Publications by authors named "Sangchoon Jeon"

105 Publications

Association of epigenetic age acceleration with risk factors, survival, and quality of life in patients with head and neck cancer.

Int J Radiat Oncol Biol Phys 2021 Apr 18. Epub 2021 Apr 18.

Emory University School of Nursing.

Purpose: Epigenetic age acceleration (EAA) is robustly linked with mortality and morbidity. This study examined risk factors of EAA and its association with overall survival (OS), progression-free survival (PFS), and quality of life (QOL) in patients with head and neck cancer (HNC) receiving radiotherapy.

Methods And Materials: Patients without distant metastasis were enrolled and followed before and end of radiotherapy, and 6-months and 12-months post-radiotherapy. EAA was calculated with DNAmPhenoAge at all four times. Risk factors included demographics, lifestyle, clinical characteristics, treatment-related symptoms, and blood biomarkers. Survival data were collected until August 2020; QOL was measured using Functional Assessment of Cancer Therapy-HNC.

Results: Increased comorbidity, HPV-unrelated, and severer treatment-related symptoms were associated with higher EAA (p=0.03 to <0.001). A non-linear association (quadratic) between body mass index (BMI) and EAA was observed: decreased BMI (when BMI<35,p=0.04) or increased BMI (when BMI≥35,p=0.01), was linked to higher EAA. Increased EAA (per year) was associated with worse OS (hazard ratio (HR)=1.11,95% CI=[1.03,1.18],p=0.004; HR=1.10,95% CI=[1.01,1.19], p=0.02, for EAA at 6-months and 12-months post-treatment, respectively), PFS (HR=1.10, 95% CI=[1.02,1.19], p=0.02; HR=1.14, 95% CI=[1.06,1.23], p<0.001; HR=1.08,95% CI=[1.02,1.14], p=0.01, for EAA before, end, and 6-months post-radiotherapy, respectively), and QOL over time (β=-0.61,p=0.001). An average of 3.25-3.33 years of age acceleration across time, which was responsible for 33% to 44% higher HRs of OS and PFS, was observed in those who died or developed recurrences compared to those who did not (all p<0.001).

Conclusion: Compared to demographic and lifestyle factors, clinical characteristics were more likely to contribute to faster biological aging in patients with HNC. Acceleration in epigenetic age resulted in more aggressive adverse events including OS and PFS. EAA could be considered as a marker for cancer outcomes, and decelerating aging could improve survival and QOL.
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http://dx.doi.org/10.1016/j.ijrobp.2021.04.002DOI Listing
April 2021

Mediating roles of psychological factors and physical and social environments between socioeconomic status and dietary behaviors among African Americans with overweight or obesity.

Res Nurs Health 2021 Jun 29;44(3):513-524. Epub 2021 Mar 29.

School of Nursing, Yale University, Orange, Connecticut, USA.

The study aim was to examine the relationship between socioeconomic status (SES) and dietary behaviors through psychological and environmental mediators among African Americans with overweight or obesity. We conducted a cross-sectional study in 225 African American men and women. Data were analyzed using structural equation modeling with bootstrapping procedures. In the multiple mediation model, SES had a significant indirect effect on dietary behaviors through psychological and environmental factors (β = -.27; p = .01; 95% confidence interval [CI] = -0.59--0.10), but it had no significant direct effect on dietary behaviors (β = .06; p = .70; 95% CI = -0.21-0.39). SES had significant direct effects on psychological (β = .52; p = .01; 95% CI = 0.31-0.77) and environmental factors (β = -.40; p = .03; 95% CI = -0.53--0.25). Psychological (β = -.31; p = .02; 95% CI = -0.68--0.04) and environmental factors (β = .26; p = .01; 95% CI = 0.04-0.47) also showed significant direct effects on dietary behaviors. Thus, psychological and environmental factors mediated the relationship between SES and dietary behaviors in African Americans with overweight or obesity. Interventions that enhance psychological and environmental factors such as self-efficacy, perceived barriers to healthy eating, health perceptions, and physical and social environments may improve dietary behaviors among socioeconomically disadvantaged African Americans.
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http://dx.doi.org/10.1002/nur.22130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068664PMC
June 2021

Metabolic Syndrome, Exercise, and Cardiovascular Fitness in Breast Cancer Survivors.

J Adv Pract Oncol 2020 Jan-Feb;11(1):98-102. Epub 2020 Jan 1.

Yale University School of Nursing, Orange, Connecticut.

Comorbid illness contributes to poorer cancer outcomes and higher mortality. Metabolic syndrome (MetS) includes a cluster of risk factors that are associated with an increased risk of comorbidities. Routine physical activity represents a risk reduction strategy for cancer survivors. From 148 participants in a 12-month randomized control trial (RCT) of a fitness center exercise intervention compared to home physical activity group, a subset analysis was conducted to explore the effect of exercise on MetS risk factors. There were 32 (21.6%) breast cancer survivors who met the criteria for MetS at baseline. Over the 12 months, there were significantly fewer participants who met the criteria for MetS ( < .01), and there was significant improvement in individual risk factors, specifically fasting blood sugar ( = .01), and high-density lipoprotein (HDL; = .02). Cardiovascular fitness was evaluated and greater heart recovery rate (HRR) was negatively associated with waist circumference, triglycerides, systolic blood pressure, fasting blood sugar, and MetS risk ( < .02) and positively associated with HDL ( = .03). Oncology advanced practitioners are uniquely qualified to integrate risk reduction into the management of at-risk oncology patients.
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http://dx.doi.org/10.6004/jadpro.2020.11.1.6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7517769PMC
January 2020

Symptom cluster profiles following traumatic orthopedic injuries: A protocol.

Res Nurs Health 2021 04 25;44(2):268-278. Epub 2020 Dec 25.

Yale School of Nursing, West Haven, Connecticut, USA.

Traumatic injuries affect millions of Americans annually, resulting in $671 billion in healthcare costs and lost productivity. Postinjury symptoms, like pain, sleep disturbance, anxiety, depression, and stressor-related disorders are highly prevalent following traumatic orthopedic injuries (TOI) and may contribute to negative long-term outcomes. Symptoms rarely present in isolation, but in clusters of two or more symptoms that co-occur to affect health in aggregate. Identifying symptom cluster profiles following TOI may identify those at highest risk for negative outcomes. Dysregulation of brain-derived neurotrophic factor (BDNF) is a potential biological mechanism responsible for symptom cluster profile membership after TOI and may be targeted in future precision-health applications. The purpose of this paper is to present the protocol of a cross-sectional study designed to identify symptom cluster profiles and measure the extent to which the BDNF val66met mutation and serum concentration of BDNF are associated with membership in symptom cluster profiles. We plan to recruit 150 TOI survivors within the first 72 h of injury. The study aims are to (1) describe TOI survivors' membership in symptom cluster profiles, indicated by pain, sleep disturbance, and symptoms of anxiety, depression, and stressor-related disorders, immediately following a TOI; (2) examine associations between demographic and clinical factors and symptom cluster profile membership among TOI survivors; (3) test the hypothesis that low serum concentrations of BDNF are associated with membership among symptom cluster profiles following TOI; and (4) test the hypothesis that the presence of the val66met mutation on one or both alleles of the BDNF gene is associated with membership among symptom cluster profiles following TOI.
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http://dx.doi.org/10.1002/nur.22102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7933085PMC
April 2021

The role of the gut microbiome in cancer-related fatigue: pilot study on epigenetic mechanisms.

Support Care Cancer 2021 Jun 20;29(6):3173-3182. Epub 2020 Oct 20.

School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta, 30322, USA.

Purpose: Recent evidence supports a key role of gut microbiome in brain health. We conducted a pilot study to assess associations of gut microbiome with cancer-related fatigue and explore the associations with DNA methylation changes.

Methods: Self-reported Multidimensional Fatigue Inventory and stool samples were collected at pre-radiotherapy and one-month post-radiotherapy in patients with head and neck cancer. Gut microbiome data were obtained by sequencing the 16S ribosomal ribonucleic acid gene. DNA methylation changes in the blood were assessed using Illumina Methylation EPIC BeadChip.

Results: We observed significantly different gut microbiota patterns among patients with high vs. low fatigue across time. This pattern was characterized by low relative abundance in short-chain fatty acid-producing taxa (family Ruminococcaceae, genera Subdoligranulum and Faecalibacterium; all p < 0.05), with high abundance in taxa associated with inflammation (genera Family XIII AD3011 and Erysipelatoclostridium; all p < 0.05) for high-fatigue group. We identified nine KEGG Orthology pathways significantly different between high- vs. low-fatigue groups over time (all p < 0.001), including pathways related to fatty acid synthesis and oxidation, inflammation, and brain function. Gene set enrichment analysis (GSEA) was performed on the top differentially methylated CpG sites that were associated with the taxa and fatigue. All biological processes from the GSEA were related to immune responses and inflammation (FDR < 0.05).

Conclusions: Our results suggest different patterns of the gut microbiota in cancer patients with high vs. low fatigue. Results from functional pathways and DNA methylation analyses indicate that inflammation is likely to be the major driver in the gut-brain axis for cancer-related fatigue.
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http://dx.doi.org/10.1007/s00520-020-05820-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8055716PMC
June 2021

Day-to-day Relationships between Physical Activity and Sleep Characteristics among People with Heart Failure and Insomnia.

Behav Sleep Med 2020 Oct 13:1-13. Epub 2020 Oct 13.

Yale University School of Nursing, Orange, Connecticut, USA.

Objective: Examine the bidirectional relationships between within-person day-to-day fluctuations in physical activity (PA) and sleep characteristics among people with heart failure (HF) and insomnia.

Participants: Ninety-seven community-dwelling adults [median age 61.9 (interquartile range 55.3,70.9) years, female 41%] with stable HF and insomnia (insomnia severity index >7).

Methods: This sub-study longitudinally analyzed 15 consecutive days and nights of wrist actigraphy recordings, that were collected for baseline data prior to participation in a randomized controlled trial of cognitive behavioral therapy for insomnia. We used two-level mixed models of within- (daily) and between-participants variation to predict daytime PA counts/minutes from sleep variables (total sleep time, sleep efficiency) and predict sleep variables from PA.

Results: PA counts/minutes were low compared to prior cohorts that did not have HF (209 (166,259)) and negatively associated with NYHA class (standardized coefficient β = -0.14, < .01), age (β = -0.13, = .01), comorbidities (β = -0.19, < .01), and body mass index (β = -0.12, = .04). After adjustment for all significant covariates, the within-participant association of total sleep time with next-day PA was estimated to be positive among participants with NYHA class II-IV HF (β = 0.09, = .01), while the within-participant association of PA with same-night total sleep time was estimated to be positive among participants aged ≥60 years (β = 0.10, = .03).

Conclusions: Depending upon age and HF class, daytime PA was associated with longer same-night sleep and/or longer sleep was associated with greater next-day PA. Among those with more advanced HF, realistic sleep improvements were associated with clinically meaningful PA gains the next day.
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http://dx.doi.org/10.1080/15402002.2020.1824918DOI Listing
October 2020

Daily variations in sleep and glucose in adolescents with type 1 diabetes.

Pediatr Diabetes 2020 12 28;21(8):1493-1501. Epub 2020 Sep 28.

Annie Goodrich Professor of Nursing and Professor of Pediatrics, Yale University, School of Nursing and School of Medicine, West Haven, Connecticut, 06477, USA.

Objective: We used multilevel models (MLMs) to determine person (between-persons) and day level (within-person) associations between glucose variability indices and sleep characteristics in adolescents with type 1 diabetes (T1D).

Methods: Adolescents with T1D (Mean age 13.4 ± 1.8 years; 37.8% male; mean HbA1c 8.2 ± 1.2%, 66 mmol/mol) monitored their sleep and glucose patterns concurrently for 3-7 days with a wrist actigraph on their non-dominant wrist and a continuous glucose monitor (CGM) (their own or a provided, blinded CGM). Glucose variability indices included J index, coefficient of variation, low and high blood glucose risk indices (LBGI and HBGI), time in range, and sleep characteristics, including bedtime, wake time, total sleep time, sleep efficiency, wake after sleep onset, awakenings, and sleep fragmentation index.

Results: More overall glucose variability was associated within person, more sleep disruptions (more awakenings and more fragmentation) or poorer sleep in our study (earlier wake time or longer wake after sleep onset). Also, more time spent in hypoglycemia <70 mg/dL and a higher LBGI was associated within person with earlier wake time indicating poorer sleep. However, a lower LBGI was associated with a later between-persons wake time.

Conclusions: Monitoring over a longer period of time in subsequent studies would allow researchers to determine the within person association between habitual short sleep duration and glucose variability. Providers should regularly assess sleep habits in adolescents as a way to improve glycemic control. Targeting a euglycemic range overnight is also important to promote better sleep and to decrease sleep disruptions.
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http://dx.doi.org/10.1111/pedi.13117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642150PMC
December 2020

Feasibility and acceptability of intensive, real-time biobehavioral data collection using ecological momentary assessment, salivary biomarkers, and accelerometers among middle-aged African Americans.

Res Nurs Health 2020 09 27;43(5):453-464. Epub 2020 Aug 27.

School of Social Ecology, Institute for Interdisciplinary Salivary Bioscience Research, University of California-Irvine, Irvine, California.

Perceived racial discrimination is linked to unhealthy behaviors and stress-related morbidities. A compelling body of research indicates that perceived racial discrimination may contribute to health disparities among African Americans (AAs). The purposes of this study were to describe the study protocol including data collection procedures and study measures and to evaluate the feasibility and acceptability of intensive biobehavioral data collection using ecological momentary assessment (EMA), salivary biomarkers, and accelerometers over 7 days among middle-aged AAs with a goal of understanding the relationships between perceived racial discrimination and biobehavioral responses to stress. Twelve AA men and women participated in the feasibility/acceptability study. They completed surveys, anthropometrics, and received in-person training in EMA and saliva sample collection at baseline. Participants were asked to respond to the random prompt text message-based EMA five times a day, wear an accelerometer daily for 7 days, and to self-collect saliva samples four times a day for 4 consecutive days. The EMA surveys included perceived racial discrimination, affective states, lifestyle behaviors, and social and physical contexts. The mean EMA response rate was 82.8%. All participants collected saliva samples four times a day for 4 consecutive days. About 83% of participants wore the accelerometer on the hip 6 out of 7 days. Despite the perception that the intensive nature of assessments would result in high participant burden, the acceptability of the study procedures was uniformly favorable.
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http://dx.doi.org/10.1002/nur.22068DOI Listing
September 2020

Rest-activity rhythms, daytime symptoms, and functional performance among people with heart failure.

Chronobiol Int 2020 08 26;37(8):1223-1234. Epub 2020 Jun 26.

Yale School of Nursing , West Haven, Connecticut, USA.

Sleep disturbance and decreased daytime activity are well-described among people with chronic heart failure (HF) who suffer from disabling daytime symptoms and poor function. Alterations in the circadian rhythmicity of rest-activity may also be associated with these outcomes. However, little is known about the associations between rest-activity rhythms (RARS), symptoms, and functional performance or the extent to which they are explained by sleep characteristics among people with HF. The purpose of this study is to evaluate parametric and non-parametric circadian characteristics of RARs and the associations between these variables, daytime symptoms, and functional performance among patients with stable heart failure (HF). We recruited adults with stable HF from HF disease management programs. Participants wore wrist actigraphs for 3 d, completed one night of unattended polysomnography and the Six Minute Walk Test, and reported daytime symptoms and physical function. We performed cosinor, non-parametric, and spectral analyses to evaluate the rest-activity rhythms and computed bivariate correlations between the rest-activity rhythm, demographics, daytime symptoms, and functional performance. We conducted multiple regression analysis to examine how RARs contribute to daytime symptoms and functional performance after controlling for insomnia and covariates. The sample included 135 participants [Mean age = 60.6 (16.1) y, n = 88 (65.2%) male]. Older age, greater comorbidity, and poorer New York Heart Association (NYHA) Class, and more EEG arousals were associated with greater intra-daily variability of the RAR. More robust rhythmicity represented by the circadian quotient was associated with better NYHA class and less sleep fragmentation. A higher circadian quotient was significantly associated with lower fatigue, depression, and sleepiness, and better functional performance after controlling for insomnia and clinical and demographic characteristics. Circadian parameters of rest-activity are associated with symptoms and functional performance among people with HF independent of insomnia or sleep disordered breathing. Interventions targeted at improving the stability and strength of rest-activity rhythms may improve symptom and functional outcomes for these patients.
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http://dx.doi.org/10.1080/07420528.2020.1779280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529895PMC
August 2020

The Feasibility of Measuring Sleep and Circadian Characteristics in Adults with Inflammatory Bowel Disease.

West J Nurs Res 2020 01 9;43(1):53-59. Epub 2020 Jun 9.

Yale School of Nursing, West Haven, CT, USA.

Interest in sleep and circadian research in inflammatory bowel disease (IBD) (Crohn's disease and ulcerative colitis) is growing; however, few studies have objectively measured sleep or circadian rhythms in people with these conditions. The purpose was to determine the feasibility of the use of wrist actigraphy, electronic sleep/activity diaries, and participant-collected saliva among adults with both active and inactive IBD. We conducted a 10-day feasibility study of adults aged 18 years to 60 years with IBD. We measured sleep and rest-activity rhythms with wrist actigraphy, self-reported sleep/activity using electronic diaries, and participant-collected saliva to compute salivary dim light melatonin onset. All 37 (100%) participants wore the wrist actigraphs, 91.8% (N = 34) participants completed at least 15 of the 18 electronic diaries, and 34 (91.9%) completed the saliva collection. It is feasible to use wrist actigraphy and electronic sleep/activity diaries in adult participants with inflammatory bowel disease.
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http://dx.doi.org/10.1177/0193945920933926DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704942PMC
January 2020

Empagliflozin in Heart Failure: Diuretic and Cardiorenal Effects.

Circulation 2020 Sep 15;142(11):1028-1039. Epub 2020 May 15.

Department of Internal Medicine, Section of Endocrinology (S.E.I.), Yale University School of Medicine, New Haven, CT.

Background: Sodium-glucose cotransporter-2 inhibitors improve heart failure-related outcomes. The mechanisms underlying these benefits are not well understood, but diuretic properties may contribute. Traditional diuretics such as furosemide induce substantial neurohormonal activation, contributing to the limited improvement in intravascular volume often seen with these agents. However, the proximal tubular site of action of the sodium-glucose cotransporter-2 inhibitors may help circumvent these limitations.

Methods: Twenty patients with type 2 diabetes mellitus and chronic, stable heart failure completed a randomized, placebo-controlled crossover study of empagliflozin 10 mg daily versus placebo. Patients underwent an intensive 6-hour biospecimen collection and cardiorenal phenotyping at baseline and again after 14 days of study drug. After a 2-week washout, patients crossed over to the alternate therapy with the above protocol repeated.

Results: Oral empagliflozin was rapidly absorbed as evidenced by a 27-fold increase in urinary glucose excretion by 3 hours (<0.0001). Fractional excretion of sodium increased significantly with empagliflozin monotherapy versus placebo (fractional excretion of sodium, 1.2±0.7% versus 0.7±0.4%; =0.001), and there was a synergistic effect in combination with bumetanide (fractional excretion of sodium, 5.8±2.5% versus 3.9±1.9%; =0.001). At 14 days, the natriuretic effect of empagliflozin persisted, resulting in a reduction in blood volume (-208 mL [interquartile range, -536 to 153 mL] versus -14 mL [interquartile range, -282 to 335 mL]; =0.035) and plasma volume (-138 mL, interquartile range, -379 to 154±453 mL; =0.04). This natriuresis was not, however, associated with evidence of neurohormonal activation because the change in norepinephrine was superior (=0.02) and all other neurohormones were similar (<0.34) during the empagliflozin versus placebo period. Furthermore, there was no evidence of potassium wasting (=0.20) or renal dysfunction (>0.11 for all biomarkers), whereas both serum magnesium (<0.001) and uric acid levels (=0.008) improved.

Conclusions: Empagliflozin causes significant natriuresis, particularly when combined with loop diuretics, resulting in an improvement in blood volume. However, off-target electrolyte wasting, renal dysfunction, and neurohormonal activation were not observed. This favorable diuretic profile may offer significant advantage in the management of volume status in patients with heart failure and may represent a mechanism contributing to the superior long-term heart failure outcomes observed with these agents. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03027960.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.045691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521417PMC
September 2020

Perceived Stress, Subjective, and Objective Symptoms of Disturbed Sleep in Men and Women with Stable Heart Failure.

Behav Sleep Med 2021 May-Jun;19(3):363-377. Epub 2020 May 12.

Yale School of Nursing, Orange, Connecticut.

: Sleep disturbance is prevalent among patients with heart failure (HF) and is associated with increased morbidity and mortality. Stress also affects health and quality of life among patients with cardiovascular disease and likely plays a prominent role in HF. However, little is known about the associations between stress and sleep among HF patients.: One hundred fifty-three stable New York Heart Association (NYHA) Classification I-IV HF patients with at least low symptoms of insomnia (M:63.0 ± 12.8, 42% Women). We examined baseline stress, sleep disturbance, and sleep-related characteristics from a randomized controlled trial of cognitive behavioral therapy for insomnia, including the Perceived Stress Scale, Insomnia Severity Index, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Sleep Disturbance Questionnaire, Dysfunctional Beliefs about Sleep Scale, PROMIS Cognitive Ability, SF-36 Mental Health, and wrist actigraphy. We used Pearson correlations and general linear models to assess stress-sleep associations, including the potential moderating effects of sex and symptom severity (NYHA).: There were moderate-to-large correlations between stress and self-reported sleep disturbance, dysfunctional beliefs about sleep, cognitive ability, and mental health ('s < 0.01). High stress was associated with more objectively-measured (i.e., actigraph-assessed) awakenings and sleep fragmentation among women than men ( = - 0.04, < 0.01;  = - 0.71, = 0.04). Relationships between stress and objectively-measured sleep did not vary by symptom severity.: Perceived stress is related to sleep disturbance among HF patients, and effects may be sex-dependent. Subsequent research should determine the temporal links between sleep and stress, and optimal opportunities for intervention among HF patients.
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http://dx.doi.org/10.1080/15402002.2020.1762601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7658015PMC
May 2020

A Self-Management Randomized Controlled Pilot Trial for Low-Income Adults with Type 2 Diabetes in Mexico City.

Curr Dev Nutr 2020 May 14;4(5):nzaa074. Epub 2020 Apr 14.

Yale School of Public Health, New Haven, CT, USA.

Background: Type 2 diabetes (T2D) is a worldwide epidemic and a leading cause of death in Mexico, with a prevalence of 15.9%, and >70% of diagnosed adults have poor glycemic control [glycated hemoglobin (HbA1c) >7.5%]. We developed a diabetes self-management education program contextualized to the study population, including dietary preferences, health literacy, and health system.

Objectives: We aimed to evaluate the efficacy of a self-management + text message program () on primary (HbA1c), and secondary behavioral (self-management), clinical, and psychosocial outcomes in adults with T2D in Mexico City.

Methods: Participants were recruited at public primary healthcare centers (), and randomly allocated to treatment ( = 26) or wait-list control groups ( = 21) with data collected at 3 and 6 mo. The program included 7 weekly sessions and 6 mo of daily text/picture messages. Descriptive statistics and a generalized linear mixed model with intent-to-treat analysis were calculated.

Results: Participants were 55.5 ± 8.8 y of age (mean ± SD), 68% female, 88.6% overweight/obese, and 57% lived in food-insecure households. Mean ± SD T2D duration was 11.9 ± 7.8 y and HbA1c was 9.2% ± 1.5%. There was 89% attendance at sessions and 6.4% attrition across both groups at 6 mo. Group-by-time effects were seen in self-monitoring of blood glucose (< 0.01) and diabetes self-efficacy (< 0.04); and a trend for lower HbA1c was seen in the intervention group at 6 mo ( = 0.11). Significant improvements in dietary behavior ( < 0.01) were demonstrated in the intervention group over time, but this did not reach statistical significance compared with the control group.

Conclusions: The program was associated with clinically significant improvements in T2D self-management, self-efficacy, and HbA1c over time. Thus, T2D self-management skills, including diet, were improved in a vulnerable metropolitan population.This trial was registered at clinicaltrials.gov as NCT03159299.
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http://dx.doi.org/10.1093/cdn/nzaa074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186776PMC
May 2020

Health and Safety in a Family Child Care Network: An Analysis of Violation Data of Routine, Full Unannounced Inspections.

Matern Child Health J 2020 Aug;24(8):1019-1027

Yale University School of Nursing, New Haven, CT, USA.

Objective: To analyze how engagement with a staffed family child network is associated with compliance on health and safety regulations among family day care (FDC) homes.

Methods: Publically available data on health and safety inspection violations on FDC homes were merged with engagement data from a staffed family child network. Descriptive analysis, logistic regression, and latent class analysis were used.

Results: Network FDC homes, compared to non-network FDC homes, were less likely to have health and safety violations in the areas of Child/Family/Staff Documentation (43.1% vs. 53.6%, p = 0.001) and Indoor Safety (36.0% vs. 42.6%, p = .041). Controlling for area median income and for decades since obtaining license, network FDC homes had fewer violations, fewer violation categories, and less variety of violation categories. Additionally, FDC homes which were not engaged with the staffed family child network but were in the city or town in which the network offered services, performed better compared to FDC homes in cities or towns without network resources.

Conclusions For Practice: The better compliance among network FDC homes and among FDC homes in cities and towns where the network offers services, suggests that the network is having positive effects on health and safety quality in FDC homes. A staffed child care network may be a means to improve child care quality and may be a means of improving educational and health outcomes for children.
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http://dx.doi.org/10.1007/s10995-020-02939-xDOI Listing
August 2020

Pilot study of combined aerobic and resistance exercise on fatigue for patients with head and neck cancer: Inflammatory and epigenetic changes.

Brain Behav Immun 2020 08 21;88:184-192. Epub 2020 Apr 21.

School of Nursing, Emory University, 1520 Clifton Road NE, Atlanta 30322, United States.

This pilot study examined whether a combined aerobic resistance exercise program reduced fatigue and the potential inflammatory and epigenetic mechanisms in patients with head and neck cancer (HNC) receiving intensity-modulated radiotherapy. The exercise group (N = 12) received a 3-month supervised aerobic resistance exercise intervention that was initiated before a 6-week radiotherapy regimen; the control group (N = 14) received standard care. Fatigue was measured using Multidimensional Fatigue Inventory-20; physical function measures included a 6-minute walk distance (6MWD), chair stands, bicep curls, and hand grip strength. Inflammatory markers and DNA methylation data were acquired using standardized protocol. Patients were mostly white (93%) and male (81%) with a mean age of 57 years. At the end of the intervention, the exercise group had a marginal decrease in fatigue compared with the control (-5.0 vs. 4.9; P = 0.10). The exercise group had a significantly greater improvement in 6MWD (29.8 vs. -55.5 m; P = 0.04), and a marginally smaller decline in hand grip (-0.3 vs. -5.8 lbs; P = 0.05) at the end of the intervention than the control. No significant difference in inflammatory markers was observed between groups. Lower plasma interleukin (IL) 6, IL1 receptor antagonist, tumor necrosis factor α (TNFα), soluble TNF receptor II and C-reactive protein were significantly associated with increased 6MWD, chair stand, and bicep curl at the end of the intervention (p < 0.05). Among the 1152 differentially methylated sites (DMS) after intervention (p < 0.001), 163 DMS were located in gene promoter regions. Enrichment analysis suggested that the top 10 upstream regulators were associated with tumor (HNF4A, RPP38, HOXA9, SAHM1, CDK7, NDN, RPS15) and inflammation (IRF7, CRKL, ONECUT1). The top 5 diseases or functions annotations of the 62 hypermethylated DMS indicated anti-tumor and anti-inflammatory effects that might be linked to exercise. These findings suggest that exercise may improve physical performance and reduce fatigue, which could be further linked to decreased inflammation, during active radiotherapy for HNC patients. Larger studies are warranted.
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http://dx.doi.org/10.1016/j.bbi.2020.04.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415514PMC
August 2020

Sleep health in young children living with socioeconomic adversity.

Res Nurs Health 2020 08 19;43(4):329-340. Epub 2020 Apr 19.

Yale School of Nursing, West Haven, Connecticut.

Racially and ethnically diverse young children who live with socioeconomic adversity are at high risk for sleep deficiency, but few behavioral sleep interventions (BSIs) are tailored to their needs. To support the future development of a feasible, acceptable, and culturally relevant sleep intervention, we conducted a community-engaged, mixed-methods study with 40 low-income, racially, and ethnically diverse parents to describe sleep characteristics, sleep habits, and parental sleep knowledge of their 6-36-month-old children and to examine the associations between children's sleep characteristics and sleep habits. This report presents quantitative data from this mixed-methods study. We measured objective (actigraphy) and parent-reported sleep (Brief Infant Sleep Questionnaire) characteristics, sleep habits at bedtime, sleep onset, and during night awakenings, parental sleep knowledge, psychological function (Brief Symptom Inventory), and parenting stress (Parenting Stress Index). Children had low sleep duration (537.2 ± 54.7 nighttime and 111.2 ± 29.8 nap minutes), late bedtimes (22:36 ± 1.5 hr), and high bedtime variability (mean squared successive difference = 3.68 ± 4.31 hr) based on actigraphy. Parental knowledge about sleep recommendations was limited. Sleep habits before bedtime, at sleep onset, and during night awakenings were varied. Sixty-five percent of parents reported co-sleeping. Feeding near bedtime or during the night was associated with later bedtimes, more fragmented sleep, and increased bedtime variability. These findings suggest the need for BSIs to support earlier bedtimes and improve sleep duration and continuity by addressing modifiable behaviors. Tailored BSIs that consider socioecological influences on the development of sleep habits are needed.
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http://dx.doi.org/10.1002/nur.22023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368803PMC
August 2020

Sleep Characteristics and Rest-Activity Rhythms Are Associated with Gastrointestinal Symptoms Among Adults with Inflammatory Bowel Disease.

Dig Dis Sci 2021 01 19;66(1):181-189. Epub 2020 Mar 19.

Yale School of Nursing, 400 West Campus Dr., Orange, CT, 06477, USA.

Background: Sleep disturbance is common in inflammatory bowel disease (IBD) and is associated with poorer quality of life and increased disease activity; however, sleep is a multidimensional process, and little is known about specific sleep characteristics and rest-activity rhythms (RARs) in this population.

Aims: The purposes were to (1) describe sleep characteristics and RARs; (2) compare sleep characteristics and RARs and GI symptoms by disease activity; and (3) describe associations between sleep characteristics, RARs, and GI symptoms among adults with IBD.

Methods: We conducted a cross-sectional study of adults with IBD. We measured sleep characteristics and RARs (continuous wrist actigraphy); GI symptoms (PROMIS-GI); and disease activity (physicians' global assessment). We conducted cosinor and nonparametric analyses to compute RAR variables and bivariate analyses to address the aims.

Results: The sample included 37 participants [age M = 38 years (SD = 13.8) and 21 (56.8%) female], of whom 23 (60.6%) were in remission. Sleep efficiency [M = 82.91% (SD 5.35)] and wake after sleep onset (WASO) [M = 42.26 min (SD 18.57)] were not associated with disease activity. Inter-daily stability of the RAR was associated with heartburn/reflux (r = - .491, p = .005) and gas/bloating (r = - .469, p = .008). Intra-daily variability of the RAR was associated with heartburn/reflux (r = .421, p = .018).

Conclusions: People with IBD may have disrupted RARs, which are associated with GI symptoms. Research is needed to improve understanding of these associations and to develop interventions to improve these characteristics in adults with IBD.
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http://dx.doi.org/10.1007/s10620-020-06213-6DOI Listing
January 2021

Sleep and Glycemia in Youth With Type 1 Diabetes.

J Pediatr Health Care 2020 Jul - Aug;34(4):315-324. Epub 2020 Mar 11.

Introduction: Short sleep duration and quality are problems for many youth, and are associated with difficulties in executive function. Our purpose was to describe subjective and objective sleep characteristics and their associations with executive function, stress and coping, adjustment, and self-management in youth with type 1 diabetes (T1D).

Method: Youth with T1D (N = 40; mean age, 13.4 ± 1.9 years; 60% female; 77.1% non-Hispanic white; diabetes duration, 7.1 ± 4.6 years; and hemoglobin A1c, 8.2 ± 1.2%) wore an actigraph and a continuous glucose monitor for 3-7 days and completed questionnaires. Descriptive and bivariate analyses were conducted.

Results: Sleep variability was associated with stress and depressive symptoms, as well as more glucose variability. Consistent rest-activity rhythm timing was associated with fewer trait anxiety symptoms. Robust rhythms were associated with better diabetes self-management.

Discussion: Providers should routinely assess sleep habits in youth, especially those with T1D. Improving consistency in sleep timing and sleep duration may be a potential therapeutic target to improve diabetes clinical outcomes.
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http://dx.doi.org/10.1016/j.pedhc.2019.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311270PMC
March 2020

Real World Use of Hypertonic Saline in Refractory Acute Decompensated Heart Failure: A U.S. Center's Experience.

JACC Heart Fail 2020 03 5;8(3):199-208. Epub 2020 Feb 5.

Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut. Electronic address:

Objectives: The purpose of this study was to investigate real world safety and efficacy of hypertonic saline therapy in cases of refractory acute decompensated heart failure (ADHF) at a large U.S. academic medical center.

Background: Hypertonic saline therapy has been described as a potential management strategy for refractory ADHF, but experience in the United States is limited.

Methods: A retrospective analysis was performed in all patients receiving hypertonic saline for diuretic therapy-resistant ADHF at the authors' institution since March 2013. The primary analytic approach was a comparison of the trajectory of clinical variables prior to and after administration of hypertonic saline, with secondary focus on predictors of treatment response.

Results: A total of 58 hypertonic saline administration episodes were identified across 40 patients with diuretic-therapy refractory ADHF. Prior to hypertonic saline administration, serum sodium, chloride, and creatinine concentrations were worsening but improved after hypertonic saline administration (p < 0.001, all). Both total urine output and weight loss significantly improved with hypertonic saline (p = 0.01 and <0.001, respectively). Diuretic efficiency, defined as change in urine output per doubling of diuretic dose, also improved over this period (p < 0.01). There were no significant changes in respiratory status or overcorrection of serum sodium with the intervention.

Conclusions: In a cohort of patients who were refractory to ADHF, hypertonic saline administration was associated with increased diuretic efficiency, fluid and weight loss, and improvement of metabolic derangements, and no adverse respiratory or neurological signals were identified. Additional study of hypertonic saline as a diuretic adjuvant is warranted.
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http://dx.doi.org/10.1016/j.jchf.2019.10.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814403PMC
March 2020

First-in-Human Experience With Peritoneal Direct Sodium Removal Using a Zero-Sodium Solution: A New Candidate Therapy for Volume Overload.

Circulation 2020 03 8;141(13):1043-1053. Epub 2020 Jan 8.

Department of Internal Medicine, Section of Cardiovascular Medicine (V.S.R., M.G., D.M., N.B., J.M. Testani), Yale University School of Medicine, New Haven, CT.

Background: Loop diuretics have well-described toxicities, and loss of response to these agents is common. Alternative strategies are needed for the maintenance of euvolemia in heart failure (HF). Nonrenal removal of sodium directly across the peritoneal membrane (direct sodium removal [DSR]) with a sodium-free osmotic solution should result in extraction of large quantities of sodium with limited off-target solute removal.

Methods: This article describes the preclinical development and first-in-human proof of concept for DSR. Sodium-free 10% dextrose was used as the DSR solution. Porcine experiments were conducted to investigate the optimal dwell time, safety, and scalability and to determine the effect of experimental heart failure. In the human study, participants with end-stage renal disease on peritoneal dialysis (PD) underwent randomization and crossover to either a 2-hour dwell with 1 L DSR solution or standard PD solution (Dianeal 4.25% dextrose, Baxter). The primary end point was completion of the 2-hour dwell without significant discomfort or adverse events, and the secondary end point was difference in sodium removal between DSR and standard PD solution.

Results: Porcine experiments revealed that 1 L DSR solution removed 4.1±0.4 g sodium in 2 hours with negligible off-target solute removal and overall stable serum electrolytes. Increasing the volume of DSR solution cycled across the peritoneum increased sodium removal and substantially decreased plasma volume (=0.005). In the setting of experimental heart failure with elevated right atrial pressure, sodium removal was ≈4 times greater than in healthy animals (<0.001). In the human proof-of-concept study, DSR solution was well tolerated and not associated with significant discomfort or adverse events. Plasma electrolyte concentrations were stable, and off-target solute removal was negligible. Sodium removal was substantially higher with DSR (4.5±0.4 g) compared with standard PD solution (1.0±0.3 g; <0.0001).

Conclusions: DSR was well tolerated in both animals and human subjects and produced substantially greater sodium removal than standard PD solution. Additional research evaluating the use of DSR as a method to prevent and treat hypervolemia in heart failure is warranted. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03801226.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.119.043062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331276PMC
March 2020

Role of Sleep Duration in the Association Between Socioecological Protective Factors and Health Risk Behaviors in Adolescents.

J Dev Behav Pediatr 2020 Feb/Mar;41(2):117-127

Boston Children's Hospital, Boston, MA.

Objective: The purpose of this study was to examine the associations of sleep duration and socioecological protective factors with patterns of adolescent risk behaviors in Fairfax County, VA-one of the largest public school districts in the United States.

Methods: A total of 21,360 and 20,330 students in 10th and 12th grades who completed the Youth Risk Behavior Survey were included in this cross-sectional analysis. Sleep duration was measured by self-report of the average number of hours of sleep on a school night. Ten socioecological protective factors included peer-individual, family, school, and community domains. Latent class analysis was used to classify 7 risk behaviors (alcohol use, cigarette use, illicit drug use, inappropriate prescription drug use, risky sexual behavior, deviant behavior, and academic failure) into 4 class memberships (low, some, moderate, and high). Multinomial regression models were adjusted for age, sex, and race.

Results: Adolescents who reported sleeping the recommended 8 to 9 hours were significantly less likely to belong to the class memberships of greater risk behaviors compared with those who reported short and long sleep duration after controlling for age, sex, race, and survey year. There was a significant inverse relationship between the number of socioecological protective factors and risk behaviors for both 10th and 12th graders. Potential risks of age, sex, and race on risk behaviors were observed. No significant interaction between sleep duration and protective factors was found in either grade.

Conclusion: This study highlights the significant associations between sleep duration and risk behaviors in adolescents with diverse socioecological protective factors. Prioritization of prevention-focused resources should consider sleep duration in addition to the socioecological protective factors commonly cited in the literature when addressing adolescent risk behaviors.
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http://dx.doi.org/10.1097/DBP.0000000000000721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7007325PMC
April 2021

Daytime and Nighttime Sleep Characteristics and Pain Among Adults With Stable Heart Failure.

J Cardiovasc Nurs 2019 Sep/Oct;34(5):390-398

Samantha Conley, PhD, RN, FNP-BC Assistant Professor, Yale School of Nursing, Orange, Connecticut. Shelli L. Feder, PhD, APRN, FNP-BC, ACHPN ACHPN, Postdoctoral Fellow, Yale School of Medicine, New Haven, Connecticut. Sangchoon Jeon, PhD Research Scientist, Yale School of Nursing, Orange, Connecticut. Nancy S. Redeker, PhD, RN Beatrice Renfield Term Professor of Nursing, Yale School of Nursing, Orange, Connecticut.

Background: Pain and sleep disturbance are common among patients with heart failure (HF) and are associated with symptom burden, disability, and poor quality of life. Little is known about the associations between specific sleep characteristics and pain in people with HF.

Objective: The aim of this study was to describe the relationships between nocturnal sleep characteristics, use of sleep medication, and daytime sleep characteristics and pain among people with HF.

Methods: We conducted a cross-sectional study of stable participants with HF. We administered the SF36 Bodily Pain Scale, Pittsburgh Sleep Quality Index, and Sleep Habits Questionnaire and obtained 3 days of wrist actigraphy and 1 night of home unattended polysomnography. We conducted bivariate analyses and generalized linear models.

Results: The sample included 173 participants (mean [SD] age, 60 [16.1] years; 65.3% [n = 113] male). Insomnia symptoms (P = .0010), sleep duration (P = .0010), poor sleep quality (P = .0153), use of sleep medications (P = .0170), napping (P = .0029), and daytime sleepiness (P = .0094) were associated with increased pain. Patients with the longest sleep duration, who also had insomnia, had more pain (P = .0004), fatigue (P = .0028), daytime sleepiness (P = .0136), and poorer sleep quality (P < .0001) and took more sleep medications (P = .0029) than did those without insomnia.

Conclusions: Pain is associated with self-reported poor sleep quality, napping, daytime sleepiness, and use of sleep medication. The relationship between pain and sleep characteristics differs based on the presence of insomnia and sleep duration. Studies are needed to evaluate the causal relationships between sleep and pain and test interventions for these cooccurring symptoms.
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http://dx.doi.org/10.1097/JCN.0000000000000593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6690780PMC
July 2020

Pilot study: an intensive care unit sleep promotion protocol.

BMJ Open Respir Res 2019 7;6(1):e000411. Epub 2019 Jun 7.

Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.

Purpose: Disturbances, such as in-room activity and sound, are significant sources of sleep disruption among critically ill patients. These factors are potentially modifiable. We tested the impact of an intensive care unit (ICU) sleep promotion protocol on overnight in-room disturbance.

Methods: Our protocol restricted non-urgent bedside care from 00:00 to 03:59. Patients were assigned to usual care (n=30) or the sleep protocol (n=26). The primary outcomes were measures of in-room activity, sound and light. These three types of disturbance were compared between arms during a baseline time block (20:00-23:59) and a rest time block (00:00-03:59). We assessed the sleep protocol effect with generalised linear models.

Results: Usual care and sleep protocol patients had equivalent levels of in-room activity, sound and light during the baseline time block (20:00-23:59). In contrast, during the rest time block (00:00-03:59), the sleep protocol arm had 32% fewer room entries (rate ratio (RR) 0.68, p=0.001) and 9.1 fewer minutes of in-room activity (p=0.0002). Also, the length of time between room entrances increased from 26.4 to 45.8 min (p=0.0004). The sleep protocol arm also had lower sound during the rest time block. Mean A-weighted sound was 2.5 decibels lower (p=0.02), and there were 36% fewer peaks (RR 0.64, p=0.02). Light levels were highly variable and not changed by the sleep protocol.

Conclusions: Sleep promotion protocols can improve in-room activity and sound. This provides a better sleep opportunity and may, therefore, improve ICU sleep.

Trial Registration Number: 1112009428.
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http://dx.doi.org/10.1136/bmjresp-2019-000411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6561389PMC
July 2020

Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: A systematic review and meta-analysis.

Sleep Med Rev 2019 08 13;46:151-160. Epub 2019 May 13.

Yale School of Nursing, USA.

Wrist actigraphy (ACT) may overestimate sleep and underestimate wake, and the agreement may be lower in people with chronic conditions who often have poor sleep and low activity levels. The purpose of this systematic review is to compare the agreement between ACT and polysomnographic (PSG) measures of sleep in adults without chronic conditions and sleep complaints (healthy) and with chronic conditions. We conducted a systematic review and meta-analysis using PRISMA guidelines. We searched PubMed, OVIDEMBASE, OVIDMEDLINE, OVIDPsycINFO, CENTRAL, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry, and Open Grey. We included 96 studies with a total of 4134 participants, of whom 762 (18.4) were healthy adults and 724 (17.5%) were adults with chronic conditions. Among adults with chronic conditions, ACT overestimated TST, compared to PSG [M = 22.42 min (CI 95%: 11.92, 32.91 min)] and SE [M = 5.21% (CI 95%: 1.41%-9.00%)]. ACT underestimated SOL [M = -7.70 min (CI 95%: -15.22, -0.18 min)], and WASO [M = -10.90 min (CI 95%: -26.01, 4.22 min)]. These differences were consistently larger between ACT and PSG sleep measures compared to healthy adults. Research is needed to better understand factors that influence the agreement between ACT and PSG among people with chronic conditions.
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http://dx.doi.org/10.1016/j.smrv.2019.05.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594867PMC
August 2019

Endocrine Therapy-Related Symptoms and Quality of Life in Female Cancer Survivors in the Yale Fitness Intervention Trial.

J Nurs Scholarsh 2019 05 15;51(3):317-325. Epub 2019 Mar 15.

Research Scientist in Nursing, Yale University School of Nursing, Orange, CT,, USA.

Purpose: The aim of the current study was to describe and compare endocrine therapy-related symptoms and quality of life in female cancer survivors taking aromatase inhibitors, tamoxifen, and no endocrine therapy, and to evaluate the effect of an exercise intervention on these symptoms and quality of life.

Design: Randomized controlled trial. An aerobic resistance exercise intervention group was compared with a home-based exercise control group over 1 year. The exercise intervention was supervised for the first 6 months, followed by 6 unsupervised months.

Methods: Perimenopausal and early postmenopausal female cancer survivors within 3 years of completing primary or adjuvant chemotherapy were selected. A total of 154 women were enrolled in the study. Type of endocrine or hormonal therapy was documented. Symptoms were measured by the Breast Cancer Prevention Trial Symptom Checklist and the Functional Assessment of Cancer Therapy-Endocrine Subscale. Quality of life was measured by the Functional Assessment of Cancer Therapy-General. Data were collected at baseline, and at 6 and 12 months.

Findings: Participants generally had mild symptom distress. There was no difference in symptoms by endocrine therapy group or by exercise group. Participants taking aromatase inhibitors in the aerobic resistance exercise intervention group reported significant improvement in social, family, and functional well-being and better quality of life compared to those in the control group at 6 months but not at 12 months.

Conclusions: Findings were similar to those of previous large clinical trials in that no significant differences were found for endocrine therapy-related symptoms and quality of life by type of endocrine therapy taken. However, exercise may improve quality of life outcomes for women taking aromatase inhibitors.

Clinical Relevance: Exercise has established efficacy for patient outcomes such as cardiovascular fitness, fatigue, weight management, and quality of life and may provide better quality of life for women who take aromatase inhibitors as adjuvant therapy.
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http://dx.doi.org/10.1111/jnu.12471DOI Listing
May 2019

Social Network Structures in African American Churches: Implications for Health Promotion Programs.

J Urban Health 2019 04;96(2):300-310

Yale University, School of Nursing, 400 West Campus Drive, Orange, CT, 06477, USA.

The prevalence of obesity among African Americans is higher than among other racial/ethnic groups. African American churches hold a central role in promoting health in the community; yet, church-based interventions have had limited impact on obesity. While recent studies have described the influence of social networks on health behaviors, obesity interventions informed by social network analysis have been limited. We conducted a cross-sectional study with 281 African American men and women from three churches in northeast urban cities in the USA. Data were collected on sociodemographic and clinical factors and anthropometrics. Using a social network survey applying a name generator, we computed network level metrics. Exponential random graph models (ERGM) were performed to examine whether each structural property found in the empirical (observed) networks occurred more frequently than expected by chance by comparing the empirical networks to the randomly simulated networks. Overall, church friendship networks were sparse (low density). We also found that while friendship ties were more reciprocated between dyads in church networks, and there were more tendencies for clustering of friendships (significant positive transitive closure) than in random networks, other characteristics such as expansiveness (number of actors with a great number of friends) did not differ from what would be expected by chance in random networks. These data suggest that interventions with African American churches should not assume a unitary network through which a single intervention should be used.
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http://dx.doi.org/10.1007/s11524-018-00339-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6458228PMC
April 2019

®: Enhancing parental reflective functioning and infant attachment in an attachment-based, interdisciplinary home visiting program.

Dev Psychopathol 2020 02;32(1):123-137

Yale Child Study Center, New Haven, CT, USA.

In this article, we describe the results of the second phase of a randomized controlled trial of Minding the Baby (MTB), an interdisciplinary reflective parenting intervention for infants and their families. Young first-time mothers living in underserved, poor, urban communities received intensive home visiting services from a nurse and social worker team for 27 months, from pregnancy to the child's second birthday. Results indicate that MTB mothers' levels of reflective functioning was more likely to increase over the course of the intervention than were those of control group mothers. Likewise, infants in the MTB group were significantly more likely to be securely attached, and significantly less likely to be disorganized, than infants in the control group. We discuss our findings in terms of their contribution to understanding the impacts and import of intensive intervention with vulnerable families during the earliest stages of parenthood in preventing the intergenerational transmission of disrupted relationships and insecure attachment.
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http://dx.doi.org/10.1017/S0954579418001463DOI Listing
February 2020

Latent Transition Analysis of the Symptom Experience of Cancer Patients Undergoing Chemotherapy.

Nurs Res 2019 Mar/Apr;68(2):91-98

Sangchoon Jeon, PhD, is Research Scientist, Division of Acute Care and Health Systems, Yale School of Nursing, West Haven, Connecticut. Alla Sikorskii, PhD, is Professor, Department of Psychiatry & Statistics and Probability, Michigan State University, East Lansing. Barbara Given, PhD, RN, FAAN, is Professor Emeritus, College of Nursing, Michigan State University, East Lansing. Charles W. Given, PhD, is Professor Emeritus, Department of Family Medicine, Michigan State University, East Lansing. Nancy S. Redeker, PhD, RN, FAHA, FAAN, is the Beatrice Renfield Professor of Nursing, Division of Acute Care and Health Systems, Yale School of Nursing, and Professor, Department of Internal Medicine, Yale School of Medicine, West Haven, Connecticut.

Background: Symptom clusters reflect the person's experience of multiple cooccurring symptoms. Although a variety of statistical methods are available to address the clustering of symptoms, latent transition analysis (LTA) characterizes patient membership in classes defined by the symptom experience and captures changes in class membership over time.

Objectives: The purposes of this article are to demonstrate the application of LTA to cancer symptom data and to discuss the advantages and disadvantages of LTA relative to other methods of managing and interpreting data on multiple symptoms.

Methods: Data from a total of 495 adult cancer patients who participated in randomized clinical trials of two symptom management interventions were analyzed. Eight cancer- and treatment-related symptoms reflected the symptom experience. Latent transition analysis was employed to identify symptom classes and evaluate changes in symptom class membership from baseline to the end of the interventions.

Results: Three classes, "A (mild symptoms)," "B (physical symptoms)," and "C (physical and emotional symptoms)," were identified. Class A patients had less comorbidity, better physical and emotional role effect, and better physical function than the other classes did. The number of symptoms, general health perceptions, and social functioning were significantly different across the three classes and were poorest in Class C. Emotional role functioning was poorest in Class C. Older adults were more likely to be in Class B than younger adults were. Younger adults were more likely to be in Class C (p < .01). Among patients in Class C at baseline, 41.8% and 29.0%, respectively, transitioned to Classes A and B at the end of the interventions.

Discussion: These results demonstrate that symptom class membership characterizes differences in the patient symptom experience, function, and quality of life. Changes in class membership represent longitudinal changes in the course of symptom management. Latent class analysis overcomes the problem of multiple statistical testing that separately addresses each symptom.
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http://dx.doi.org/10.1097/NNR.0000000000000332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6399048PMC
November 2019

Effects of Cognitive Behavioral Therapy for Insomnia on Sleep, Symptoms, Stress, and Autonomic Function Among Patients With Heart Failure.

Behav Sleep Med 2020 Mar-Apr;18(2):190-202. Epub 2018 Nov 21.

Yale School of Nursing, Orange, CT.

: Insomnia is common among patients with stable heart failure (HF) and associated with inflammation and altered autonomic function. : The purposes of this study were to examine the effects of cognitive behavioral therapy for insomnia (CBT-I) on the Hypothalamic Pituitary (HPA) Axis, autonomic function, inflammation, and circadian rhythmicity and the associations between these biomarkers and insomnia, sleep characteristics, symptoms, functional performance, and sleep-related cognitions. : We conducted a subanalysis of a pilot randomized controlled trial (RCT, NCT02827799) whose primary aim was to test the effects of CBT-I on insomnia. We randomized 51 patients with stable Class II-IV HF to CBT-I ( = 30) or attention control ( = 21). Participants completed wrist actigraphy and self-reported insomnia severity, sleep characteristics, sleep-related cognitions, daytime symptoms, and functional performance. We measured day and nighttime urinary free cortisol, melatonin sulfate, epinephrine, and norepinephrine at baseline, and two weeks after CBT-I and computed general linear models and partial correlations. : CBT-I had no effects on the biomarkers, but there were statistically significant negative cross-sectional correlations between the ratio of day and night urinary free cortisol and sleep disturbance, anxiety, fatigue, depression, and negative sleep cognitions. Increases in the ratio between day and night cortisol were associated with statistically significant improvements in fatigue, depression, sleep duration, and sleep-related cognitions. : Biomarkers of stress and autonomic function are associated with sleep, sleep-related symptoms, and cognitions among people with chronic HF. Future studies are needed to identify potential causal relationships and the impact of sleep interventions.
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http://dx.doi.org/10.1080/15402002.2018.1546709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529289PMC
June 2020

The Association Between HIV Infection and the Use of Palliative Care in Patients Hospitalized With Heart Failure.

Am J Hosp Palliat Care 2019 Mar 10;36(3):228-234. Epub 2018 Oct 10.

Yale School of Nursing, West Haven, CT, USA.

Background: The number of adults with heart failure (HF) and HIV infection is increasing. These patients may benefit from palliative care (PC).

Objectives: Determine the association between HIV infection, other HIV characteristics, and PC among hospitalized patients with HF in the Veterans Health Administration (VHA).

Design: Nested case-control study of patients with HF hospitalized from 2003 to 2015 and enrolled in the Veterans Aging Cohort Study.

Setting/patients: Two hundred and ten hospitalized patients with HF who received PC matched to 1042 patients with HF who did not receive PC, by age, discharge date, and left ventricular ejection fraction.

Measurements: Palliative care use was the primary outcome. Independent variables included HIV infection identified by code and further characterized as the primary diagnosis for hospitalization, unsuppressed HIV-1 RNA, CD4 counts <200 cells/mm, and other covariates. We examined associations between independent variables and PC using conditional logistic regression.

Results: The sample was 99% male, mean age was 64 years (standard deviation ±10), 54% of cases and 59% of controls were black, and 30% of cases and 31% of controls were HIV-infected. In adjusted models, HIV as the primary diagnosis for hospitalization (odds ratio [OR]: 3.69, 95% confidence interval [CI]: 1.30-10.52), unsuppressed HIV-1 RNA (OR: 2.62, 95% CI: 1.31-5.24), and CD4 counts <200 cells/mm (OR: 3.47; 1.78-6.77), but not HIV infection (OR: 0.79, 95% CI: 0.55-1.13), were associated with PC.

Conclusions: HIV characteristics indicative of severe disease are associated with PC for hospitalized VHA patients with HF. Increasing access to PC for patients with HF and HIV is warranted.
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http://dx.doi.org/10.1177/1049909118804465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457998PMC
March 2019