Psychiatric disorders and treatment in low-income pregnant women.

AIMS: This study estimated the prevalence of twenty-two 12-month and lifetime psychiatric disorders in a sample of 744 low-income pregnant women and the frequency that women with psychiatric disorders received treatment. METHOD: To identify psychiatric disorders, the Diagnostic Interview Schedule (DIS) was administered to Medicaid or Medicaid-eligible pregnant women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). The sample was stratified by the rural or urban location of the WIC sites in southeastern Missouri and the city of St. Louis. Eligible women were enrolled at each site until their numbers were proportional to the racial distribution of African American and Caucasian pregnant women served there. RESULTS: The 12-month prevalence of one or more psychiatric disorders was 30.9%. Most common were affective disorders (13.6%), particularly major depressive disorder (8.2%) and bipolar I disorder (5.2%). Only 24.3% of those with a psychiatric disorder reported that they received treatment in the past year. Lifetime prevalence of at least one disorder was 45.6%, with affective disorders being the most frequent (23.5%). Caucasian women were more likely than African Americans to have at least one 12-month disorder, with the difference largely accounted for by nicotine dependence. Higher prevalence of lifetime disorders was also found in Caucasian women, particularly affective disorders and substance use disorders. There were no differences in the prevalence of 12-month or lifetime psychiatric disorders by the urban or rural residence of subjects. CONCLUSIONS: With nearly one third of pregnant women meeting criteria for a 12-month psychiatric disorder and only one fourth receiving any type of mental health treatment, comprehensive psychiatric screening during pregnancy is needed along with appropriate treatment.

Psychiatric disorders among low-income women and unintended pregnancies.

BACKGROUND: The prevalence of both unintended pregnancy and psychiatric disorders in pregnancy is high. Each is associated with compromised birth outcomes and challenges in child-rearing. This study examines the relationship between mental illness and unintended pregnancy in seeking to improve the care provided to women and our ability to minimize the number of children born unwanted or ill-cared for. METHODS: The sample consisted of 744 pregnant Women, Infants, and Children (WIC) participants with a stratified enrollment design by residence and representative by race for each WIC county. Analysis consisted of post-stratification by developmental age group with logistic regression models estimating odds of unintended pregnancy among women with and without a psychiatric disorder. Covariates included race, education, and marital status. FINDINGS: Almost one third (30.9%) had at least one psychiatric disorder with over two thirds (67.3%) reporting their pregnancy as unintended. No grouped psychiatric disorder was associated with unintended pregnancy with all ages combined. However, adolescents (ages 15-19) with a substance disorder were less likely to have an unintended pregnancy (adjusted odds ratio [aOR], 0.3; 95% confidence interval [CI], 0.1-0.7) than women without a substance disorder and emerging adult women (ages 20-23) with an anxiety disorder were less likely to have an unintended pregnancy (aOR, 0.4; 95% CI, 0.2-1.0) compared with those without the targeted disorder. CONCLUSION: The prevalence of unintended pregnancy is not associated with having a psychiatric disorder, although substance use disorders and anxiety disorders were associated with a decreased likelihood for an unintended pregnancy in a specific age group. Importantly, targeted efforts are needed to identify and counsel women with mental illness about pregnancy planning.

The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit.

OBJECTIVE: The purpose of this study was to determine the effects of a simple low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. DESIGN: Preintervention and postintervention observational study. SETTING: Twenty-four bed surgical/trauma/burn intensive care units in an urban university hospital. PATIENTS: All mechanically ventilated patients that were admitted to the intensive care unit between June 1, 2004 and May 31, 2005. INTERVENTIONS: An oral care protocol to assist in prevention of bacterial growth of plaque by cleaning the patients' teeth with sodium monoflurophosphate 0.7% paste and brush, rinsing with tap water, and subsequent application of a 0.12% chlorhexidine gluconate chemical solution done twice daily at 12-hour intervals. MEASUREMENTS AND MAIN RESULTS: During the preintervention period from June 1, 2003 to May 31, 2004, there were 24 infections in 4606 ventilator days (rate = 5.2 infections per 1000 ventilator days). After the institution of the oral care protocol, there were 10 infections in 4158 ventilator days, resulting in a lower rate of 2.4 infections per 1000 ventilator days. This 46% reduction in ventilator-associated pneumonia was statistically significant (P = .04). Staff compliance with the oral care protocol during the 12-month period was also monitored biweekly and averaged 81%. The total cost of the oral care protocol was US$2187.49. There were 14 fewer cases of ventilator-associated pneumonia, which led to a decrease in cost of US$140 000 to US$560 000 based on the estimated cost per ventilator-associated pneumonia infection of US$10 000 to US$40 000. There was an overall reduction in ventilator-associated pneumonia without a change to the gram-negative or gram-positive microorganism profile. CONCLUSIONS: The implementation of a simple, low-cost oral care protocol in the surgical intensive care unit led to a significantly decreased risk of acquiring ventilator-associated pneumonia.

Comparison of forehead and digit oximetry in surgical/trauma patients at risk for decreased peripheral perfusion.

OBJECTIVE: Measurement of pulse oximetry (Spo(2)) is often impaired in critically ill patients. Forehead reflectance oximetry, the Max-Fast (Nellcor, Pleasanton, CA), may be less susceptible to poor tissue perfusion and could improve accuracy of oxygen saturation measurement. The objective of this study was to evaluate the use of forehead oximetry measures in critically ill surgical/trauma patients. METHODS: A prospective interventional study of 30 critically ill surgical/trauma patients at risk for decreased peripheral perfusion, as evidenced by need for vasopressor support (24 patients), transfusion of more than 6 unit packed cells in 24 hours (two patients), or an inability to obtain consistent saturation from a digit sensor (four patients), compared forehead and digit-based oximeter Spo(2) readings with co-oximetry (Sao(2)) measurements from arterial blood samples. Sao(2) values were converted to functional oxygen saturation (SO(2)) measurements for the final comparison. Patients were fitted with forehead (Nellcor Max-Fast) and digit (Nellcor Max A; digit 1) sensors connected to Nellcor OxiMax N-595 oximeters and a digit sensor (Nellcor Max A; digit 2) connected to a multiparameter monitor (Philips CMS [Andover, MA]). Three measurements of Sao(2) were obtained from each subject over a 24-hour time period, and simultaneous measurements of Spo(2) were recorded from the three monitors. RESULTS: The three Spo(2) measurements (forehead, digit 1, and digit 2) were compared with SO(2) values using the Bland-Altman method to assess agreement. Forehead measurements demonstrated a mean bias of -1.39, whereas digit 1 was -2.61 and digit 2 was -3.84. Pearson correlations (r) for forehead, digit 1, and digit 2 with SO(2) were .834, .433, and .254, respectively. There were fewer unsuccessful measurements with the forehead oximetry technique. CONCLUSIONS: Forehead sensors improve measurement of oxygen saturation in critically ill surgical/trauma patients at risk for decreased peripheral perfusion.

Ethics education in MSN programs: a study of national trends.

The aim of this study was to determine the manner in which master's of science in nursing programs, accredited by either the National League for Nursing Accrediting Commission or the Commission on Collegiate Nursing Education, conduct ethics education. A survey method was employed to obtain requisite data. Among the main variables investigated were: the percentage of programs that require a course with formal ethics content; the average number of class hours a program or track dedicates to ethics education; required and actual credentials of instructors who teach ethics; and objectives, topics, teaching methods, and grading methods of required courses with formal ethics content. Results indicated that most programs do not require instructors to have completed formal ethics training. In terms of content, few common trends exist and there are important gaps in clinical ethics topics. Comparisons between school of medicine ethics content reported in the literature and MSN ethics content reported in this study indicate that medical schools are more exacting of their students. The study concludes with a call for the establishment of guidelines or standards relevant to ethics content in MSN curricula in the United States.

Cancer-related fatigue: "It's so much more than just being tired".

Fatigue is highly prevalent among persons with cancer and has great impact on their lives. The cancer-related fatigue (CRF) experience is subjective and multidimensional; understanding it from the individual's perspective is essential. This qualitative study explored the meaning of CRF from the individual's perspective. A phenomenological approach, embodiment, served as the philosophical framework. The study was conducted in a freestanding outpatient cancer clinic in a major metropolitan area. Ten cancer patients who were undergoing chemotherapy received audio-tape recorded semi-structured individual interviews and six completed a 2-week daily diary keeping activity. Data analysis proceeded through reduction methodology to seek commonalities in meanings, situations, and embodied experiences. The analysis resulted in the following thematic categories: different fatigue, physical sensations, "I cannot...", emotional sensations, gaining sense of control, fatigue as holistic experience. Participants described fatigue of an unexpected kind and degree that was much more than just being tired. Their inability to anticipate the scope of CRF and lack of awareness of strategies to combat CRF distressed some participants. Various individual strategies, based on personal experience, were developed to regain a sense of control. Health care providers can be instrumental in enabling cancer patients to recognize and manage CRF.

Persistent tobacco use during pregnancy and the likelihood of psychiatric disorders.

OBJECTIVES: We examined the association between psychiatric disorders and tobacco use during pregnancy. METHODS: Data were derived from a population-based cohort of 744 pregnant African American and White low-income women living in urban and rural areas. The Diagnostic Interview Schedule was used to assess women for 20 different psychiatric disorders. RESULTS: In comparison with nonusers, persistent tobacco users (women who had used tobacco after confirmation of their pregnancy) and nonpersistent users (women who had used tobacco but not after pregnancy confirmation) were 2.5 and 2 times as likely to have a psychiatric disorder. Twenty-five percent of persistent users had at least 1 of the following diagnoses: generalized anxiety disorder, bipolar I disorder, oppositional disorder, drug abuse or dependence, and attention deficit-hyperactivity disorder. CONCLUSIONS: In this cohort study, 5 diagnoses were more prevalent among persistent tobacco users than among nonusers, suggesting that several psychiatric disorders contribute to difficulty discontinuing tobacco use during pregnancy. Smoking cessation efforts focusing on pregnant women may need to address co-occurring psychiatric disorders if they are to be successful.

Assessing fatigue in persons with cancer: further validation of the Wu Cancer Fatigue Scale.

Cancer-related fatigue (CRF) is a significant clinical symptom. Effective assessment of CRF attributes from the patients' perspective is essential. This study tested the psychometric properties of the Wu Cancer Fatigue Scale (WCFS). A total of 172 outpatients with breast cancer, who were at various stages and on various chemotherapy regimens, and were undergoing treatment at one of three cancer clinics in a Midwest metropolitan area, participated in this study. The participants were instructed to complete four instruments in the following order: the 16-item WCFS, Schwartz Cancer Fatigue Scale (SCFS), Geriatric Depression Scale (GDS), and Cancer-Related Fatigue Distress Scale (CRFDS). Structural equation modeling (LISREL 8.54) supported the one-factor measurement model with nine items remaining. Nonsignificant Satorra-Bentler Scaled Chi-square (27)=32.52, P=0.21, standardized root mean square residual=0.032, nonnormal fit index=0.97, comparative fit index=0.98, and incremental fit index=0.98 indicated a good model fit. Convergent validity with the SCFS was 0.78, concurrent validity with the GDS was 0.60, and predictive validity with the CRFDS was 0.73. Internal consistency reliability was alpha=0.91 for the nine-item scale. The revised WCFS is a reliable and valid instrument that aims to measure the subjective characteristics of CRF from the patients' perspective. It may prove useful in both clinical and research settings.

Primary reasons for ED visits and procedures performed for patients who saw nurse practitioners.

INTRODUCTION: Little is known, from a national perspective, about what types of patients are seen by nurse practitioners in the emergency department. METHODS: Data from 1545 participating emergency departments across the United States during 1997, 1998, 1999, and 2000 were collected from nationally representative samples of urban and rural hospitals using the National Hospital Ambulatory Medical Care Surveys. Results Nurse practitioners saw 5.76 million ED patients during the 4-year period. Using the Reason for Visit Classification developed by the National Center for Health Statistics, the primary category for patients seen by nurse practitioners was classified as "Injury by type and/or location." The types of injuries in this category were lacerations and cuts to an upper extremity and facial area; injuries to the head, neck, and face; and foreign bodies in the eye. The next most common category was classified under "General symptoms." Nurse practitioners saw patients in this category with symptoms of chest pain, side or flank pain, fever, and edema. DISCUSSION: The findings from this study provide insight into the types of patient visits seen by nurse practitioners in emergency departments in the United States and the services and procedures that were received by patients.

Assessing fatigue in persons with cancer: an instrument development and testing study.

BACKGROUND: Cancer-related fatigue (CRF) is a highly prevalent, subjective experience of patients with and survivors of cancer. Effective assessment of the attributes of CRF from the patient's perspective is essential. The current study developed a measure of CRF from the patient's perspective and determined its psychometric properties for patients with cancer undergoing chemotherapy. METHODS: Chemotherapy outpatients in a free-standing metropolitan area cancer clinic participated in the current multiphase study. In the instrument development phase, 42 items were generated from a qualitative study with 10 semistructured individual interviews and 6 daily fatigue diaries. These items were revised based on content evaluation by 20 cancer patient content experts. In the instrument analysis phase, the 30 content-validated items were pilot tested by 30 patients with breast carcinoma using cognitive interview techniques. The psychometric properties of the resulting 16-item, 5-point CRF rating scale were tested with 82 patients with breast carcinoma. RESULTS: Principal axis factoring gave a one-factor solution accounting for 59% variance. Coefficient alpha reliability was 0.95 for the final 15-item scale. Convergent validity with the Schwartz Cancer Fatigue Scale was 0.84, concurrent validity with the Geriatric Depression Scale was 0.61, and predictive validity with the Cancer-Related Fatigue Distress Scale was 0.83. CONCLUSIONS: This newly developed instrument to assess the subjective fatigue symptoms of patients with cancer demonstrated effective use of diary and interview methods in instrument development and both cognitive interviewing and traditional psychometric techniques in instrument analysis. The instrument has promising psychometric properties, but confirmatory testing is needed.

The use of nebulized opioids in the management of dyspnea: evidence synthesis.

PURPOSE/OBJECTIVES: To analyze the evidence about the use of nebulized opioids to treat dyspnea using the Priority Symptom Management (PRISM) level-of-evidence framework and to make a practice recommendation. DATA SOURCES: Computerized database and manual search for articles and abstracts that included experimental trials, chart reviews, and case studies. DATA SYNTHESIS: 20 articles with evaluable evidence were identified. Analysis was complex because of heterogeneous variables and outcome measures. A major limitation is small sample sizes. The majority of PRISM level I and II studies indicated unfavorable evidence. CONCLUSIONS: Scientific data supporting the use of nebulized opioids to treat dyspnea in patients with chronic pulmonary disease, including malignancy, are lacking. IMPLICATIONS FOR NURSING: Insufficient data identify a need for further research with random crossover designs involving larger samples that are stratified according to prior opioid use. Consistency of study variables should be emphasized.

Posttraumatic stress disorder in pregnancy: prevalence, risk factors, and treatment.

OBJECTIVE: To estimate the prevalence of posttraumatic stress disorder and its treatment in economically disadvantaged pregnant women. METHODS: The sample included 744 pregnant Medicaid-eligible women from Women, Infants and Children Supplemental Nutrition Program sites in 5 counties in rural Missouri and the city of St. Louis. Race (black and white) was proportional to clients seen at each site. Women were assessed by using standardized measures of posttraumatic stress disorder, 18 other psychiatric disorders, environmental stressors, and pregnancy characteristics. Logistic regression identified risk factors associated with posttraumatic stress disorder. RESULTS: Posttraumatic stress disorder prevalence was 7.7% (n = 57/744). Comorbid disorders were common. Women with posttraumatic stress disorder were 5 times more likely to have a major depressive episode (odds ratio 5.17; 95% confidence interval 2.61, 10.26) and more than 3 times as likely to have generalized anxiety disorder (odds ratio 3.25; 95% confidence interval 1.22, 8.62). Besides these comorbid disorders, risk factors for posttraumatic stress disorder included a history of maternal separation for 6 months and multiple traumatic events. Although most women with posttraumatic stress disorder reported moderate impairment in their daily lives, only 7 of the 57 women with this disorder reported speaking with any health professional about it in the last 12 months. CONCLUSIONS: The prevalence of posttraumatic stress disorder in pregnancy and low treatment rates suggest that screening for this disorder should be considered in clinical practice. LEVEL OF EVIDENCE: II-2

Evaluation of chemical dot thermometers for measuring body temperature of orally intubated patients.

BACKGROUND: Recent research indicates that oral measurement of body temperature is a reliable option in orally intubated patients. In situations such as protective isolation, where dedicated electronic thermometers are not available, are single-use chemical dot thermometers an acceptable alternative? OBJECTIVE: To determine the accuracy of single-use chemical dot thermometers in orally intubated adult patients. METHODS: Subjects included a convenience sample of 85 adult patients admitted to 1 of 2 intensive care units (surgical trauma and neuroscience). For each patient, oral temperatures were measured concurrently (within 5 minutes) with a chemical dot thermometer and an electronic thermometer. The sequence of temperature measurements was alternated with each subsequent patient. Both thermometers were placed in the same posterior sublingual pocket opposite the side of the endotracheal tube. RESULTS: Measurements obtained with electronic and single-use chemical dot thermometers correlated strongly (r = 0.937). With the chemical dot thermometer, body temperature was overestimated in 11.8% of the measurements and underestimated in 10.8% of the measurements by 0.4 degree C or more. The difference between oral temperatures measured with the 2 different thermometers was not related to the patient's age, sex, or sublingual pocket location or to the order of thermometer use. CONCLUSION: The chemical dot thermometer is useful and reliable for measuring body temperature of orally intubated patients. When measurements of body temperature have important consequences for decisions about treatment, clinicians should use an electronic thermometer to confirm measurements made with a chemical dot thermometer.

Nurse practitioners and physician assistants revisited: do their practice patterns differ in ambulatory care?

The education and regulation of nurse practitioners and physician assistants would suggest unique role differentiations and practice functions between the professions. This study explored to what extent their practice patterns in primary care actually differ. It was hypothesized that the primary care services provided by nurse practitioners would tend to be women and family health services, health prevention and promotion oriented, provided to minority and socioeconomic disadvantaged patients, and less dependent on physician supervision. In contrast, the services provided by physician assistants would more likely be medical/surgical oriented; diagnostic, procedural, and technical in nature; likely to be in rural areas; and more dependent on physician supervision. The study used patient data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Although some differences emerged, the argument is not compelling to suggest strong, unique, practice differences across all ambulatory care settings between the two types of nonphysician providers. It is the specific type of ambulatory setting that influences the practice pattern for both provider groups. If practice patterns are less distinctive than previously believed, more opportunities for interdisciplinary education need to be explored, and health policies that promote a discipline-specific primary care workforce may need to be reexamined.