Prognostic significance of pericardial effusion in systemic sclerosis-associated pulmonary hypertension: analysis from the PHAROS Registry.

OBJECTIVES: Pulmonary hypertension (PH) is a leading cause of death in patients with systemic sclerosis (SSc). The purpose of this study was to determine the prognostic significance of pericardial effusion in patients with SSc-PH. METHODS: Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma (PHAROS) is a prospective multicentre registry which enrolled patients with newly diagnosed SSc-PH from 2005 to 2016. The prognostic impact of pericardial effusion status, including those who ever or never had pericardial effusion, and those who had persistent or intermittent pericardial effusion, was analyzed. Kaplan-Meier survival analyses, log-rank test, and multivariable Cox proportional hazards regression were performed. RESULTS: Of the 335 patients with SSc-PH diagnosed by right heart catheterization and documentation of pericardial effusion presence or absence on echocardiogram, 166 (50%) ever had pericardial effusion. Ever having pericardial effusion was not predictive of survival (Log-rank test p= 0.49). Of the 245 SSc-PH patients who had at least two echocardiograms, 44% had a change in pericardial effusion status over an average of 4.3 years of follow up. Having a persistent pericardial effusion was an independent predictor of survival (adjusted hazard ratio [aHR] = 2.34, 95% CI 1.20-4.64, p= 0.002), while intermittent pericardial effusion was not a predictor of survival (aHR = 0.89, 95% CI 0.52-1.56, p= 0.68), in a multivariable-adjusted analysis. CONCLUSION: Persistent pericardial effusion, but not ever having had pericardial effusion or intermittent pericardial effusion, was independently associated with poorer survival. Incorporating information from serial echocardiograms may help clinicians better prognosticate survival in their SSc-PH patients.

Development and preliminary evaluation of EMPOWER for surrogate decision-makers of critically ill patients.

OBJECTIVE: The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates' mental health and patient outcomes. METHOD: Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15-20 min modules, totaling 1.5-2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments. RESULTS: Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = -0.41), peritraumatic distress (d = -0.24), and experiential avoidance (d = -0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = -0.94), depression (d = -0.23), anxiety (d = -0.29), and experiential avoidance (d = -0.30). SIGNIFICANCE OF RESULTS: Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

Family interaction among young Chinese breast cancer survivors.

BACKGROUND: Family interaction is an important factor contributing to the quality of survivorship among breast cancer survivors. The dearth of studies involving young females with breast cancer has limited the understanding of family interaction in this increasingly large population. METHODS: The aim of this study was to explore family interaction patterns among young Chinese breast cancer survivors. We conducted in-depth interviews with seventeen young breast cancer survivors (YBCSs) in China between May 2019 and December 2019. A content analysis was performed to identify the characteristics of family interaction in this population. Conceptualizations of feminism and social support were used to guide the data analysis. RESULTS: Family interaction patterns were categorized into 5 domains from the perceptions of Chinese YBCSs: (1) adjustment of parenthood (changes in child-rearing approaches, perception of children's care) (2) ambivalence towards intimacy (desire for intimate relationships, perceived relationship insecurity); (3) concerns regarding fertility; (4) return to work (coping with gratitude and guilt by working, readapting to family and society by working); (5) activation of the support system in a large family (instrumental support from core family members, instrumental, informational, and appraisal support from relatives). CONCLUSIONS: The study provides a deeper understanding of the interactions between young breast cancer survivors and their family members in China. These findings can support health professionals in developing female-sensitive, culturally specific interventions to assist Chinese YBCSs and their families in increasing positive interactions and family resilience as well as quality of life. In addition, the findings are highly applicable to other female cancer survivors and their vulnerable families exposed to similar social and cultural contexts.

The experience of patients with cancer on narrative practice: A systematic review and meta-synthesis.

BACKGROUND: In recent years, narrative practice has been applied in clinical settings to address the relational and psychological concerns that occur in tandem with physical illness. It is an emerging strategy to treat patients as individuals with their own stories, rather than purely based on symptoms. OBJECTIVE: To synthesize the experience of patients with cancer using narrative practice. METHODS: Following a systematic search strategy, a literature search was conducted to identify qualitative studies on the experience of patients with cancer using narrative practice. Nine databases were searched up to April 2018, which included six English databases and three Chinese databases. A meta-synthesis was conducted to synthesize the findings of the included studies. MAIN RESULTS: Seven studies out of 2894 studies were included in this review. Patients with cancer had different preferences on narrative practices. In terms of the impacts of narrative practice on patients with cancer, six themes were identified, which included '(a) reducing the gap between patients and clinicians; (b) healing effect; (c) social connection; (d) facilitating self-reflection, self-recognition and self-realization; (e) risk of negative impacts; and (f) Patients' preference on different approaches of narrative practice'. CONCLUSIONS: Patients with cancer experienced positive effects regarding narrative practice. Although some patients may experience negative effects, narrative practice is a humanized way to provide care for patients with cancer in the clinical settings.

Trends in Maternal and Fetal Outcomes Among Pregnant Women With Systemic Lupus Erythematosus in the United States: A Cross-sectional Analysis.

Background: Although pregnancy in systemic lupus erythematosus (SLE) carries a high risk for mother and fetus, outcomes may be improving. Objective: To assess nationwide trends and disparities in maternal and fetal complications among pregnant women with SLE. Design: Retrospective cohort study. Setting: United States, 1998 to 2015. Patients: Adult pregnant women with and without SLE who had hospitalizations recorded in the National Inpatient Sample (NIS) database. Measurements: Outcome measures were in-hospital maternal mortality, fetal mortality, preeclampsia or eclampsia, caesarean sections, non-delivery-related admissions, and length of stay. To assess whether trends in outcomes over time differed between patients with SLE and those without SLE, logistic or linear regression with an interaction term between year and SLE (yes or no) was used. Nationwide population estimates incorporating sampling and poststratification weights were obtained. Results: An estimated 93 820 pregnant women with SLE and 78 045 054 without SLE were hospitalized in the United States from 1998 through 2015. Outcomes improved during those 18 years. In-hospital maternal deaths (per 100 000 admissions) declined among patients with as well as those without SLE (442 vs. 13 for 1998 to 2000 and <50 vs. 10 for 2013 to 2015), although the decrease was greater in women with SLE (difference in trends, P < 0.002). The percentage of patients with SLE in all pregnancy-related, as well as delivery-related, admissions increased significantly. Limitations: The sample for this analysis was identified by using diagnostic codes; detailed information on hospital-specific trends, SLE disease activity, and medications was not available. Race trends could not be analyzed. Given that NIS uses weighted estimates, the incidence of outcomes reported may not be exact. Conclusion: In this large study examining SLE and non-SLE pregnancies over 18 years, in-hospital maternal mortality and overall outcomes improved markedly, particularly among women with SLE. However, improvement is still needed, because SLE pregnancy risks remain high. Primary Funding Source: None.

Thirty-Day Hospital Readmissions for Granulomatosis With Polyangiitis in the United States: A Nationwide Analysis.

BACKGROUND/OBJECTIVE: Granulomatosis with polyangiitis (GPA) is a systemic necrotizing vasculitis that often results in frequent hospitalizations. We investigated the characteristics and predictors of 30-day hospital readmissions in GPA. METHODS: We performed a cross-sectional analysis using the 2014 National Readmission Database. We included nonelective admissions with a primary or secondary diagnosis of GPA. We compared characteristics between readmissions and nonreadmissions. Independent predictors for readmissions were studied using mixed-effects multivariable logistic regression. RESULTS: We evaluated a total of 9749 hospital admissions with GPA, among which there were 2173 readmissions (22.3%) within 30 days of discharge. The top 5 primary reasons for readmissions were GPA, sepsis, pneumonia, acute respiratory failure, and acute kidney injury. Granulomatosis with polyangiitis readmissions were associated with higher length of stay (8.0 vs 7.2 days; p = 0.019) and less discharge home (50% vs 63%, p < 0.001). Independent predictors for readmissions were younger age (odds ratio [OR], 0.99; p = 0.013), no private insurance (OR, 0.50; p < 0.001), higher Charlson Comorbidity Index (OR, 1.12; p = 0.039), congestive heart failure (OR, 1.71; p = 0.001), acute kidney injury (OR, 1.39; p = 0.005), and discharge to home health care (OR, 1.29; p = 0.039). CONCLUSIONS: We found a significant burden of 30-day readmissions among GPA populations. Clinicians should be vigilant regarding patients with high risk of readmissions, including those with younger age, public insurance, higher comorbidity burden, cardiac and renal complications, and unfavorable discharge dispositions.

Effects of the "AI-TA" Mobile App With Intelligent Design on Psychological and Related Symptoms of Young Survivors of Breast Cancer: Randomized Controlled Trial.

BACKGROUND: Young women often face substantial psychological challenges in the initial years following cancer diagnosis, leading to a comparatively lower quality of life than older survivors. While mobile apps have emerged as potential interventions, their effectiveness remains inconclusive due to the diversity in intervention types and variation in follow-up periods. Furthermore, there is a particular dearth of evidence regarding the efficacy of these apps' intelligent features in addressing psychological distress with these apps. OBJECTIVE: This study aims to evaluate the effectiveness of a mobile app with intelligent design called "AI-TA" on cancer-related psychological health and ongoing symptoms with a randomized controlled design. METHODS: Women aged 18 to 45 years diagnosed with breast cancer were randomly assigned to the intervention or control group. The intervention was AI-TA, which included 2-way web-based follow-up every 2 weeks. Both intention-to-treat (ITT) and per-protocol (PP) analyses employed repeated measurement analysis of variance. The participants' background features, primary outcomes (psychological distress and frequency, self-efficacy, and social support), and secondary outcomes (quality of life) were measured using multiple instruments at 3 time points (baseline, 1-month intervention, and 3-month intervention). RESULTS: A total of 124 participants were randomly allocated to the control group (n=62, 50%) or intervention group (n=62, 50%). In total, 92.7% (115/124) of the participants completed the intervention. Significant improvements in psychological symptoms (Memorial Symptom Assessment Scale-Short Form) were observed in the ITT group from baseline to 1-month intervention relative to the control group (ITT vs control: 1.17 vs 1.23; P<.001), which persisted at 3-month follow-up (ITT vs control: 0.68 vs 0.91; P<.001). Both the ITT and PP groups exhibited greater improvements in self-efficacy (Cancer Behavior Inventory-Brief Version) than the control group at 1-month (ITT vs PP vs control: 82.83 vs 77.12 vs 65.35; P<.001) and 3-month intervention (ITT vs PP vs control: 92.83 vs 89.30 vs 85.65; P<.001). However, the change in social support (Social Support Rating Scale) did not increase significantly until 3-month intervention (ITT vs control: 50.09 vs 45.10; P=.002) (PP vs control: 49.78 vs 45.10; P<.001). All groups also experienced beneficial effects on quality of life (Functional Assessment of Cancer Therapy-Breast), which persisted at 3-month follow-up (P<.001). CONCLUSIONS: The intelligent mobile app AI-TA incorporating intelligent design shows promise for reducing psychological and cancer-related symptoms among young survivors of breast cancer. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2200058823; https://www.chictr.org.cn/showproj.html?proj=151195.

Associations between beta-blocker use and psychological distress in bereaved adults with cardiovascular conditions.

The death of a close other is a major life stressor that disrupts mental and physical health. Beta-blocker medications are indicated treatments for cardiovascular conditions that may also mitigate psychological distress in the context of stressors by reducing adrenergic activity. We sought to examine observational links between beta-blocker medication use and psychological distress during bereavement. Using publicly available data from the Midlife in the United States Refresher study, we examined associations between beta-blocker use and general distress, depressive symptoms, and anxiety symptoms (as measured by the Mood and Anxiety Symptom Questionnaire) among bereaved adults with cardiovascular conditions (n = 161) using t-tests and regression models. Beta-blocker users reported lower levels of anxiety-related general distress (b = -2.49, SE = 0.88, p = 0.005) and depression-related general distress than non-users (b = -2.39, SE = 1.14, p = 0.039) in multivariate linear regression models adjusting for demographic characteristics, mental health treatments, time since loss and comorbid health conditions. These observed links between beta-blockers and lower psychological distress in bereavement warrant further investigation in prospective and randomized studies, as beta-blockers could be a scalable intervention for mitigating distress following loss.

Clotting of Hemodialysis Access in Patients with COVID-19 in an Inner-City Hospital.

BACKGROUND: An increased incidence of thrombotic complications in patients with coronavirus disease 2019 (COVID-19) has been reported. Severe acute kidney injury (AKI) is one of the major clinical manifestations of COVID-19 with the need for renal replacement therapy. It was observed that hemodialysis (HD) accesses tended to thrombose more often in the COVID-19 population than in non-COVID-19 patients. We hypothesize that the hypercoagulable state of COVID-19 is associated with higher incidence of access clotting. METHOD: In this retrospective single-centered study at Kings County Hospital in New York City, 1,075 patients with COVID-19 were screened, and 174 patients who received HD from January 3, 2021 to May 15, 2020 were enrolled to examine the risk factors of dialysis access clotting in patients with COVID-19. RESULTS: Of the 174 patients, 109 (63%) were COVID-19 positive. 39 (22.6%) patients had dialysis access clotting at least once during their hospitalization, and they had significantly higher body mass index (BMI) (p = 0.001), higher rates of COVID-19 (p = 0.015), AKI (p < 0.001), higher platelet counts (p = 0.029), higher lactate dehydrogenase levels (p = 0.009), and lower albumin levels (p = 0.001) than those without access malfunctions. Low albumin levels (p = 0.008), AKI (p = 0.008), and high BMI (p = 0.018) were risk factors associated with HD access clotting among COVID-19 patients. CONCLUSION: Patients with COVID-19 who receive HD for AKI with high BMI are at a higher risk of clotting their HD access.

Synthesis and enhanced photocatalytic performance of graphene-Bi2WO6 composite.

Graphene possesses excellent conductivity, adsorptivity, and controllability. The combination of photocatalysts and graphene will introduce these properties of graphene into photocatalysis. In this paper, graphene oxide-Bi(2)WO(6) composite was firstly prepared via in situ hydrothermal reaction in the presence of graphene oxide, then the graphene oxide was reduced by ethylene glycol and the graphene-Bi(2)WO(6) (G-BWO) composite was formed. The as-prepared graphene-Bi(2)WO(6) photocatalyst shows enhanced photocatalytic activity for the degradation of rhodamine B (RhB) under visible light (λ > 420 nm). The electronic interaction and charge equilibration between graphene and Bi(2)WO(6) lead to the shift of the Fermi level and decrease the conduction band potential, which has an important influence on the photocatalytic process. The enhanced photocatalytic activity could be attributed to the negative shift in the Fermi level of G-BWO and the high migration efficiency of photoinduced electrons, which may suppress the charge recombination effectively.

Outer Macular Microvascular Supply in Retinitis Pigmentosa Examined using Optical Coherence Tomography Angiography.

PURPOSE: To determine the vessel density of the superior (SCP) and deep retinal capillary plexuses (DCP) in patients with retinitis pigmentosa (RP) using optical coherence tomography angiography (OCTA). METHODS: This was a cross-sectional study. A total of 25 eyes of 25 healthy volunteers and 30 eyes of 17 patients with RP were evaluated in this study. The integrity of the ellipsoid zone in the macular fovea was evaluated as an intact or defect using a spectral-domain OCT. Commercial spectral domain coherence tomography angiography (OCTA) was used to scan the macular region of approximately 3 × 3 mm2. The vessel density in the SCP and DCP were calculated after appropriate layer segmentation and removal of projection artifacts. The central retinal thickness (CRT) was measured with automated software. The vessel densities in the SCP and DCP were compared between different groups using SPSS. RESULTS: A total of 25 eyes of 25 healthy subjects and 30 eyes of 17 patients with RP were evaluated in the study. There was no significant difference in ages between the two groups (F = 0.065 and P=0.937). There was a significant difference in SCP and DCP between the patients with RP and healthy individuals (P < 0.001 and P < 0.001). The DCP was significantly reduced in the parafovea region between the macular intact and defect groups (P < 0.05), except in the fovea and nasal regions. After linear regression, the DCP/SCP ratio in the whole, fovea, and parafovea regions was closely related to the DCP vessel density (P < 0.05), and CRT in the fovea and parafovea was not related to the whole DCP (P=0.186 and P=0.539). CONCLUSION: The vessel density decreased in patients with RP, especially in the DCP of the parafovea region. A greater loss of capillaries in the DCP was found when the macular region was involved. The DCP/SCP ratio may be an important indicator of RP.

Use of Magnetic Resonance Imaging in Acute Traumatic Brain Injury Patients is Associated with Lower Inpatient Mortality.

OBJECTIVES: While magnetic resonance imaging (MRI) has higher sensitivity than computed tomography for certain types of traumatic brain injury (TBI), it remains unknown whether the increased detection of intracranial injuries leads to improved clinical outcomes in acute TBI patients, especially given the resource requirements involved in performing MRI. We leveraged a large national patient database to examine associations between brain MRI utilization and inpatient clinical outcomes in hospitalized TBI patients. MATERIAL AND METHODS: The National Inpatient Sample database was queried to find 3,075 and 340,090 hospitalized TBI patients with and without brain MRI, respectively, between 2012 and 2014 in the United States. Multivariate regression analysis was performed to independently evaluate the association between brain MRI utilization and inpatient mortality rate, complications, and resource requirements. RESULTS: The MRI group had a lower unadjusted mortality rate of 0.75% compared to 2.54% in the non-MRI group. On multivariate regression analysis, inpatient brain MRI was independently associated with lower mortality (adjusted OR 0.32, 95% CI 0.12-0.86), as well as higher rates of intracranial hemorrhage (adjusted OR 2.20, 95% CI 1.27-3.81) and non-home discharge (adjusted OR 1.33, 95% CI 1.07-1.67). Brain MRI was independently associated with 3.4 days (P < 0.001) and $8,934 (P < 0.001) increase in the total length and cost of hospital stay, respectively. CONCLUSION: We present the first evidence that inpatient brain MRI in TBI patients is associated with lower inpatient mortality, but with increased hospital resource utilization and likelihood of non-home discharge.

Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale.

Although the concept of pathological grief dates back at least as far as Freud's "Mourning and Melancholia", there has been opposition to its recognition as a distinct mental disorder. Resistance has been overcome by evidence demonstrating that distinctive symptoms of prolonged grief disorder (PGD) - an attachment disturbance featuring yearning for the deceased, loss of meaning and identity disruption - can endure, prove distressing and disabling, and require targeted treatment. In acknowledgement of this evidence, the American Psychiatric Association Assembly has recently voted to include PGD as a new mental disorder in the DSM-5-TR. We tested the validity of the new DSM criteria for PGD and of an adapted version of our PG-13 scale, the PG-13-Revised (PG-13-R), designed to map onto these criteria, using data from investigations conducted at Yale University (N=270), Utrecht University (N=163) and Oxford University (N=239). Baseline assessments were performed at 12-24 months post-loss; follow-up assessments took place 5.3-12.0 months later. Results indicated that the PG-13-R grief symptoms represent a unidimensional construct, with high degrees of internal consistency (Cronbach's alpha = 0.83, 0.90 and 0.93, for Yale, Utrecht and Oxford, respectively). The DSM PGD diagnosis was distinct from post-traumatic stress disorder (phi=0.12), major depressive disorder (phi=0.25) and generalized anxiety disorder (phi=0.26) at baseline. Temporal stability was remarkable for this diagnosis (r=0.86, p<0.001). Kappa agreement between a PG-13-R threshold symptom summary score of 30 and the DSM symptom criterion for PGD was 0.70-0.89 across the datasets. Both the DSM PGD diagnosis and the PG-13-R symptom summary score at baseline were significantly associated (p<0.05) with symptoms and diagnoses of major depressive disorder, post-traumatic stress disorder and/or generalized anxiety disorder, suicidal ideation, worse quality of life and functional impairments at baseline and at follow-up, in the Yale, Utrecht and Oxford datasets. Overall, the DSM-5-TR criteria for PGD and the PG-13-R both proved reliable and valid measures for the classification of bereaved individuals with maladaptive grief responses.

Socio-Ecological Environmental Characteristics of Young Chinese Breast Cancer Survivors.

PURPOSE: To explore the environmental characteristics of young breast cancer survivors (YBCSs) in China. PARTICIPANTS & SETTING: 17 participants aged 18-45 years were recruited from hospitals and through participant referral in Shanghai, China. METHODOLOGIC APPROACH: Semistructured interviews were conducted to explore the environmental characteristics of YBCSs. Content analysis was performed to analyze the data. FINDINGS: The following four domains emerged from the analysis. IMPLICATIONS FOR NURSING: The study provides insights into the specific issues of YBCSs at different environmental levels. Nurses should collaborate with the healthcare team, family members, and other stakeholders in addressing these issues to support YBCSs. Culturally tailored support should be developed to release the burden of socially desired roles and other cultural issues for Chinese YBCSs.

Associations Between Hospice Care and Scary Family Caregiver Experiences.

CONTEXT: Hospice deaths in the U.S. are increasing. Dying hospice patients may have rapidly emerging needs the hospice team cannot immediately meet, exposing family caregivers to fright-inducing (i.e., scary) situations. OBJECTIVES: To examine relationships between hospice care and family caregiver exposures and psychological responses to witnessing common and distressing patient symptoms near the end of life. METHODS: Secondary analysis of prospective cohort study of 169 patients with advanced cancer and their family caregivers was analyzed. Multivariable regression analyses modeled associations between hospice use and caregiver exposures and psychological responses (fear and helplessness) to witnessing distressing symptoms common near death, adjusting for potential confounding influences (e.g., home death, patient characteristics, and suffering). Caregiver self-reported exposures and responses to observing patient symptoms during the last month of life were assessed using the validated Stressful Caregiving Response to Experiences of Dying (SCARED) scale. RESULTS: Hospice care was significantly positively associated with more exposures and negative psychological responses to distressing patient symptoms, adjusting for home death, patient characteristics, and physical and mental suffering. On average, hospice patients' caregivers scored 1.6 points higher on the SCARED exposure scale and 6.2 points higher on the SCARED psychological response scale than caregivers of patients without hospice (exposure: 10.53 vs. 8.96; psychological responses: 29.85 vs. 23.67). Patient pain/discomfort, delirium, and difficulty swallowing/choking were reported by three-fourths of caregivers and associated with the most fear and helplessness among caregivers. CONCLUSION: Hospice care is associated with more exposures to and caregiver fear and helplessness in response to scary patient experiences. Research is needed to understand how better to support family caregivers of hospice patients to enable them to cope with common distressing symptoms of dying cancer patients. Hospice clinicians providing additional education and training about these symptoms might enable caregivers to better care for dying loved ones and reduce the stresses of end-of-life caregiving.

Trends in the Inpatient Burden of Coronary Artery Disease in Granulomatosis With Polyangiitis: A Study of a Large National Dataset.

OBJECTIVE: Cardiovascular (CV) diseases are serious comorbidities in patients with granulomatosis with polyangiitis (GPA). In a sample of patients hospitalized for GPA, we sought to examine trends in the burden of coronary artery disease (CAD) and its 2 serious manifestations, acute myocardial infarction (AMI) and heart failure (HF). METHODS: We used the National Inpatient Sample to conduct a retrospective cross-sectional analysis. Our sample consisted of hospitalizations for GPA between 2005 and 2014. We examined trends in the proportion of CAD, AMI, and HF in all hospitalizations with GPA compared to those without GPA. We used logistic regression adjusted for potential confounders and included interaction terms. RESULTS: Among a total of 103,453 GPA hospitalizations, 20,351 (19.7%) hospitalizations had a concurrent diagnosis of CAD. GPA with CAD was associated with overall lower burden of traditional CV risk factors compared to non-GPA with CAD, with the exception of chronic kidney disease (57% vs 21%). Over the 10-year study period, there were rising trends in the inpatient burden of CAD (16.6% in 2005 to 22.7% in 2014) and CAD with HF (4.3% in 2005 to 9.9% in 2014), but not AMI (1.2% in 2005 to 1.1% in 2014), in GPA hospitalizations compared to non-GPA controls. CONCLUSION: In this national sample of GPA hospitalizations, we found that the burden of CAD and CAD with HF was on the rise over the 10-year period compared to non-GPA; however, it was not the case for AMI.

Survival in hospice patients with dementia: the effect of home hospice and nurse visits.

BACKGROUND: Hospice patients with dementia are at increased risk for live discharge and long lengths of stay (>180 days), causing patient and family caregiver stress and burden. The location and timing of clinician visits are important factors influencing whether someone dies as expected, in hospice, or experiences a live discharge or long length of stay. OBJECTIVE: Examine how home hospice and nurse visit frequency relate to dying in hospice within the Medicare-intended 6-month period. DESIGN: Retrospective cohort study. SETTING: Non-profit hospice agency. PARTICIPANTS: Three thousand eight hundred and thirty seven patients with dementia who received hospice services from 2013 to 2017. METHODS: Multivariable survival analyses examined the effects of receiving home hospice (vs. nursing home) and timing of nurse visits on death within 6 months of hospice enrollment, compared to live discharge or long length of stay. Models adjust for relevant demographic and clinical factors. RESULTS: Thirty-nine percent (39%) of patients experienced live discharge or long length of stay. Home hospice patients were more likely to experience live discharge or long length of stays (HR for death: 0.77, 95%CI: 0.69-0.86, p < 0.001). Frequency of nurse visits was inversely associated with live discharge and long lengths of stay (HR for death: 2.87, 95%CI: 2.47-3.33, p < 0.001). CONCLUSION: Nearly 40% of patients with dementia in our study experienced live discharge or a long length of stay. Additional research is needed to understand why home hospice may result in live discharge or a long length of stay for patients with dementia. Nurse visits were associated with death, suggesting their responsiveness to deteriorating patient health. Hospice guidelines may need to permit longer stays so community-dwelling patients with dementia, a growing segment of hospice patients, can remain continuously enrolled in hospice and avoid burden and costs associated with live discharge.

Screening and identification of key genes and pathways in metastatic uveal melanoma based on gene expression using bioinformatic analysis.

The current study aimed to elucidate the molecular mechanisms and identify the potential key genes and pathways for metastatic uveal melanoma (UM) using bioinformatics analysis.Gene expression microarray data from GSE39717 included 39 primary UM tissue samples and 2 metastatic UM tissue samples. Differentially expressed genes (DEGs) were generated using Gene Expression Omnibus 2R. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed using the online Database for Annotation, Visualization and Integrated Discovery (DAVID) tool. The web-based STRING tool was adopted to construct a protein--protein interaction (PPI) network. The MCODE tool in Cytoscape was used to generate significant modules of the PPI network.A total of 213 DEGs were identified. GO and KEGG analyses revealed that the upregulated genes were mainly enriched in extracellular matrix organization and blood coagulation cascades, while the downregulated DEGs were mainly related to protein binding, negative regulation of ERK cascade, nucleus and chromatin modification, and lung and renal cell carcinoma. The most significant module was extracted from the PPI network. GO and KEGG enrichment analyses of the module revealed that the genes were mainly enriched in the extracellular region and space organization, blood coagulation process, and PI3K-Akt signaling pathway. Hub genes, including FN1, APOB, F2, SERPINC1, SERPINA1, APOA1, FGG, PROC, ITIH2, VCAN, TFPI, CXCL8, CDH2, and HP, were identified from DEGs. Survival analysis and hierarchical clustering results revealed that most of the hub genes were associated with prognosis and clinical progression.Results of this bioinformatics analysis may provide predictive biomarkers and potential candidate therapeutic targets for individuals with metastatic UM.

Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes.

BACKGROUND: The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses' perceptions of patients' distress and quality of death. METHODS: 200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women's Hospital in Boston. Nurses were interviewed about their perceptions of the patients' quality of death using validated measures. Patients were divided into 3 groups-no DNR, early DNR, late DNR placement during the patient's final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient's comorbidities, length of ICU stay, and procedures were also included in the model. RESULTS: 59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09-0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1-0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12-0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12-0.94]), controlling for non-beneficial procedures. CONCLUSIONS: Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.