subject were obtained daily. Using a subset of best image per patient per day, artifacts were grouped, and their effect on image quality was statistically evaluated. Of a total of 1761 images collected from 137 subjects, 8% were rated as poor. In the subset, 70% had good quality ratings. Four groups of artifacts were identified as follows: "bubbles," "texture problems," "layer nondifferentiation," and "reduced area for evaluation." Artifacts from at least one group were found in 83% of images. Bubbles were most frequently seen, but artifacts with adverse effect on image quality were "layer nondifferentiation," "texture problems," and "reduced area for evaluation." HFUS image evaluation is still in the development phase with respect to tissue injury use. Artifacts are generally omnipresent. Quickly recognizing artifacts that most significantly affect image quality during scanning will result in higher quality images for research and clinical applications. Good quality images were achievable in study units; although frequent artifacts were present in images, in general, they did not interfere with evaluation. Artifacts related to "layer nondifferentiation" was the greatest predictor of poor image quality, prompting operators to immediately rescan the area.
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http://dx.doi.org/10.1089/wound.2017.0727DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5665098PMC
November 2017

High-Frequency Ultrasound: Description of Sacral Tissue Characteristics in Healthy Adults.

J Wound Ostomy Continence Nurs 2017 Sep/Oct;44(5):434-439

Ruth S. Burk, PhD, RN, ANP-BC, Virginia Commonwealth University, Richmond. Christine M. Schubert, PhD, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Ohio. Anathea Pepperl, PhD, School of Engineering, Virginia Commonwealth University, Richmond. Mary Jo Grap, PhD, RN, FAAN, School of Nursing, Virginia Commonwealth University, Richmond.

Objectives: The purpose of this study was to describe selected sacral tissue characteristics in a convenience sample of healthy volunteer subjects.

Design: Descriptive.

Sample And Setting: Fifty healthy volunteers in a clinical learning center in a school of nursing.

Methods: Sacral scans were obtained using a 20-MHz ultrasound scanning system in 3 positions: prone and 60° and 90° side-lying from the back. The images were analyzed by software in the ultrasound program using quantitative parameters of dermal thickness and density (dermal median intensity and derived number of low-echogenic pixels to total pixels [LEP:TP] ratio).

Results: In general, average values were as follows: dermal thickness between 2.32 and 2.65 mm; median pixel intensity between 102 and 112; and the LEP:TP ratio between 0.39 and 0.56. There were significant differences in sacral tissue characteristics between measures of thickness and dermal density (median intensity and LEP:TP ratio) by subject side-lying position (60° and 90°) versus prone position, with all P values less than .0001.

Conclusions: Overall, the ranges were consistent across measures of thickness and dermal density except for systematic differences between side-lying and prone positions. When comparing thickness, median intensity, or LEP:TP ratio, it is important to report subject position. To best recognize tissue inflammation indicative of pressure injuries before surface changes are seen, it is useful to understand healthy high-frequency ultrasound sacral tissue characteristics. It is anticipated that quantitative assessment of dermal thickness, density, and LEP:TP ratio could help identify individuals with incipient pressure injury.
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http://dx.doi.org/10.1097/WON.0000000000000354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5587369PMC
November 2017

High frequency ultrasound sacral images in the critically ill: Tissue characteristics versus visual evaluation.

Intensive Crit Care Nurs 2017 Oct 6;42:62-67. Epub 2017 Mar 6.

University of South Florida, Tampa, FL, United States.

Purpose: High frequency ultrasound (HFUS) systems may identify tissue injury. We compared HFUS tissue characteristics (dermal thickness and dermal density) with visual image examination.

Methods: Longitudinal study in critically ill mechanically ventilated adults, from three ICUs (Surgical Trauma, Medical Respiratory, Neuroscience) enrolled within 24hours of airway intubation. Sacral HFUS images were obtained daily for up to seven days. Expert evaluation of the best image per day was completed and compared to HFUS generated tissue characteristics (dermal thickness and dermal density).

Results: Of the113 subjects with 1614 comparisons analysed, 73.2% to 84% were normal, and 6.3% to 11.8% of the comparisons had injury present but no change was noted in the injury observed. There were no significant differences in one-day comparisons among type of injury and mean dermal thickness (p=0.6645) or dermal median intensity (adjusted p=0.06-0.17). All other day-to-day comparisons were similarly non-significant.

Conclusions: We found no association among dermal density, dermal thickness and visual examination of changes in sacral HFUS images for any day-to-day comparison. The use of sacral HFUS as a screening tool for the development of tissue injury is in its infancy. Additional comparative studies should be conducted to identify its future clinical usefulness.
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http://dx.doi.org/10.1016/j.iccn.2017.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5585020PMC
October 2017

Tissue interface pressure and skin integrity in critically ill, mechanically ventilated patients.

Intensive Crit Care Nurs 2017 Feb 8;38:1-9. Epub 2016 Nov 8.

Department of Surgery, Virginia Commonwealth University Heath System, Richmond, VA, United States.

Objective: To describe tissue interface pressure, time spent above critical pressure levels and the effect on skin integrity at seven anatomical locations.

Design, Setting, Patients: Descriptive, longitudinal study in critically ill mechanically ventilated adults, from Surgical Trauma ICU-STICU; Medical Respiratory ICU-MRICU; Neuroscience ICU-NSICU in a Mid-Atlantic urban university medical centre. Subjects were enroled in the study within 24hours of intubation.

Measurements: Tissue interface pressure was measured continuously using the XSENSOR pressure mapping system (XSENSOR Technology Corporation, Calgary, Canada). Skin integrity was observed at all sites, twice daily, using the National Pressure Ulcer Advisory Panel staging system, for the first seven ICU days and at day 10 and 14.

Results: Of the 132 subjects, 90.9% had no observed changes in skin integrity. Maximum interface pressure was above 32mmHg virtually 100% of the time for the sacrum, left and right trochanter. At the 45mmHg level, the left and right trochanter had the greatest amount of time above this level (greater than 95% of the time), followed by the sacrum, left and right scapula, and the left and right heels. Similarly, at levels above 60mmHg, the same site order applied. For those six subjects with sacral skin integrity changes, maximum pressures were greater than 32mmHg 100% of the time. Four of the six sacral changes were associated with greater amounts of time above both 45mmHg and 60mmHg than the entire sample.

Conclusions: Maximum tissue interface pressure was above critical levels for the majority of the documented periods, especially in the sacrum, although few changes in skin integrity were documented. Time spent above critical levels for mean pressures were considerably less compared to maximum pressures. Maximum pressures may have reflected pressure spikes, but the large amount of time above the critical pressure levels remains substantial.
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http://dx.doi.org/10.1016/j.iccn.2016.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5641974PMC
February 2017

Backrest Elevation and Tissue Interface Pressure by Anatomical Location During Mechanical Ventilation.

Am J Crit Care 2016 05;25(3):e56-63

Mary Jo Grap is an emeritus professor and Ruth S. Burk is affiliate faculty, Adult Health and Nursing Systems Department, School of Nursing, Paul A. Wetzel is an associate professor and Anathea Pepperl is an assistant professor, Biomedical Engineering Department, School of Engineering, and Valentina Lucas is a nurse practitioner, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is a professor and associate dean, Research and Innovation, College of Nursing, University of South Florida, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio.

Background: Backrest elevations less than 30° are recommended to reduce pressure ulcers, but positions greater than 30° are recommended during mechanical ventilation to reduce risk for ventilator-associated pneumonia. Interface pressure may vary with level of backrest elevation and anatomical location (eg, sacrum, heels).

Objective: To describe backrest elevation and anatomical location and intensity of skin pressure across the body in patients receiving mechanical ventilation.

Methods: In a longitudinal study, patients from 3 adult intensive care units in a single institution receiving mechanical ventilation were enrolled within 24 hours of intubation from February 2010 through May 2012. Backrest elevation (by inclinometer) and pressure (by a pressure-mapping system) were measured continuously for 72 hours. Mean tissue interface pressure was determined for 7 anatomical areas: left and right scapula, left and right trochanter, sacrum, and left and right heel.

Results: Data on 133 patients were analyzed. For each 1° increase in backrest elevation, mean interface pressure decreased 0.09 to 0.42 mm Hg. For each unit increase in body mass index, mean trochanter pressure increased 0.22 to 0.24 mm Hg. Knee angle (lower extremity bent at the knee) and mobility were time-varying covariates in models of the relationship between backrest elevation and tissue interface pressure.

Conclusions: Individual factors such as patient movement and body mass index may be important elements related to risk for pressure ulcers and ventilator-associated pneumonia, and a more nuanced approach in which positioning decisions are tailored to optimize outcomes for individual patients appears warranted.
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http://dx.doi.org/10.4037/ajcc2016317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5539907PMC
May 2016

A nonparametric fiducial interval for the Youden index in multi-state diagnostic settings.

Stat Med 2016 Jan 16;35(1):78-96. Epub 2015 Aug 16.

Department of Mathematics and Statistics, Graduate School of Engineering and Management, Air Force Institute of Technology, 2950 Hobson Way, Wright-Patterson AFB, OH, 45433-7765, U.S.A.

The Youden index is a commonly employed metric to characterize the performance of a diagnostic test at its optimal point. For tests with three or more outcome classes, the Youden index has been extended; however, there are limited methods to compute a confidence interval (CI) about its value. Often, outcome classes are assumed to be normally distributed, which facilitates computational formulas for the CI bounds; however, many scenarios exist for which these assumptions cannot be made. In addition, many of these existing CI methods do not work well for small sample sizes. We propose a method to compute a nonparametric interval about the Youden index utilizing the fiducial argument. This fiducial interval ensures that CI coverage is met regardless of sample size, underlying distributional assumptions, or use of a complex classifier for diagnosis. Two alternate fiducial intervals are also considered. A simulation was conducted, which demonstrates the coverage and interval length for the proposed methods. Comparisons were made using no distributional assumptions on the outcome classes and for when outcomes were assumed to be normally distributed. In general, coverage probability was consistently met, and interval length was reasonable. The proposed fiducial method was also demonstrated in data examining biomarkers in subjects to predict diagnostic stages ranging from normal kidney function to chronic allograph nephropathy. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.
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http://dx.doi.org/10.1002/sim.6613DOI Listing
January 2016

Effects of position and operator on high-frequency ultrasound scan quality.

Intensive Crit Care Nurs 2015 Jun 27;31(3):148-54. Epub 2015 Jan 27.

School of Nursing, Virginia Commonwealth University, 1100 East Leigh Street, Richmond, VA 23298-0567, United States. Electronic address:

Objectives: High-frequency ultrasound may evaluate those at risk for pressure ulcers. Images may be obtained by clinicians with limited training. The prone position is recommended for obtaining sacral scans but may not be feasible in the critically ill. This study investigated image quality using multiple operators and a variety of patient positions.

Research Methodology: Sacral scans were performed in three randomised positions in 50 volunteers by three different investigators using a 20 MHz ultrasound system. General linear models and ANOVA random effects models were used to examine the effects of operator and position on image quality rating, and measures of dermal thickness and dermal density.

Results: The best scan for each position and operator was used for analysis (n=447 images). Image rating varied by operator (p=0.0004), although mean ratings were 3.5 or above for all operators. Dermal thickness was less for the prone position than in 90° or 60° side-lying positions (p=0.0137, p=0.0003). Dermal density was lower for the prone position than for the 90° or 60° positions (p<0.0001 for both).

Conclusions: These data show that overall scan quality was acceptable in all positions with all operators. However, differences were found between side-lying positions and the prone for dermal thickness and dermal density measures.
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http://dx.doi.org/10.1016/j.iccn.2014.11.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4466000PMC
June 2015

Use of high frequency ultrasound to detect changes in skin integrity: An image evaluation validation procedure.

Intensive Crit Care Nurs 2015 Jun 16;31(3):141-7. Epub 2014 Oct 16.

Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, OH, United States.

Objectives: High frequency ultrasound (HFUS) scanning may be used for prevention, detection and monitoring of pressure ulcers in patients at risk and is amenable for portable, bedside use by a variety of clinicians. Limited data are available about the criteria to determine an ideal image or measures of tissue changes representative of tissue injury. We developed and evaluated criteria for overall image quality and measures of tissue integrity.

Methods: In 40 mechanically ventilated adults in 3 ICUs, 241 HFUS sacral images were evaluated for agreement using criteria for overall image quality and tissue changes (dermal, hypodermal layer thickness and layer density).

Results: HFUS sacral images (N=241) were evaluated in three analyses and showed poor agreement in all three analyses using the specific criteria for global quality, however when criteria were collapsed agreement was good to substantial. Evaluator agreement for layer thickness and layer density was also good.

Conclusions: A global rating is adequate for identifying good images. Agreement for measurements of layer thickness and density were also good and may be useful to identify early changes in tissue integrity leading to tissue injury. Additional data are needed concerning the association of changes in layer thickness and layer density to eventual tissue injury.
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http://dx.doi.org/10.1016/j.iccn.2014.08.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4400186PMC
June 2015

Predictors of agitation in critically ill adults.

Am J Crit Care 2014 Sep;23(5):414-23

Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center in Houston. Mary Jo Grap is the Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is an associate dean, Research and Innovation, and a professor, University of South Florida College of Nursing, Tampa, Florida. Christine M. Schubert is an associate professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio.

Background: Agitation in critically ill adults is a frequent complication of hospitalization and results in multiple adverse outcomes. Potential causes of agitation are numerous; however, data on factors predictive of agitation are limited.

Objectives: To identify predictors of agitation by examining demographic and clinical characteristics of critically ill patients.

Methods: A medical record review was performed. Documentation of agitation was indicated by scores on the Richmond Agitation-Sedation Scale or the use of an agitation keyword. Records of 200 patients from 1 medical and 1 surgical intensive care unit were used for the study. Risk factors were determined for 2 points in time: admission to the intensive care unit and within 24 hours before the first episode of agitation. Data on baseline demographics, preadmission risk factors, and clinical data were collected and were evaluated by using logistic multivariable regression to determine predictors of agitation.

Results: Predictors of agitation on admission to intensive care were history of use of illicit substances, height, respiratory and central nervous system subscores on the Sequential Organ Failure Assessment, and use of restraints. Predictors of agitation within 24 hours before the onset of agitation were history of psychiatric diagnosis, height, score on the Sequential Organ Failure Assessment, ratio of Pao2 to fraction of inspired oxygen less than 200, serum pH, percentage of hours with restraints, percentage of hours of mechanical ventilation, pain, and presence of genitourinary catheters.

Conclusions: Predictors of agitation on admission and within 24 hours before the onset of agitation were primarily clinical variables.
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http://dx.doi.org/10.4037/ajcc2014714DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4451811PMC
September 2014

Agitation onset, frequency, and associated temporal factors in critically ill adults.

Am J Crit Care 2014 Jul;23(4):296-304

Ruth S. Burk is an assistant professor, Department of Acute and Continuing Care, University of Texas Health Science Center School of Nursing in Houston, Texas. Mary Jo Grap is Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems Department, School of Nursing, and Curtis N. Sessler is the Orhan Muren Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia. Cindy L. Munro is associate dean for research and innovation and a professor, University of South Florida, College of Nursing, Tampa, Florida. Christine M. Schubert is an assistant professor, Department of Mathematics and Statistics, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio.

Background: Agitation is a frequent complication in critically ill adults, can result in life-threatening events for patients or care providers, and extends the hospital length of stay, thereby increasing hospital costs.

Objectives: To describe the incidence, onset, and temporal factors related to agitation in critically ill adults.

Methods: Data were collected for the first 5 days of stay of all adult patients consecutively admitted to a medical respiratory intensive care unit and a surgical trauma intensive care unit during a 2-month period. Agitation was documented by using scores on the Richmond Agitation-Sedation Scale or notation of agitation in the medical record. The hour was used as the documentation epoch, and data were summarized by hour, 4-hour block, and day for each patient.

Results: Data were collected on 200 patients, 100 from each unit. Among the sample, 118 (59%) were agitated at some time during the 5 days. The overall agitation rate was 7.8% of the total hourly time. Mean onset of agitation was 11.6 hours from time of admission to the unit. Of the 118 patients who were agitated at some time, 102 (86%) had agitation on day 1. Compared with patients in the surgical trauma unit, patients in the medical respiratory unit had significantly more hours of agitation the first day and first hour of admission and significantly earlier onset of agitation.

Conclusions: Agitation was present in more than one-half of the patients in the sample, typically developed on the first day, and involved consecutive days.
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http://dx.doi.org/10.4037/ajcc2014186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4451814PMC
July 2014

Confidence intervals around Bayes Cost in multi-state diagnostic settings to estimate optimal performance.

Stat Med 2014 Aug 24;33(19):3280-99. Epub 2014 Apr 24.

Department of Mathematics and Statistics, Graduate School of Engineering and Management, Air Force Institute of Technology, 2950 Hobson Way, Wright-Patterson AFB, OH 45433-7765, U.S.A.

A critical feature of diagnostic testing is correctly classifying subjects based upon specified thresholds of some measure. The commonly employed Youden index determines a test's optimal thresholds by maximizing the correct classification rates for a diagnostic scenario. An alternative to the Youden index is the cost function, Bayes Cost (BC). BC determines a test's optimal setting by minimizing the sum of all misclassification rates from the test. Unlike the Youden index, BC can consider a priori costs of all the diagnostic outcomes including class specific misclassifications regardless of the number of classes. Delta method approximate confidence intervals around BC are derived under the assumption of normally distributed classes as a means for quantifying a test's performance and comparing classifiers at their optimal settings in a multi-state diagnostic framework. A simulation study is conducted to demonstrate the performance of the derived confidence intervals that are found to perform well, especially for sample sizes of 50 or larger in each diagnostic class. Finally, the proposed methods are applied to a four-class breast tissue classification problem, where four possible discriminatory features are compared under varying decision cost structures. Using the confidence intervals around BC, the best feature for classification is selected, and the optimal thresholds and their 95% confidence intervals are determined.
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http://dx.doi.org/10.1002/sim.6174DOI Listing
August 2014

Reducing cost in sequential testing: a limit of indifference approach.

Stat Med 2013 Jul 22;32(16):2715-27. Epub 2013 Jan 22.

Department of Epidemiology and Biostatistics, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

In noninferiority studies, a limit of indifference is used to express a tolerance in results such that the clinician would regard such results as being acceptable or 'not worse'. We applied this concept to a measure of accuracy, the Receiver Operating Characteristic (ROC) curve, for a sequence of tests. We expressed a limit of indifference for the range of acceptable sensitivity values and examined the associated cost of testing within this range. In doing so, we generated the minimum cost maximum ROC (MCMROC) curve, which reflects the reduced sensitivity and cost of testing. We compared the MCMROC and its associated cost curve between limits of indifference set to 0.999 [a 0.1% reduction in true positive rate (TPR)], 0.95 (a 5% reduction in TPR), and 1 (no reduction in TPR). The limit of indifference tended to have less of an effect on the MCMROC curves than on the associated cost curves that were greatly affected. Cost was reduced at high false positive rates (FPRs) at higher limit of indifference (0.999) and at small FPRs as the limit of indifference decreased (0.95). These patterns were also observed as applied to sequential strategies used to diagnose diabetes in the Pima Indians.
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http://dx.doi.org/10.1002/sim.5741DOI Listing
July 2013

A pilot study of a weekend retreat intervention for family survivors of homicide.

West J Nurs Res 2012 Oct 6;34(6):766-94. Epub 2012 May 6.

North Carolina Agricultural and Technical State University, Greensboro, NC 27411, USA.

Homicide causes negative unintended consequences for family survivors. Family survivors face complicated grief and overwhelming loss with minimal support from others. The authors offered a retreat intervention as a way to ameliorate the effects of the homicidal death for family survivors of homicide. An exploratory longitudinal pilot study examined the feasibility and acceptability of the intervention and explored the impact of the TOZI© Healing intervention on participants' distress symptoms. Eight family members participated in the 2-day retreat and completed surveys at five time intervals over 30 months. Descriptive statistics and correlations were used to analyze the data. Although sample sizes were too small to achieve statistical significance, changes on selected holistic health outcomes, supported by overwhelmingly positive focus group responses to the intervention, affirm the need for further study.
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http://dx.doi.org/10.1177/0193945912443011DOI Listing
October 2012

A longitudinal systems biology analysis of lactulose withdrawal in hepatic encephalopathy.

Metab Brain Dis 2012 Jun 12;27(2):205-15. Epub 2012 Apr 12.

Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, 23249, USA.

The pathogenesis of hepatic encephalopathy(HE) is unclear. However gut flora changes, inflammation and neuro-glial injury have been implicated. The aim was to evaluate factors that were associated with HE recurrence after lactulose withdrawal by analyzing the clinical phenotype, stool microbiome and systemic metabolome longitudinally. HE patients on a standard diet who were adherent on lactulose underwent characterization of their phenotype [cognition, inflammatory cytokines, in-vivo brain MR spectroscopy(MRS)], gut microbiome (stool Multitag Pyrosequencing) and metabolome (urine/serum ex-vivo MRS) analysis while on lactulose and on days 2, 14 and 30 post-withdrawal. Patients whose HE recurred post-withdrawal were compared to those without recurrence. We included seven men (53 ± 8 years) who were adherent on lactulose after a precipitated HE episode were included. HE recurred in three men 32 ± 6 days post-withdrawal. In-vivo brain MRS showed increased glutamine+glutamate (Glx) and decreased myoinositol with a reduction in stool Faecalibacterium spp., post-withdrawal. HE recurrence was predicted by poor baseline inhibitory control and block design performance and was associated with a shift of choline metabolism from tri-methylamine oxide formation towards the development of di-methylglycine, glycine and creatinine. This was accompanied by a mixed effect on the immune response (suppressed IL-10 and Th1/Th2/Th17 response). The correlation network showed Prevotella to be linked to improved cognition and decreased inflammation in patients without HE recurrence. We conclude that lactulose withdrawal results in worsening cognition, mixed inflammatory response effect, lowered stool Faecalibacterium and increase in MR-measurable brain Glx. HE recurrence post-lactulose withdrawal can be predicted by baseline cognitive performance and is accompanied by disrupted choline metabolism.
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http://dx.doi.org/10.1007/s11011-012-9303-0DOI Listing
June 2012

Secular trends in body composition for children and young adults: the Fels Longitudinal Study.

Am J Hum Biol 2012 Jul-Aug;24(4):506-14. Epub 2012 Mar 12.

Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, Virginia 23298-0032, USA.

Objectives: To determine secular trends by birth decade in body mass index (BMI), waist circumference/height (W/Ht), percent body fat (PBF), and fat-free mass adjusted for height squared (FFM/Ht(2) ) in children and adolescents aged 8-18 years.

Methods: Serial data were analyzed from 628 boys and 591 girls aged 8-18 years who participated in the Fels Longitudinal Study. Subjects were stratified by birth decade from 1960 to 1999. Means and standard deviations were computed for all measurements by birth decade, age, and sex. A repeated-measures analysis of variance was used data to ascertain secular trends separately for boys and girls.

Results: Boys and girls born in the 1990s had significantly higher mean BMI, W/Ht, and PBF than did children born in previous decades. Mean FFM/Ht(2) was significantly smaller in boys born in the 1990s than boys of the same age born in earlier decades. No secular trend was noted in FFM/Ht(2) in girls by decade of birth.

Conclusion: Our analysis of serial data collected over 4 decades confirms the secular trend in childhood BMI previously observed in successive cross-sectional studies. Our analysis discloses significant positive secular trends in W/Ht and PBF in both boys and girls and a significant negative secular trend in FFM/Ht(2) in boys over the last 4 decades of the 20th century. The secular changes presage increases in the prevalence of conditions associated with childhood and adolescent obesity-such as hypertension, glucose intolerance, and dyslipidemia-that may appear as early as the second decade of life.
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http://dx.doi.org/10.1002/ajhb.22256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3372655PMC
October 2012

Pain and inflammation in women with early-stage breast cancer prior to induction of chemotherapy.

Biol Res Nurs 2013 Apr 14;15(2):234-41. Epub 2011 Nov 14.

Department of Adult Health and Nursing Systems, Virginia Commonwealth University School of Nursing, Richmond, VA 23298, USA.

Context: Pain is a commonly experienced and distressing symptom in women with breast cancer (BCA), and recent evidence suggests that immune activation may be associated with pain and other co-occurring symptoms. However, no studies to date have explored the relationships among perceived pain and biomarkers of inflammation in women with early-stage BCA during the initial course of treatment.

Objectives: The purpose of this research study was to examine the relationships among pro- and anti-inflammatory biomarkers and the presence of pain and other symptoms (anxiety, depression, fatigue, and sleep disorder) prior to induction of chemotherapy.

Method: This was a secondary analysis of data that measured perceived symptoms, including the presence of pain and pain interference, and plasma levels of pro- and anti-inflammatory cytokines and C-reactive protein (CRP) in women with early-stage BCA (N = 32) at 1 month postsurgery but prior to induction of chemotherapy.

Results: Women experiencing pain had significantly higher levels of CRP (p < .01), interleukin (IL) 13 (p < .02), and IL-7 (p < .02) and more pain interference (p < .01), depression (p < .01), and sleep disturbance (p < .01) compared to women reporting no pain.

Conclusion: The presence of pain during the initial course of treatment in women with early-stage BCA was associated with significantly higher levels of CRP, IL-7, and IL-13, suggesting a potential role of immune activation in perceived pain. Further research to examine the precise effects of these biological factors in modulating pain is needed. Perceived pain was also associated with multiple co-occurring symptoms, and this finding has important implications for symptom management.
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http://dx.doi.org/10.1177/1099800411425857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3729026PMC
April 2013

Supportive relationships, self-care confidence, and heart failure self-care.

J Cardiovasc Nurs 2012 Sep-Oct;27(5):384-93

Department of Adult Health and Nursing Systems, School of Nursing, Virginia Commonwealth University, Richmond, USA.

Background: The theory of heart failure (HF) self-care proposes that confidence mediates relationships between social support and self-care behaviors.

Objective: This study aimed to examine the effects of supportive relationships on self-care behaviors and the mediating effects of self-care confidence in HF outpatients.

Methods: Structural equation modeling (SAS version 9.1, SAS Institute Inc, Cary, North Carolina) was used to examine the influence of supportive relationships and self-care confidence on self-care management and maintenance in a cross-section of patients with HF (n = 97; age = 56 years; 57% men; 45% African American; 55% married). Models included 3 variables characterizing supportive relationships: marital status (1 = currently married, 0 = not currently married), social network size (number of persons available to provide support), and perceived social support (Medical Outcomes Study Social Support Scale). To account for the effects of severity of illness, 2 measures characterizing severity of HF were included: left ventricular ejection fraction and New York Heart Association functional classification of HF. The Self-Care of Heart Failure Index (version 4) was used to measure self-care confidence, management, and maintenance. A consensus of fit indices estimated overall model fit.

Results: Initial models fit the data; however, to improve fit and identify the most parsimonious models, 3 nonsignificant paths were removed, and modified models, including only social support and social network size, were proposed and tested. Modified models fit the data well and accounted for 15% in the variance in self-care maintenance (χ(2) P = .29) and 18% of the variance in self-care management (χ(2) P = .631). The indirect effect of social support (β = 0.37; P = .0004) through self-care confidence (β = 0.35; P = .0002) on self-care management, in the absence of a significant direct effect, supports the hypothesis that self-care confidence mediates the relationship between social support and self-care management. Social network size had a negative effect on self-care confidence (β = -0.22; P = .029), but this effect was mediated by self-care confidence (β = 0.33; P = .0002), which reduced the total negative effects. Self-care confidence was the best predictor of self-care management. In the self-care maintenance model, direct (β = 0.27; P = .003) and indirect effects of social support (β = 0.37; P = .0002) on self-care maintenance through self-care confidence (β = 0.22; P = .001) attenuated negative effects of social network size (β = -0.22; P = .0145). Social support was the best predictor of self-care maintenance.

Conclusions: Findings support the positive influence of social support on self-care behaviors. Self-care confidence mediated the relationship between social support and self-care behaviors and had direct influence on these behaviors as well. This suggests that self-care confidence and self-care behaviors can be enhanced by improving the quality of social support.
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http://dx.doi.org/10.1097/JCN.0b013e31823228cdDOI Listing
January 2013

Accuracy and cost comparison in medical testing using sequential testing strategies.

Stat Med 2011 Dec 4;30(29):3416-30. Epub 2011 Oct 4.

Advanced Analytics Department, King Abdullah International Medical Research Center, National Guard Health Affairs, Riyadh, Saudi Arabia.

The practice of sequential testing is followed by the evaluation of accuracy, but not by the evaluation of cost. This paper focuses on three logic rules for combining two sequences of tests: believe the positive (BP), which diagnoses disease if any of two tests is positive, believe the negative (BN), which diagnoses disease if any of two tests is negative, and believe the extreme (BE), which diagnoses disease if the first test is positive or, after a first inconclusive test, a second test is positive for disease. Comparisons of these strategies are provided in terms of accuracy using false positive rate, sensitivity pairs that make up the maximum receiver operating characteristic curve, and cost of testing, defined as the proportion of subjects needing two tests to diagnose disease. A method to incorporate the cost of testing into the definition of the optimal operating point is also presented. The performance of the testing strategies is examined with respect to the ratio of standard deviations and the correlation between test results under the bivariate normal assumptions. Under all parameter settings, the maximum receiver operating characteristic curve of the BE strategy never performed worse than the BN and BP strategies; the BE strategy also had the lowest cost. The use of body mass index and plasma glucose concentration to diagnose diabetes in Pima Indians was presented as a real-world application. The optimal operating points found by the BN and BE strategies produce lower false positive rate values than the BP strategy for these data.
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http://dx.doi.org/10.1002/sim.4358DOI Listing
December 2011

Tryptophan degradation in women with breast cancer: a pilot study.

BMC Res Notes 2011 May 26;4:156. Epub 2011 May 26.

Department of Family and Community Health Nursing, Virginia Commonwealth University School of Nursing, 1100 East Leigh Street, Richmond, Virginia, 23298, USA.

Background: Altered tryptophan metabolism and indoleamine 2,3-dioxygenase activity are linked to cancer development and progression. In addition, these biological factors have been associated with the development and severity of neuropsychiatric syndromes, including major depressive disorder. However, this biological mechanism associated with both poor disease outcomes and adverse neuropsychiatric symptoms has received little attention in women with breast cancer. Therefore, a pilot study was undertaken to compare levels of tryptophan and other proteins involved in tryptophan degradation in women with breast cancer to women without cancer, and secondarily, to examine levels in women with breast caner over the course of chemotherapy.

Findings: Blood samples were collected from women with a recent diagnosis of breast cancer (n = 33) before their first cycle of chemotherapy and after their last cycle of chemotherapy. The comparison group (n = 24) provided a blood sample prior to breast biopsy. Plasma concentrations of tryptophan, kynurenine, and tyrosine were determined. The kynurenine to tryptophan ratio (KYN/TRP) was used to estimate indoleamine 2,3-dioxygenase activity. On average, the women with breast cancer had lower levels of tryptophan, elevated levels of kynurenine and tyrosine and an increased KYN/TRP ratio compared to women without breast cancer. There was a statistically significant difference between the two groups in the KYN/TRP ratio (p = 0.036), which remained elevated in women with breast cancer throughout the treatment trajectory.

Conclusions: The findings of this pilot study suggest that increased tryptophan degradation may occur in women with early-stage breast cancer. Given the multifactorial consequences of increased tryptophan degradation in cancer outcomes and neuropsychiatric symptom manifestation, this biological mechanism deserves broader attention in women with breast cancer.
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http://dx.doi.org/10.1186/1756-0500-4-156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3117722PMC
May 2011

Challenges in interpreting cytokine biomarkers in biobehavioral research: a breast cancer exemplar.

Biol Res Nurs 2011 Jan;13(1):25-31

Department of Family and Community Health Nursing, Virginia Commonwealth University School of Nursing, Richmond, VA 23298, USA.

Purpose: This report extends the findings of a prior study comparing the level of plasma cytokines in women with breast cancer to those of women with a benign breast biopsy with the addition of a normal comparison group. The results of this three-group comparison are presented as background for discussing several methodologic challenges for biobehavioral research in inflammatory-based conditions.

Method: This study used a descriptive, cross-sectional design to compare the levels of plasma cytokines in women with breast cancer, women with a benign breast biopsy, and a normal comparison group. The levels of 17 cytokines were measured using multiplex bead array assays (Bio-Plex®). Data analysis included a variety of descriptive and graphical techniques to illustrate between-group differences in cytokine profiles.

Results: The levels of plasma cytokines in the sample of 35 women who had recently been diagnosed with breast cancer, 24 women with a suspicious breast mass, who subsequently were found to have a benign breast biopsy, and 33 women in a normal comparison group present a background for discussing the implications of extreme between-group differences for biobehavioral nursing research. Both the levels of individual cytokines and their patterns were distinctly different in the three groups.

Conclusion: The exemplar presented from the three-group comparison has implications for planning biobehavioral nursing research in patients with conditions characterized by inflammation.
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http://dx.doi.org/10.1177/1099800410383304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3966622PMC
January 2011

Variance in abdominal wall anatomy and port placement in women undergoing robotic gynecologic surgery.

J Minim Invasive Gynecol 2010 Sep-Oct;17(5):583-6. Epub 2010 Jul 2.

Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center, Richmond, VA 23298, USA.

Study Objectives: To estimate whether variability in the size and ratios of the lower and upper abdomen exist in women undergoing robotic gynecologic surgery and whether demographic variables are significantly associated, and to determine the association between abdominal wall dimensions and supraumbilical robotic port placement.

Design: Prospective cohort study (Canadian Task Force classification II-2).

Setting: University teaching hospital.

Patients: Seventy-eight women undergoing robotic surgery between May 2008 and March 2009.

Intervention: Measurements from the symphysis pubis to the umbilicus (lower abdomen), umbilicus to the xyphoid process (upper abdomen), and distance between the anterior superior iliac crests were obtained at surgery. A multiple linear regression model was created to determine the relationships between abdominal wall measurements, demographic variables, and need for supraumbilical robotic port placement.

Measurements And Main Results: Fifty-six white and 22 black women were enrolled. Mean lower abdominal length was significantly affected by body mass index (BMI) (p <.001) and race (p = .006), with white women having longer measurements (17.1 cm vs 15 cm). Mean lower abdominal width was independent of age (p = .95) or race (p = .98), but was significantly correlated with BMI (p <.001). Mean upper abdominal length correlated with BMI (p <.001) and age (p = .03) but not race (p = .13). Ratios of bottom to top were significantly affected by race (p = .002) and age (p = .008) but not BMI (p = .07). Adjustments to port placement above the umbilicus were made in 44 of the 74 women (59.5%). Those who required supraumbilical port placement had a significantly shorter mean (SD) distance between the symphysis pubis and the umbilicus (14.99 [1.36] vs 18.55 [2.21]; p <.001).

Conclusions: Significant variability in abdominal wall anatomy exists in women undergoing robotic gynecologic surgery, and the need for supraumbilical robotic port placement is common.
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http://dx.doi.org/10.1016/j.jmig.2010.04.008DOI Listing
November 2010

Is laminin gamma-1 a candidate gene for advanced pelvic organ prolapse?

Am J Obstet Gynecol 2010 May 12;202(5):505.e1-5. Epub 2010 Mar 12.

Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center, Richmond, VA, USA.

Objective: We sought to determine allele frequencies of 3 LAMC1 single nucleotide polymorphisms (SNPs) in Caucasian and African American (AA) women with stage>II pelvic organ prolapse (POP) (cases) and in ethnicity-matched controls with stage
Study Design: Allelic discrimination was performed for LAMC1 SNPs rs10911193 (C/T), rs20563 (A/G), and rs20558 (T/C). SNP and haplotype-specific tests were used to examine associations among POP, ethnicity, and LAMC1.

Results: In all, 411 women were enrolled. Significant differences in allele and haplotype frequencies existed among AAs and Caucasians: rs10911193 "T" (P=.0014); rs20563 "G" (P<.0001); rs20558 "C" (P<.0001); rs20563, rs20558 "GC" (P<.0001); and rs20563, rs20558 "AT" (P<.0001). No significant associations between POP and LAMC1 SNPs or haplotypes were found within ethnicities.

Conclusion: While significant differences were identified between AA and Caucasian women, no associations were found between any LAMC1 gene variant and advanced POP.
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http://dx.doi.org/10.1016/j.ajog.2010.01.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866811PMC
May 2010

Persistence of cognitive impairment after resolution of overt hepatic encephalopathy.

Gastroenterology 2010 Jun 20;138(7):2332-40. Epub 2010 Feb 20.

Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia 23249, USA.

Background & Aims: In patients with cirrhosis, hepatic encephalopathy (HE) has acute but reversible as well as chronic components. We investigated the extent of residual cognitive impairment following clinical resolution of overt HE (OHE).

Methods: Cognitive function of cirrhotic patients was evaluated using psychometric tests (digit symbol, block design, and number connection [NCT-A and B]) and the inhibitory control test (ICT). Improvement (reduction) in ICT lures and first minus second halves (DeltaL(1-2)) were used to determine learning of response inhibition. Two cross-sectional studies (A and B) compared data from stable cirrhotic patients with or without prior OHE. We then prospectively assessed cognitive performance, before and after the first episode of OHE.

Results: In study A (226 cirrhotic patients), 54 had experienced OHE, 120 had minimal HE, and 52 with no minimal HE. Despite normal mental status on lactulose after OHE, cirrhotic patients were cognitively impaired, based on results from all tests. Learning of response inhibition (DeltaL(1-2) > or =1) was evident in patients with minimal HE and no minimal HE but was lost after OHE. In study B (50 additional patients who developed > or =1 documented OHE episode during follow-up), the number of OHE hospitalizations correlated with severity of residual impairment, indicated by ICT lures (r = 0.5, P = .0001), digit symbol test (r = -0.39, P = .002), and number connection test-B (r = 0.33, P = .04). In the prospective study (59 cirrhotic patients without OHE), 15 developed OHE; ICT lure response worsened significantly after OHE (12 before vs 18 after, P = .0003), and learning of response inhibition was lost. The 44 patients who did not experience OHE did not have deteriorations in cognitive function in serial testing.

Conclusions: In cirrhosis, episodes of OHE are associated with persistent and cumulative deficits in working memory, response inhibition, and learning.
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http://dx.doi.org/10.1053/j.gastro.2010.02.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2883684PMC
June 2010

Long-term outcomes after catheter ablation of cavo-tricuspid isthmus dependent atrial flutter: a meta-analysis.

Circ Arrhythm Electrophysiol 2009 Aug 23;2(4):393-401. Epub 2009 Jun 23.

Division of Cardiology, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0053, USA.

Background: Despite the success of catheter ablation of cavotricuspid isthmus-dependent atrial flutter (AFL), important postablation outcomes are ill-defined. The purpose of our study was to analyze long-term outcomes after catheter ablation of cavotricuspid isthmus-dependent AFL.

Methods And Results: A meta-analysis was performed of articles reporting clinical outcomes after catheter ablation of AFL published between January 1988 and July 2008. The analysis included 158 studies comprising 10 719 patients (79% men, 59.8+/-0.5 years old, 46% left atrial enlargement, 46% heart disease, 42% with history of atrial fibrillation, 14.3+/-0.4 months of follow-up). The overall acute success rate adjusted for reporting bias was 91.1% (95% CI, 89.5 to 92.4), 92.7% (95% CI, 90.0 to 94.8) for 8- to 10-mm tip/or irrigated radiofrequency catheters, and 87.9% (95% CI, 84.2 to 90.9) for 4- to 6-mm tip catheters (P>0.05). Atrial flutter recurrence rates were significantly reduced by use of 8- to 10-mm tip or irrigated radiofrequency catheters (6.7% versus 13.8%, P<0.05) and by use of bidirectional cavotricuspid isthmus block as a procedural end point (9.3% versus 23.6%, P<0.05). The AFL recurrence rate did not increase over time. The overall occurrence rate of atrial fibrillation after AFL ablation was 33.6% (95% CI, 29.7 to 37.3) but was 52.7% (95% CI, 47.8 to 57.6) in patients with a history of atrial fibrillation before ablation and 23.1% (95% CI, 17.5 to 29.9) in those without atrial fibrillation before ablation (P<0.05). The incidence of atrial fibrillation increased over time in both groups; however, 5 years after ablation, the incidence of atrial fibrillation was similar in those with and without atrial fibrillation before ablation. The acute complication rate was 2.6% (95% CI, 2 to 3). The mortality rate during follow-up was 3.3% (95% CI, 2.4 to 4.5). Antiarrhythmic drug use after ablation was 31.6% (95% CI, 25.6 to 37.8). The long-term use of coumadin was 65.9%, (95% CI, 43.8 to 82.8). Quality of life data were very limited.

Conclusions: AFL ablation is safe and effective. Ablation technology and procedural end points have greater influences on AFL recurrences than on acute ablation success rates. Atrial fibrillation is common after AFL ablation. Almost one third of patients take antiarrhythmic drugs after AFL ablation. Atrial fibrillation before AFL ablation may indicate a more advanced state of electric disease.
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http://dx.doi.org/10.1161/CIRCEP.109.871665DOI Listing
August 2009

Mindfulness-based stress reduction for the treatment of adolescent psychiatric outpatients: A randomized clinical trial.

J Consult Clin Psychol 2009 Oct;77(5):855-66

Department of Child and Adolescent Psychiatry, Kaiser Permanente Hospital, San Jose, CA 95136, USA.

Research has shown that mindfulness-based treatment interventions may be effective for a range of mental and physical health disorders in adult populations, but little is known about the effectiveness of such interventions for treating adolescent conditions. The present randomized clinical trial was designed to assess the effect of the mindfulness-based stress reduction (MBSR) program for adolescents age 14 to 18 years with heterogeneous diagnoses in an outpatient psychiatric facility (intent-to-treat N = 102). Relative to treatment-as-usual control participants, those receiving MBSR self-reported reduced symptoms of anxiety, depression, and somatic distress, and increased self-esteem and sleep quality. Of clinical significance, the MBSR group showed a higher percentage of diagnostic improvement over the 5-month study period and significant increases in global assessment of functioning scores relative to controls, as rated by condition-naïve clinicians. These results were found in both completer and intent-to-treat samples. The findings provide evidence that MBSR may be a beneficial adjunct to outpatient mental health treatment for adolescents.
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http://dx.doi.org/10.1037/a0016241DOI Listing
October 2009