Diabetes Group Medical Visits and Biophysical Outcomes of Care in Uninsured Persons with Diabetes

Background. Rural populations with low socioeconomic status are at higher risk of late diabetes diagnosis, poor diabetes control, decreased self-management, and development of complications. Diabetes Group Medical Visits (DGMVs) have been used to improve outcomes for persons with diabetes. A gap in the literature exists related to the effectiveness of DGMVs for uninsured persons with diabetes.;Aims. The aims of the study were to describe the characteristics of uninsured persons with diabetes cared for in a free clinic, describe the biophysical outcomes of care, explore the differences in biophysical outcomes of care before and after attending DGMVs versus receiving usual care, and explore the impact of dose of DGMVs on biophysical outcomes of care.;Methods. This retrospective study was conducted at a free clinic in West Virginia, using chart review of a convenience sample of patients following approval of the WVU IRB. The inclusion criteria were: (1) age ≥ 18 years, (2) diagnosis of diabetes, (3) uninsured and received care at a free clinic between May 2007 and August 18, 2009. A total of 111 patients were studied. There were 53 participants who attended DGMVs and 58 participants who received usual care. Statistical Package of Social Sciences (SPSS), version 18 was used for analysis of the data.;Results. The majority of the patients were female, white, severely obese, had a high-school education or less, were age 50 or younger, had a mean of 5 co-morbid conditions other than diabetes, and drove long distances to receive care. The patients who attended DGMVs had a higher HgA1C, reported more pain, had increased depression levels and were more obese at baseline than those who received usual care. There was a statistically significant decrease in systolic blood pressure from time one to time two in patients who attended DGMVs. There was no significant impact on biophysical outcomes of care in patients who received usual care from time one to time two. Dose of DGMVs did not impact biophysical outcomes of care.;Conclusion. DGMV as an intervention is not enough to improve biophysical outcomes in this population. Interventions targeted to the unique characteristics of this population are needed to prevent devastating complications

Using Multidisciplinary Focus Groups to Inform the Development of mI SMART: A Nurse-Led Technology Intervention for Multiple Chronic Conditions

Used as integrated tools, technology may improve the ability of healthcare providers to improve access and outcomes of care. Little is known about healthcare teams’ preferences in using such technology. This paper reports the findings from focus groups aimed at evaluating a newly developed primary care technology platform. Focus groups were completed in academic, outpatient, and community settings. Focus groups were attended by 37 individuals. The participants included professionals from multiple disciplines. Both prescribing (=8) and nonprescribing healthcare team members ( = 21) completed the focus groups and survey. The majority were practicing for more than 20 years (44.8%) in an outpatient clinic (62%) for 20–40 hours per week (37.9%). Providers identified perceived obstacles of patient use as ability, willingness, and time. System obstacles were identified as lack of integration, lack of reimbursement, and cost. The positive attributes of the developed system were capability for virtual visits, readability, connectivity, user-friendliness, ability to capture biophysical measures, enhanced patient access, and incorporation of multiple technologies. Providers suggested increasing capability for biophysical and symptom monitoring for more common chronic conditions. Technology interventions have the potential to improve access and outcomes but will not be successful without the input of users

A Pilot One Group Feasibility, Acceptability, and Initial Efficacy Trial of LISTEN for Loneliness in Lonely Stroke Survivors.

Loneliness is a prevalent problem for adult stroke survivors, and a known contributor to hypertension, secondary stroke, functional decline, poorer quality of life, and mortality in older adults. LISTEN (Loneliness Intervention using Story Theory to Enhance Nursing-sensitive outcomes), a theoretically based behavioral health intervention designed to target loneliness, in a sample of lonely survivors of ischemic stroke

The development of LISTEN: A Novel Intervention for Loneliness

Purpose: The purpose of this paper is to present the development of LISTEN (Loneliness Intervention using Story Theory to Enhance Nursing-sensitive outcomes), a new intervention for loneliness. Methods: LISTEN was developed using the Medical Research Council (MRC) framework for intervention development. Extensive literature review revealed that belonging, relating, place in community, challenges, and meanings of coping were concepts significant to loneliness. Past interventions were limited but it was determined from a recent meta-analysis that enhanced effectiveness may result from interventions that targeted the poorly adapted cognitive processes of loneliness. These processes include social undesirability, stigma, and negative thoughts about self in relation to others. LISTEN is designed to be delivered in a determined logical sequence of 5 sessions, each focusing on the concepts relevant to loneliness as derived from the literature. For each session, intervention delivery is guided by the concepts from story theory (including intentional dialogue, nurse as listener, examination of self in relation to others and community, synthesizing concerns and patterns, and identifying messages) and the principles of cognitive restructuring (self-assessment of maladaptive cognitions, emotions, and behaviors, identifying challenges of changing, reconceptualization of self, new skill acquisition through group interaction, and identifying patterns of meaning in loneliness). Results: LISTEN is developed and the first randomized trial is complete with a sample of 27 lonely, chronically ill, community dwelling, and older adults. LISTEN was evaluated as feasible to deliver by the study team and acceptable for significantly diminishing loneliness by participants of the LISTEN groups who were compared to attention control groups (p \u3c 0.5). Conclusions: LISTEN has the potential to enhance health by diminishing loneliness which could result in improving the long-term negative known sequelae of loneliness. Future longitudinal randomized trials are needed in varied populations to assess long term health and healthcare system benefit of using LISTEN to treat loneliness

Perceived Self-Efficacy, Confidence, and Skill Among Factors of Adult Patient Participation in Transitional Care: A Systematic Review of Quantitative Studies.

Introduction: An advancing healthcare system in which patients are often required to self-manage care needs across countless settings and clinicians is increasing focus on participation in care. Mismanagement of care during already risky care-transitions further increases adverse care outcomes. Understanding factors of patient participation in transitional care in an adult population can help guide ways to reduce this burden. Methods: A systematic review of the literature guided by the PRISMA method was conducted to identify factors of patient participation in transitional care. Quantitative studies in which patient participation was measured as an outcome variable and related statistics reported, and data were collected from an adult sample, were included. Two authors independently reviewed, critiqued, and synthesized the articles, and later categorized study variables according to identified trends. Results: Twelve studies across international and multidisciplinary backgrounds were identified. Across studies, efforts were largely based on understanding or improving patient self-management of care during transitions. The majority of studies were experimental and care interventions grounded in patient and healthcare team partnerships, delivered beyond the hospital setting. An array of measures was used to quantify patient participation. Factors of patient participation in transitional care included higher perceived levels of self-efficacy, confidence, and skills to participate in care. Conclusion: The results of this study suggest patient participation in transitional care is largely based on perceptions of self-efficacy, confidence, and skill. Patient-centric transitional care interventions targeting these factors and delivered beyond the hospital setting may improve care outcomes. Implications and direction for further studies includes conceptual clarity, the study of a broader-reaching patient population demographic, and use of multidisciplinary interventions. Outcome variables should remain focused on patient perception of care involvement and participation and expanded to include variables such as functional abilities and social determinants of health

Review of: Ailing in Place: Environmental Inequities and Health Disparities in Appalachia

The Journal of Appalachian Health is committed to reviewing published media that relate to contemporary concepts affecting the health of Appalachia. The Appalachian environmental inequities and the health disparities we face have a direct effect on our experience of illness. Dr. Jerome Paulson reviews the book Ailing in Place: Environmental Inequities and Health Disparities in Appalachia

Life after stroke in Appalachia

Objective The purpose of this study was to describe the structure of meaning in the experience of surviving stroke for adults living in Appalachia. Methods This qualitative phenomenological study includes a sample of 6 adult survivors of ischemic stroke who were discharged from either a community or university hospital to home in the Appalachian region. Data was collected through semi-structured interviews, transcribed, and analyzed thematically by two investigators. The explicated themes were verified by the survivors as representative of their experience. Results Five main themes emerged: 1) Frustration with new physical and functional impairment, 2) Negative emotions including anger, guilt, loneliness, and depression 3) Need for accessible support, 4) Longing for home during recovery and, 5) Stepping forward after stroke which included sub-themes of perseverance, acceptance, and retraining. Anger was described as contributing to delayed recover and emotional lability was described as a source of anger. The familiarity of home was viewed as key to reestablishing control over one\u27s life. Survivors described how they developed perseverance to move forward and emphasized that willingness to participate in retraining led to adapting to impairments. Acceptance was described as letting go of prior expectations of self and others so one could live in the present

Effectiveness of LISTEN on Loneliness, Neuroimmunological Stress Response, Psychosocial Functioning, Quality of Life, and Physical Health Measures of Chronic Illness

Objectives: Loneliness is a biopsychosocial determinant of health and contributes to physical and psychological chronic illnesses, functional decline, and mortality in older adults. This paper presents the results of the first randomized trial of LISTEN, which is anew cognitive behavioral intervention for loneliness, on loneliness, neuroimmunological stress response, psychosocial functioning, quality of life, and measures of physical health. Methods: The effectiveness of LISTEN was evaluated in a sample population comprising 27lonely, chronically ill, older adults living in Appalachia. Participants were randomized intoLISTEN or educational attention control groups. Outcome measures included salivary cortisol and DHEA, interleukin-6, interleukin-2, depressive symptoms, loneliness, perceived social support, functional ability, quality of life, fasting glucose, blood pressure, and body mass index. Results: At 12 weeks after the last intervention session, participants of the LISTEN group reported reduced loneliness (p¼0.03), enhanced overall social support(p¼0.05), and decreased systolic blood pressure (p¼0.02). The attention control group reported decreased functional ability (p¼0.10) and reduced quality of life (p¼0.13). Conclusions: LISTEN can effectively diminish loneliness and decrease the systolic blood pressure in community-dwelling, chronically ill, older adults. Results indicate that this population, if left with untreated loneliness, may experience functional impairment over a period as short as 4 months. Further studies on LISTEN are needed with larger samples, in varied populations, and over longer periods of time to assess the long-term effects of diminishing loneliness in multiple chronic condition

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

The effectiveness of mI SMART: A nurse practitioner led technology intervention for multiple chronic conditions in primary care

Aims: Used as integrated tools, technology may improve access and outcomes of care. A new intervention that integrates multiple technologies called mI SMART has been developed, implemented, and evaluated by Nurse Practitioners. The aim of this paper is to present the initial effectiveness of a web-based, structure of sensors and mobile devices designed to overcome the known health determinant of access to care for rural, chronically ill patients by using technology. Methods: The study was conducted at a community primary-care clinic that provides free healthcare to impoverished adults. Adults with at least one chronic condition, a minimum of 3rd grade reading level, and without dementia/psychosis were recruited. Participants were given a Nexus7 tablet and Bluetooth self-monitoring devices. The intervention lasted for 12 weeks. Blood glucose, blood pressure, and weight were collected using the provided Bluetooth devices and means were evaluated with paired-samples t-tests before and after the intervention. Results: Thirty participants were majority female, white, married, high-school educated or less, earning less than $20,000 per annum, and had multiple chronic conditions. Pre-intervention glucose, systolic blood pressure, diastolic blood pressure, weight and Body Mass Index were all reduced after the 12-week intervention. Conclusions: The mI SMART intervention is efficacious for use in improvised adults living in rural areas with multiple chronic conditions. As previously reported, the intervention was also shown to be feasible and acceptable to patients. The next step is a larger randomized controlled trial. Keywords: Health disparities, mHealth, Multiple chronic conditions, Nursing informatics, Rura