Prevalence and correlates of bleeding and emotional harms in a national US sample of patients with venous thromboembolism: A cross-sectional structural equation model.

INTRODUCTION: Venous thromboembolism (VTE) including deep vein thrombosis (DVT) or pulmonary embolism (PE) is associated with reduced survival, poorer quality of life, and substantial health-care-costs. Limited research, primarily qualitative, suggests that those with VTE may have elevated fear of recurrence, and associated emotional dysfunction and distress. METHODS: A national online survey was administered to 907 patients who had experienced a VTE event in the past two years. The survey assessed for the prevalence of self-reported bleeding harms associated with VTE, the levels of anxiety, depression, cognitive dysfunction and distress experienced by patients, and a range of potential psychosocial correlates that may be associated with these bleeding or emotional harms. RESULTS: The majority (63.0%) of respondents had experienced at least one bleeding related harm following their VTE diagnosis, and 40.6% indicated they experienced fear of another clot often or almost all the time. One-in-four (24.7%) and one-in-ten (11.6%) had abnormal levels of anxiety and depression, respectively. Structural equation modeling was used to define two composite latent bleeding harm and emotional harm factors. Emotional and bleeding harms were associated with younger age, a belief that one's health is due to luck, having multiple comorbidities, having a history of prior VTE events, having multiple barriers to VTE care, and experiencing medical mistakes in diagnosis or treatment. Emotional harms were uniquely predicted by having poorer health literacy, having low self-reported medication adherence, belief others are responsible for one's health, and more recent VTE events. Bleeding harms were uniquely predicted by having a lower frequency of primary care provider contact and having a history of switching between warfarin and direct oral anticoagulants for VTE treatment. CONCLUSIONS: The findings show high levels of self-reported bleeding and emotional harms in a general population of VTE sufferers that are clearly associated with readily identifiable demographic, health status, and psychosocial characteristics. These represent targets for intervention and changes in clinical practice.

Reaching emergency medical services providers: is one survey mode better than another?

OBJECTIVES: To determine which mode of completing a survey yields the highest response rate among emergency medical services (EMS) providers, examine rural and urban differences, and determine the completeness of questions by mode of response. METHODS: A random sample of EMS providers was mailed one of the following: 1) a paper survey, with instructions to return it via the enclosed self-addressed, stamped envelope; 2) a letter, with instructions to complete the survey at the provided URL (Web address); or 3) a paper survey with a self-addressed, stamped envelope and a URL, with the option of choosing the mode of response. We compared response rates based on the three different modes. We conducted analysis of the number of skipped multiple-choice and open-ended questions by mode and content analysis of the open-ended questions. RESULTS: The paper-only option resulted in the highest response rate (40.4%, p = 0.003) compared with the response rates from Web-only and choice of mode. Overall, rural EMS providers responded at a higher rate than urban EMS providers (40.3% vs. 31.6%, respectively [p = 0.0002]). Web respondents were more likely to complete all the open-ended questions (p = 0.003). Almost a fourth (22.8%) of the paper respondents skipped multiple-choice questions. There was a pattern of more complete responses for open-ended questions among the Web-based participants, but this was not significant (p = 0.17). CONCLUSION: EMS providers seem to prefer a more traditional mode (paper) when responding to a survey. Rural providers are more likely to respond. Mode of response influences the number of skipped questions but does not impact the quality of open-ended answers.

Social contexts of regular smoking in adolescence: towards a multidimensional ecological model.

Using data from the Add Health, this study examined multilevel factors of adolescent smoking after controlling for the baseline smoking behavior and individual characteristics. Results showed that peer, family and school were all important life domains contextually influencing subsequent smoking behavior among adolescents. Time spent with peers, best friend smoking and household member smoking were associated with higher risk. Parent-child closeness, parental control, attending a private school and having a higher percentage of Hispanic students at school were protective factors. Significant interaction effects were found between parental control and household member smoking and between parent-child closeness and communication. None of the neighborhood- and state-level factors were significant in the final full model but they were significant in reduced models. More proximate social contexts appear to play a more direct and immediate role in adolescent smoking than macro-level factors. An ecological model incorporating multiple social systems seems more fruitful than single-system models to reveal etiology of adolescent smoking.

Alterations in glucose homeostasis in the pediatric intensive care unit: Hyperglycemia and glucose variability are associated with increased mortality and morbidity.

OBJECTIVES: Critically ill patients with alterations in glucose equilibrium may experience adverse outcomes. We sought to describe the distribution of blood glucose values in the absence of insulin therapy and to evaluate the association of hyperglycemia, hypoglycemia, and glucose variability with mortality and morbidity of critically ill children. DESIGN: Retrospective cohort analysis. SETTING: University-affiliated children's hospital pediatric intensive care unit (PICU). PATIENTS: All children admitted to the PICU for >24 hrs with at least one blood glucose level recorded from a 1-yr period. Patients were excluded if >18 yrs of age, if insulin was administered during their PICU stay, and if the PICU admitting diagnosis included diabetes mellitus or hypoglycemia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were categorized with isolated hyperglycemia (blood glucose >or=150 mg/dL, [>or=8.3 mmol/L]), isolated hypoglycemia (blood glucose

Lower hospital mortality and complications after pediatric hematopoietic stem cell transplantation.

OBJECTIVE: To assess protective and risk factors for mortality among pediatric patients during initial care after hematopoietic stem cell transplantation (HSCT) and to evaluate changes in hospital mortality. DESIGN: Retrospective cohort using the 1997, 2000, and 2003 Kids Inpatient Database, a probabilistic sample of children hospitalized in the United States with a procedure code for HSCT. SETTING: Hospitalized patients in the United States submitted to the database. PATIENTS: Age, <19 yrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Hospital mortality significantly decreased from 12% in 1997 to 6% in 2003. Source of stem cells changed with increased use of cord blood. Rates of sepsis, graft versus host disease, and mechanical ventilation significantly decreased. Compared with autologous HSCT, patients who received an allogenic HSCT without T-cell depletion were more likely to die (adjusted odds ratio, 2.4; 95% confidence interval, 1.5, 3.9), while children who received cord blood HSCT were at the greatest risk of hospital death (adjusted odds ratio, 4.8; 95% confidence interval, 2.6, 9.1). Mechanical ventilation (adjusted odds ratio, 26.32; 95% confidence interval, 16.3-42.2), dialysis (adjusted odds ratio, 12.9; 95% confidence interval, 4.7-35.4), and sepsis (adjusted odds ratio, 3.9; 95% confidence interval, 2.5-6.1) were all independently associated with death, while care in 2003 was associated with decreased risk (adjusted odds ratio, 0.4; 95% confidence interval, 0.2-0.7) of death. CONCLUSIONS: Hospital mortality after HSCT in children decreased over time as did complications including need for mechanical ventilation, graft versus host disease, and sepsis. Prevention of complications is essential as the need for invasive support continues to be associated with high mortality risk.