Melissa D. Zullo

The association between heavy metals, endometriosis and uterine myomas among premenopausal women: National Health and Nutrition Examination Survey 1999–2002

BACKGROUND It has been hypothesized that exposure to exogenous estrogens may be associated with endometriosis and uterine myomas. We sought to investigate the association between heavy metals which have been shown to be hormonally active and these disorders using data from the National Health and Nutrition Examination Survey, 1999-2002. METHODS Women aged 20-49 years who had data on metals and the outcomes of interest, were premenopausal and neither pregnant nor breastfeeding were eligible (n = 1425). Lead, cadmium and mercury were measured in whole blood. Diagnosis of outcomes was based upon self-report. Logistic regression was used to examine the association between tertiles of heavy metals and disease adjusting for age, race/ethnicity, use of birth control pills prior to diagnosis and smoking status at diagnosis. RESULTS A dose-response association between cadmium and endometriosis was observed [tertile 2 versus 1: adjusted odds ratio (OR) = 1.94, 95% confidence interval (CI): 0.73-5.18; tertile 3 versus 1: adjusted OR = 3.39, 95% CI 1.37-8.40]. This association persisted in subanalyses: (i) limiting analysis to women diagnosed in the past 10 years and (ii) limiting analysis to women diagnosed since last pregnancy, although limited by sample size. CONCLUSIONS These results must be interpreted with caution given the cross-sectional study design. The observed association between cadmium and endometriosis deserves further investigation in properly designed studies.

Post-acute care services received by older adults following a cardiac event: a population-based analysis.

Background:Post-acute care (PAC) is available for older adults who need additional services after hospitalization for acute cardiac events. With the aging population and an increase in the prevalence of cardiac disease, it is important to determine current PAC use for cardiac patients to assist health care workers to meet the needs of older cardiac patients. The purpose of this study was to determine the current PAC use and factors associated with PAC use for older adults following hospitalization for a cardiac event that includes coronary artery bypass graft and valve surgeries, myocardial infarction (MI), percutaneous coronary intervention (PCI), and heart failure (HF). Methods and Results:A cross-sectional design and the 2003 Medicare part A database were used for this study. The sample (n = 1493521) consisted of patients 65 years and older discharged after their first cardiac event. Multinomial logistic regression was used to examine factors associated with PAC use. Overall, PAC use was 55% for cardiac valve surgery, 50% for MI, 45% for HF, 44% for coronary artery bypass graft, and 5% for PCI. Medical patients use more skilled nursing facility care, and surgical patients use more home health care. Only 0.1% to 3.4% of the cardiac patients use intermediate rehabilitation facilities. Compared with those who do not use PAC, those who use home health care and skilled nursing facility care are older and female, have a longer hospital length of stay, and have more comorbidity. Asians, Hispanics, and Native Americans were less likely to use PAC after hospitalization for an MI or HF. Conclusions:The current rate of PAC use indicates that almost half of nondisabled Medicare patients discharged from the hospital following a cardiac event use one of these services. Health care professionals can increase PAC use for Asians, Hispanics, and Native Americans by including culturally targeted communication. Optimizing recovery for cardiac patients who use PAC may require focused cardiac rehabilitation strategies.

Evaluation of the recommended core components of cardiac rehabilitation practice: an opportunity for quality improvement.

PURPOSE: Guidelines have been established that describe recommended core components for cardiac rehabilitation (CR) programs; yet, there are no national efforts to monitor the integration of the guidelines. The purpose of this research was to describe incorporation of core components in CR programs. METHODS: This was a cross-sectional study using the Ohio Phase II Cardiac Rehabilitation Survey. Descriptive analyses were stratified on American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) certification, case management, and staff mix. RESULTS: Sixty-six percent (n = 94) of programs responded, 39% (n = 37) were AACVPR certified, 40% (n = 38) used case management, and 73% (n = 75) staffed an exercise physiologist. Notable findings included that only 44% of programs obtained/performed a 12-lead electrocardiogram and 36% screened for depression. AACVPR-certified programs compared with uncertified programs were more likely to manage overweight/obesity (100% vs 84% instruct on weight control, respectively, P = .02) and perform health assessments upon admission (89% vs 70% respectively, P = .04). Programs using case management when compared with programs that did not use case management were more likely to administer a health survey (92% vs 65%, respectively, P = .003) and risk stratify (100% vs 84%, respectively, P = .02). Programs with an exercise physiologist were more likely to administer/obtain a stress test when compared with those without an exercise physiologist (78% vs 56%, respectively, P = .04). CONCLUSIONS: There was a lack of consistency in the incorporation of core component guidelines; certification, case management, and staff mix offered little improvement. This study provides direction for statewide quality improvement initiatives to improve care delivered in CR programs.

Consumption of alcoholic beverages among pregnant urban Ugandan women.

The World Health Organization estimated alcohol consumption in Uganda to be one of the highest in the world. We examined alcohol consumption among Ugandan women prior to and after learning of pregnancy. We developed a screening algorithm using factors that predicted alcohol consumption in this study. In 2006, we surveyed 610 women attending antenatal care at the national referral hospital in Kampala, Uganda about consumption of traditional and commercial alcoholic beverages before and after learning of pregnancy. Predictors of alcohol consumption during pregnancy were examined and a practical screening algorithm was developed for use in antenatal clinics. One hundred eighty women (30%) drank alcohol at least monthly before learning of their pregnancy. Among these women, almost one-third reported usual consumption of at least one beverage type at quantities that equal binging levels for women. Overall, 151 women (25%) consumed alcohol after learning of pregnancy. Commercial beverages, particularly beer, were consumed more often than traditional drinks. A two-stage screening algorithm asking women about their religion, male partner or friends’ drinking, and any lifetime drinking predicted self-reported consumption of alcohol during pregnancy with 97% sensitivity and 89% specificity. Alcohol consumption among pregnant Ugandan women attending antenatal care is high. A feasible screening algorithm can help providers target education and counseling to women who are likely drinking during pregnancy. Given the preference for commercial alcoholic beverages, it is recommended that labels be placed prominently on bottled alcoholic beverages warning of the adverse effects of consuming alcohol during pregnancy.

Cardiac Rehabilitation, Health Behaviors, and Body Mass Index Post‐Myocardial Infarction

PURPOSE Cardiac rehabilitation (CR) is a multifactorial program that encourages healthy behaviors in persons with a recent cardiovascular event or procedure. Research on the association between CR and health-behavior maintenance has focused on physical activity. Therefore, the purpose of this research was to examine the association of health behaviors (fruit/vegetable consumption and physical activity) and body mass index (BMI) with CR attendance and time since participation in respondents reporting history of myocardial infarction (MI). METHODS This was a cross-sectional study using the 2003 Behavioral Risk Factor Surveillance System (n = 1,374). Eligible respondents were those with a history of MI. Outcomes were fruit/vegetable consumption, physical activity, and BMI. Time since CR was based on age at MI and age at survey. Logistic (polytomous) regression was used to identify predictors. RESULTS CR attendees were 69% more likely to meet fruit/vegetable guidelines than were nonattendees (P = .02). CR was not associated with meeting physical activity guidelines. CR had a protective, yet nonsignificant effect on BMI. Meeting fruit/vegetable guidelines was associated with CR attendance in the past year (odds ratio = 4.64, confidence interval, CI: 1.03–20.95). CR attendees were 75% less likely to be overweight 1 to 2 years post-CR (CI: 0.08–0.73) and 59% less likely to be obese 2 to 5 years post-CR than were nonattendees (CI: 0.20–0.85). CONCLUSIONS CR attendance was associated with healthy behaviors, though maintenance diminished over time. Understanding the factors associated with healthy behaviors, and the time when behavior performance decreases, will assist with program planning directed at behavior maintenance.

Initial Efficacy of a Cardiac Rehabilitation Transition Program: Cardiac TRUST

The purpose of this pilot study was to test the initial efficacy, feasibility, and safety of a specially designed postacute care transitional rehabilitation intervention for cardiac patients. Cardiac Transitional Rehabilitation Using Self-Management Techniques (Cardiac TRUST) is a family-focused intervention that includes progressive low-intensity walking and education in self-management skills to facilitate recovery following a cardiac event. Using a randomized two-group design, exercise self-efficacy, steps walked, and participation in an outpatient cardiac rehabilitation (CR) program were compared in a sample of 38 older adults (17 Cardiac TRUST, 21 usual care). At discharge from postacute care, the intervention group trended toward higher levels of self-efficacy for exercise outcomes than the usual care group. During the 6 weeks following discharge, the intervention group had greater attendance in outpatient CR and a trend toward more steps walked during the first week. The feasibility of the intervention was better for the home health care participants than for those in the skilled nursing facility. The provision of CR during postacute care has the potential to bridge the gap in transitional services from hospitalization to outpatient CR for these patients at high risk for future cardiac events. Further evidence of the efficacy of Cardiac TRUST is warranted.

Safety Culture in the Gynecology Robotics Operating Room

STUDY OBJECTIVE To measure the safety culture in the robotics surgery operating room before and after implementation of the Robotic Operating Room Computerized Checklist (RORCC). DESIGN Prospective study. SUBJECTS Gynecology surgical staff (n = 32). SETTING An urban community hospital. INTERVENTIONS The Safety Attitudes Questionnaire domains examined were teamwork, safety, job satisfaction, stress recognition, perceptions of management, and working conditions. Questions and domains were described using percent agreement and the Cronbach alpha. Paired t-tests were used to describe differences before and after implementation of the checklist. MEASUREMENTS AND MAIN RESULTS Mean (SD) staff age was 46.7 (9.5) years, and most were women (78%) and worked full-time (97%). Twenty respondents (83% of nurses, 80% of surgeons, 66% of surgical technicians, and 33% of certified registered nurse anesthetists) completed the Safety Attitudes Questionnaire; 6 were excluded because of non-matching identifiers. Before RORCC implementation, the highest quality of communication and collaboration was reported by surgeons and surgical technicians (100%). Certified registered nurse anesthetists reported only adequate levels of communication and collaboration with other positions. Most staff reported positive responses for teamwork (48%; α = 0.81), safety (47%; α = 0.75), working conditions (37%; α = 0.55), stress recognition (26%; α = 0.71), and perceptions of management (32%; α = 0.52). No differences were observed after RORCC implementation. CONCLUSION Quality of communication and collaboration in the gynecology robotics operating room is high between most positions; however, safety attitude responses are low overall. No differences after RORCC implementation and low response rates may highlight lack of staff support.

Influenza Vaccination in Adults with Chronic Obstructive Pulmonary Disease: The Impact of a Diagnostic Breathing Test on Vaccination Rates

Introduction Influenza vaccination rates are low in adults with chronic obstructive pulmonary disease (COPD). A diagnostic breathing test in adults with COPD may increase vaccination rates; however, research has not demonstrated this relationship. The purpose of this research was to determine if adults with COPD diagnosed by a breathing test were more likely to have had an influenza vaccination during the past 12 months when compared to those with COPD diagnosed without a breathing test. Methods This was a cross-sectional study using data from the 2011 Behavioral Risk Factor Surveillance System. Logistic regression examined the relationship between influenza vaccination among adults with COPD diagnosed with a breathing test (n = 13,201) compared to those diagnosed without a breathing test (n = 3,108), after controlling for all potential confounders. Results Overall, 49% of respondents with COPD received an influenza vaccination within the past 12 months and 78% reported their COPD was diagnosed by a breathing test. The prevalence of influenza vaccination in the past 12 months was greater in those with COPD diagnosed by a breathing test (53%) compared to those diagnosed without a breathing test (36%). In adjusted analysis, adults with COPD who had a breathing test were 31% (confidence interval 1.1, 1.6) more likely to have received an influenza vaccination in the past 12 months compared to those without a breathing test. Discussion A diagnostic breathing test for COPD was associated with increased likelihood of having had an influenza vaccination in the past 12 months. This may be an indicator of the relationship between knowledge of lung function and the need for preventative care, a sign of quality healthcare, or good health-seeking behaviors in patients with COPD. This research is the first to use a nationally representative sample to suggest that spirometry diagnosis of COPD may increase rates of influenza vaccination.

Validation of an instrument to measure registered dietitians'/nutritionists' knowledge, attitudes and practices of an intuitive eating approach.

OBJECTIVE The purpose of the present study was to develop and assess the construct validity of a tool to measure knowledge, attitudes and practices of registered dietitians/nutritionists (RD/N) regarding an intuitive eating lifestyle. DESIGN Cross-sectional study design that utilized a survey administered to a random sample and remaining full population of RD/N. SETTING A national survey conducted via online survey software. SUBJECTS A random sample of 10 % of all RD/N in the USA (n 8834) was invited to participate. Survey completion rate was 22·2 % (n 1897). After initial validation, the survey was distributed to the remaining 90 % of RD/N to confirm validation. RESULTS After removing items with insufficient factor loadings, results were consistent with a four-factor solution: (i) knowledge of intuitive eating; (ii) attitudes towards intuitive eating; (iii) traditional and restrictive practices; and (iv) non-restrictive and intuitive eating practices. Confirmatory factor analysis provided further evidence of the validity of the four factors and the factors had strong reliability. CONCLUSIONS Unlike the hypothesized three-factor solution (knowledge, attitudes and practices), validation analysis revealed that the survey measures knowledge of intuitive eating, attitudes towards intuitive eating, use of traditional and restrictive weight-management practices, and use of non-restrictive and intuitive eating practices. With the landscape of weight management and health promotion undergoing a shift towards a health centred, size acceptance approach, this instrument will provide valuable information regarding the current knowledge, attitudes and practices of RD/N and other health promotion professionals.

Health-related quality of life in current smokers with COPD: factors associated with current smoking and new insights into sex differences

Findings from studies that examined the association between health-related quality of life (HRQOL) and smoking status among COPD patients have been mixed. Moreover, factors associated with current smoking in COPD patients and differences by sex have not been fully elucidated. Data from the 2011 and 2012 Behavioral Risk Factor Surveillance System was used in this study. Four HRQOL indicators were examined in this study: general health, physical health, mental health, and activity limitations. General health was dichotomized into two groups: “excellent/very good/good” and “fair/poor”, and the other three HRQOL indicators were dichotomized into <14 (infrequent) and ≥14 (frequent) unhealthy days in the past 30 days. To examine HRQOL indicators in association with current versus former smoking and identify factors associated with current smoking, logistic regression models were used. Sex differences were explored. In COPD patients, current smokers compared to former smokers had significantly poor HRQOL on all subdomains: “fair/poor” general health (adjusted odds ratio [AOR]: 1.2 [95% confidence interval {CI}: 1.1–1.5]); poor physical health (AOR: 1.3 [CI: 1.1–1.5]); poor mental health (AOR: 1.8 [CI: 1.4–2.2]); and poor activity limitations (AOR: 1.5 [CI: 1.3–1.9]). HRQOL subdomains affected by current smoking differed by sex except activity limitations. General health (AOR: 1.5 [CI: 1.1–2.0]) and activity limitations (AOR: 1.6 [95% CI: 1.2–2.2]) in males and physical health (AOR: 1.3 [CI: 1.0–1.6]), mental health (AOR: 2.1 [CI: 1.7–2.6]), and activity limitations (AOR: 1.5 [CI: 1.2–1.9]) in females were significantly impaired due to current smoking. Factors associated with current smoking differed by sex except being unmarried and having less than a college degree, which were associated with current smoking in both males and females. These findings have important implications for health care providers in designing more effective interventions which tailor to and target specific subgroups for smoking cessation.