Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review.

The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.

Severe Acute Pancreatitis Prediction: A Model Derived From a Prospective Registry Cohort.

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

Robotic assisted kidney auto-transplantation as a safe alternative for treatment of nutcracker syndrome and loin pain haematuria syndrome: A case series report.

BACKGROUND: Describe the outcomes and safety of robotic-assisted kidney auto-transplantation (RAKAT) in the treatment of nutcracker syndrome (NCS) and loin pain haematuria syndrome (LPHS). METHODS: This retrospective study included 32 cases of NCS and LPHS seen during December 2016 to June 2021. RESULTS: Three (9%) patients had LPHS and 29 (91%) NCS. All were non-Hispanic whites, and 31 (97%) women. The mean age was 32 years (SD = 10) and the BMI 22.8 (SD = 5). The RAKAT was completed in all patients, 63% had a total improvement of pain. According to the Clavien-Dindo classification, 47% presented with type 1, and 9% with type 3 complications with a mean follow-up of 10.9 months. The incidence of acute kidney injury in post-procedure was 28%. No one required blood transfusions, and there were no deaths during the follow-up. CONCLUSION: RAKAT was a feasible procedure with a similar complication rate to those reported for other surgical techniques.

Outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing robotic (RPD) or open pancreaticoduodenectomies (OPD): a propensity score-weighted survival analysis.

The purpose of this study was to compare the survival, recurrence, and complication rates in patients with pancreatic ductal adenocarcinoma (PDAC) who underwent robotic pancreaticoduodenectomy (RPD) or open pancreaticoduodenectomy (OPD) and who received adjuvant therapy. The study was a single-center retrospective analysis of consecutive PDAC patients who underwent RPD/OPD. Patient characteristics, tumor findings, neoadjuvant therapy, adjuvant therapies, overall survival (OS) and recurrence-free survival (RFS) were compared between the OPD and RPD cohorts. Cox proportional hazard regression with and without propensity score matching was used to establish the association between predictors and outcomes. One hundred PDAC patients underwent OPD (n = 36) or RPD (n = 64) from 2013 to 2019. Cox proportional hazard models showed that baseline bilirubin (HR 1.6, p = 0.0006) and operative characteristics such as the number of positive lymph nodes (HR 1.1, p = 0.002), lymph node ratio (HR 1.6, p = 0.001), tumor grade (HR 1.7, p = 0.02), and TNM classification (HR 2.3, p = 0.01) were associated with OS. The independent predictors post-intervention associated with mortality were adjuvant therapy (HR 0.4, p = 0.0003), ISGPS complications (HR 2.8, p = 0.02), and 90-day readmission (HR 2, p = 0.004). After adjustment for these predictors, adjuvant therapy, baseline bilirubin, lymph node ratio, and tumor grade remained the main predictors of mortality. Baseline bilirubin, adjuvant therapy, lymph node ratio, and tumor grade were the main determinants of mortality after OPD or RPD. There was no significant difference in OS and RFS after RPD or OPD in PC patients who received adjuvant therapy.

Albumin-Bilirubin (ALBI) Score and Systemic Immune-Inflammation Indexes Used As Pretreatment Outcome Predictors in Patients With Pancreatic Ductal Adenocarcinoma Undergoing Robotic or Open Whipple Procedures: A Logistic Regression Analysis.

Background Pancreatic ductal adenocarcinoma (PDAC) is the most common type of pancreatic cancer (PC) in the United States. In patients with resectable PC, identification of pretreatment biomarkers before surgery can help in the decision-making process by weighing the benefits of neo-adjuvant therapy, surgical procedure, and adjuvant therapy. The purpose of this study was to determine if the albumin-bilirubin (ALBI) score and immune-inflammatory marker levels can be used in combination as pretreatment predictors of mortality risk in patients undergoing the Whipple procedure (alternatively, pancreatoduodenectomy (PD)) for PDAC. Methods This retrospective study included 115 patients with PDAC who underwent open or robotic Whipple procedures between January 2013 and December 2022 at a single tertiary medical center. Logistic regression analysis was used to find the association between predictors and mortality. Machine learning algorithms were used to calculate the performance of the different models. Results Bivariate analysis showed that the variables "sex" and "body mass index (BMI)" had a potential association with mortality, although statistical significance was not achieved for sex (p = 0.07). Patients with BMIs >25 kg/m2 had a higher risk of mortality compared to patients with BMIs ≤24.9 kg/m2 (odds ratio (OR) = 2.2, 95% CI = 1.03-4.8, p = 0.04). Higher (more positive) ALBI scores (>-2.24) were also associated with increased mortality risk (OR = 4.6, 95% CI = 2-10.5, p = 0.0003). When the cutoff values of the inflammatory markers were used to categorize these variables, values greater than the cutoff values were associated with an increased risk of mortality. In the multivariate logistic regression model, an ALBI score >-2.24 (OR = 4.3, 95% CI = 1.8-10.3, p = 0.0008), neutrophil-to-lymphocyte ratio (NLR) >3.5 (OR = 3.3, 95% CI = 1.4-7.9, p = 0.007), and being a woman (OR = 2.6, 95% CI = 1.1-6.4, p = 0.03) remained influential predictors of increased mortality (c value = 0.77). Conclusion The ALBI score and the NLR are easily accessible markers; their use, combined with a patient's sex, can provide useful pre-surgical information regarding mortality risk after PD. This can aid in treatment planning as well as expedite decisions about the type of Whipple procedure, adjuvant therapy, and surveillance, which can subsequently improve a patient's outcomes and survival.

Peptide receptor radionuclide therapy implementation and results in a predominantly gastrointestinal neuroendocrine tumor population: A two-year experience in a nonuniversity setting.

ABSTRACT: Neuroendocrine tumors (NETs) are rare, but the incidence and prevalence of NETs are increasing in the United States. While surgery is the preferred treatment for NETs, it is not a viable option for metastatic disease. Lutathera (177Lu-DOTATATE) is approved by the United States Food and Drug Administration and the European Medicines Agency for the treatment of gastroenteropancreatic (GEP)-NETs in adults. There is limited information on GEP-NET treatment responses to Lutathera.Our institution launched a peptide receptor radionuclide therapy (PRRT) service line using Lutathera with involvement from a multidisciplinary team and complete collaboration between hospital administration and clinical providers. A prospective registry study was also established in order to collect patient demographics and clinical data regarding the treatment of GEP primary NETs with Lutathera.Between August 2018 and July 2020, 35 GEP-NET patients were treated with Lutathera, of which 65.71% received 4 complete cycles and 25.71% received 3 cycles; 5.71% and 2.86% received 2 and 1 cycles of PRRT, respectively. Most adverse events during the course of our study were low grade using the common terminology criteria for adverse events system. Of the patients who completed all 4 cycles: 22% showed partial response to Lutathera, 44% showed stable disease, and 13% showed disease progression based on a qualitative assessment of positron emission tomography/computed tomography imaging.From our experience, Lutathera was well tolerated in patients with GEP-NET. Additional studies are needed to examine long-term clinical and patient-reported outcomes associated with GEP-NET treatment as well as financial considerations for hospitals embarking on a PRRT program.

Investigating the Relationship between Ambulatory and Hospital Patient Experience Scores in a Neurosurgery Practice.

Patient experience is critically important on both clinical and business levels to healthcare organizations, medical groups, and physician practices. We sought to understand whether a relationship exists between patient satisfaction scores in different settings for medical providers who practice in multiple settings (such as in the ambulatory setting and the hospital) within a system. Press Ganey (PG) ambulatory and hospital-based patient satisfaction surveys of a neurosurgery practice were retrospectively compared. Questions and sections related to the care provider, likelihood to recommend, and overall experience were examined. The ambulatory dataset included 2270 surveys, and the hospital dataset included 376. Correlation analysis of hospital survey patients who also completed an ambulatory survey (N = 120) was conducted, and weak, yet statistically significant, negative correlations between hospital "Likelihood to Recommend" and ambulatory "Care Provider Overall" (r = -0.20421, p = 0.0279), "Likelihood to Recommend" (r = -0.19622, p = 0.0356), and "Survey Overall" (r = -0.28482, p = 0.0019) were found. Our analyses found weak, yet significant, negative correlations between ambulatory and hospital PG scores. This could suggest that patient perception established in ambulatory and clinic settings could translate to a patient's perception of their hospital experience and subsequent satisfaction scores.

Prognostic factors of unresectable hepatocellular carcinoma treated with yttrium-90 radioembolization: results from a large cohort over 13 years at a single center.

BACKGROUND: A previous study of patients with unresectable hepatocellular carcinoma (HCC) was extended to further examine factors associated with overall survival (OS) after selective internal radiation therapy with yttrium-90 resin microspheres (Y90 SIRT). METHODS: Data from patients of any age diagnosed with unresectable HCC and treated with Y90 SIRT at our institution from 2004 through 2017 were retrospectively analyzed. Among other criteria, patients had to have Eastern Cooperative Oncology Group performance status 0 to 2, not have received Y90 SIRT previously, and not have extrahepatic disease. Primary outcome was OS; secondary outcomes included tumor response and adverse events (AEs). Kaplan-Meier survival analyses and multivariable Cox proportional hazards models were used to evaluate prognostic factors for OS. RESULTS: Of the 226 patients, 59% were White, 77% were male, and the mean age at first SIRT procedure was 65.1±9.4 years. More than half had received previous treatment for HCC. The most common etiology was hepatitis C (n=138/224 available, 62%), followed by alcohol use (n=45, 20%), and nonalcoholic steatohepatitis (n=27, 12%). The mean model for end-stage liver disease score at baseline was 8.8±2.2. Patients were followed-up for a median of 12.2 months (95% CI, 0.0-62.6). Median OS was 16.6 months (95% CI, 13.1 to not reached). Bilobar disease, higher albumin-bilirubin score at baseline, prior treatment with sorafenib, alcohol use etiology, and higher administered dose were associated with shorter survival, whereas subsequent liver transplant [in 26 patients (11.5%)] was associated with longer survival. Of the 186 patients with AEs data, 75 (40.3%) patients reported an event and, of these, 13 (17.3%) patients had grade 4 bilirubin values. CONCLUSIONS: In a large, diverse population treated at a single center over 13 years, Y90 SIRT produced a median OS of 16.6 months in patients with unresectable HCC and enabled subsequent transplantation in a subset of patients. Factors affecting the length of survival should be considered when making treatment decisions for unresectable HCC.

Improving the Standard of Care for All-A Practical Guide to Developing a Center of Excellence.

Pancreatic surgery is one of the more challenging procedures performed by surgeons. The operations are technically complex and have historically been accompanied by a substantial risk for mortality and postoperative complications. Other pancreatic pathologies require advanced therapeutic procedures that are highly endoscopist-dependent, requiring specific, knowledge-based training for optimal outcomes. An increase in diagnosed pancreatic pathologies every year reinforces a critical need for experienced surgeons, gastroenterologists/endoscopists, hospitals, and support personnel in the management of complex pancreatic cases and thus, well-designed Centers of Excellence (CoE). In this paper, we outline the framework for a Pancreas CoE across three developmental domains: (1) establishing the foundation; (2) formalizing the program; (3) solidifying the CoE status. This framework can likely be translated to any disease or procedure-specific service-line and facilitate the development of a successful CoE.

Mindfulness at Methodist-A Prospective Pilot Study of Mindfulness and Stress Resiliency Interventions in Patients at a Tertiary Care Medical Center.

Individuals with chronic medical conditions like cancer often experience heightened stress levels that can impact medical decision-making. The aim of this study was assess the impact of mindful stress-reduction interventions in cancer patients and support group participants (which included current and former cancer patients and their caregivers). A pilot study was conducted in which participants were provided a mindful stress-reduction intervention to determine whether they reduced stress, anxiety, and communication issues. Participants were provided a one-hour mindful stress-reduction intervention by a licensed physical therapist. Surveys were given to participants immediately before and after, and again 7-days after the intervention. Perceived stress was ascertained by asking participants: "Which emotional/mental state do you most frequently find yourself in?" Anxiety and communication abilities were measured using Neuro-QoL™ Anxiety and Communication v.1 instruments. Fifty-nine participants with a mean age of 60.6 years completed the study. Of these, 30.5%, 6.8%, 23.7%, and 39% were diagnosed (or were a caregiver to someone diagnosed) with pancreas, liver, breast, or unknown cancers, respectively. The surveys showed that participants' perceived stress scores (p < 0.001), anxiety levels (p = 0.0067), and pain scores (p < 0.0001) were reduced after the mindful stress-reduction intervention. Larger studies with control groups are needed to confirm the interventions' benefits.

The Value of Managing Acute Pancreatitis With Standardized Order Sets to Achieve "Perfect Care".

OBJECTIVES: We aimed to define perfect care index (PCI) metrics and to evaluate whether implementation of standardized order sets would improve outcomes without increasing hospital-based charges in patients with acute pancreatitis (AP). METHODS: This is a retrospective, pre-post, observational study measuring clinical quality, processes of care, and hospital-based charges at a single tertiary care center. The first data set included AP patients from August 2011 to December 2014 (n = 219) before the implementation of a standardized order set (Methodist Acute Pancreatitis Protocol [MAPP]) and AP patients after MAPP implementation from January 2015 to September 2018 (n = 417). The second data set included AP patients (n = 150 in each group) from January 2013 to September 2014 (pre-MAPP) and January 2018 to September 2019 (post-MAPP) to evaluate perfect care between the 2 cohorts after controlling for systemic inflammatory response syndrome at baseline. Length of stay, PCI, and hospital-based charges were measured. RESULTS: The post-MAPP cohort had a significantly shorter length of stay (median, 3 days vs 4 days; P = 0.01). In the second data set, PCI significantly increased after implementation of MAPP order sets (5.3%-35.3%, P < 0.0001). CONCLUSIONS: The MAPP order sets increased the value of care by improving clinical outcomes without increasing hospital-based charges.

Analysis of 102 Fully Robotic Pancreaticoduodenectomies: Clinical and Financial Outcomes.

OBJECTIVES: The value of robotic pancreaticoduodenectomy (RPD) remains undefined. The aim of this retrospective study was to compare and assess clinical outcomes and financial variables of patients undergoing RPD versus open pancreaticoduodenectomy (OPD) at a single high-volume center. METHODS: The study design is a retrospective analysis of a prospectively maintained database of consecutive PD patients from 2013 to 2019. Clinical variables and total hospital charges were evaluated as an unadjusted and adjusted intention-to-treat analysis. RESULTS: A total of 156 patients (54 OPD, 102 RPD) were identified. In the RPD group, patients were significantly older (P = 0.0304) and had shorter length of stay (mean, 7 vs 11.8 days; P < 0.0001) and longer operative times (mean, 352.7 vs 211.5 minutes; P < 0.0001) compared with OPD. There was no significant difference in 90-day readmissions, bleeding, or complications between OPD and RPD. Adjusted charge analyses show no difference in total charges (P = 0.057). CONCLUSIONS: Robotic pancreaticoduodenectomy is safe, feasible, and valid alternative to OPD. Because of comparable results within each group, randomized trials may be indicated. High-volume RPD centers should collaborate to better understand the differences and advantages over laparoscopic or OPD.

Minimally invasive liver resection in the era of robotics: analysis of 214 cases.

BACKGROUND: Minimally Invasive Liver Resection (MILR) techniques range from a hybrid-technique to full robotic approaches. When compared with open techniques, MILR has been shown to be advantageous by reducing pain, complications, length of stay and blood loss. The aim of this study was to compare clinical outcomes and hospital resource utilization between full laparoscopic, hand-assisted, and robotic liver resections among major (≥ 3 segments) and minor (≤ 2 segments) resections. METHODS: A single-center comparative retrospective review was completed on 214 patients undergoing full laparoscopic, hand-assisted, or robotic liver resection procedures between 2005 and 2018. RESULTS: Among minor resections: 85 full laparoscopic, 40 hand-assisted, and 35 robotic liver resection cases were analyzed; and among major resections: 13, 33, and 8 cases were analyzed, respectively. In the adjusted subgroup analysis of minor resections, OR time was significantly longer for the minor hand-assisted group ([Formula: see text] = 181 min; p < 0.05), and the average lesion size was smaller for the minor full laparoscopic group ([Formula: see text] = 4.2 cm; p < 0.05). Overall, direct hospital charges were lowest in the group of patients who underwent a minor resection using the full laparoscopic technique ([Formula: see text] = $39,054.90; p < 0.05), compared to the robotic technique. Due to the smaller sample size (n = 54) in the major resection subgroup, only two significant observations were made - the full laparoscopic group had the least amount of blood loss ([Formula: see text] = 227 cc; p < 0.05) and incurred the least amount of room and board charges compared to the other two techniques. CONCLUSIONS: The robotic approach appears favorable for minor resections as evidenced by shorter length of stay but more costly than full laparoscopy. Clinical outcomes appear to be more dependent upon the magnitude of the resection (i.e. major vs. minor) than the MILR technique chosen. Randomized trials may be indicated to discern the best indications and advantages of each technique.

Acute Pancreatitis Task Force on Quality: Development of Quality Indicators for Acute Pancreatitis Management.

INTRODUCTION: Detailed recommendations and guidelines for acute pancreatitis (AP) management currently exist. However, quality indicators (QIs) are required to measure performance in health care. The goal of the Acute Pancreatitis Task Force on Quality was to formally develop QIs for the management of patients with known or suspected AP using a modified version of the RAND/UCLA Appropriateness Methodology. METHODS: A multidisciplinary expert panel composed of physicians (gastroenterologists, hospitalists, and surgeons) who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity was convened. A literature review was conducted, and a list of proposed QIs was developed. In 3 rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets. RESULTS: Supporting literature and a list of 71 proposed QIs across 10 AP domains (Diagnosis, Etiology, Initial Assessment and Risk Stratification, etc.) were sent to the expert panel to review and independently rate in round 1 (95% of panelists participated). Based on a round 2 face-to-face discussion of QIs (75% participation), 41 QIs were classified as valid. During round 3 (90% participation), panelists rated the 41 valid QIs for necessity and proposed performance thresholds. The final classification determined that 40 QIs were both valid and necessary. DISCUSSION: Hospitals and providers managing patients with known or suspected AP should ensure that patients receive high-quality care and desired outcomes according to current evidence-based best practices. This physician-led initiative formally developed 40 QIs and performance threshold targets for AP management. Validated QIs provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected AP.

A Cross-Sectional Study of Stress and the Perceived Style of Decision-Making in Clinicians and Patients With Cancer.

BACKGROUND AND AIMS: Perceived stress and mindfulness can impact medical decision-making in both patients and clinicians. The aim of this study was to conduct a cross-sectional evaluation of the relationships between stress, mindfulness, self-regulation, perceptions of treatment conversations, and decision-making preferences among clinicians. Also, perceptions of treatment conversations and decision-making preferences among patients with cancer were evaluated. METHODOLOGY: Survey instruments were developed for clinicians and patients incorporating previously published questions and validated instruments. Institutional review board approval was obtained. Patients, physicians, and advanced practice providers from a tertiary referral center were asked to complete surveys. Continuous variables were evaluated for normality and then bivariate relationships between variables were evaluated using χ2, Fisher's exact test, Cochran-Mantel-Haenszel (CMH) row mean scores differ statistic, or Kruskal-Wallis tests, where appropriate. Significance was defined at P < .05. All tests were conducted using SAS v.9.4. RESULTS: 77 patients and 86 clinicians (60.1% and 43% response rates, respectively) participated in the surveys. More clinicians who reported feeling "great/good" said they always/sometimes had enough time to spend with patients (66.1%) compared to those that hardly ever/never had enough time (26.3%), χ2(1, N = 75) = 6.62, P = .0101; CMH row mean scores differ statistic). Interestingly, 40.3% of patients preferred a paternalistic style of decision-making compared to 6.3% of clinicians, χ2(2, N = 146) = 27.46, P < .0001; χ2 test. Higher levels of dispositional mindfulness (Mindful Attention Awareness Scale) were found among clinicians who reported they felt "great/good" (median = 4.5) as compared to those who reported that they were "definitely stressed/stressed out" (3.3), χ2(2, N = 80) = 10.32, P = .0057; Kruskal-Wallis test. Higher levels of emotional self-regulation (Emotional Regulation Questionnaire-Cognitive Reappraisal facet) were found among clinicians who reported they felt "great/good" (median = 31.0) compared to those who reported that they were "definitely stressed/stressed out" (20.0), χ2(2, N = 79) = 8.88, P = .0118; Kruskal-Wallis test. CONCLUSION: In order to have meaningful conversations about treatment planning, an understanding of mental well-being and its relationship to decision-making preferences is crucial for both oncology patients and clinicians. Our results show that for clinicians, lower perceived stress was associated with higher levels of mindfulness (experiencing the present moment), emotional self-regulation, and spending more time with patients. Larger prospective studies are needed to validate these findings.

A Cross-Sectional Study of Perceived Stress, Mindfulness, Emotional Self-Regulation, and Self-Care Habits in Registered Nurses at a Tertiary Care Medical Center.

INTRODUCTION: Workplace stress and burnout may influence nurses' physical and emotional well-being, which can impact the quality of care patients receive and their overall satisfaction with their hospitalization. OBJECTIVES: The objectives of the study were to evaluate whether there are significant statistical relationships between nurses' perceived stress, frequency of stressors, mindfulness, emotional self-regulation, self-care habits, and patient satisfaction scores. METHODS: The study took place over the course of 4 weeks. In this study, 340 nurse participants were surveyed using cross-sectional voluntary sampling design. The survey included previously developed and validated instruments. SAS v. 9.4 was used for statistical analysis. RESULTS: Significant differences were noted in average patient satisfaction scores by perceived stress; major nursing units in the Death and Dying, Conflict with Physicians, Lack of Support, and Work Load subscales of the Nursing Stress Scale; and major nursing units and dispositional mindfulness. CONCLUSIONS: Hospital administrators can use this information in their organizations and set priorities and tailor mindfulness-based stress-reduction interventions for nursing professionals.

Factors Associated With Parents' Intent to Vaccinate Adolescents for Human Papillomavirus: Findings From the 2014 National Immunization Survey-Teen.

INTRODUCTION: While factors associated with receipt of human papillomavirus (HPV) vaccination have been well characterized, less is known about the characteristics associated with parents' intent to have their adolescent children vaccinated. This study aimed to examine factors associated with parental intention toward HPV vaccination. METHODS: We analyzed data on 10,354 adolescents aged 13 to 17 years from the 2014 National Immunization Survey-Teen. Weighted multivariable logistic regression was used to examine associations between sociodemographic characteristics of mothers and adolescents, as well as a health care provider recommendation with parents' intention to have their children receive HPV vaccine. RESULTS: Among unvaccinated adolescents, Hispanic ethnicity (boys adjusted odds ratio [AOR], 1.87, 95% confidence interval [CI], 1.34-2.61; and girls AOR, 1.57; 95% CI, 1.05-2.35), mothers with less than a high school diploma (boys AOR, 2.41; 95% CI, 1.58-3.67; and girls AOR, 1.86; 95% CI, 1.02-3.38), and having a health care provider recommend the vaccine (boys AOR, 1.87; 95% CI, 1.52-2.31; and girls AOR, 1.38; 95% CI, 1.05-1.82) were significantly associated with parents' intention to have their adolescent child vaccinated within the next 12 months. In addition, non-Hispanic black race was a significant predictor of parents' intent to vaccinate for boys (AOR, 1.89; 95% CI, 1.35-2.65). CONCLUSION: Maternal education and Hispanic ethnicity were the strongest predictors of parental intent to vaccinate against HPV, followed by provider recommendation. As HPV vaccination rates in the United States remain below the Healthy People 2020 goal, messages may need to be targeted based on maternal education, race/ethnicity, and provider recommendation.

Prenatal and postnatal exposure to pet ownership, blood pressure, and hypertension in children: the Seven Northeastern Cities study.

OBJECTIVE: There is little information about how exposure to pets impacts blood pressure (BP) in children. The objective of the present study was to investigate the association between pet exposure and BP in children. METHODS: A total of 9354 children, aged 5-17 years, from 24 elementary schools and 24 middle schools in the Seven Northeastern Cities were evaluated during 2012-2013. BP measurements were taken using a mercury sphygmomanometer. Hypertension in children was defined as having an average DBP or SBP in the 95th percentile or higher for the child's sex, age, and height. RESULTS: Overall, 2127 of the 9354 participants (22.7%) had current exposures to pets, with 989 of all participants having dogs (10.6%). Pet exposure was negatively associated with hypertension and BP in men and women. Keeping dogs in the home was related to a significantly lower prevalence of hypertension in men [adjusted odds ratio (aOR) = 0.68; 95% confidence interval (CI): 0.49-0.94] and women (aOR = 0.66; 95% CI: 0.48-0.90). When the analysis was stratified by sex, in-utero exposure to pets was negatively associated with hypertension in men (aOR = 0.66; 95% CI: 0.45-0.97), and the associations with lower BP strengthened with higher levels of current pet exposure. As for BP, the associations between pet exposure and DBP were detected more in women; estimated decreases in mean DBP was 1.10 mmHg (95% CI: -1.75 to -0.45) for current pet exposure. CONCLUSION: Pet ownership reduces the odds of hypertension and elevated BP in children.