Impact of Complex Wounds on Health-Related Quality of Life: A Descriptive Study.

PURPOSE: To describe health-related quality of life (HRQoL) using the Wound-Quality of Life (Wound-QoL) questionnaire for those individuals referred to an academic medical center wound clinic. DESIGN: Prospective, descriptive study. SUBJECTS AND SETTING: One hundred eleven participants receiving care in an academic medical center wound clinic in the Southeastern United States. The sample comprised 67 males (60.4%) and 44 females (39.6%) with wounds of 6 major etiologies. METHODS: From June 2019 through May 2020, a convenience sample of 111 individuals completed the Wound-QoL questionnaire at the initial visit to the wound clinic. The Wound-QoL questionnaire is a valid and reliable tool consisting of 17 questions related to wound-QoL measured on a 5-point Likert scale, ranging from 0 (not at all affected) to 4 (very much affected). The questions are assigned to the 3 subscales: "body," "psyche," and "everyday life." The Wound-QoL individual items, subscales, and the total wound score (TWS) were calculated as mean values of the item scores, ranging from 0 to 4, where higher values correspond to decreased HRQoL. The TWS is defined as the sum of the 17 item responses, with values ranging from 0 to 68. Descriptive and parametric statistics were used to analyze the data from the Wound-QoL questionnaire. RESULTS: The mean TWS was approximately 3 points higher for Whites (n = 84) than for Blacks (n = 27) (32.42, SD = 17.96 vs 29.51, SD = 19.39), but this difference was not significant (P = .473). An independent-samples t test of TWS versus sex was not significant (P = .446). The TWS by age category was significant (P = .015), showing differences in mean scores based on age category. We found that the youngest (ages 17-39 years) and oldest (ages 70-98 years) participants were less bothered by their wounds in almost all respects than those in the middle age range (ages 40-69 years). The individual item means varied between 0.84 and 2.72, out of a possible range of 0 to 4. The highest means were for items on the emotional subscale with means from 1.93 to 2.72. Analysis of variance was used to examine the TWS and the 3 subscales over the 6 wound types; none were found to be significant (TWS: P = .454, body: P = .722, psyche: P = .452, everyday life: P = .087). CONCLUSION: Wound-QoL questionnaire scores indicated that the greatest impact of a wound on HRQoL was on the emotional subscale. These 4 items are related to the individual expressing worry, fear, unhappiness, or frustration with wound healing. The Wound-QoL questionnaire may be used to evaluate the impact the wound has on the individual's HRQoL.

Aqueous Metabolite Trends for the Progression of Nonalcoholic Fatty Liver Disease in Female Bariatric Surgery Patients by Targeted 1H-NMR Metabolomics.

Determining biomarkers and better characterizing the biochemical progression of nonalcoholic fatty liver disease (NAFLD) remains a clinical challenge. A targeted 1H-NMR study of serum, combined with clinical variables, detected and localized biomarkers to stages of NAFLD in morbidly obese females. Pre-surgery serum samples from 100 middle-aged, morbidly obese female subjects, grouped on gold-standard liver wedge biopsies (non-NAFLD; steatosis; and fibrosis) were collected, extracted, and analyzed in aqueous (D2O) buffer (1H, 600 MHz). Profiled concentrations were subjected to exploratory statistical analysis. Metabolites varying significantly between the non-NAFLD and steatosis groups included the ketone bodies 3-hydroxybutyrate (↓; p = 0.035) and acetone (↓; p = 0.012), and also alanine (↑; p = 0.004) and a putative pyruvate signal (↑; p = 0.003). In contrast, the steatosis and fibrosis groups were characterized by 2-hydroxyisovalerate (↑; p = 0.023), betaine (↓; p = 0.008), hypoxanthine (↓; p = 0.003), taurine (↓; p = 0.001), 2-hydroxybutyrate (↑; p = 0.045), 3-hydroxyisobutyrate (↑; p = 0.046), and increasing medium chain fatty acids. Exploratory classification models with and without clinical variables exhibited overall success rates ca. 75-85%. In the study conditions, inhibition of fatty acid oxidation and disruption of the hepatic urea cycle are supported as early features of NAFLD that continue in fibrosis. In fibrosis, markers support inflammation, hepatocyte damage, and decreased liver function. Complementarity of NMR concentrations and clinical information in classification models is shown. A broader hypothesis that standard-of-care sera can yield metabolomic information is supported.

Simulation strategies to increase nursing student clinical competence in safe medication administration practices: A quasi-experimental study.

BACKGROUND: Nursing student medication errors often result from deficits in knowledge and application of fundamental safe administration practices. Factors such as high faculty-student ratios and legal restrictions have decreased clinical learning opportunities for nursing students to practice safe medication administration in the clinical setting. Evidence suggests that use of a structured medication safety enhancement (MSE) simulation program can significantly improve student knowledge and competency in safe medication administration. PURPOSE: To examine the effects of an educational strategy using a MSE simulation program with integrated technology on the medication administration knowledge, competency, and confidence levels of undergraduate nursing students. METHODS: This quasi-experimental replication study designed and implemented medication simulations enhanced by integrated information technologies in an undergraduate-nursing curriculum. Third-year BSN students (n = 83) were randomized into intervention or control groups. Control groups participated in standard training while the intervention group received additional clinical simulation experience and debriefing sessions focused on medication safety practices. Participant knowledge was measured using pre/post Medication Safety Knowledge Assessment (MSKA) and competency was evaluated using the Medication Safety Critical Element Checklist (MSCEC). RESULTS: The MSKA and MSCEC were analyzed using two-sided independent t-tests. Post-test knowledge scores increased in both groups but results were not statistically significant (α = 0. 05). Students who received the medication safetfy enhancement intervention performed significantly better in a subsequent simulation than students who did not have prior simulation experience (p < .001). CONCLUSION: Findings suggest that educators should consider high fidelity simulation as an evidence-based teaching strategy to engage students in understanding and implementing medication safety practices in the clinical setting.

Using video education to improve outcomes in heart failure.

BACKGROUND: Heart Failure (HF) guidelines recommend HF self-care education. An optimal method of educating HF patients does not currently exist. OBJECTIVES: To evaluate the effectiveness of supplementing usual HF education with video education and evaluate patients' satisfaction with video education. METHODS: A mixed methods design was used. A convenience sample of 70 patients was recruited from an academic medical center. Participants completed the Atlanta Heart Failure Knowledge Test and the Self-care of Heart Failure Index before and after receiving video education, to measure HF knowledge, self-efficacy, and self-care respectively. Video usage and satisfaction with video education data were collected. All-cause 30-day readmissions data were compared to a historical group. RESULTS: HF knowledge and self-care maintenance scores increased significantly. Self-efficacy, self-care management and all-cause 30-day readmissions did not significantly improve. Most HF patients were highly satisfied. CONCLUSION: Supplementing usual HF education with VE was associated with improved HF knowledge and self-care maintenance.

Quality of Life in Individuals With Peripheral Arterial Disease Who Underwent Toe Amputations: A Descriptive, Cross-sectional Study.

Studies have shown above- or below-the-knee amputation has a profound impact on physical, mental, and emotional health; the impact of having a toe(s) amputated is unknown. PURPOSE: This descriptive research study measured health-related quality of life (HRQoL) using the Vascular Quality-of-Life Questionnaire-6 (VascuQol-6) among persons with peripheral arterial disease (PAD) who had undergone toe amputations. METHODS: A list of 127 patients discharged from the hospital in 2016 with a diagnosis of PAD and toe amputation was provided to the investigator. The independent variables of age (subsequently divided into groups of persons <65 and ≥65 years of age), gender, race, diabetes mellitus, and time of PAD diagnosis (within the year or 2 to 7 years before 2016) were abstracted from the patient charts. A letter was mailed to potential participants that explained the study and the VascuQol-6 tool, along with a prepaid envelope to return the completed tool. The VascuQol-6 tool is a valid and reliable instrument for assessing HRQoL that covered the different aspects of quality of life (QoL) affected by PAD. The tool contains six 4-point Likert scale questions about activity, symptoms, pain, emotional status, and social life, resulting in a total score between 6 and 24. Higher values indicate better perceived quality of life. Variables were analyzed using frequencies, percentages, means, and standard deviations, and a standard t test was used to compare interval scale items. Statistical significance was noted when P <.05. RESULTS: Thirty-eight (38) completed surveys were returned (30% completion rate). The mean total score was 15.5 ± 3.93 (range 7-24), and the mean overall score of the 6 items was 2.66 ± 0.90 (range 1-4). In addition to a low overall QoL score, the data showed QoL was negatively affected in every area assessed, but some participants were strongly affected whereas others were not affected at all. No significant differences in QoL scores were noted concerning age groups, gender, race, the presence of diabetes mellitus, or time since PAD diagnosis. CONCLUSION: In this study, patients with PAD and toe amputations had low QoL scores related to their disease. Additional research is needed to better understand HRQoL related to PAD to facilitate education of patients considering toe amputation.

End-of-Life Plans for African American Older Adults With Dementia.

African Americans are perceived to be least likely of all racial and ethnic groups to prepare for the end of life. However, verbal plans for the end of life are of particular importance to this population and may help understand why they are less likely to possess a formal end-of-life care planning document. The purpose of this study was to determine the number of formal and/or informal end-of-life care plans that existed among a convenience sample of African American older adults with dementia. For this descriptive study, data were collected from African American family caregivers (N = 65) of older adults with dementia. Descriptive statistics were conducted. Caregivers in this sample reported high rates of formal and/or informal end-of-life plans for their care recipients. Agency forms (power of attorney, health-care surrogate, or guardianship forms) had been obtained by 74% of the care recipients, while 63% of them possessed a formal end-of-life care planning document. All combined, 88% of the caregivers possessed at least 1 document or verbal information concerning end-of-life care for their care recipient or at least there was an assigned surrogate. Although limited, these findings reflect more end-of-life planning in this population than previous studies reported and could improve the quality of end-of-life outcomes in this population by giving health-care providers increased understanding of African American end-of-life planning preferences. This may, in turn, help the providers to inform and educate these care recipients and their family caregivers.

Nonuniform sampling by quantiles.

A flexible strategy for choosing samples nonuniformly from a Nyquist grid using the concept of statistical quantiles is presented for broad classes of NMR experimentation. Quantile-directed scheduling is intuitive and flexible for any weighting function, promotes reproducibility and seed independence, and is generalizable to multiple dimensions. In brief, weighting functions are divided into regions of equal probability, which define the samples to be acquired. Quantile scheduling therefore achieves close adherence to a probability distribution function, thereby minimizing gaps for any given degree of subsampling of the Nyquist grid. A characteristic of quantile scheduling is that one-dimensional, weighted NUS schedules are deterministic, however higher dimensional schedules are similar within a user-specified jittering parameter. To develop unweighted sampling, we investigated the minimum jitter needed to disrupt subharmonic tracts, and show that this criterion can be met in many cases by jittering within 25-50% of the subharmonic gap. For nD-NUS, three supplemental components to choosing samples by quantiles are proposed in this work: (i) forcing the corner samples to ensure sampling to specified maximum values in indirect evolution times, (ii) providing an option to triangular backfill sampling schedules to promote dense/uniform tracts at the beginning of signal evolution periods, and (iii) providing an option to force the edges of nD-NUS schedules to be identical to the 1D quantiles. Quantile-directed scheduling meets the diverse needs of current NUS experimentation, but can also be used for future NUS implementations such as off-grid NUS and more. A computer program implementing these principles (a.k.a. QSched) in 1D- and 2D-NUS is available under the general public license.

Understanding End-of-Life Decision-Making Terminology Among African American Older Adults.

The purpose of the current study was to examine understanding of end-of-life (EOL) decision-making terminology among family caregivers of African American older adults with dementia. This qualitative descriptive study was part of a larger mixed-methods study from which a subset of caregivers (n = 18) completed interviews. Data were analyzed using descriptive statistics and content analyses guided by methods of qualitative analysis. Caregiver interpretation of EOL decision-making terminology varied between associations before and/or after death. EOL decision making was most often a family decision, based on past experiences, and included reliance on resources such as faith or spirituality and health care providers. Patients and families attach meaning to health care terms that should be aligned with health care providers' understanding of those terms. Results provide insight to improve EOL decision making in this population via tailored interventions for patients, families, and health care providers. [Journal of Gerontological Nursing, 44(2), 33-40.].

Vascular Graft Infection: Incidence and Potential Risk Factors.

PURPOSE: The purpose of this study was to identify factors that increase the risk of vascular graft infections (VGI) in patients following abdominal or lower extremity revascularization surgery. DESIGN: Retrospective, descriptive study. METHODS: We reviewed the electronic health records of 223 patients who had undergone abdominal or lower extremity revascularization procedures from July 2012 to November 2014, looking for factors associated with VGI. We reviewed 28 preoperative, intraoperative, and post-operative factors. Descriptive statistics (mean, range, and standard deviation) were used to describe the sample; χ was used to determine correlations between the risk factors and subsequent VGIs. The level of significance was determined at P = .05, with a confidence level of 95%. RESULTS: We identified 33 cases of VGIs for the 223 charts reviewed, yielding an incidence rate of 15%. Seventeen of the 33 patients with VGI (51.5%) were male. The average age of patients who experienced VGI was 60.9 years (standard deviation, 12.2 years, range, 29-81 years). Preoperative factors that were shown to show statistical significance for the development of VGI were sequential procedures (P = .003), diabetes mellitus (P = .002), hemoglobin A1c more than 7.0 (P = .0002), blood glucose more than 180 mg/dL (P = .0006), and lack of mobility (0.0097). Intraoperative factors associated with VGI were hemostatic agents applied to the surgical field intraoperatively (P = .003) and perioperative hypoxemia (P = .027). Postoperative factors associated with VGI were discharge from the hospital to skilled nursing facility or acute rehabilitation facility (P = .005) and unscheduled clinic visits (P = .008). CONCLUSION: We measured a 15% incidence of VGI and identified multiple pre-, intra-, and postoperative associated factors. Vigilance is required to prevent VGI and knowledge of specific risk factors is important.

Pain management in home hospice patients: A retrospective descriptive study.

The development and evaluation of evidence-based, safe, and effective home-based pain management models for caregivers implementation is receiving greater attention in the literature because of international initiatives intended to increase the number of people who receive end-of-life care in home-based settings. The purpose of this "retrospective descriptive design" study was to describe pharmacological pain management and outcomes for 40 cancer and non-cancer patients receiving hospice care at home. While the median pain score was higher at admission in the cancer group than in the hospice care at home group, the difference was not significant at or within 48 hour of admission. Overall, there was a significant decrease in pain from the first measurement to the second. Within the last seven days of life, the majority of participants were not able to provide a pain severity score when asked to evaluate the effectiveness of pain management, thus their caregiver provided a proxy evaluation. Pain management was effective in the home setting. More research is needed on the best methods to teach lay caregivers to assess pain and evaluate the effectiveness of pharmacological modalities to manage pain.

Are International Classification of Diseases Codes in Electronic Health Records Useful in Identifying Obesity as a Risk Factor When Evaluating Surgical Outcomes?

This research addresses an important methodological issue on patient safety and obesity for the purposes of examining clinical and administrative data for the reliability of using International Classification of Diseases (ICD) diagnoses codes alone to reliably identify obesity as a comorbidity and risk factor in care and management. The findings of this research confirm ICD codes for the obese surgical populations were underutilized. Despite more than 70% of patients classified as overweight or obese, ICD-9 codes for obesity were assigned in less than 10% of the overall sample. Patients in the extreme category of obesity (body mass index [BMI] >40 kg/m) were more likely to have a corresponding ICD-9 code compared with patients in the BMI range of 25 to 40 kg/m. International Classification of Diseases, Ninth Revision coding for obesity was underutilized in patients with a BMI of greater than 25 kg/m. The associated health risks, costs, and potential adverse events associated with obesity make it imperative to continue to study the barriers to coding.

A Patient Safety Dilemma: Obesity in the Surgical Patient.

Patient safety and the delivery of quality care are major concerns for healthcare in the United States. Special populations (eg, obese patients) need study in order to support patient safety, quantify risks, advance education for healthcare-workers, and establish healthcare policy. Obesity is a complex chronic disease and is considered the second leading cause of preventable death in the United States with approximately 300,000 deaths per year. Obesity is recognized by the Agency for Healthcare Research and Quality (AHRQ) as a comorbid condition. These concerns emphasize the need to focus further research on the obese patient. Through the use of clinical and administrative data, this study examines the incidence of adverse outcomes in the obese surgical population through AHRQ Patient Safety Indicators (PSI) and allows for the engagement PSIs as measures to guide and improve performance. In this study, the surgical population was overwhelmingly positive for obesity. Body mass index (BMI) was also a significant positive predictor for 2 of 3 postoperative outcomes. This finding suggests that as BMI reaches the classification of obesity, the risk of these adverse outcomes increases. It further suggests there exists a threshold BMI that requires anticipation of alterations to systems and processes to revise outcomes.

Relationships among moral distress, level of practice independence, and intent to leave of nurse practitioners in emergency departments: results from a national survey.

The aims of this research study were to investigate moral distress among emergency department (ED) nurse practitioners (NPs) and examine relationships between moral distress and level of practice independence as well as intent to leave a position. Moral distress has been studied regarding registered nurses and physicians (MDs) but less so in NPs. It is important to explore moral distress in NPs because they tread a unique path between nursing and physician roles. Moral distress may play a significant role in staff nurses' intention to leave practice, and level of practice independence is found to have a relationship with NPs' intention to leave. A convenience sample of ED NPs was obtained from a mailing list of a national nursing specialty organization, the Emergency Nurses Association. Using a correlational design, survey methods assessed moral distress with the Moral Distress Scale-Revised (MDS-R), level of practice independence with the Dempster Practice Behavior Scale, and intent to leave with self-report. Correlational and regression analyses of data were conducted to characterize moral distress among ED NPs and associations between moral distress, level of practice independence, and intent to leave. Results found ED NPs do experience moral distress with poor patient care results from inadequate staff communication and working with incompetent coworkers in their practice. The MDS-R was a significant predictor of intention to leave among respondents. This study is the first of its kind to explore moral distress in ED NPs. Results suggest moral distress influences ED NPs' intent to leave their position. Further studies are needed to explore the findings from this research and to formulate interventions to alleviate moral distress in ED NPs and improve retention in the clinical setting.

A Health-Related Quality of Life Measure for Older Adolescents With Asthma: Child Health Survey for Asthma-T (Teen Version).

BACKGROUND: Although adolescent substance use can have direct effects on asthma symptoms and interact with medications used to treat asthma, no validated health-related quality of life (HRQL) instrument exists for adolescents 17 to 19 years of age with asthma. PURPOSE: The American Academy of Pediatric's HRQL instrument, the Child Health Survey for Asthma (CHSA)-Child version, was modified with a substance use subscale to address outcomes specific to adolescents ages 17 to 19 years with asthma. METHODS: Two cohorts (N = 70) were recruited for instrument testing at pediatric primary care practices and two university clinics. A small methodological study with 24 adolescents was conducted to obtain initial support of the psychometric properties for the CHSA-Teen version at baseline, day 14, and day 16. A follow-up study included 46 teens to provide further support. RESULTS: The psychometric properties of the CHSA-Teen version were good and comparable with the CHSA-Child version for feasibility, reliability, and validity. CONCLUSIONS: Health care providers need to be aware of each adolescent's substance use to personalize counseling related to asthma medications.

A decision aid to improve smoking abstinence for families facing cancer.

PURPOSE/OBJECTIVES: To test the feasibility of a multidisciplinary, multicomponent, theory-based decision aid. DESIGN: Prospective, one-group repeated measures. SETTING: Thoracic surgery clinic in a university hospital cancer center in central Virginia. SAMPLE: 8 dyads, consisting of 16 total participants. METHODS: A multidisciplinary, multicomponent smoking cessation intervention incorporated a theory-based decision aid. Enrollment occurred preoperatively; four face-to-face visits and an exit interview were conducted during six months. MAIN RESEARCH VARIABLES: Feasibility was evaluated based on four criteria: recruitment, retention, adherence, and acceptability. FINDINGS: The recruitment rate was 44%, and the retention rate was 100%. Adherence to the intervention and the acceptability of the decision aid were greater for patients than family members. Patients had greater abstinence than family members before surgery and at six months. Exit interview themes included (a) preoperative timing was acceptable and (b) involving household members who smoke was important. CONCLUSIONS: Recruiting male patients and their female partners is feasible. Participants liked convenience, autonomy, and a family approach. Family members wanted more control over cessation timing and a more intensive approach to weight and mental health management. Successful dyads worked together to maintain abstinence. IMPLICATIONS FOR NURSING: Oncology nurses can assess patients' and family members' smoking status, facilitate understanding about specific benefits of smoking cessation and the obstacle posed by household smokers, and make referrals to expert resources. Encouraging smoke-free environments is an important step toward reducing secondhand smoke exposure and promoting cessation.

Cleanliness of disposable vs nondisposable electrocardiography lead wires in children.

BACKGROUND: Mediastinitis costs hospitals thousands of dollars a year and increases the incidence of patient morbidity and mortality. No studies have been done to evaluate adenosine triphosphate (ATP) counts on disposable and nondisposable electrocardiography (ECG) lead wires in pediatric patients. OBJECTIVE: To compare the cleanliness of disposable and nondisposable ECG lead wires in postoperative pediatric cardiac surgery patients by measuring the quantity of ATP (in relative luminescence units [RLUs]). ATP levels correlate with microbial cell counts and are used by institutions to assess hospital equipment and cleanliness. METHODS: A prospective, randomized trial was initiated with approval from the institutional review board. Verbal consent was obtained from the parents/guardians for each patient. Trained nurses performed ATP swabs on the right and left upper ECG cables on postoperative days 1, 2, and 3. RESULTS: This study enrolled 51 patients. The disposable ECG lead wire ATP count on postoperative day 1 (median, 157 RLUs) was significantly lower (P < .001) than the count for nondisposable ATP lead wires (median, 610 RLUs). On postoperative day 2, the ATP count for the disposable ECG lead wires (median, 200 RLUs) was also lower (P = .06) than the count for the nondisposable ECG lead wires (median, 453 RLUs). CONCLUSION: Results of this study support the use of disposable ECG lead wires in postoperative pediatric cardiac surgery patients for at least the first 48 hours as a direct strategy to reduce the ATP counts on ECG lead wires.

Promoting heart health in rural women.

PURPOSE: To compare 2 strategies, stage-matched nursing and community intervention (SMN+CI) and community intervention (CI) alone in changing cardiovascular risk factors in up to 3 behavioral areas: diet, physical activity, and/or smoking among rural women. METHODS: A 14-month, multisite randomized controlled trial of 117 rural women was conducted. Transtheoretical model was used in identification of stage of change and development of the SMN+CI nursing interventions. A social-ecological model was used to address issues of rurality in the development of interventions. FINDINGS: The SMN + CI group was superior on 4 outcomes. There were significant increases in 2 measures of dietary intake; improvement in dietary stage of change for fruits and vegetables; and reduced diastolic blood pressure (DBP) in the SMN + CI group. After log transformation DBP significance was lost. The CI group had a significant reduction in change in total cholesterol; however, significance was lost after control for the initiation of lipid lowering medications. There was a significant reduction in Framingham risk scores pre- to postintervention, regardless of group. CONCLUSIONS: There continues to be a need to improve cardiovascular risk factors in rural women. There should be an exploration of whether intensified dose and fidelity of the intervention strategies of diet and physical activity are effective in improving anthropometric and laboratory values. Further investigation is warranted into factors influencing the pre- to postreduction in Framingham risk scores.

Parents' perceptions of continuity of care in the neonatal intensive care unit: pilot testing an instrument and implications for the nurse-parent relationship.

Nurse-parent relationships are a key aspect of high-quality family-centered care in the neonatal intensive care unit. Few studies have examined nursing continuity of care that includes (a) chronological continuity, that is, the number of nurses caring for an infant over time, (b) the consistency of information transferred to the parent and colleagues, and (c) the consistency of interactions between parent and nurse as an important factor in the nurse-parent relationship. The aims of this pilot study were to develop and test a scale of parental perceptions of nursing continuity of care in the newborn intensive care setting and to characterize the association between parents' perceptions and chronological nursing continuity. Fifty-four parents completed the Parents' Perceptions of Continuity Scale and a demographic questionnaire. Also, medical record and a count of the number of nurses caring for infant in past 7 days were collected. The Parents' Perceptions of Continuity Scale demonstrated good internal consistency (Cronbachα, 0.81). Parents' Perceptions of Continuity Scale scores were significantly associated with chronological nursing continuity, suggesting that the number of nurses caring for an infant plays a role in parents' perceptions of overall nursing continuity.

Evaluation of an office protocol to increase exclusivity of breastfeeding.

OBJECTIVE: The purpose of this study was to determine whether implementing a program based on a clinical protocol affects breastfeeding rates within a pediatric primary care setting. Increasing breastfeeding rates is an important public health initiative identified by multiple agencies. METHODS: The Academy of Breastfeeding Medicine (ABM) clinical protocol ("The Breastfeeding-Friendly Physician's Office, Part 1: Optimizing Care for Infants and Children") was used as a template for the provision of breastfeeding services within a pediatric primary care clinic. There were 757 mother-infant pairs included in the study. A retrospective before-and-after study design was used. Data collection points included the hospital stay, the newborn visit, and the 2-, 4-, and 6-month health maintenance visits. The 2 groups were compared to estimate the protocol's effectiveness as a method of increasing breastfeeding rates. RESULTS: The results of this evaluation were positive for exclusive breastfeeding, with group comparisons showing a statistically significant increase in exclusive breastfeeding rates at all 5 time points. CONCLUSIONS: Our diverse patient population within a pediatric practice had increased initiation rates and exclusive breastfeeding rates after implementation of the ABM's breastfeeding-friendly protocol. Families who receive care in a pediatric primary care setting that has implemented the ABM clinical protocol may have increased rates of exclusive breastfeeding.

Preprocedural distress in children with cancer: an intervention using biofeedback and relaxation.

Children diagnosed with cancer experience many invasive procedures throughout diagnosis and treatment of their disease. These procedures, oftentimes a source of distress in children, can elicit a variety of anticipatory symptoms prior to the actual procedure. Although there have been efforts to develop approaches to alleviate this distress through use of distraction, relaxation, sedation, guided imagery, and hypnosis, there has not been a combination treatment that merged relaxation techniques and biofeedback within a pediatric framework. A group of 12 children diagnosed with cancer participated in a 4-session intervention combining relaxation and biofeedback. This feasibility study suggests that the combination intervention offered in a clinical setting may be beneficial to children experiencing procedural distress as a novel coping strategy.