Trends and variability of implicit rationing of care across time and shifts in an acute care hospital : a longitudinal study

The proposed study was funded for 2 years (2018‐2020) by the Medical Practice Plan, Faculty of Medicine, American University of Beirut, Lebanon.Background Implicit rationing of nursing care is associated with work environment factors. Yet a deeper understanding of trends and variability is needed. Aims To explore the trends and variability of rationing of care per shift between individual nurses, services over time, and its relationship with work environment factors. Methods Longitudinal study including 1,329 responses from 90 nurses. Intraclass correlation coefficients (ICC) were computed to examine variability of rationing per shift between individual nurses, services, and data collection time; generalized linear mixed models were used to explore the relationship with work environment factors. Results Percentage of rationing of nursing activities exceeded 10% during day and night shifts. Significant variability in rationing items was observed between nurses, with ICCs ranging between 0.20 and 0.59 in day shifts, and between 0.35 and 0.85 in night shifts. Rationing of care was positively associated with nurses’ self‐perceived workload in both shifts, but not with patient‐to‐nurse ratios. Conclusion Most variability in rationing over time was explained by the individual.PostprintPeer reviewe

Depression and hippocampal volume in the aging brain: an epidemiological investigation

Background: Magnetic resonance imaging (MRI) studies have reported that patients with depression have smaller hippocampal volume (HcV) than healthy controls. However, the temporality of this association is unresolved. Two main hypotheses are proposed to explain the depression-HcV relationship. The neurotoxicity hypothesis suggests that HcV atrophy results from biological and neurochemical alterations that accompany depression and stress; an alternative hypothesis is that reduced HcV could be a susceptibility factor for depression. Disentangling the temporality of the depression-HcV atrophy relationship is of particular interest in older adults as it can help unravel the complex processes underlying aging-related cerebral, cognitive, and mood changes. Research objectives: The overall aim of this thesis was to examine the two main hypotheses on the temporal relationship between depression and HcV atrophy in a population-based sample of older adults; the specific objectives were: 1) To assess whether history of previous depression and more proximal depressive symptoms are related to HcV atrophy; 2) To estimate the association between life-course socioeconomic position (SEP), as a proxy for increased stress, and HcV atrophy; 3) To examine whether HcV atrophy is associated with subsequent depressive symptoms. Study population: Data come from the Three-City-Dijon-MRI cohort, a prospective population-based French cohort of older adults (n=1328, age=65-80 years) who were followed biennially for over ten years and who had two cerebral MRI scans, at baseline and four-year follow-up. Manuscript 1- Examining the neurotoxicity hypothesis: We estimated the association between history of previous depression and proximal depressive symptoms (Center for Epidemiologic Studies-Depression (CES-D) scale) and both baseline HcV and rate of HcV atrophy. We found that baseline depressive symptoms were associated with smaller HcV in women; in contrast, history of depression and more proximal depressive symptoms were associated with faster HcV atrophy in women but not in men. Our findings also showed that treatment for depression was associated with slower HcV atrophy in men and women. Manuscript 2- Life-course SEP and HcV atrophy: To further explore the neurotoxicity hypothesis and its implication that stressful conditions may contribute to HcV atrophy, we examined the relationships of SEP with HcV and HcV atrophy using three life-course SEP models: (i) the sensitive/critical-period model which focused on SEP at three periods over the life-course: childhood SEP (parental education), early-adulthood SEP (participants’ education), and mid-life SEP (participants’ socioprofessional attainment); (ii) life-course cumulative SEP; and (iii) social-mobility of life-course SEP trajectories. Childhood and early-adulthood SEP were not related to HcV outcomes. Participants with lower socioprofessional attainment in mid-life had smaller HcV and faster HcV atrophy. Results also suggested that cumulative low SEP and disadvantageous SEP trajectories over the life-course were associated with faster HcV atrophy. Manuscript 3- Exploring the hypothesis that HcV atrophy is a susceptibility factor for depression: We used linear mixed-models to estimate the associations between rate of HcV atrophy and (i) average-over-follow-up depressive symptoms (CES-D scores) measured biennially over the subsequent six years and (ii) change in depressive symptoms. Results indicated that, in women, faster HcV atrophy was associated with more average over-follow-up depressive symptoms and with worsening of symptoms over the two subsequent years. No association was detected in men. Conclusion: Our findings suggest a complex and bi-directional relationship between HcV atrophy and depressive symptoms in women but not in men. The results also highlight the role for stress-related experiences (previous depression and lower SEP) in explaining some of the variability in HcV atrophy at older age.Contexte: Des études d’imagerie par résonance magnétique (IRM) ont observé que les patients atteints de dépression ont des volumes de l’hippocampe (VHc) réduits. Cependant, la temporalité de cette relation n’est pas connue. Deux hypothèses sont proposées: l’hypothèse de neurotoxicité suggère que l’atrophie du VHc est le résultat des dérèglements biologiques qui accompagnent le stress et les épisodes dépressifs; une autre hypothèse suggère que l’atrophie hippocampique contribue à la susceptibilité aux épisodes dépressifs. Une meilleure compréhension de la temporalité de la relation entre la dépression et l’atrophie du VHc est particulièrement importante chez les personnes âgées pour améliorer les connaissances sur les relations entre les modifications cérébrales, les performances cognitives, et les symptômes dépressifs au cours du vieillissement. Objectifs: Le but de cette thèse est d’examiner les deux hypothèses sur la temporalité de la relation dépression-atrophie hippocampique chez les personnes âgées. Les objectifs sont d’analyser: 1) les relations entre les antécédents de dépression, ainsi que les symptômes dépressifs récents, et l’atrophie hippocampique; 2) l’association entre le statut socioéconomique (SSE) au cours de la vie (indicateur de conditions stressantes) et l’atrophie hippocampique; 3) la relation entre l’atrophie hippocampique et les symptômes dépressifs subséquents. Population de l’étude: Les projets sont basés sur l’étude des Trois-Cités-Dijon-IRM, une étude de cohorte prospective de personnes âgées (n=1328, âge=65-80) suivies pendant plus de 10 ans et ayant 2 examens par IRM (à l’inclusion et 4 ans de suivi). Manuscrit 1- Une étude de l’hypothèse de neurotoxicité: Nous avons estimé les associations entre les: (i) antécédents de dépression et (ii) symptômes dépressifs plus récents (Center for Epidemiologic Studies-Depression CES-D scale) et: a) le VHc et b) le taux annuel d’atrophie du VHc. Chez les femmes, le VHc était uniquement associé aux symptômes dépressifs mesurés en même temps que le VHc. Les antécédents de dépression et les symptômes dépressifs récents étaient associés à une atrophie du VHc accélérée chez les femmes. Le traitement contre la dépression était associé à une atrophie plus lente chez les hommes et les femmes. Manuscrit 2- SSE et atrophie hippocampique: Afin d’évaluer l’hypothèse de neurotoxicité, nous avons aussi examiné les relations entre le SSE au cours de la vie et le VHc et l’atrophie du VHc suivant: (i) le modèle de la période critique/sensible évaluant le SSE durant des périodes spécifiques: pendant l’enfance (niveaux d’études des parents), au début de l’âge adulte (niveau d’études des participants), et en âge adulte (niveau socioprofessionnel des participants); (ii) le modèle des effets cumulatifs du SSE; et (iii) le modèle des trajectoires socioéconomiques. Les participants ayant un niveau socioprofessionnel plus bas avaient des VHc plus petits et une atrophie du VHc accélérée. Le cumul de SSE défavorable et les trajectoires socioéconomiques désavantageuses au cours de la vie étaient liés à un taux d’atrophie plus rapide. Manuscrit 3- Une étude de l’hypothèse que l’atrophie du VHc contribue à la dépression: En utilisant des modèles mixtes linéaires, nous avons examiné les associations entre l’atrophie du VHc et: (i) les symptômes dépressifs (CES-D) mesurés tous les 2 ans sur une période de 6 ans suivant la mesure de l’atrophie; (ii) les changements de ces symptômes. Chez les femmes, une atrophie hippocampique accélérée était associée à une augmentation des symptômes dépressifs subséquents et à une aggravation des symptômes au cours des 2 années suivantes. Conclusion: Les résultats suggèrent que la relation entre les symptômes dépressifs et l’atrophie hippocampique est complexe et bidirectionnelle chez les femmes et que les expériences reliées au stress (antécédents de dépression et SSE défavorable) sont associées à une atrophie hippocampique accélérée chez les personnes âgées

‘Life should go on’: a qualitative inquiry of parental reactions, experiences, and perceived needs following adolescents’ recent traumatic exposure

International audienceBackground: Parents have a significant role in supporting children who have been exposed to traumatic events. Little is known about parental experiences and needs in the wake of traumatic exposure, which could help in designing tailored early interventions.Objective: This qualitative study explored experiences, perceived needs, and factors impacting those needs being met, in parents of adolescents aged 11-16 years who had been exposed in the past 3 months to a potentially traumatic event, in the city of Montpellier, France.Method: We purposively sampled 34 parents of 25 adolescents aged 11-16 years meeting the inclusion criteria and used semi-structured in-depth interviews. Thematic analysis was applied using a multistage recursive coding process.Results: Parents lacked trauma-informed explanations to make sense of their child's reduced functioning. They experienced stigma attached to the victim label and were reluctant to seek help. School avoidance and lack of collaboration with schools were major obstacles experienced by parents. Parents trying to navigate conflicting needs fell into two distinct categories. Those who experienced distressing levels of shame and guilt tended to avoid discussing the traumatic event with their child, pressuring them to resume life as it was before, despite this perpetuating conflictual interactions. Others adapted by revisiting their beliefs that life should go on as it was before and by trying to come up with new functional routines, which improved their relationship with their child and helped them to restore a sense of agency and hope, but at the cost of questioning their parental role.Conclusions: Key domains of parental experiences could provide potential early intervention targets, such as psychoeducation on traumatic stress, representations about recovery and the victim status, parent-child communication, and involvement of schools and primary caregivers. Further research is needed to validate the impact of these domains in early post-traumatic interventions

Work environment-related factors and nurses’ health outcomes : a cross-sectional study in Lebanese hospitals

The proposed study was funded for 2 years (2018–2020) by the Medical Practice Plan funding award, Faculty of Medicine, American University of Beirut, Lebanon.Background Worldwide, studies show a relationship between nurses’ health and some work environment factors; however, data on nurses’ health and self-perceived workload and nursing task allocation are lacking, particularly for Lebanese nurses. We assessed the relationship of several work environment factors: overall workload and specific temporal, physical, mental, effort, frustration, and performance demands (NASA Task Load Index), staffing resources and adequacy and leadership (Practice Environment Scale of Nursing Work Index), teamwork climate (Safety Attitudes Questionnaire), and nursing task allocation (Basel Extent of Rationing of Nursing Care)) with self-reported musculoskeletal, cardiovascular, skin, and mental health diseases (Work Ability Index) and emotional exhaustion (Maslach Burnout Inventory) among Lebanese nurses. Methods A cross-sectional self-report survey was distributed to all 289 registered nurses (RNs) in the medical, surgical, and pediatric units in two Lebanese university-affiliated hospitals; 170 RNs had complete data. Adjusted multivariable logistic regression models were used to estimate the association between work environment factors and health outcomes. Results The most prevalent outcomes were musculoskeletal disease (69%), emotional exhaustion (59%), and mental health problems (56%); 70% of RNs had ≥2 and 35.29% had ≥4 co-occurring health problems. Musculoskeletal disease was associated with higher overall (OR = 1.36 (95%CI = 1.03, 1.80)), temporal (OR = 1.30 (95%CI = 1.09, 1.55)), and physical demands (OR = 1.20 (95%CI = 1.03, 1.49)), higher task allocation to RNs (OR = 1.11 (95%CI = 1.01, 1.23)) and lower teamwork climate (OR = 0.60 (95%CI = 0.36, 0.98). Higher odds of mental/emotional problems were associated with higher overall, temporal, frustration, and effort demands, and lower teamwork climate, performance satisfaction, and resources adequacy (increased odds ranging from 18 to 88%). Work environment indicators were associated with higher co-occurrence of health problems. Conclusions Results show elevated health burden and co-morbidity among Lebanese RNs and highlight the value of comprehensive approaches that can simultaneously improve several work environment factors (namely self-perceived workload, teamwork,, resources, and nursing task allocation) to reduce this burden.Publisher PDFPeer reviewe

Variability, shift-specific workloads, and rationed care predictors of work satisfaction among registered nurses providing acute care: : a longitudinal study

The proposed study was funded for 2 years (2018-2020) by the Medical Practice Plan, Faculty of Medicine, American University of Beirut, Lebanon.Aims: The aim of this study was to explore nurses’ shift-work satisfaction variability across time and its shift-specific predictors: perceived workload, patient-to-nurse ratio and rationing of nursing care. Design: Longitudinal study of 90 Registered nurses (N = 1,303 responses) in a Lebanese hospital over 91 days of data collection. Methods: Intraclass correlation coefficients (ICCs) were computed to determine shift-work satisfaction variability between individual nurses and working-unit clusters. Generalized linear mixed models were used to explore the workloads and rationed care predictors of nurses’ shift-work satisfaction separately for day and night shifts. Results: Variability in shift-work satisfaction was noted between individual nurses in day (ICC = 0.43) and night shifts (ICC = 0.37), but not between medical/surgical units. Nurses satisfied with their shift-specific work were less probably to ration necessary nursing care (OR = 0.68; 95% CI = 0.60–0.77) in day shifts and to perceive high workload demands in both, day (OR = 0.29; 95% CI = 0.23–0.37) and night (OR = 0.29; 95% CI = 0.18–0.47) shifts. Monitoring and lowering workload demands while observing rationing of care is necessary to improve nurses’ shift-work satisfaction.Publisher PDFPeer reviewe

Life-Course Socioeconomic Position and Hippocampal Atrophy in a Prospective Cohort of Older Adults

International audienceObjective: Low socioeconomic position (SEP) has been linked to an increased risk of dementia and cognitive decline. However, little is known about the association between SEP and morphologic brain changes in older age. This study examines the relationships between indicators of life-course SEP with both hippocampal volume (HcV) and HcV loss in a population-based cohort of 1328 older adults aged 65 to 80 years.Methods: Multivariable linear regression models were used to estimate the associations of SEP with baseline HcV and the annual rate of HcV atrophy according to three life-course conceptual models: the sensitive/critical periods model (which explored SEP in specific periods: in childhood [using parental education], early adulthood [based on participants' education], and midlife [based on participants' socioprofessional group]); the accumulation-of-risk model (life-course cumulative SEP), and the social mobility model (life-course SEP trajectories).Results: Participants with lower midlife SEP had smaller HcV (-0.08 cm3; 95% confidence interval, -0.15 to -0.01) and 0.17% (95% confidence interval, 0.04%-0.30%) faster hippocampal atrophy than participants with higher midlife SEP. Childhood and early adulthood SEPs were not related to hippocampal measures. The accumulation-of-risk and the social mobility models revealed that the accumulation of socioeconomic disadvantage and declining socioeconomic trajectories were related to faster hippocampal atrophy.Conclusions: In this cohort of older adults, lower socioprofessional attainment in midlife and disadvantageous life-course socioeconomic position were associated with faster hippocampal atrophy, a cerebral change linked to cognitive disorders. Results support the hypothesized links between socioenvironmental exposures related to stress and/or cognitive enrichment and brain/cognitive reserve capacities

Hippocampal atrophy and subsequent depressive symptoms in older men and women: results from a 10-year prospective cohort.

International audienceSeveral studies have reported smaller hippocampal volume in patients with depression. However, the temporality of the association is undetermined. One hypothesis is that hippocampal atrophy might be a susceptibility factor for depression. In the present study, we assessed whether hippocampal atrophy was associated with subsequent depressive symptoms in a cohort of older French adults (n = 1,309) who were 65-80 years of age and enrolled into the study in 1999-2001 in Dijon, France. Subjects were followed for more than 10 years. Participants underwent 2 cerebral magnetic resonance imaging scans, one at baseline and one at the 4-year follow-up. We used linear mixed models to estimate the associations of hippocampal atrophy with 1) the average depressive symptom scores over follow-up (using the Center for Epidemiologic Studies-Depression scale) measured biennially over the subsequent 6 years and 2) changes in symptom scores over follow-up. In women, a 2-standard-deviation increase in annual hippocampal atrophy was associated with a 1.67-point (95% confidence interval: 0.59, 2.77) increase in the average depressive symptom score over follow-up and with a 1.97-point (95% confidence interval: 0.68, 3.24) increase in scores over the 2 subsequent years but not with later changes in symptoms. No association was detected in men. Accounting for potential selective attrition (using inverse probability weights) did not alter results. Hippocampal atrophy was associated with more subsequent depressive symptoms and with shorter-term worsening of symptoms in women

TOAST classification and risk factors of ischemic stroke in Lebanon

Objectives Ischemic stroke is a common cause of morbidity and mortality especially in the increasingly older population. The variability in ischemic stroke subtypes and its risk factors across different populations suggest that more effort is needed to describe the stroke characteristics in order to develop a more tailored management for each population. We aim to describe the demographic characteristics, risk factors, and subtype distribution of subjects with ischemic stroke in the Lebanese population. Materials and methods We conducted a cross‐sectional study based on chart review on patients with ischemic stroke/transient ischemic attack at the American University of Beirut Medical center between 2015 and 2017. Results: A total of 284 cases were included with a mean age of 72 years, and 58% male gender. The most commonly identified risk factors were hypertension (77%), dyslipidemia (62%), and diabetes mellitus (42%), while atrial fibrillation was only found in 27% of cases. The cohort distribution according to TOAST classification was as follows: 15% large artery stroke, 31% cardioembolic stroke, 17% small artery stroke, 10% stroke of other determined causes, and 27% stroke of unknown cause. Conclusion This is the first study to address ischemic stroke characteristics in Lebanon.</p

Associations of Religious Service Attendance With Cognitive Function in Midlife: Findings From The CARDIA Study.

OBJECTIVES: Growing evidence suggests that religiosity is an important social determinant of health, including cognitive health. Yet most prior work focused on older adults or was conducted in racially and denominationally homogeneous regional samples. This study investigates the association of religious service attendance in midlife with cognitive function later in midlife. METHODS: Using data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a racially and geographically diverse prospective cohort study, we explored the association of religious service attendance in midlife with cognitive function 5&nbsp;years later. Cognitive function was measured using four cognitive tests administered by CARDIA technicians. Multivariable linear regression was used for analyses. Primary analyses controlled for sociodemographics, physical health, depression, and prior religious involvement. Sensitivity analyses additionally controlled for baseline cognition and social support. RESULTS: Our study population included 2,716 participants (57.2% female, 44.9% Black, and mean age 50). In primary analyses, attending services more than weekly (compared to never) in midlife was associated with better global cognition (β&nbsp;=&nbsp;0.14 standard deviations, 95% [confidence interval] CI&nbsp;=&nbsp;0.02, 0.26) and verbal memory (β&nbsp;=&nbsp;0.17 standard deviations, 95% CI&nbsp;=&nbsp;0.04, 0.30), but not with processing speed (β&nbsp;=&nbsp;0.04 standard deviations, 95% CI&nbsp;=&nbsp;-0.08, 0.16). A&nbsp;reverse association was observed with executive function (β&nbsp;=&nbsp;-0.16 standard deviations, 95% CI&nbsp;=&nbsp;-0.30, -0.02). Most findings persisted in analyses accounting for loss to follow-up via inverse probability weighting. DISCUSSION: Our findings suggest that frequent involvement in religious services at midlife is associated with better global cognition and verbal memory but worse executive function. There was no association with processing speed