Electronic Structures of Radical-Pair-Forming Cofactors in a Heliobacterial Reaction Center.

Photosynthetic reaction centers (RCs) are membrane proteins converting photonic excitations into electric gradients. The heliobacterial RCs (HbRCs) are assumed to be the precursors of all known RCs, making them a compelling subject for investigating structural and functional relationships. A comprehensive picture of the electronic structure of the HbRCs is still missing. In this work, the combination of selective isotope labelling of 13C and 15N nuclei and the utilization of photo-CIDNP MAS NMR (photochemically induced dynamic nuclear polarization magic-angle spinning nuclear magnetic resonance) allows for highly enhanced signals from the radical-pair-forming cofactors. The remarkable magnetic-field dependence of the solid-state photo-CIDNP effect allows for observation of positive signals of the electron donor cofactor at 4.7 T, which is interpreted in terms of a dominant contribution of the differential relaxation (DR) mechanism. Conversely, at 9.4 T, the emissive signals mainly originate from the electron acceptor, due to the strong activation of the three-spin mixing (TSM) mechanism. Consequently, we have utilized two-dimensional homonuclear photo-CIDNP MAS NMR at both 4.7 T and 9.4 T. These findings from experimental investigations are corroborated by calculations based on density functional theory (DFT). This allows us to present a comprehensive investigation of the electronic structure of the cofactors involved in electron transfer (ET).

Improvement in nurse staffing ratios according to policy changes: a prospective cohort study.

BACKGROUND: Since 1999, reimbursements for nursing services for inpatients have been paid differentially according to the nurse staffing ratios in Korea. However, differentiated nursing fees are insufficient for nurse staffing; thus, steps have been taken to improve the policy. This study aimed to identify the impact of a policy that changed the method of calculating nurse staffing ratios from the nurse-to-bed ratio to the nurse-to-patient ratio on improving the nurse staffing ratio in medical institutions. METHODS: Data were collected from 1,339 medical institutions that continuously provided medical services from 2017 to of 2021, and a prospective cohort was used for analysis. A generalized estimating equation for longitudinal ordered logistic regression was used to identify the impact of this policy change on the nurse staffing ratios in medical institutions. RESULTS: During the cohort study, 59.8% of the first-applied group of medical institutions and 65.6% of the second-applied group of medical institutions improved their nurse staffing ratios. However, only 22.6% of the medical institutions to which the revised calculation method was not applied improved their nurse staffing ratios. A statistically significant difference was found in the improved nurse staffing ratio depending on whether and when the revised calculation method was applied (χ2 = 89.830, p < .001). The analysis of nurse staffing ratios of medical institutions from 2017 to 2021 showed that the likelihood of improving the nurse staffing ratio increased gradually after the revised calculation method was adopted. Also,the likelihood of the nurse staffing ratio improving in the first-applied group was 1.41 times higher (odds ratio = 1.41, 95% confidence interval = 1.04-1.92) than in the non-applied group. The odds ratio for the improvement of nurse staffing ratio in the second-applied group was 2.35 (95% confidence interval = 1.76-3.14). CONCLUSIONS: Financial incentives inherent in the new policy can be regarded as the driving force behind improvements in nurse staffing ratios. The revised calculation method should be extended to all medical institutions nationwide, and the law should be revised to secure the minimum number of nurses.

Effects of a disincentive policy on behavioral changes by South Korean medical institutions that do not submit official nursing grade data.

AIM: This study aimed to determine whether the policy of imposing deductions on medical institutions in South Korea led to increased submission of nursing grade data. BACKGROUND: In Korea, medical institutions are required to report data on their nursing workforce; however, many institutions did not comply with this regulation, making it difficult to gauge their level of nurse staffing. Therefore, in 2020, a nursing fee deduction policy was introduced that penalizes medical institutions financially for failing to submit nursing workforce data. METHODS: We prospectively collected data on the characteristics, nursing grade, and data submission status of 1,200 hospitals in South Korea from 2015 to 2021. We analyzed the submission rate of data related to nursing grades according to the characteristics of the medical institutions and evaluated the effect of policy change on data submission status using multiple logistic regression. FINDINGS: The submission rate of data increased from 50.2% in 2015 to 93.3% in 2021, and 39.3% of medical institutions that had not previously submitted data did so after the policy was introduced. The submission rate of medical institutions unaffected by the policy also increased after its introduction. Compared with 2015, the likelihood of medical institutions submitting data increased by 23.69 times in 2020 and 20.47 times in 2021. CONCLUSION: The appropriate use of disincentive policies, such as financial deductions for medical institutions showing inappropriate behavior, was found to be effective in inducing desirable changes in the behavior of medical institutions. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Properly planned and implemented policies can contribute to improved quality of medical services and patient safety through effective administrative control.

Turnover Rates and Factors Associated With Turnover: A Longitudinal Analysis of the Retention Period of Clinical Nurses in Korea Using National Data.

Many countries, including Korea, are struggling with a nursing workforce shortage. This study aimed to identify the actual turnover rate of Korean clinical nurses and the factors affecting the turnover rate, considering the time required for nurses to gain experience at their current medical institution. This longitudinal study followed up on a cohort consisting of all 107,682 nurses from January 1, 2017 to July 30, 2020. Differences in the distribution of retention and turnover according to the medical institutions' and nurses' characteristics were analyzed using the chi-square test. The hazard ratios (HRs) for turnover in each analysis interval were analyzed using multilevel Cox proportional-hazards analysis. The mean turnover rate was 10.0% within 1 year and 33.4% within 3.5 years. Several organizational characteristics (the type and ownership of the hospital, its location, and the bed-to-nurse ratio) and individual characteristics (gender, age, and clinical experience) were found to be associated with turnover risk. Among these factors, compared to hospitals with a bed-to-nurse ratio in general wards of 6.0 or more, those with a ratio of 3.5-3.9 had an HR for 1-year turnover of 0.81 (95% confidence interval [CI] = 0.67-0.98), and those with a ratio of 2.5-2.9 had an HR for 3.5-year turnover of 0.77 (95% CI = 0.66-0.90). The bed-to-nurse ratio is a condition that can be modified through collaboration between government policy-makers and medical institutions. To reduce nurse turnover and retain experienced nurses, appropriate staffing should be implemented.

Difference in functional connectivity between end-stage renal disease patients with and without restless legs syndrome: A prospective study.

PURPOSE: The purpose of this study was to examine differences in functional connectivity between patients with end-stage renal disease (ESRD) with and without restless legs syndrome (RLS). In addition, the study aimed to identify any potential associations between RLS severity and functional connectivity. METHODS: We enrolled patients with ESRD who had been undergoing hemodialysis. Patients with and without RLS were separated into two groups. Using functional near-infrared spectroscopy (fNIRS) and a graph theory approach, we determined the functional connectivity of patients with ESRD. The data were collected during a 300-s resting state evaluation performed in the dialysis room prior to dialysis. RESULTS: Eighteen of 48 patients with ESRD were diagnosed with RLS, whereas 30 patients did not exhibit RLS symptoms. Notably, functional connectivity metrics differed significantly between patients with and without RLS. Specifically, patients with ESRD and RLS displayed higher values for mean clustering coefficient (0.474 vs. 0.352, p = 0.001), global efficiency (0.520 vs. 0.414, p = 0.001), strength (6.538 vs. 4.783, p = 0.001), and transitivity (0.714 vs. 0.521, p = 0.001), while values for diameter (5.451 vs. 7.338, p = 0.002), eccentricity (4.598 vs. 5.985, p = 0.004), and characteristic path length (2.520 vs. 3.271, p = 0.002) were lower in patients with ESRD and RLS compared to those without RLS. In addition, there were correlations between the RLS severity score and the assortative coefficient (r = 0.479, p = 0.044), the small-worldness index (r = -0.475, p = 0.046), and transitivity (r = 0.500, p = 0.034). CONCLUSIONS: We demonstrated differences in functional connectivity between patients with ESRD with and without RLS, which may shed light on the pathophysiology of RLS. Notably, a number of functional connectivity metrics demonstrated strong associations with RLS severity. Our study also confirmed the applicability of fNIRS as a tool for investigating functional connectivity in patients with RLS.

Changes in the glymphatic system before and after dialysis initiation in patients with end-stage kidney disease.

INTRODUCTION: The aims of this study were to evaluate 1) glymphatic system function in patients with end-stage kidney disease (ESKD) before initiating dialysis compared to healthy controls, and 2) changes in the glymphatic system function after kidney replacement therapy including dialysis in patients with ESKD using the diffusion tensor image analysis along the perivascular space (DTI-ALPS) method. MATERIALS AND METHODS: This study was prospectively conducted at a single hospital. We enrolled 14 neurologically asymptomatic patients who first initiated hemodialysis or peritoneal dialysis for ESKD and 17 healthy controls. Patients had magnetic resonance imaging scans before initiating dialysis and again 3 months after initiating dialysis and the DTI-ALPS index was calculated. We compared the DTI-ALPS index before and after the initiation of dialysis and compared the DTI-ALPS index between the patients with ESKD and healthy control. RESULTS: There were differences in the DTI-ALPS index between ESKD patients before initiating dialysis and healthy controls (1.342 vs. 1.633, p = 0.003). DTI-ALPS index between ESKD patients before initiating dialysis and those after dialysis were not different (1.342 vs. 1.262, p = 0.386). There was a positive correlation between DTI-ALPS index and phosphate (r = 0.610, p = 0.020) in patients with ESKD. CONCLUSION: We confirmed the presence of glymphatic dysfunction in patients with ESKD. However, there was no difference in the glymphatic system before and after dialysis initiation. This finding may be related to uremic toxins that are not removed by dialysis in patients with ESKD. This study can be used for the development of pathophysiology of patients with ESKD.

Association between type 2 diabetes mellitus and depression among Korean midlife women: a cross-sectional analysis study.

BACKGROUND: The prevalence of depression is higher among midlife women, and they have less control over their diabetes during the menopausal transition. However, there is limited evidence on the association between type 2 diabetes mellitus and depression among Korean women in their midlife. This study aimed to examine the association between type 2 diabetes mellitus and depression and explore the levels of awareness and treatment of depression among Korean midlife women with T2DM. METHODS: This is a cross-sectional analysis study conducted using data from the Korea National Health and Nutrition Examination Surveys of 2014, 2016, and 2018. Korean women aged 40-64 years who randomly participated in the surveys were included, and 4,063 midlife women were selected as study participants. The diabetes progression status of the participants was classified into diabetes, pre-diabetes, and non-diabetes. Furthermore, the Patient Health Questionnaire-9 was used for screening depression. Participants' awareness rate, treatment rate among incident cases of depression, and treatment rate among awareness cases of depression were also analyzed. For data analysis, the Rao-Scott χ2 test, multiple logistic regression, and linear regression were conducted using SAS 9.4 software program. RESULTS: The prevalence of depression significantly differed between diabetes, pre-diabetes, and non-diabetes groups. However, depression awareness, treatment/incident, and treatment/awareness rates did not differ statistically between the diabetes progression status groups. Compared to the non-diabetes group, diabetes group had a higher odds ratio of depression after adjusting for general and health-related factors. Thus, the diabetes group had significantly higher PHQ-9 scores than the non-diabetes group after adjusting for covariates. CONCLUSIONS: Women in their midlife who have type 2 diabetes mellitus tend to have higher levels of depressive symptoms and are at risk of depression. However, we found no significant differences between diabetes and non-diabetes regarding the awareness and treatment rates of depression in South Korea. We recommend that future studies focus on developing clinical practice guidelines aimed at additional screening and intervention for depression in midlife women with type 2 diabetes mellitus to ensure prompt treatment and improved outcomes.

Long-term adjuvant metronomic chemotherapy in a dog with recurrent maxillofacial osteosarcoma.

Osteosarcoma (OSA) is the most common malignant bone tumour in dogs; however, OSA of the maxilla is uncommon compared to appendicular OSA. Oral melanoma also commonly occurs in dogs with frequent distant metastasis. The role of adjuvant chemotherapy has been questioned in maxillary OSA and melanoma. A 17-year-old English Cocker Spaniel was referred with a growing mass on the right maxilla and a right lower lip mass. Osteosarcoma was diagnosed after partial maxillectomy, and the right lower lip mass was diagnosed as oral melanoma. Metronomic chemotherapy (MC) was performed, and the number of doses was tapered due to side effects at 5 weeks after initiation of MC. After 130 weeks of MC, chemotherapy was suspended due to kidney disease. After the suspension of chemotherapy, findings suggesting recurrence and metastasis were detected. The dog suddenly died 193 weeks after surgery, which was 8-14 times longer than the expected survival time. To the best of our knowledge, this is the first case report of successful long-term combination therapy, including surgery and MC, in a dog with maxillary OSA and lip melanoma. Our results show that the survival time can be greatly extended if MC is performed with proper management.

Photo-CIDNP in Solid State.

Photo-CIDNP (photo-chemically induced dynamic nuclear polarization) refers to nuclear polarization created by the spin-chemical evolution of spin-correlated radical pairs (SCRPs). This phenomenon occurs in gases, liquids and solids. Based on the solid-state photo-CIDNP effect observed under magic-angle spinning (MAS), photo-CIDNP MAS NMR has been developed as analytical method. Here we report the origin, the theory and the state of the art of this method.

Changes in renal function and predictors affecting renal outcome of living kidney donors: a nationwide prospective cohort study.

AIM: The safety of donors is an important issue in living donor kidney transplantation. We investigated serial changes in renal function and predictors affecting the renal outcome of living kidney donors. METHODS: We obtained the data of 456 kidney donors registered to the Korean Organ Transplantation Registry from 2014 to 2016. The estimated glomerular filtration rate (eGFR) changes according to the development of incident chronic kidney disease (CKD) and factors related to CKD were analysed. CKD was defined as an eGFR <60 ml/min/1.73 m2 or the presence of proteinuria or albuminuria. The change in eGFR over time was analysed using a linear mixed model. RESULTS: At 2 years after kidney donation, 21.7% of the donors (99/456) developed CKD. Annual eGFR changes after nephrectomy were 2.2 ml/min/1.73 m2 /year in donors without CKD, and - 0.4 ml/min/1.73 m2 /year in donors with CKD. Higher systolic blood pressure was associated with higher risk of CKD (odds ratio [OR] 1.322 per 10 mmHg increment, 95% confidence interval [CI] 1.036-1.686, p = .025). Higher pre-donation eGFR (OR 0.906 per 1 ml/min/1.73 m2 increment, 95% CI 0.876-0.936, p < .001) and higher ratio of eGFR at discharge to pre-donation (OR 0.603 per 0.1 increment, 95% CI 0.426-0.849, p = .004) were related to lower risk of CKD. CONCLUSION: Kidney donors without incident CKD at 2 years after donation showed gradual increases in eGFR, whereas donors with CKD had relatively constant eGFR. A low ratio of eGFR at discharge after nephrectomy to baseline was a risk factor of CKD.

Genetic identification of inherited cystic kidney diseases for implementing precision medicine: a study protocol for a 3-year prospective multicenter cohort study.

BACKGROUND: Inherited cystic kidney disease is a spectrum of disorders in which clusters of renal cysts develop as the result of genetic mutation. The exact methods and pipelines for defining genetic mutations of inherited cystic kidney disease are not clear at this point. This 3-year, prospective, multicenter, cohort study was designed to set up a cohort of Korean patients with inherited cystic kidney disease, establish a customized genetic analysis pipeline for each disease subtype, and identify modifying genes associated with the severity of the disease phenotype. METHODS/DESIGN: From May 2020 to May 2022, we aim to recruit 800 patients and their family members to identify pathogenic mutations. Patients with more than 3 renal cysts in both kidneys are eligible to be enrolled. Cases of simple renal cysts and acquired cystic kidney disease that involve cyst formation as the result of renal failure will be excluded from this study. Demographic, laboratory, and imaging data as well as family pedigree will be collected at baseline. Renal function and changes in total kidney volume will be monitored during the follow-up period. Genetic identification of each case of inherited cystic kidney disease will be performed using a targeted gene panel of cystogenesis-related genes, whole exome sequencing (WES) and/or family segregation studies. Genotype-phenotype correlation analysis will be performed to elucidate the genetic effect on the severity of the disease phenotype. DISCUSSION: This is the first nationwide cohort study on patients with inherited cystic kidney disease in Korea. We will build a multicenter cohort to describe the clinical characteristics of Korean patients with inherited cystic kidney disease, elucidate the genotype of each disease, and demonstrate the genetic effects on the severity of the disease phenotype. TRIAL REGISTRATION: This cohort study was retrospectively registered at the Clinical Research Information Service ( KCT0005580 ) operated by the Korean Center for Disease Control and Prevention on November 5th, 2020.

Activation of the alternative complement pathway predicts renal outcome in patients with lupus nephritis.

OBJECTIVES: The aims of this study were to clarify the activation of complement pathways in patients with lupus nephritis (LN), and to elucidate the association between these complement activation types and clinical outcomes. METHODS: We enrolled 115 patients with biopsy-proven LN from 2003 to 2016 from the lupus cohort at the Busan Paik Hospital and the Jeju National University Hospital in Korea. The patients were divided into two groups based on the patterns of glomerular complements deposits. The presence of C1q, C4 and/or C3 deposits in the glomerulus was considered evidence for the activation of the classical pathway with or without alternative pathway activation (group 1, N = 93), and glomerular C3 deposition without C1q and C4 deposits was considered as a marker for the alternative pathway limited activation (group 2, N = 22). The study end point was progression of kidney disease defined as a ≥50% reduction in estimated glomerular filtration rate from baseline values or advancement to end-stage renal disease. RESULTS: The mean estimated glomerular filtration rate and median urine protein-to-creatinine ratio of the patients were 85.7 ± 32.4 mL/min/1.73 m2 and 3.1 g/g, respectively, at the time of kidney biopsy. Forty-nine patients (43%) had nephrotic range of proteinuria. Compared to group 1 patients, those in group 2 were older, were more likely to be males and were more hypertensive. In addition, plasma C3 and C4 levels were significantly lower in group 1 patients compared to those in group 2. Moreover, anti-dsDNA concentration was significantly higher in group 1 patients compared to those in group 2. The mean follow-up time was 5.4 ± 3.4 years. The rates of response to one-year immunosuppressive treatment were poorer in group 2 patients compared to those in group 1. During the follow-up time, the progression of kidney disease was significantly higher in group 2 than in group 1 patients. CONCLUSION: This study showed that there was alternative complement pathway limited activation in the renal tissue in a small number of patients with LN, and these patients had worse renal outcomes compared to patients with glomerular classical complement pathway activation with or without alternative pathway activation.

Maternal Antenatal Depression and Early Childhood Sleep: Potential Pathways Through Infant Temperament.

OBJECTIVE: Maternal depression is associated with infant and child sleep patterns, and with infant temperament. Here, we examine whether infant temperament mediated an association between maternal antenatal depression and toddler sleep. METHOD: Within the prebirth longitudinal cohort Growing Up in New Zealand, symptoms of antenatal and postnatal depression were measured in 5,568 women using the Edinburgh Postnatal Depression Scale (EPDS). Infant temperament was measured at age 9 months using the Very Short Form of Infant Behavior Questionnaire-Revised (IBQ-R VSF). Sleep duration and nighttime awakenings were reported by parents when children were 2 years old. RESULTS: Independent associations of maternal depression with child sleep patterns at age 2 years, adjusted for maternal demographics, physical health, family relationships, and child health and feeding, were determined using multivariate logistic regression analysis. The odds of having ≥2 nighttime awakenings were increased for children whose mothers had antenatal (1.36, 1.07-1.73) but not postnatal (1.22, 0.88-1.68) or both antenatal and postnatal depression (0.89, 0.56-1.36). There was no association of maternal depression with shorter sleep duration. Two of five dimensions of infant temperament (fear and negative affect) were associated with both antenatal depression scores and increased nighttime awakenings. Mediation analyses controlling for postnatal depression and other predictors of child sleep supported an indirect pathway of antenatal depression to child sleep through infant temperamental negative affectivity. CONCLUSION: Antenatal depression is independently associated with more frequent nighttime awakenings in early childhood. Findings support an indirect pathway through infant negative affect characteristics.

Terminal lucidity in the teaching hospital setting.

Terminal lucidity is an unpredictable end-of-life experience that has invaluable implications in preparation for death. We retrospectively evaluated terminal lucidity at a university teaching hospital. Of 338 deaths that occurred during the study period (187 in the ICU and 151 in general wards), terminal lucidity was identified in 6 cases in general wards. Periods of lucidity ranged from several hours to 4 days. After experiencing terminal lucidity, half of the patients died within a week, and the remainder died within 9 days. More attention should be directed toward understanding terminal lucidity to improve end-of-life care in a meaningful way.

Association between the bed-to-nurse ratio and 30-day post-discharge mortality in patients undergoing surgery: a cross-sectional analysis using Korean administrative data.

BACKGROUND: The likelihood of inpatient mortality has been found to be reduced by increased nurse staffing in several settings, including general wards, emergency departments, and intensive care units. However, less research has investigated cases where patients die in the community setting due to a health problem that occurred after they were discharged post-surgery, because it is difficult to integrate hospital data and local community data. Therefore, this study investigated the association between the bed-to-nurse ratio and 30-day post-discharge mortality in patients undergoing surgery using national administrative data. METHODS: The study analyzed data from 129,923 patients who underwent surgery between January 2014 and December 2015. The bed-to-nurse ratio was categorized as level 1 (less than 2.5), level 2 (2.5-3.4), level 3 (3.5-4.4), and level 4 (4.5 or greater). The chi-square test and GEE logistic regression analyses were used to explore the association between the bed-to-nurse ratio and 30-day post-discharge mortality. RESULTS: 1355 (0.01%) patients died within 30 days post-discharge. The 30-day post-discharge mortality rate in hospitals with a level 4 was 2.5%, representing a statistically significant difference from the rates of 0.8, 2 and 1.8% in hospitals with level 1, level 2, and level 3 staffing, respectively. In addition, the death rate was significantly lower at hospitals with a level 1 (OR = 0.62) or level 2 (OR = 0.63) bed-to-nurse ratio, using level 4 as reference. CONCLUSION: The results of this study are highly meaningful in that they underscore the necessity of in-hospital discharge nursing and continued post-discharge nursing care as a way to reduce post-discharge mortality risk. Furthermore, the relationship between nurse staffing levels and 30-day post-discharge mortality implies the need for a greater focus on discharge education. Policies are required to achieve proper nurse staffing levels in Korea, and thereby to enhance patient outcomes.

Association between registered nurse staffing levels and in-hospital mortality in craniotomy patients using Korean National Health Insurance data.

BACKGROUND: The level of registered nurse (RN) staffing is a fundamental factor influencing patient safety. Craniotomy patients need intensive care after surgery, the majority of which is provided by RNs. METHODS: This study was conducted to investigate the relationship of the RN staffing level of general wards and intensive care units (ICUs) with in-hospital mortality after craniotomy using Korean National Health Insurance claim data. The RN staffing level was categorized based on the bed-to-RN ratio. RESULTS: The in-hospital mortality rate of craniotomy patients was elevated at hospitals with a high bed-to-RN ratio in general wards, ICUs, and hospitals overall. It was determined that in-hospital mortality of craniotomy patients could be decreased by more than 50% by reducing the bed-to-RN ratio from 4.5 or more to less than 3.5 in general wards, from 1.25 or more to less than 0.88 in ICUs, and from 2.5 or more to less than 1.67 in hospitals overall. CONCLUSIONS: Since the RN staffing level is related to the in-hospital mortality rate of craniotomy patients, a sufficient staffing level of RNs should be ensured to reduce the mortality of craniotomy patients.

Effect of the Contents in Advance Directives on Individuals' Decision-Making.

Completing an advance directive offers individuals the opportunity to make informed choices about end-of-life care. However, these decisions could be influenced in different ways depending on how the information is presented. We randomly presented 185 participants with four distinct types of advance directive: neutrally framed (as reference), negatively framed, religiously framed, and a combination. Participants were asked which interventions they would like to receive at the end of life. Between 60% and 70% of participants responded "accept the special interventions" on the reference form. However, the majority (70%-90%) chose "refuse the interventions" on the negative form. With respect to the religious form, 70% to 80% chose "not decided yet." Participants who refused special life-sustaining treatments were older, female, and with better prior knowledge about advance directives. Our findings imply that the specific content of advance directives could affect decision-making with regard to various interventions for end-of-life care.

A Context-oriented Communication Algorithm for Advance Care Planning: A Model to Assist Palliative Care in Heart Failure.

BACKGROUND: Access to consultation or referral for decisions about advance care planning (ACP) is limited, particularly for nonmalignant models pertinent to palliative care in heart failure (HF). OBJECTIVES: The aim of this study was to solicit professional opinions about the feasibility of using an exemplary context-oriented communication algorithm for ACP discussions. METHODS: Using a panel of expert physicians and nurses in cardiovascular care, a 3-round Delphi study was conducted to evaluate the proposed model. RESULTS: A consensus was determined based on a content validity ratio (CVR) of 0.318 or greater, a critical value for selection of an item scored as important (≥4 on a 5-point Likert scale). A total of 50, 44, and 38 experts in Korea completed each round, respectively. Item evaluation did not differ across rounds (Friedman χ > P = .05), except for timing of the ACP discussion. A lack of consensus was observed on the issue of after HF diagnosis for right timing of the ACP discussion across rounds (CVRs from -0.80 to -0.83); consensus was reached on the expectation of a terminal state (CVRs from 0.60 to 0.78). Content validity ratios were moderately high for Korean advance directive, ranging from 0.59 to 0.91. Experts also reached consensus about each of 5 steps of a communication model-patients' determination of decisional capacity (CVR, 0.72-1.0), awareness (CVR, 0.95-1.0), willingness for advance care planning (CVR, 0.76-0.84), family dynamics (CVR, 0.92-1.0) and patient readiness for advance care planning (CVR, 0.76-0.95). CONCLUSIONS: A context-oriented communication model could be used to facilitate the decision-making process for palliative care and continuity of care in HF.

Effect of nurse staffing variation and hospital resource utilization.

In this study, we examined the effect of variations in nurse staffing levels on the length of stay and medical expenses of patients who underwent hip or knee surgeries. A cross-sectional study was conducted using the National Health Insurance database and hospital surveys from 2010. Patient length of stay and medical expenses by nurse staffing level and skill mix were compared after adjusting for hospital and patient characteristics. Nurse staffing was measured based on staffing grade, the bed-to-registered nurse/nurse aid ratio, the bed-to-nursing personnel ratio, and the RN proportion. Generalized estimation models were used to analyze the associations. Decreased nurse staffing was consistently associated with increased length of stay, regardless of nurse staffing measures. The medical expenses associated with the lowest staffing level were approximately $US 1142.2 more than those associated with the highest staffing level. The study results suggest that maintaining a high nurse staffing level could be a cost-effective strategy for government and insurers, as well as for patients. We propose that policy makers implement more efficient nurse staffing strategies.

The association of time-updated ambulatory blood pressure and renal progression in hypertensive patients with chronic kidney disease: post hoc analysis of ACCURATE study.

OBJECTIVES: : This study aimed to evaluate the effect of time-updated ambulatory blood pressure on chronic kidney disease (CKD) progression in patients with hypertension. METHODS: : Among patients with hypertension and CKD stages 3 and 4, enrolled in a clinical trial in which hypertension was treated based on office or ambulatory blood pressure (BP), participants assigned to the ambulatory BP were included in this study. Ambulatory BP was measured at the start of the study and 3, 6, and 18 months. Renal events were defined as a decrease in the estimated glomerular filtration rate (eGFR) by at least 30%, dialysis, or transplantation. RESULTS: : A total of 21 cases of renal events were observed. For baseline BP, a multivariate Cox model revealed that neither office SBP nor any component of ambulatory SBP, including mean, day-time, night-time BPs was associated with the risk of renal events. For time-updated BP, a marginal structural model revealed that the office SBP was not associated with renal events [hazard ratio 1.03, 95% confidence interval (CI) 0.99-1.07, P  = 0.117], but higher ambulatory SBPs, including day-time (hazard ratio 1.05, 95% CI 1.01-1.10, P  = 0.014), night-time (hazard ratio 1.05, 95% CI 1.02-1.08, P  = 0.001), and mean (hazard ratio 1.06, 95% CI 1.02-1.10, P  = 0.002) ambulatory SBPs, were significantly associated with an increased risk of renal events. CONCLUSION: : A higher time-updated ambulatory BP was associated with an increased risk of renal events in patients with hypertension and CKD, whereas baseline office and ambulatory BP, and time-updated office BP were not.