Comparison of hepatitis C treatment outcomes between primary care and specialty care.

BACKGROUND: Hepatitis C virus (HCV) infections have increased significantly in the United States recently, having tripled by 2014. Seventy-five percent of those with HCV are aging baby boomers, which places increased pressure on the medical system to provide treatment. There are not enough specialists available to treat everyone infected with HCV. PURPOSE: The aim of this research was to determine whether treatment of hepatitis C with new direct-acting antivirals in primary care settings resulted in equivalent cure rates when compared with those patients treated by specialists. METHODOLOGY: A retrospective cohort design was used. Participants were those treated for hepatitis C in specialty care at large public hospitals by gastroenterologists and/or hepatologists and those treated in two primary care community health centers in Seattle. Multivariate logistic regression was used to determine differences of sustained virologic response between those treated in primary care and those treated in specialty care. Treatment failure and those lost to follow-up were combined into one category. RESULTS: Failure rates were only 4% in primary care and 1.1% in specialty care. After adjustment, patients treated in primary care were statistically significantly less likely to have failure/lost to follow-up than those treated in specialty care. Hepatitis C treatment can be successfully provided in primary care with equivalent treatment outcomes. IMPLICATIONS FOR PRACTICE: Primary care advanced practice nurses are in a good position to identify and treat hepatitis C. In addition, as patients are typically more engaged with their primary care provider, follow-up rates may be better versus referring these patients to a specialty provider.

Developing a screening tool to identify harmful sibling aggression in a primary care setting.

BACKGROUND: Despite the possibility of adversely affecting the mental health of children, sibling aggression, the most common form of family violence, is often dismissed as normal or less harmful than other types of violence. Currently, there is no easily administered screening method for sibling aggression. PURPOSE: The goal of this project was to develop and test a brief sibling aggression screening tool for use in pediatric primary care. METHODS: The project was implemented in four phases: phase I reviewed the literature for adolescent and child aggression screening tools and to create a draft for expert content analysis. Phase II used a focus group of family mental health providers to modify draft items for the screening tool (N = 5). In phase III, the first draft of a screening tool was critiqued by individual pediatric providers (N = 8) for clarity and feasibility of use in pediatric primary care. In phase IV, the screening tool was piloted by one provider in pediatric clinical practice, who used the tool with six children over 3 weeks. RESULTS: All providers in phase II (N = 13) identified sibling aggression as an underassessed area of pediatric care. All providers in phase III found the revised questions to be clearly stated and child friendly; 75% (N = 6) agreed they could incorporate the questions into their current assessment, 25% disagreed citing limited time and resources. Pilot testing with six children demonstrated feasibility for use in pediatric primary care. IMPLICATIONS FOR PRACTICE: Utilization of a brief screening tool to assess for sibling aggression may help providers to identify and therapeutically respond to the most common type of childhood violence.

The DNP Degree: Are We Producing the Graduates We Intended?

OBJECTIVE: This study addressed how recently graduated doctor of nursing practice (DNP) nurses describe their current practice, how their supervisors describe the DNP's current practice, and whether nurse and supervisor descriptions of the practices reflect the American Association of Colleges of Nursing (AACN) DNP Essentials and, if so, how? BACKGROUND: Introduced in 2004, the goal of DNP programs was to educate advanced practice RNs for effective leadership in complex healthcare environments. The value of the DNP degree for nurses in healthcare systems is evolving. METHODS: We used conventional content analysis to inductively describe how DNP graduates from 7 different schools and their supervisors described the practice of the recently graduated DNPs. Interviews were reviewed to assess whether the AACN DNP Essentials were enacted in practice. RESULTS: The overarching theme was "becoming more: re-envisioning self as an agent of change." CONCLUSIONS: Results support the claim that DNP education prepares advanced practice nurses for leadership across complex healthcare systems. Evidence of the DNP Essentials is realized when graduates perceive themselves as equal to other leaders and capable of driving change using evidence and effective collaboration.

Re-Examining Genetic Screening and Oral Contraceptives: A Patient-Centered Review.

The World Health Organization classifies combined hormonal contraception as an unacceptable health risk in the presence of a known thrombogenic mutation but advises against routine thrombophilia screening before initiating combined oral contraceptives (COCs) on the grounds of high screening costs and low prevalence. From the perspective of patient-centered care, we examine cost, prevalence, and other published arguments for and against thrombophilia screening before initiating COCs. Our patient-centered review draws on relevant empirical evidence concerning the advantages and disadvantages of thrombophilia screening, while placing the discussion in the broader context of evolving attitudes toward genetic testing and a shifting policy landscape that provides many women direct access to COCs and/or thrombophilia screening. Given variation in prior probabilities of thrombophilia, expected exposure to other risk factors for venous thromboembolism, attitudes towards risk, expected reactions to a positive test result, ability to pay, and concerns about genetic discrimination, we conclude that the current one-size-fits-most approach is not consistent with patient-centered care. Instead, we advocate for greater patient and provider education concerning the implications of thrombophilia screening. Moreover, we recommend offering patients optional thrombophilia screening before initiating COCs.

Using the Vulnerability Index® to Assess the Health Needs of a Homeless Community.

Compiling a health needs profile of a difficult-to-reach population such as the homeless can be challenging, particularly when using a community-based participatory research approach. In this article, we describe our experience using the Vulnerability Index® (VI), a questionnaire developed by 100,000 Homes Campaign to assess and prioritize individuals in need of housing based on their risk of mortality. We found the VI easy to administer and helpful in creating a health needs profile of participants.

Sibling Violence and Children Hospitalized for Serious Mental and Behavioral Health Problems.

Violence between siblings is prevalent, can have long-lasting negative effects, and yet it is often dismissed as normal. This study explores sibling violence (SV) documented in medical records of children hospitalized in a psychiatric hospital. Retrospective chart review was conducted of all medical records of children ages 5 years to 12 years, living with a sibling in the home, admitted during the 2007 calendar year to a northwestern psychiatric hospital that serves a five state area ( N = 135). Using a data collection tool, quantitative and qualitative data were extracted from the charts, and descriptive statistical analysis was used to identify patterns and trends. The records showed that 103 (76%) of the 135 patients perpetrated SV and 30 (22%) were victims of SV. Many of the patients perpetrating SV were also violent toward themselves and toward peers, mothers, and teachers. The majority of patients did not have a psychiatric diagnosis that included violent behavior as a criterion and most of the patients had one or more past adverse experiences. Findings suggest that children hospitalized with psychiatric problems should be screened for SV perpetration and victimization, that health care staff and parents should be educated about SV, and that further research is needed to better understand what constitutes SV, the context within which it occurs, and effects of non-protection by parents.

Economic Evaluations of Thrombophilia Screening Prior to Prescribing Combined Oral Contraceptives: A Systematic and Critical Review.

BACKGROUND: Combined oral contraceptives (COCs) increase the risk of venous thromboembolism (VTE), particularly among women with inherited clotting disorders. The World Health Organization classifies combined hormonal contraception as an "unacceptable health risk" for women with thrombogenic mutations but advises against universal thrombophilia screening before prescribing COCs given the low prevalence of thrombophilia and high screening costs. OBJECTIVE: Through the lens of lifetime costs and benefits, this paper systematically and critically reviews all published economic evaluations of thrombophilia screening prior to prescribing COCs. METHODS: We searched relevant databases for economic evaluations of thrombophilia screening before prescribing COCs. After extracting the key study characteristics and economic variables, we evaluated each article using the Quality of Health Economic Studies (QHES) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) instruments. RESULTS: Seven economic evaluations of thrombophilia screening before prescribing COCs met our inclusion criteria. Only the two economic evaluations focusing exclusively on selective screening exceeded the 75-point threshold for high-quality economic studies based on the QHES instrument, whereas only one of these exceeded the 85% CHEERS threshold. Only three of the seven economic evaluations performed sensitivity analysis on key parameters. Most studies underestimated the benefits of thrombophilia screening by comparing one-time costs of genetic screening against benefits per person-year, thus implicitly assuming a 1-year duration of COC use, neglecting the long-term implications of VTE and/or neglecting the lifetime benefits of awareness of inherited thrombophilia. CONCLUSION: Our review highlights the lack of methodologically rigorous economic evaluations of universal thrombophilia screening before prescribing COCs.

Somali Families' Experiences of Parenting in the United States.

The purpose of this study was to gain an understanding of first-generation Somali families' experiences of parenting in the United States to discover potential barriers to effective parenting with the goal to design supportive interventions. Using descriptive phenomenological design, 20 Somali families in Seattle, Washington, were interviewed. Interview transcripts were then analyzed using steps outlined by Colaizzi. The overarching theme that emerged was "Parenting: A Balancing Act," which represents Somali parents trying to balance traditional cultural values and parenting traditions with dominant cultural expectations. Participants expressed fear of losing their children to American lifestyle choices, such as drugs or gangs, and misuse of the American system to turn on their parents. Parents also acknowledged the benefits of access to education and health care for children. To cope with the stressors of their new life, participants sought to preserve traditional cultural and religious values, thus strengthening their Somali community.

Perceived discrimination and children's mental health symptoms.

Perceived discrimination has been shown to be strongly associated with mental health outcomes, such as depression, anxiety, chronic stress, post traumatic stress disorder, and low self-esteem. This study (N = 88) examined the effects of perceived discrimination and its association with child mental health symptoms. African American children had a significantly stronger association between social stress and a sense of exclusion/rejection than Multiracial or European American children. Nurses need to assess and counsel families of color about their experiences with perceived discriminatory acts.

From coach to colleague: adjusting pedagogical approaches and attitudes in accelerated nursing programs.

Accelerated nursing programs are an innovative approach to training nurses and advanced practice nurses that are growing steadily in number and popularity. Although there is ample evidence to show that these programs have good outcomes, acceptance by both faculty and nurses in the community remains low. This article gives a description of the accelerated nursing student, which provides some insight as to why this student is both a challenge and a joy to mentor. In addition, an overview of pedagogical approaches that may be helpful in teaching this bright group of accelerated nursing students is provided. Accelerated nursing students enrich the nursing profession with the myriad of skills and varied backgrounds they bring to nursing. As professionals, mentors, and educators, we need to not only embrace accelerated students but also be advocates and mentors for them as they assimilate into our profession.

The role of culture in parents' socialization of children's emotional development.

Parents' emotion coaching of children and modeling of effective emotional responses are associated with children's positive emotional development. However, much of the research in this area has been with European American families. This study examined parents' self-reports about their emotion regulation patterns and coaching their children about emotions, across three racial and ethnic groups (African American, European American, and Multiracial), to determine how well these parental behaviors predicted their children's self-reports of depressive and anxiety symptoms 18 to 24 months later (N = 99). For the African American families, a higher level of coaching about anger and sadness by mothers was linked with lower depressive symptoms in their children. A higher level of anger coaching by fathers within the Multiracial group was also associated with lower anxiety and depressive symptoms. This study supports the importance of cultural values, within racial and ethnic groups, in parenting approaches associated with children's mental health outcomes.

Like parent, like child: parent and child emotion dysregulation.

PURPOSE: This study examined the association between children's emotion regulatory processes and parents' emotional problems. DESIGN: A 5-year longitudinal study of families from Northwestern United States with data collected over 3 time points. Families were recruited in an effort to oversample for multiracial and African American families because these families have historically not been well represented in research studies. METHOD: Parental hostility characteristics and subclinical levels of depression were assessed in combination with teachers' reports of children's externalizing and internalizing behaviors. Ninety-one families with married parents and an elementary school-aged child participated in the study. FINDINGS: There was a significant main effect for the association between fathers' self-reports of hostility and teacher reports of children's externalizing behaviors. Neither parental hostility nor depressive symptoms were significantly associated with the children's internalizing behaviors. CONCLUSION: The results suggest that children's externalizing behaviors are associated with their fathers' dysregulated expression of hostility. CLINICAL RELEVANCE: Parent-child interactions are a key component of children's emotion regulation development. Our findings may guide health care professionals in identifying and intervening in parental behaviors, particularly fathers' behaviors, that may adversely affect the healthy emotional development of their children.

Emotion regulation related to children's future externalizing and internalizing behaviors.

PROBLEM: Emotion regulation in children is a construct with important theoretical and clinical implications for healthcare providers, yet currently there is not a reliable and valid instrument that can be easily administered to young children. METHODS: The study was based on interviews with 126 children ages 5.5-12 years from a longitudinal study conducted over 4 years. Reliability, internal construct, and discriminant and predictive validity were examined. FINDINGS: The study was able to distinguish between two types of emotions, sadness and anger, and provided evidence that outcomes may be different for each of these emotion dysregulations. CONCLUSIONS: This study provides empirical evidence that an interview with children as young as 5.5 years can provide researchers with a reliable and valid measure of emotion regulation.

Understanding the gender differences in pathways to social deviancy: relational aggression and emotion regulation.

This study explored the associations among childhood emotion regulation, overt aggression, relational aggression, and adolescent deviant social behaviors. Data were drawn from the Family Health Project, a longitudinal study conducted over 4 years. The sample consisted of 111 children at Time 1 who ranged in age from 51/2 to 12 years at Time 1 and 8 to 14 years at Time 3. A significant finding was that, for girls, lower emotion regulation predicted later relational aggression (beta = -2.95, P < .05). Moreover, low prosocial skills coupled with relational aggression were associated with deviant social behaviors.

Clinical performance expectations: using the "you-attitude" communication approach.

Clinical rotations can be very stressful for nursing students, particularly novice students. Clinical course objectives are normally written from the viewpoint of the faculty, using a specialized professional language that is unfamiliar to the new nursing student. The author discusses use of a communication approach, the You-Attitude, that considers and reflects the viewpoint of the reader and may be able to reduce student anxiety and help them better achieve course objectives.

Relational aggression, gender, and the developmental process.

TOPIC: Defining and exploring the concept of relational aggression, or the purposeful intent to inflict harm on another through a social relationship. PURPOSE: This study aims to describe the concept of relational aggression as it has been shaped through recent research, to contrast relational aggression with other types of aggression, and to explore the influence of gender and the formation of a self-concept in the development of relational aggression. SOURCES: A review of the literature from 1969 to 2005 from selected nursing, child development, women's studies, and psychology publications. CONCLUSIONS: Some degree of relational aggression seems to be a normal response to conflict for many girls, from preschool through adolescence; however, more research needs to be conducted to determine at what level, or what subtypes, of relational aggression are predictive of future deviant behavior.