Patient-related decisional regret: An evolutionary concept analysis.

BACKGROUND: Health-related decision-making is a complex process given the variability of treatment options, conflicting treatment plans, time constraints and variable outcomes. This complexity may result in patients experiencing decisional regret following decision-making. Nonetheless, literature on decisional regret in the healthcare context indicates inconsistent characterization and operationalization of this concept. AIM(S): To conceptually define the phenomenon of decisional regret and synthesize the state of science on patients' experiences with decisional regret. DESIGN: A concept analysis. METHODS: Rodgers' evolutionary method guided the conceptualization of this review. An interdisciplinary literature search was conducted from 2003 until 2023 using five databases, PubMed, CINAHL, Embase, PsycINFO and Web of Science. The search informed how the concept manifested across health-related literature. We used PRISMA-ScR checklist to guide the reporting of this review. RESULTS: Based on the analysis of 25 included articles, a conceptual definition of decisional regret was proposed. Three defining attributes underscored the negative cognitive-emotional nature of this concept, post-decisional experience relating to the decision-making process, treatment option and/or treatment outcome and an immediate or delayed occurrence. Antecedents preceding decisional regret comprised initial psychological or emotional status, sociodemographic determinants, impaired decision-making process, role regret, conflicting treatment plans and adverse treatment outcomes. Consequences of this concept included positive and negative outcomes influencing quality of life, health expectations, patient-provider relationship and healthcare experience appraisal. A conceptual model was developed to summarize the concept's characteristics. CONCLUSION: The current knowledge on decisional regret is expected to evolve with further exploration of this concept, particularly for the temporal dimension of regret experience. This review identified research, clinical and policy gaps informing our nursing recommendations for the concept's evolution. NO PATIENT OR PUBLIC CONTRIBUTION: This concept analysis examines existing literature and does not require patient-related data collection. The methodological approach does not necessitate collaboration with the public.

Intersection of social determinants of health with ventricular assist device therapy: An integrative review.

BACKGROUND: Social determinants of health (SDOH) may influence the clinical management of patients with heart failure. Further research is warranted on the relationship between SDOH and Ventricular Assist Device (VAD) therapy for heart failure. OBJECTIVES: The purpose of this integrative review was to synthesize the state of knowledge on the intersection of SDOH with VAD therapy. METHODS: Guided by Whittemore and Knafl's methodology, this literature search captured three concepts of interest including VAD therapy, SDOH, and their domains of intersection with patient selection, decision-making, treatment outcome, and resource allocation. CINAHL, Embase, PsycINFO, PubMed, and Web of Science were searched in March 2023. Articles were included if they were peer-reviewed publications in English, published between 2006 and 2023, conducted in the United States, and examined VAD therapy in the context of adult patients (age ≥ 18 years). RESULTS: 22 quantitative studies meeting the inclusion criteria informed the conceptualization of SDOH using the Healthy People 2030 framework. Four themes captured how the identified SDOH intersected with different processes relating to VAD therapy: patient decision-making, healthcare access and resource allocation, patient selection, and treatment outcomes. Most studies addressed the intersection of SDOH with healthcare access and treatment outcomes. CONCLUSION: This review highlights substantial gaps in understanding how SDOH intersect with patient and patient selection for VAD. More research using mixed methods designs is warranted. On an institutional level, addressing bias and discrimination may have mitigated health disparities with treatment outcomes, but further research is needed for implementing system-wide change. Standardized assessment of SDOH is recommended throughout clinical practice from patient selection to outpatient VAD care.

Cardiovascular Health in Black and Latino Adults With Type 2 Diabetes.

BACKGROUND: The incidence of type 2 diabetes (T2DM) among U.S. adults has been rising annually, with a higher incidence rate in Black and Hispanic adults than Whites. The American Heart Association (AHA) has defined cardiovascular health according to the achievement of seven health behaviors (smoking, body mass index [BMI], physical activity, diet) and health factors (total cholesterol, blood pressure, fasting glucose). Optimal cardiovascular health has been associated with a lower risk of cardiovascular disease, and awareness of this risk may influence healthy behaviors. OBJECTIVES: This study aimed to assess cardiovascular health in a sample of Black and Hispanic adults (age 18-40) with T2DM and explore the barriers and facilitators to diabetes self-management and cardiovascular health. METHODS: This was an explanatory sequential mixed method design. The study staff recruited adults with T2DM for the quantitative data followed by qualitative interviews with a subsample of participants using maximum variation sampling. The seven indices of cardiovascular health as defined by the AHA's "Life's Simple 7" were assessed: health behaviors (smoking, body mass index, physical activity, diet) and health factors (total cholesterol, blood pressure, A1C). Qualitative interviews were conducted to explore their results as well as the effects of the pandemic on diabetes self-management. Qualitative and quantitative data were integrated into the final analysis phase. RESULTS: The majority of the sample was female, with 63% identifying as Black and 47% Hispanic. The factor with the lowest achievement of ideal levels was BMI, followed by a healthy diet. Less than half achieved ideal levels of blood pressure or physical activity. Themes that emerged from the qualitative data included the impact of social support, the effects of the pandemic on their lives, and educating themselves about T2DM. DISCUSSION: Achievement of ideal cardiovascular health factors varied, but the achievement of several health factors may be interrelated. Intervening on even one factor while providing social support may improve other areas of cardiovascular health in this population.

Factors Associated With the Cardiovascular Health of Black and Latino Adults With Type 2 Diabetes.

AIMS: The purpose of this study was to assess the levels of cardiovascular health (CVH) of Black and Latino adults with type 2 diabetes (T2D) and examine the association of individual and microsystem level factors with their CVH score. METHODS: This was a cross-sectional design in 60 Black and Latino Adults aged 18-40 with T2D. Data were collected on sociodemographic, individual (sociodemographic, diabetes self-management, sleep disturbance, depressive symptoms, quality of life, and the inflammatory biomarkers IL-6 and hs-CRP) and microsystem factors (family functioning), and American Heart Association's Life's Simple 7 metrics of CVH. Factors significantly associated with the CVH score in the bivariate analyses were entered into a linear regression model. RESULTS: The sample had a mean age 34 ± 5 years and was primarily female (75%) with a mean CVH score was 8.6 ± 2.2 (possible range of 0-14). The sample achieved these CVH factors at ideal levels: body mass index <25 kg/m2 (8%); blood pressure <120/80 (42%); hemoglobin A1c < 7% (57%); total cholesterol <200 mg/dL (83%); healthy diet (18%); never or former smoker > one year (95%); and physical activity (150 moderate-to-vigorous minutes/week; 45%). In the multivariable model, two factors were significantly associated with cardiovascular health: hs-CRP (B = -0.11621, p < .0001) and the general health scale (B = 0.45127, p = .0013). CONCLUSIONS: This sample had an intermediate level of CVH, with inflammation and general health associated with overall CVH score.

Implementing a Clinical Decision Support Tool to Improve Physical Activity.

BACKGROUND: Currently, only about half of U.S. adults achieve current physical activity guidelines. Routine physical activity is not regularly assessed, nor are patients routinely counseled by their healthcare provider on achieving recommended levels. The three-question physical activity vital sign (PAVS) was developed to assess physical activity duration and intensity and identify adults not meeting physical activity guidelines. Clinical decision support provided via a best practice advisory in an electronic health record (EHR) system can be triggered as a prompt, reminding healthcare providers to implement the best practice intervention when appropriate. Remote patient monitoring of physical activity can provide objective data in the EHR. OBJECTIVES: This study aimed to evaluate the feasibility and clinical utility of embedding the PAVS and a triggered best practice advisor into the EHR in an ambulatory preventive cardiology practice setting to alert providers to patients reporting low physical activity and prompt healthcare providers to counsel these patients as needed. METHODS: Three components based in the EHR were integrated for the purpose of this study: Patients completed the PAVS through their electronic patient portal prior to an office visit, a best practice advisory was created to prompt providers to counsel patients who reported low levels of physical activity, and remote patient monitoring via Fitbit synced to the EHR provided objective physical activity data. The intervention was pilot-tested in the Epic EHR for 1 year (July 1, 2021 to June 30, 2022). Qualitative feedback on the intervention from both providers and patients was obtained at the completion of the study. RESULTS: Monthly assessments of the use of the PAVS and best practice advisory and remote patient monitoring were completed. Patients' completion of the PAVS varied from 35% to 48% per month. The best practice advisory was signed by providers between 2% and 65% and was acknowledged by 2%-22% per month. The majority (58%) of patients were able to sync a Fitbit device to their EHR for remote monitoring. DISCUSSION: Although uptake of each component needs improvement, this pilot demonstrated the feasibility of incorporating a physical activity promotion intervention into the EHR. Qualitative feedback provided guidance for future implementation.

A single-cell genomic atlas for maturation of the human cerebellum during early childhood.

Inflammation early in life is a clinically established risk factor for autism spectrum disorders and schizophrenia, yet the impact of inflammation on human brain development is poorly understood. The cerebellum undergoes protracted postnatal maturation, making it especially susceptible to perturbations contributing to the risk of developing neurodevelopmental disorders. Here, using single-cell genomics of postmortem cerebellar brain samples, we characterized the postnatal development of cerebellar neurons and glia in 1- to 5-year-old children, comparing individuals who had died while experiencing inflammation with those who had died as a result of an accident. Our analyses revealed that inflammation and postnatal cerebellar maturation are associated with extensive, overlapping transcriptional changes primarily in two subtypes of inhibitory neurons: Purkinje neurons and Golgi neurons. Immunohistochemical analysis of a subset of these postmortem cerebellar samples revealed no change to Purkinje neuron soma size but evidence for increased activation of microglia in those children who had experienced inflammation. Maturation-associated and inflammation-associated gene expression changes included genes implicated in neurodevelopmental disorders. A gene regulatory network model integrating cell type-specific gene expression and chromatin accessibility identified seven temporally specific gene networks in Purkinje neurons and suggested that inflammation may be associated with the premature down-regulation of developmental gene expression programs.

Pregnancy programs the brain for mothering.

Progesterone and estrogen exert separate effects on the brains of pregnant mice.

Why and How to Account for Sex and Gender in Brain and Behavioral Research.

Long overlooked in neuroscience research, sex and gender are increasingly included as key variables potentially impacting all levels of neurobehavioral analysis. Still, many neuroscientists do not understand the difference between the terms "sex" and "gender," the complexity and nuance of each, or how to best include them as variables in research designs. This TechSights article outlines rationales for considering the influence of sex and gender across taxa, and provides technical guidance for strengthening the rigor and reproducibility of such analyses. This guidance includes the use of appropriate statistical methods for comparing groups as well as controls for key covariates of sex (e.g., total intracranial volume) and gender (e.g., income, caregiver stress, bias). We also recommend approaches for interpreting and communicating sex- and gender-related findings about the brain, which have often been misconstrued by neuroscientists and the lay public alike.

The Impact of an Electronic Best Practice Advisory on Patients' Physical Activity and Cardiovascular Risk Profile.

BACKGROUND: Regular physical activity (PA) is a component of cardiovascular health and is associated with a lower risk of cardiovascular disease (CVD). However, only about half of US adults achieved the current PA recommendations. OBJECTIVE: The study purpose was to implement PA counseling using a clinical decision support tool in a preventive cardiology clinic and to assess changes in CVD risk factors in a sample of patients enrolled over 12 weeks of PA monitoring. METHODS: This intervention, piloted for 1 year, had 3 components embedded in the electronic health record: assessment of patients' PA, an electronic prompt for providers to counsel patients reporting low PA, and patient monitoring using a Fitbit. Cardiovascular disease risk factors included PA (self-report and Fitbit), body mass index, blood pressure, lipids, and cardiorespiratory fitness assessed with the 6-minute walk test. Depression and quality of life were also assessed. Paired t tests assessed changes in CVD risk. RESULTS: The sample who enrolled in the remote patient monitoring (n = 59) were primarily female (51%), White adults (76%) with a mean age of 61.13 ± 11.6 years. Self-reported PA significantly improved over 12 weeks (P = .005), but not Fitbit steps (P = .07). There was a significant improvement in cardiorespiratory fitness (469 ± 108 vs 494 ± 132 m, P = .0034), and 23 participants (42%) improved at least 25 m, signifying a clinically meaningful improvement. Only 4 participants were lost to follow-up over 12 weeks of monitoring. CONCLUSIONS: Patients may need more frequent reminders to be active after an initial counseling session, perhaps getting automated messages based on their step counts syncing to their electronic health record.

Time, Technology, Social Support, and Cardiovascular Health of Emerging Adults With Type 1 Diabetes.

BACKGROUND: Emerging adults with Type 1 diabetes (T1DM) face an increased risk of cardiovascular disease; however, there are both barriers and facilitators to achieving ideal cardiovascular health in this stage of their lives. OBJECTIVES: The aim of this study was to qualitatively explore the barriers and facilitators of achieving ideal levels of cardiovascular health in a sample of emerging adults with T1DM ages 18-26 years. METHODS: A sequential mixed-methods design was used to explore achievement of ideal cardiovascular health using the seven factors defined by the American Heart Association (smoking status, body mass index, physical activity, healthy diet, total cholesterol, blood pressure, and hemoglobin A1C [substituted for fasting blood glucose]). We assessed the frequency of achieving ideal levels of each cardiovascular health factor. Using Pender's health promotion model as a framework, qualitative interviews explored the barriers and facilitators of achieving ideal levels of each factor of cardiovascular health. RESULTS: The sample was mostly female. Their age range was 18-26 years, with a diabetes duration between 1 and 20 years. The three factors that had the lowest achievement were a healthy diet, physical activity at recommended levels, and hemoglobin A1C of <7%. Participants described lack of time as a barrier to eating healthy, being physically active, and maintaining in-range blood glucose levels. Facilitators included the use of technology in helping to achieve in-range blood glucose and social support from family, friends, and healthcare providers in maintaining several healthy habits. DISCUSSION: These qualitative data provide insight into how emerging adults attempt to manage their T1DM and cardiovascular health. Healthcare providers have an important role in supporting these patients in establishing ideal cardiovascular health at an early age.

Neural Control of Sexually Dimorphic Social Behavior: Connecting Development to Adulthood.

Rapid advances in the neural control of social behavior highlight the role of interconnected nodes engaged in differential information processing to generate behavior. Many innate social behaviors are essential to reproductive fitness and therefore fundamentally different in males and females. Programming these differences occurs early in development in mammals, following gonadal differentiation and copious androgen production by the fetal testis during a critical period. Early-life programming of social behavior and its adult manifestation are separate but yoked processes, yet how they are linked is unknown. This review seeks to highlight that gap by identifying four core mechanisms (epigenetics, cell death, circuit formation, and adult hormonal modulation) that could connect developmental changes to the adult behaviors of mating and aggression. We further propose that a unique social behavior, adolescent play, bridges the preweaning to the postpubertal brain by engaging the same neural networks underpinning adult reproductive and aggressive behaviors.

Microglia phagocytosis mediates the volume and function of the rat sexually dimorphic nucleus of the preoptic area.

The sexually dimorphic nucleus of the preoptic area (SDN-POA) is the oldest and most robust sex difference reported in mammalian brain and is singular for its presence across a wide range of species from rodents to ungulates to man. This small collection of Nissl-dense neurons is reliably larger in volume in males. Despite its notoriety and intense interrogation, both the mechanism establishing the sex difference and the functional role of the SDN have remained elusive. Convergent evidence from rodent studies led to the conclusion that testicular androgens aromatized to estrogens are neuroprotective in males and that higher apoptosis (naturally occurring cell death) in females determines their smaller SDN. In several species, including humans, a smaller SDN correlates with a preference for mating with males. We report here that this volume difference is dependent upon a participatory role of phagocytic microglia which engulf more neurons in the female SDN and assure their destruction. Selectively blocking microglia phagocytosis temporarily spared neurons from apoptotic death and increased SDN volume in females without hormone treatment. Increasing the number of neurons in the SDN in neonatal females resulted in loss of preference for male odors in adulthood, an effect paralleled by dampened excitation of SDN neurons as evidenced by reduced immediate early gene (IEG) expression when exposed to male urine. Thus, the mechanism establishing a sex difference in SDN volume includes an essential role for microglia, and SDN function as a regulator of sexual partner preference is confirmed.

The immune cell profile of the developing rat brain.

Little is known about the peripheral immune cell (PIC) profile of the developing brain despite growing appreciation for these cells in the mature nervous system. To address this gap, the PIC profile, defined as which cells are present, where they are located, and for how long, was examined in the developing rat using spectral flow cytometry. Select regions of the rat brain (cerebellum, hippocampus, and hypothalamus) were examined at embryonic day 20, and postnatal days 0, 7 and 16. At their peak (E20), PICs were most abundant in the cerebellum, then the hippocampus and hypothalamus. Within the PIC pool, monocytes were most prevalent in all regions and time points, and shifted from being majority classical at E20 to non-classical by PN7. T cells increased over time, and shifted from majority cytotoxic to T-helper cells by PN7. This suggests the PIC profile transitions from reactive to adaptive and surveilling in the second postnatal week. NK cells and mast cells increased temporarily, and mast cells were restricted to the hippocampus and hypothalamus, suggesting they may play a specific role in the development of those regions. Mimicking a viral infection by administration of Poly I:C increased the influx of PICs into the neonatal brain, particularly of NK cells and in the case of males only, non-classical monocytes. This work provides a map for researchers as they study immune cell contributions to healthy and pathological brain development.

Fatty acid amide hydrolase inhibition and N-arachidonoylethanolamine modulation by isoflavonoids: A novel target for upcoming antidepressants.

Modulation of the endocannabinoid system (ECS) is a novel putative target for therapeutic intervention in depressive disorders. Altering concentrations of one of the principal endocannabinoids, N-arachidonoylethanolamine, also known as anandamide (AEA) can affect depressive-like behaviors through several mechanisms including anti-inflammatory, hormonal, and neural circuit alterations. Recently, isoflavonoids, a class of plant-derived compounds, have been of therapeutic interest given their ability to modulate the metabolism of the endogenous ligands of the ECS. To determine the therapeutic potential of isoflavonoids, we screened several candidate compounds (Genistein, Biochanin-A, and 7-hydroxyflavone) in silico to determine their binding properties with fatty acid amide hydrolase (FAAH), the primary degrative enzyme for AEA. We further validated the ability of these compounds to inhibit FAAH and determined their effects on depressive-like and locomotor behaviors in the forced swim test (FST) and open field test in male and female mice. We found that while genistein was the most potent FAAH inhibitor, 7-hydroxyflavone was most effective at reducing immobility time in the forced swim test. Finally, we measured blood corticosterone and prefrontal cortex AEA concentrations following the forced swim test and found that all tested compounds decreased corticosterone and increased AEA, demonstrating that isoflavonoids are promising therapeutic targets as FAAH inhibitors.

Where Sex Meets Gender: How Sex and Gender Come Together to Cause Sex Differences in Mental Illness.

Sex differences are prevalent in multiple mental disorders. Internalizing disorders are more commonly diagnosed in women, whereas externalizing and neurodevelopmental disorders are more often diagnosed in men. Significant sex/gender differences are reported in prevalence, symptom profile, age of onset, comorbidities, functional impairment, prognosis, as well as in responses to various treatments. In this conceptual article, we discuss theories and empirical studies of sex- and gender-related influences in mental health, by focusing on three examples: autism spectrum disorder (ASD), acknowledged as a disorder whose roots are mainly biological; eating disorders, whose origins are considered to be mainly psychosocial, and posttraumatic stress disorder (PTSD), an environmentally caused disorder with both psychosocial and biological underpinnings. We examine the ways in which sex differences emerge, from conception through adulthood. We also examine how gender dichotomies in exposures, expectations, role assumptions, and cultural traditions impact the expression of our three selected mental illnesses. We are especially interested in how sex-based influences and gender-based influences interact with one another to affect mental illness. We suggest that sex and gender are multi-faceted and complex phenomena that result in variations, not only between men and women, but also within each sex and gender through alterations in genes, hormone levels, self-perceptions, trauma experiences, and interpersonal relationships. Finally, we propose a conceptual diatheses-stress model, depicting how sex and gender come together to result in multiple sex/gender differences across mental disorders. In our model, we categorize diatheses into several categories: biological, intrapersonal, interpersonal, and environmental. These diatheses interact with exposure to stressors, ranging from relatively minor to traumatic, which allows for the sometimes bidirectional influences of acute and long-term stress responses. Sex and gender are discussed at every level of the model, thereby providing a framework for understanding and predicting sex/gender differences in expression, prevalence and treatment response of mental disorders. We encourage more research into this important field of study.

Associations of insomnia symptoms with sociodemographic, clinical, and lifestyle factors in persons with HF: Health and retirement study.

Insomnia symptoms are very common in persons with heart failure (HF). However, many of the correlates and predictors of insomnia symptoms in this population remain unclear. The purpose of this study is to investigate the associations of sociodemographic, clinical, and lifestyle factors with insomnia symptoms in persons with HF. A theoretical framework was adapted from the neurocognitive model of chronic insomnia to guide the study. Data from the health and retirement study were used for the analysis. Parametric and nonparametric bivariate and multivariate analyses were conducted to investigate these associations. Age, depressive symptoms, comorbidity, dyspnea, pain, and smoking had significant bivariate associations with all insomnia symptoms. Race, Hispanic ethnicity, marital status, household income, poverty, and physical activity were associated with difficulty initiating sleep (DIS) and early morning awakening (EMA). Female sex, education, and alcohol consumption had a significant bivariate association with DIS. Sleep-disordered breathing and body mass index were significantly associated with EMA. Multivariate analysis suggested that depressive symptoms, comorbidity, dyspnea, and pain had independent associations with each insomnia symptom. Age explained DIS and difficulty maintaining sleep, and significant interaction effects between age and physical activity on DIS and EMA were revealed. Results suggest that insomnia symptoms are associated with several sociodemographic, clinical, and lifestyle factors. Age below 70 years, depressive symptoms, comorbidity, dyspnea, and pain might be considered as a phenotype to identify persons with HF who are at increased risk for insomnia symptoms.