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AnteayerNursing Research

Transition From Acute to Chronic Pain in Lower Extremity Fracture Patients: A Pain Phenotyping Protocol

imageBackground Traumatic injury is a major source of chronic pain, particularly for individuals with traumatic fracture of the fibula and/or tibia (lower extremity fracture [LEFx]). Although several factors (e.g., older age, being female, high pain intensity at time of initial injury) have been identified as risk factors for chronic pain associated with LEFx. Comprehensive biopsychosical models to predict the odds of transitioning from acute to chronic pain after LEFx are needed to better understand the underlying processes, predict risk for chronic pain, and develop personalized therapies for individuals at higher risk for developing chronic pain. Objective The aim of the study was to outline the study design that will be used to examine the physiological, psychological, and genetic/genomic variables—models that predict the transition from acute to chronic pain after LEFx. Method This prospective descriptive cohort study will enroll 240 participants with a fibula and/or tibia fracture and 40 controls with no LEFx. Data will be collected during an in-hospital baseline visit, five in-person clinic visits (6 weeks, 12 weeks, 24 weeks, 52 weeks, and 24 months), and seven online between-visit surveys (2 weeks, 4 weeks, 8 weeks, 10 weeks, 16 weeks, 20 weeks, and 18 months) from participants with LEFx and at concordant intervals from controls. Measures will consist of 19 questionnaires characterizing pain and psychological status, neurophysiological testing for peripheral sensory nerve function, and peripheral blood samples collections for RNA sequencing. Illumina standard protocols will be used to sequence RNA, and read counts will be used to measure gene expression. Analysis Direct-entry, multiple logistic regression will be used to produce odds ratios expressing the relative risk on each explanatory variable when controlling for other predictors/covariates in the model. Conclusion This study is one of the first to longitudinally characterize the biopsychosocial variables associated with a clinically relevant problem of the transition from acute to chronic posttraumatic fracture pain in individuals with LEFx. Results from this study will be used to construct predictive risk models of physiological, psychological, and genetic/genomic variables associated with increased risk for transitioning from acute to chronic pain status after LEFx. This work will lead to a better understanding of the trajectory of pain and relevant variables over time; initiate a better understanding of variables associated with risk for transitioning from acute to chronic pain; and, in the future, could provide a foundation for the identification of novel therapeutic targets to improve the outcomes of individuals with LEFx.

Self-Management Behaviors, Glycemic Control, and Metabolic Syndrome in Type 2 Diabetes

imageBackground Diabetes self-management and glycemic control are suboptimal among Chinese patients with Type 2 diabetes with a large proportion of patients identified with metabolic syndrome. Objectives Based on social cognitive theory, this study examines the effect of selected personal, behavioral, and environmental factors on self-management behaviors, glycemic control, metabolic syndrome and Type 2 diabetes. Methods A cross-sectional study was conducted among 207 Chinese with Type 2 diabetes living in a suburban area of Beijing, China. Regression models were applied to examine the effect of selected personal, behavioral, and environmental factors on self-management behaviors, glycemic control, and metabolic syndrome. The relationship among individual self-management behaviors, glycemic control, and metabolic syndrome was also examined. Results Self-efficacy was significantly associated with all self-management behaviors. Social support was related to overall self-management, diabetes knowledge was related to diet, and depressive symptoms was related to self-monitoring. Problem-solving and self-management behaviors related to medication adherence and diet were significant correlates of glycemic control. Health literacy and self-management behaviors related to physical activity were correlates of metabolic syndrome. Discussion Findings suggest that a multifactorial approach may be beneficial when providing care for Chinese with Type 2 diabetes. In addition, these findings provide support for developing and testing tailored interventions that address problem-solving, health literacy, and self-efficacy, among other factors, to help patients achieve optimal glycemic control and thereby reduce their risk for metabolic syndrome and related complications.

Mobile Health Technology for Pediatric Symptom Monitoring: A Feasibility Study

imageBackground Pediatric blood and marrow transplant (PBMT) patients experience significant symptom distress. Mobile health (mHealth) technologies can be leveraged to improve understanding of the patient’s symptom experience by providing continuous, real-time, in situ, patient-generated symptom data. This rich data stream can subsequently enhance symptom management strategies. However, limited research has been conducted in this area. Objectives This pilot study seeks to (a) explore the feasibility of integrating mHealth technologies to monitor symptom data for PBMT patients and (b) evaluate the study design, measures, and procedures. Methods An exploratory longitudinal design was employed to assess the feasibility of monitoring 10 PBMT patients’ symptoms using data from two mHealth technologies: (a) a smartphone mHealth application (app) to collect symptom data and (b) a wearable tracking device (Apple watch) to collect physiological data. Feasibility was measured as usability and acceptability. Monthly patient interviews and an end-of-study feasibility survey were employed and analyzed to further understand reasons for sustained interest in and attrition from the study. Results Overall usability of the wearable was 51%, and app was 56%. Children reported devices were easy to use and acceptable. The study demonstrated acceptability with an enrollment rate of 83% and an attrition rate of 30%, with 70% of the children remaining in the study for at least 40 days. Discussion This pilot study is among the first to explore the feasibility of using mobile technologies to longitudinally obtain patient-generated symptom data to enhance understanding of the PBMT symptom experience. In addition, it will improve our understanding of how these data present, interact, and cluster together throughout the posttransplant period.

Physical Symptom Cluster Subgroups in Chronic Kidney Disease

imageBackground Symptom burden associated with chronic kidney disease can be debilitating, with a negative effect on patient health-related quality of life. Latent class clustering analysis is an innovative tool for classifying patient symptom experience. Objectives The aim of the study was to identify subgroups of patients at greatest risk for high symptom burden, which may facilitate development of patient-centered symptom management interventions. Methods In this cross-sectional analysis, baseline data were analyzed from 3,921 adults enrolled in the Chronic Renal Insufficiency Cohort Study from 2003 to 2008. Latent class cluster modeling using 11 items on the Kidney Disease Quality of Life symptom profile was employed to identify patient subgroups based on similar observed physical symptom response patterns. Multinomial logistic regression models were estimated with demographic variables, lifestyle and clinical variables, and self-reported measures (Kidney Disease Quality of Life physical and mental component summaries and the Beck Depression Inventory). Results Three symptom-based subgroups were identified, differing in severity (low symptom, moderate symptom, and high symptom). After adjusting for other variables in multinomial logistic regression, membership in the high-symptom subgroup was less likely for non-Hispanic Blacks and men. Other factors associated with membership in the high-symptom subgroup included lower estimated glomerular filtration rate, history of cardiac/cardiovascular disease, higher Beck Depression Inventory scores, and lower Kidney Disease Quality of Life physical and mental component summaries. Discussion Three symptom subgroups of patients were identified among patients with mild-to-moderate chronic kidney disease. Several demographic and clinical variables predicted membership in subgroups. Further research is needed to determine if symptom subgroups are stable over time and can be used to predict healthcare utilization and clinical outcomes.

Perceived Infant Well-Being and Self-Reported Distress in Neonatal Nurses

imageBackground Infants who are admitted to a neonatal intensive care unit (NICU) may experience significant symptom burden. Parents are often distressed by these symptoms, which can affect their long-term coping and distress. There is limited research examining nurse perceptions of infant well-being (symptoms, suffering, and quality of life [QOL]) and associations with nurse distress. Objective The objective of this descriptive study was to explore associations between nurse perceptions of infant well-being and self-reported distress. Methods Nurses caring for infants with potentially life-threatening/life-limiting conditions were recruited from a Level IV NICU in the Midwestern United States as a part of a study on infant symptom burden. Nurses reported their perceptions of infant well-being and their own distress on a 5-point Likert scale. Surveys were administered at the bedside weekly for up to 12 weeks, depending on length of stay. Infant suffering and QOL were examined in relation to nurse distress. A cross-classified multilevel model was used to account for dependence within nurse and within patient. Results A total of 593 surveys were collected from nurses. Using a cross-classified multilevel model with variables entered simultaneously, nurse perceptions of greater infant suffering and lower infant QOL were significantly associated with greater nurse distress. Discussion Preliminary evidence shows that greater perceived infant suffering and lower perceived infant QOL may be associated with greater levels of self-reported distress in NICU nurses. Further work is needed to better understand factors related to symptom management in the NICU and the potential role of caregiver distress and compassion fatigue in NICU nurses.

Nursing Care for Hospitalized Older Adults With and Without Cognitive Impairment

imageBackground The presence of cognitive impairment (CI) among hospitalized older adults (aged 85 years and older) could interfere with the identification and treatment of other important symptoms experienced by these patients. Little is known, however, about the nursing care provided to this group. Contrasting the nursing care provided to patients with and without CI may reveal important insights about symptom treatment in the CI population. Objective The aim of this study was to examine the relationship of CI to nursing care provided and length of stay for hospitalized older adults using standardized nursing data retrieved from electronic health records. Methods We conducted a comparative secondary data analysis. A data set of standardized nursing plan of care data retrieved from electronic health record data of nine units at four hospitals was analyzed. The plan of care data for this study were previously transformed into one of eight categories (family, well-being, mental comfort, physical comfort, mental, safety, functional, and physiological care). Fisher exact tests were used to compare the differences in the nursing care for hospitalized older adults with and without CI. Mixed-effects models were used to examine associations of patient’s cognitive status and nursing care, and cognitive status and length of stay. Results We identified 4,354 unique patients; 746 (17%) had CI. We observed that older adults with CI were less likely to receive physical comfort care than those without CI for seven of nine units. Older adults’ cognitive status was associated with the delivery of mental comfort care. In addition, a worsening in cognitive status was associated with an increase in length of stay for older adults with CI. Discussion Older adults with CI appeared to be undertreated for symptoms of pain when compared to those without CI across units. There is a need for further research to improve symptom recognition and management for this population. The presence of CI was associated with variation in nursing care provided and length of stay. Future studies that include the analysis of nursing data merged with elements stored in the electronic health record representing the contributions of other health professions are expected to provide additional insights into this gap.

One Year of Continuous Positive Airway Pressure Adherence Improves Cognition in Older Adults With Mild Apnea and Mild Cognitive Impairment

imageBackground Mild cognitive impairment frequently represents a predementia stage of Alzheimer’s disease. Although obstructive sleep apnea is increasingly recognized as a common comorbidity of mild cognitive impairment, most apnea research has focused on middle-aged adults with moderate-to-severe obstructive sleep apnea. Mild obstructive sleep apnea, defined as 5–14 apneas or hypopneas per hour slept, is common in older adults. Little is known about the effect on cognition of adherence to continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea in older adults with mild obstructive sleep apnea and mild cognitive impairment. Objective The objective of this study was to explore the effect of CPAP adherence on cognition in older adults with mild obstructive sleep apnea and mild cognitive impairment. Methods We conducted a secondary analysis of data from Memories 1, a 1-year quasiexperimental clinical trial on the effect of CPAP adherence in older adults with mild cognitive impairment and obstructive sleep apnea. Those with mild obstructive sleep apnea were divided into two groups based on their CPAP adherence over 1 year: (a) CPAP adherent group (mild cognitive impairment + CPAP) with an average CPAP use of ≥4 hours per night and (b) CPAP nonadherent group (mild cognitive impairment − CPAP) with an average CPAP use of

Consensus Definition of Muscle Tightness From Multidisciplinary Perspectives

Background Muscle tightness is a complex ailment that affects quality of life in people who experience it. Muscle tightness is not clearly defined by the National Library of Medicine, which creates confusion in clinical practice. Objectives The purpose of this study was to identify the attributes of muscle tightness from expert clinicians’ perception and develop a consensus definition from multidisciplinary perspectives. Methods This nonintervention study employed semistructured interviews using qualitative design. Twelve multidisciplinary expert clinicians participated in the study. Results The results indicate that limited range of motion is a key feature of muscle tightness; however, there are six other attributes: loss of function, changes in muscle texture, change in sensation, asymmetry, pain, and contracted muscle state. These attributes are largely subjective and are interrelated. Discussion The new definition captures the multiple domains of muscle tightness. Lack of a standardized tool is a challenge, particularly when subjective assessments require patients’ input. Development of such a tool to measure muscle tightness is advocated.

Two Methods for Calculating Symptom Cluster Scores

imageBackground Symptom clusters are conventionally distilled into a single score using composite scoring, which is based on the mathematical assumption that all symptoms are equivalently related to outcomes of interest; this may lead to a loss of important variation in the data. Objectives This article compares two ways of calculating a single score for a symptom cluster: a conventional, hypothesis-driven composite score versus a data-driven, reduced rank regression score that weights the symptoms based on their individual relationships with key outcomes. Methods We conducted a secondary analysis of psychoneurological symptoms from a sample of 356 low-income mothers. Four of the psychoneurological symptoms (fatigue, cognitive dysfunction, sleep disturbance, and depressed mood) were measured with the Center for Epidemiological Studies Depression Scale; the fifth (pain) was measured using an item from the Medical Outcomes Study 12-item Short Form Health Survey (SF-12). Mothers’ function was measured using the 12-item Short Form Health Survey. The composite score was calculated by summing standardized scores for each individual psychoneurological symptom. In contrast, reduced rank regression weighted the individual symptoms using their respective associations with mothers’ function; the weighted individual symptom scores were summed into the reduced rank regression symptom score. Results The composite score and reduced rank regression score were highly correlated at .93. The cluster of psychoneurological symptoms accounted for 53.7% of the variation in the mothers’ function. Depressed mood and pain accounted for almost all the explained variation in mothers’ function at 37.2% and 15.0%, respectively. Discussion The composite score approach was simpler to calculate, and the high correlation with the reduced rank regression score indicates that the composite score reflected most of the variation explained by the reduced rank regression approach in this data set. However, the reduced rank regression analysis provided additional information by identifying pain and depressed mood as having the strongest association with a mother’s function, which has implications for understanding which symptoms to target in future interventions. Future studies should also explore composite versus reduced rank regression approaches given that reduced rank regression may yield different insights in other data sets.

Measurement of Irritability in Cancer Patients

imageBackground Irritability is common among people who are physically ill, but a physical underpinning of irritability is not assessed by existing measures. A measure that assesses multidimensionality of irritability can help nurses and clinicians provide better care for people with cancer and, thus, reduce a risk for developing depression during cancer treatment. Objectives We pilot tested a new measure, The Irritability Scale–Initial Version (TISi), for assessing irritability of cancer patients on three dimensions: physical, affective, and behavioral. Methods We conducted thee pilot studies to develop the 35-item TISi on a 5-point Likert scale. TISi was tested in 48 early-stage, nonmetastasized breast cancer patients at baseline (before) and 3 months (during chemotherapy). Of these patients, 62.5% received neoadjuvant and 37.5% received adjuvant chemotherapy, but none received hormonal treatment before or during the study. Measures of other correlates, including depression, anxiety, symptom distress, and social disconnectedness, were also administered, and biomarkers of hsCRP, TNF-α, IL-6, and BDNF were obtained from blood draws at both assessments. Results TISi has a high internal consistency (Cronbach’s α = .97), satisfactory test–retest reliability (retest r = .69, intraclass correlation coefficient = .86), and moderate correlation with other constructs over time (r ≈ .40–.70). Its physical subscale significantly correlated with hsCRP (r = .32, p = .025) at baseline and TNF-α (r = .44, p = .002) at 3 months. A confirmatory factor analysis yields three factor loadings that are in line with conceptualization of the subscales. Discussion The findings support psychometric properties of TISi and its application for assessing cancer patients’ irritability in multiple dimensions. Further investigation using a large study sample is necessary for improving construct and criterion validity and reducing item redundancy. Conclusion TISi can be used to measure the level of irritability in cancer patients

Challenges and Strategies for Conducting Research With Grandparent–Grandchild Dyads

imageBackground Given a marked increase in the number of grandparents who play a caregiving role for their grandchildren, there is a parallel urgency for more research involving grandparent–grandchild dyads. Objective The aim of this study was to describe methodological challenges we encountered when conducting grandparent–grandchild dyadic research, some of which were challenges specific to working with dyads where the grandparents were caregivers to the child participants and others, which were challenges of a sort that might be encountered in any research involving data collection with multigenerational family units and, in particular, multigenerational family units including older adults. Methods During and after an observational study conducted by the researchers involving grandparent–grandchild dyads, we explored challenges we encountered and strategies for improving our research outcomes. Results We found several challenges specific to grandparent–grandchild dyads, including complications with reaching legal guardians to obtain permission for child participants; collecting accelerometer data from grandchildren was difficult, particularly if the grandparents did not live with their grandchildren; and participants who had various preferences for data collection methods. We also found challenges that might be found with any family context dyadic research, particularly involving older adults and across multiple generations, including relatively low follow-up response rates from those grandparents who initially expressed interest and a need for an extended data collection period. We employed targeted strategies to overcome those obstacles, and in this article, we describe the outcomes of those strategies. Discussion Recommendations from our results include the following: (a) find a way to involve the parents and/or legal guardian as early as possible, (b) have multiple team members involved in recruitment/data collection, (c) be flexible about data collection methods, (d) use flexible scheduling, and (e) use multiple simultaneous recruitment activities/multiple advertisement channels. Additional strategies include enhancing children’s sense of control during the consent process, simplifying study procedures, considering usability when creating online data surveys, and identifying power dynamics within the families. Conclusion The insights we gained will be useful for informing future family context dyadic research, in particular, research involving grandparent–grandchild dyads.

Protocol for Pilot Study on Self-Management of Depressive Symptoms in Pregnancy

imageBackground Pregnant women with depressive symptoms face significant treatment challenges and are in great need of safe, effective, accessible, inexpensive, and nonpharmacological self-management therapies to enhance well-being, reduce the burden of symptoms both during their pregnancy and postpartum, and prevent chronic sequelae. Objectives In this article, we describe the protocol for our pilot study testing a self-management intervention entitled, “Mindful Moms,” designed to foster women’s ability to address current depressive symptoms and enhance resilience to prevent recurrence. Methods We will conduct a longitudinal pilot trial of the 12-week intervention with pregnant women with depressive symptoms (n = 40); the primary aim is to determine the feasibility and acceptability of the intervention. The secondary aim is to examine preliminary effects of the intervention on maternal psychobehavioral outcomes in pregnancy and 6 weeks postpartum. The third aim will quantify genome-wide and gene-specific DNA methylation patterns associated with depressive symptoms during pregnancy and investigate whether intervention participation influences these patterns. Results This study is currently ongoing. Discussion Findings from this study will inform future research addressing the need for nonpharmacological self-management interventions for pregnant women with depressive symptoms.

Moderator Effects in Intervention Studies

imageBackground Although nursing intervention studies typically focus on testing hypothesized differences between intervention and control groups, moderator variables can reveal for whom or under what circumstances an intervention may be most effective. Objectives The aim of the study was to explain and illustrate moderator effects using data from a nursing intervention study to improve cognitive abilities in those with a chronic health condition. Methods The sample consisted of 178 individuals with multiple sclerosis participating in an experimental study of a cognitive intervention. General linear models were used for analyses. Interaction terms were created to represent moderator effects on three outcomes: self-reported cognitive abilities, use of memory strategies, and verbal memory performance. Results The Charlson comorbidity index significantly moderated the intervention effect on self-perceived cognitive abilities. Years of education significantly moderated the intervention effect on use of memory strategies. Scores on a general self-efficacy measure significantly moderated the intervention effect on the Controlled Verbal Learning Test–Second Edition. Discussion These analyses highlight the key role that moderator effects can play in nursing research. Although random assignment to groups can control potentially biasing effects of extraneous differences among individuals in intervention and control groups, those very differences may suggest fruitful avenues for hypothesis generating research about what works best for whom in intervention studies.

Characteristics and Practices Within Research Partnerships for Health and Social Equity

imageBackground As federal research funding focuses more on academic/community collaborations to address health inequities, it is important to understand characteristics of these partnerships and how they work to achieve health equity outcomes. Objectives This study built on previous National Institutes of Health-funded research to (a) describe partnership characteristics and processes of federally funded, community-based participatory research (CBPR) or community-engaged research projects; (b) explore characteristics of these projects by stage of funding; and (c) build on previous understanding of partnership promising practices. Methods Between fall 2016 and spring 2017, we completed a cross-sectional analysis and principal component analysis of online survey data from key informants of federally funded CBPR and community-engaged research projects. Respondents for 179 projects (53% response rate) described project characteristics (e.g., type of partner, stage of partnership, and population) and the use of promising practices (e.g., stewardship, advisory board roles, training topics) by stage of partnership. Results Projects involved community, healthcare, and government partners, with 49% of respondents reporting their project was in the early stage of funding. More projects focused on Black/African American populations, whereas principal investigators were mostly White. The more established a partnership (e.g., with multiple projects), the more likely it employed the promising practices of stewardship (i.e., community safeguards for approval), community advisory boards, and training on values and power. Conclusions Community engagement is a developmental process with differences between early-stage and established CBPR partnerships. Engaging in active reflection and adopting promising partnering practices are important for CBPR partnerships working to improve health equity. The data provided in this study provide key indicators for reflection.

Recruitment Strategies for Nurse Enrollment in an Online Study

imageBackground Although there is a great deal of literature regarding effective recruitment and challenges of recruiting specific patient populations, there is less known about best practices for recruitment of nurses as study subjects. Objectives The purpose of this article is to report our experience with recruitment and retention for a randomized trial of an online educational program to prepare oncology nurses to discuss oncology clinical trials with patients. Methods The study population included currently employed oncology nurses with direct patient interaction. There were three phases of this study: (1) qualitative interviews, (2) a pilot test, and (3) the randomized trial. Phase 3 was rolled out in five waves of recruitment. The distinct phases of the study—and the gradual roll out of recruitment during Phase 3—allowed us to test and refine our recruitment and retention methods for the randomized trial. Upon analysis of our response rate and attrition after the first wave of recruitment in Phase 3, we made several changes to improve recruitment and retention, including adding incentives, shortening the survey, and increasing the number of reminders to complete the program. Results The response rate was higher when we used both e-mail and U.S. postal mail solicitations. After the first wave of recruitment in the final phase, changes in our strategies did not increase our overall response rate significantly; however, the rate of attrition following baseline declined. Discussion Recruitment planning is an important component of successful clinical research. The use of the Internet for both recruitment of subjects and testing of interventions remains a cost-effective and potentially high yield methodology. Our research demonstrated several successful approaches to yield increased participation and retention of subjects, including seeking formal relationships with professional organizations as sponsors or supporters, providing meaningful incentives to participants, keeping surveys or questionnaires as short as possible, and planning multiple follow-up contacts from the outset.

Sleep–Wake States and Feeding Progression in Preterm Infants

imageBackground Previous studies demonstrated a short-term relationship between infant sleep–wake states and oral feeding performance, with state being an indication of infants’ neurobehavioral readiness for feeding. However, the relationship between sleep–wake states and feeding skills has not been evaluated longitudinally during hospitalization. Objectives The purpose of this study was to examine preterm infants’ sleep–wake state developmental trajectories and their associations with feeding progression during hospitalization. Methods This descriptive and exploratory study was a secondary analysis using data from a longitudinal two-group, randomized controlled trial evaluating the effects of early and late cycled light on health and developmental outcomes among extremely preterm infants who were born ≤28 weeks of gestational age. Sleep–wake states were assessed for two 2-hour interfeeding periods per day (day and night hours), 30 weeks postmenstrual age, and every 3 weeks until discharge. Occurrences of active sleep, quiet sleep, and waking were recorded every 10 seconds. Feeding progression was assessed based on an infant’s postmenstrual age at five milestones: first enteral feeding, full enteral feeding, first oral feeding, half oral feeding, and full oral feeding. Trajectory analyses were used to describe developmental changes in sleep–wake states, feeding progression patterns, and associations between feeding progression and sleep–wake trajectories. Results Active sleep decreased while waking, and quiet sleep increased during hospitalization. Two distinct feeding groups were identified: typical and delayed feeding progression. In infants with delayed feeding progression, rates of active and quiet sleep development during the day were delayed compared to those with typical feeding progression. We also found that infants with delayed feeding progression were more likely to be awake more often during the night compared to infants with typical feeding progression. Discussions Findings suggest that delays in sleep–wake state development may be associated with delays in feeding progression during hospitalization. Infants with delayed feeding skill development may require more environmental protection to further support their sleep development.

Systematic Review and Meta-analysis of Psychosocial Uncertainty Management Interventions

imageBackground Psychosocial uncertainty management interventions (UMIs) targeting patients and their family members might help to alleviate the negative influences of illness-related uncertainty, such as diminished quality of life and poor adjustment. Objectives The aims of this study were to evaluate the key characteristics of psychosocial UMIs and assess intervention effects on patients' and their family members' short-term and long-term illness-related uncertainty. Methods We conducted a systematic review and meta-analysis of psychosocial UMIs published through 2017. We performed a comprehensive electronic search and manual review. The outcome indicator was illness-related uncertainty experienced by patients or their family members. Results We included 29 studies in the systematic review and 14 studies in the meta-analysis. The main intervention components were information and resource provision, coping skills training, social and emotional support, communication skills, symptom management and self-care, coordination of care, and exercise. Compared to usual care, patients who received UMIs reported less uncertainty immediately after intervention delivery (g = −0.44, 95% confidence interval [CI] [−0.71, −0.16]) and at later follow-up points (g = −0.47, 95% CI [−0.91, −0.03]). Family members who received UMIs also reported less uncertainty immediately after intervention delivery (g = −0.20, 95% CI [−0.33, −0.06]) and at later follow-up points (g = −0.20, 95% CI [−0.36, −0.04]). Discussion Psychosocial UMIs had small to medium beneficial effects for both patients and their family members. Questions remain regarding what intervention components, modes of delivery, or dosages influence effect size. More rigorously designed randomized controlled trials are needed to validate intervention effects on patients' and family members' uncertainty management.

Inpatient Maternal Mortality in the United States, 2002–2014

imageBackground Although prior studies of inpatient maternal mortality in the United States provide data on the overall rate and trend in inpatient maternal mortality, there are no published reports of maternal mortality data stratified by timing of its occurrence across the pregnancy continuum (antepartum, intrapartum, and postpartum). Objective The study objective was to determine whether the maternal mortality rate, trends over time, self-reported race/ethnicity, and associated factors vary based on the timing of the occurrence of death during pregnancy. Methods We conducted a cross-sectional analysis of the Nationwide Inpatient Sample database to identify pregnancy-related inpatient stays stratified by timing. Among women in the sample, we determined in-hospital mortality and used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify comorbidities and behavioral characteristics associated with mortality, including alcohol, drug, and tobacco use. Joinpoint regression was used to calculate rates and trends of in-hospital maternal mortality. Results During the study period, there were 7,411 inpatient maternal mortalities among an estimated 58,742,179 hospitalizations of women 15–49 years of age. In-hospital maternal mortality rate stratified by race showed that African Americans died at significantly higher rates during antepartum, intrapartum, and postpartum periods compared to hospitalizations for Whites or Hispanics during the same time period. Although the postpartum hospitalization represents only 2% of pregnancy-related hospitalizations among women aged 15–49 years, hospitalization during this time period accounted for 27.2% of all maternal deaths during pregnancy-related hospitalization. Discussion Most in-hospital maternal mortalities occur after hospital discharge from child birth (postpartum period). Yet, the postpartum period continues to be the time period with the least maternal healthcare surveillance in the pregnancy continuum. African American women experience three times more in-hospital mortality when compared to their White counterparts.