Initiating and Continuing Long-Term Exercise in Heart Failure: A Qualitative Analysis From the GEtting iNTo Light Exercise-Heart Failure Study

BACKGROUND

Exercise is a class 1A recommendation to improve the lives of patients with heart failure, yet less than one-third adhere to physical activity guidelines, and less than 3% attend cardiac rehabilitation.

OBJECTIVE

The aim of this study was to determine the effect of gentle nonaerobic exercise on initial and long-term adherence in patients with heart failure.

METHODS

We used a qualitative descriptive approach with qualitative content analysis to analyze previously recorded interview data collected as part of the 6-month GEtting iNTo Light Exercise-Heart Failure study and looked for trends in responses among our sample. Thematic statements, representing salient aspects of the participants' experiences, were created and supported by illustrative excerpts from the data.

RESULTS

Twenty-two interviews were analyzed. Eight participants had ≥80% adherence, and the remaining 14 participants were super-adherers (>100% adherence). Super-adherers tended to be male and 65 years or older, and have no exercise for 3 months before the study, a body mass index ≥ 30, and poor to good Kansas City Cardiomyopathy Questionnaire scores. Participants initially enrolled because they saw the program as an opportunity to improve a health issue and to exercise. Long-term adherence was facilitated by convenience, individualization, experiencing psychological and physical improvements, and peer fellowship.

CONCLUSIONS

The GEtting iNTo Light Exercise-Heart Failure study that used home-based gentle nonaerobic exercise had 64% of participants come more than was asked. It is imperative that clinicians incorporate what participants with heart failure have directly stated is important for their initiation and long-term adherence to exercise so that we can work toward bridging sedentary patients to the full exercise guidelines to reduce morbidity and mortality.

Effectiveness of an Advance Care Planning Intervention in Adults Receiving Dialysis and Their Families: A Cluster Randomized Clinical Trial

Importance

Evidence of effectiveness of advance care planning (ACP) strategies for patients receiving dialysis and their families is needed.

Objectives

To test the effectiveness of an ACP intervention to prepare patients and their surrogates for end-of-life (EOL) decision-making and to improve surrogate bereavement outcomes.

Design, Setting, and Participants

This cluster randomized clinical trial, An Effectiveness-Implementation Trial of SPIRIT (Sharing Patients' Illness Representations to Increase Trust) in ESRD, was conducted from December 2017 to March 2023 and included 42 dialysis clinics in 5 US states (Georgia, New Mexico, North Carolina, Pennsylvania, and Virginia) randomized to provide intervention or usual care. Recruitment was from February 15, 2018, to January 31, 2022, and patient-surrogate dyads were followed up for 21 months (until January 17, 2023) or until patient death.

Intervention

Each clinic selected 1 or 2 health care workers (eg, nurse practitioner, registered nurse, or social worker) to conduct 45- to 60-minute ACP discussions with dyads in the clinic or remotely. After March 13, 2020 (commencement of the COVID-19 emergency declaration), all discussions were conducted remotely. An ACP summary was placed in patients' medical records.

Main Outcomes and Measures

The primary, 2-week preparedness outcomes were dyad congruence on EOL goals of care, patient decisional conflict, surrogate decision-making confidence, and a composite of dyad congruence and surrogate decision-making confidence. Secondary bereavement outcomes were anxiety, depression, and posttraumatic distress 3 months after patient death. To adjust for COVID-19 pandemic effects on bereavement outcomes, a variable to indicate the timing of baseline and 3-month assessment relative to the COVID-19 emergency declaration was created.

Results

Of the 426 dyads enrolled, 231 were in the intervention clinics, and 195 were in the control clinics. Among all dyads, the mean (SD) patient age was 61.9 (12.7) years, and the mean (SD) surrogate age was 53.7 (15.4) years. At 2 weeks, after adjusting for baseline values, dyad congruence (odds ratio [OR], 1.61; 95% CI, 1.12-2.31; P = .001), decisional conflict scores (β, -0.10; 95% CI, -0.13 to -0.07; P < .001), and the composite (OR, 1.57; 95% CI, 1.06-2.34; P = .03) were higher in the intervention group than in the control group. Surrogate decision-making confidence was similar between groups (β, 0.06; 95% CI, -0.01 to 0.13; P = .12). Among 77 bereaved surrogates, after adjusting for baseline values and assessment timing, intervention group anxiety was lower than control group anxiety (β, -1.55; 95% CI, -3.08 to -0.01; P = .05); however, depression (β, -0.18; 95% CI, -2.09 to 1.73; P = .84) and posttraumatic distress (β, -0.96; 95% CI, -7.39 to 5.46; P = .75) were similar.

Conclusions and Relevance

In this randomized clinical trial, the ACP intervention implemented by health care workers at dialysis centers improved preparation for EOL decision-making but showed mixed effectiveness on bereavement outcomes. The ACP intervention implemented in dialysis centers may be an effective strategy to the dyad preparation for end-of-life care as opposed to the current focus on advance directives.

Trial Registration

ClinicalTrials.gov Identifier: NCT03138564.

Prevalence of Cognitive Impairment and Relationships with Other Factors in Patients with End Stage Kidney Disease Receiving Hemodialysis

Despite recommendations, cognitive screening in patients with end stage kidney disease (ESKD) rarely happens, leading to underestimates of cognitive impairment (CI) prevalence and missed opportunities for intervention. We aimed to describe CI prevalence and associated factors in 100 patients receiving in-center hemodialysis aged 50 years and older. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA). Descriptive analysis techniques characterized the sample and estimated mean scores. Non-parametric and parametric tests explored relationships among MoCA scores and other patient factors. Of the 100 patients, 32% had normal cognitive function, 56% mild CI, and 12% moderate CI. Age, income, and education level significantly corelated with cognitive function in our sample. Identifying clinical factors and appropriate follow up for abnormal screening are crucial next steps in managing cognitive impairment in patients with ESKD receiving in-center hemodialysis.

Getting Into Light Exercise (GENTLE-HF) for Patients With Heart Failure: the Design and Methodology of a Live-Video Group Exercise Study

OBJECTIVE

Newer therapies have increased heart failure (HF) survival rates, but these therapies are rarely curative. The consequence of increased longevity is the likelihood that patients with HF will experience higher symptom burdens over time. Exercise such as cardiac rehabilitation programs can palliate symptom burdens, but numerous barriers prevent exercise participation and adherence. Small pilot studies indicate short-term beneficial effects of gentle forms of exercise such as yoga to address symptom burdens and accommodate comorbidities. Long-term symptom benefit and adherence to yoga are currently unknown. Therefore, a novel a home-based, gentle-stretching intervention that addresses issues of exercise access and adherence is described in this article.

PURPOSE

The purpose of this article is to describe the background, design and study methodology of the Getting Into Light Exercise for HF (GENTLE-HF) randomized controlled trial. Gentle-HF will test a gentle stretching and education intervention compared to an education control group concerning symptom burden (dyspnea, exercise, activity adherence, depression, and anxiety) and quality of life. As an exploratory aim, we also will determine whether rurality moderates the relationships between exercise participation and symptom burden as a measure of health equity.

METHODS

We designed a randomized controlled trial study (n = 234) with 2 arms: a gentle stretching intervention arm with HF education and an HF education-only control. Participants will be recruited from U.S. cardiology clinics in the mid-Atlantic and the San Francisco Bay areas. This recruitment strategy will include individuals from urban, suburban and rural areas and individuals that have diverse racial and ethnic backgrounds. All participants will be provided with an iPad set up to access HF educational topics, and the intervention arm will have both educational and gentle-stretching class links. Both arms will access the HF health education icons on their iPads weekly; they correspond to the 6 months (26 weeks) of study participation. Symptom burden (dyspnea, fatigue, exercise intolerance, depression, anxiety) and quality of life will be measured at the study's start and completion. Study adherence will be measured by using attendance rates and number of class minutes attended.

RESULTS

The GENTLE-HF study is a randomized study that will test the effect of a home-based, video-conference-delivered gentle stretching and HF education intervention designed for patients with HF. The findings will inform whether gentle stretching can decrease symptom burden and potentially provide access to symptom palliation for a diverse population of patients with HF.

Perceptions of Caregiving Experience, Level of Burden, and Sense of Well-Being Among Caregivers of Patients Receiving In-Center Hemodialysis

Family caregivers are essential to the well-being of patients receiving hemodialysis. Yet poor understanding of caregivers' most pressing needs and factors that adversely affect caregivers impede targeted intervention development. To address this gap, 46 caregivers (38 female, 28 White, 21 spouses/partners, mean age 54 years) of patients from seven hemodialysis centers completed surveys and semi-structured interviews via telephone. Most caregivers denied depressive symptoms and negative impact of caregiving on their self-esteem, but reported adverse effects on their health, schedule, and finances. Greater acknowledgment of the important role of family caregivers, assistance with instrumental activities of daily living, transportation, and resources for education and emotional support may address their most pressing challenges. Age, race, and relationship to the patient influenced caregiver perspectives. Interventions to support these invaluable members of the health care team are warranted.

A Study Describing Patients' Perspectives on Cognitive Function Screening During Hemodialysis

Routine screening of cognitive function in patients with end stage kidney disease (ESKD) is recommended, yet rarely it happens. This study sought to identify barriers to cognitive function screening for patients with ESKD receiving in-center hemodialysis. To ascertain their perceptions of cognitive function screening, 100 patients aged 50 years and older (48% female, 49% Black/African-American) from seven hemodialysis centers participated in structured interviews after completing the Montreal Cognitive Assessment and Geriatric Depression Scale. Participants rated the screening experience favorably, indicating cognitive function screening is acceptable to patients receiving hemodialysis. The level of cognitive impairment was the only factor significantly associated with screening evaluation scores, with participants with scores indicating mild or moderate impairment evaluating screening less favorably than those with normal cognitive function scores. Next steps include identifying systems level barriers and establishing appropriate follow up for patients with abnormal screening results.

Cultivating inclusive learning environments that foster nursing education program resiliency during the Covid-19 pandemic

Nursing education programs faced multiple challenges to increase the size, diversity, and skill set of the nursing workforce while contending with shortage of clinical placement sites and retiring faculty. A program that is unable to be resilient in the face of crisis will fail in its mission to graduate resilient nurses. The purpose of this paper is to describe how nursing programs can respond to the challenge of creating a resilient program poised to graduate a diverse, inclusive, and resilient workforce. Utilizing resilience-oriented strategies to impact educational services solidified program relevancy, promoted student belonging, and enhanced student recruitment/retention. While programs have become accustomed to doing more with fewer resources, many of these programs may not survive these unprecedented times without incorporating a holistic approach for organizational well-being that promotes resilience through inclusivity.

A Narrative Review of Management Strategies for Common Symptoms in Advanced CKD

Patients with advanced chronic kidney disease (CKD) experience multiple bothersome symptoms, undermining their quality of life (QOL). With growing attention to the importance of symptom management in advanced CKD, the evidence regarding symptoms is increasing. In this review, we briefly summarize the current evidence of effective pharmacologic and nonpharmacologic interventions to improve symptoms and QOL in patients with advanced CKD, including those on dialysis. We focused on symptoms that are commonly experienced by patients, such as pain, fatigue, sleep disturbances, itching, nausea and vomiting, cognitive impairment, and anxiety and depression. We noted that research in symptom science focused on improving symptom management in CKD is still very limited. In addition to the lack of clinical practice guidelines to address those common symptoms, the major gaps in the current literature include the evidence regarding mechanistic pathways to inform the development of effective symptom management for CKD populations, the evidence to confirm effective pharmacologic interventions in other populations for CKD populations, and research on how to incorporate effective symptom management approaches into clinical care. Although improving mortality remains as an important area in the kidney community, there is an urgent need to focus on improving symptom management to improve QOL in advanced CKD.

Nephrology and Palliative Care Collaboration in the Care of Patients With Advanced Kidney Disease: Results of a Clinician Survey

Rationale & Objective

Despite calls for integrating palliative care into chronic kidney disease (CKD) care, uptake remains low. The study aim was to describe clinicians’ perceptions of the clinical and research priorities in CKD care and the main barriers to collaboration.

Study Design

This was a descriptive cross-sectional study using an online survey developed by clinicians and researchers as the primary data collection method.

Setting & Participants

Clinicians in nephrology and palliative care departments (N = 195) at an academic health center in Virginia were invited to participate. Of the 48.7% (n = 95) who responded, most were registered nurses (65.3%) in nephrology (80%) with more than 15 years’ experience (40%).

Predictors

Factors including discipline (nursing, social work, and physician) and practice area (palliative care or nephrology) were assessed.

Outcomes

Main outcomes of interest included clinicians’ perceptions of the role of palliative care, barriers to collaboration, and the top clinical and research priorities for patients with advanced CKD.

Analytic Approach

Survey data were analyzed using SPSS using descriptive statistics.

Results

Respondents reported being comfortable caring for patients near the end of life and endorsed advance care planning and collaboration between nephrology and palliative care teams. However, both rarely happen. Fragmentation, or poor coordination of care, was perceived to be the main barrier to collaboration. Perceptions regarding collaboration facilitation differed; nephrology clinicians identified patient/family education as the most important facilitator while palliative care clinicians identified clinician education as most important. Top clinical priorities differed. Palliative care clinicians reported pain/symptom management as taking priority while nephrology clinicians identified caregiver/family support. Developing interventions to support treatment-related decision making was the top research priority.

Limitations

Results reflect perceptions of about half the clinicians at 1 academic health center.

Conclusions

Additional studies to capture patients’ and families’ perspectives and examine end-of-life care processes are needed. Results may inform future targeted interventions.

Fourth-Year Baccalaureate Nursing Students' Perceptions of Inclusive Learning Environments

BACKGROUND

Creating inclusive learning environments is a priority in nursing education, yet faculty are hindered by a dearth of evidence-based inclusive pedagogical strategies. In addition, little is known about students' perceptions of inclusive learning environments.

METHOD

Fourth-year baccalaureate nursing students from majority and underrepresented minority groups (n = 13) participated in focus groups at two time points across the academic year. Discussion topics included pedagogical strategies most strongly associated with inclusivity, facilitators and barriers to inclusivity, outcomes of inclusive learning experiences, and recommendations for promoting inclusivity in education and nursing practice.

RESULTS

Qualitative content analysis resulted in three themes: 1) underrepresented minority and majority groups described inclusive learning environments differently, 2) every aspect of the learning community affects inclusivity but teachers are especially influential, and 3) the outcomes of an inclusive learning environment extend beyond the classroom.

CONCLUSION

These findings may help create inclusive learning environments that support diversity and inclusive excellence in nursing education. [J Nurs Educ. 2020;59(5):256-262.].

Trajectory of extracellular fluid volume over time and subsequent risks of end-stage kidney disease and mortality in chronic kidney disease: a prospective cohort study

BACKGROUND

Extracellular fluid volume (ECF) is independently associated with chronic kidney disease (CKD) progression and mortality in patients with CKD, but the prognostic value of the trajectory of ECF over time beyond that of baseline value is unknown.

OBJECTIVES

To characterize ECF trajectory and evaluate its association with the risks of end-stage kidney disease (ESKD) and mortality.

METHODS

From the prospective tricentric NephroTest cohort, we included 1588 patients with baseline measured glomerular filtration rate (mGFR) ≥15 mL min^-1 /1.73 m² and ECF measurement. ECF and GFR were measured repeatedly using the distribution volume and clearance of ⁵¹ Cr-EDTA, respectively. ESKD and mortality were traced through record linkage with the national registries. Adjusted shared random-effect joint models were used to analyse the association between the trajectory of ECF over time and the two competing outcomes.

RESULTS

Patients were mean age 58.7 years, 66.7% men, mean mGFR of 43.6 ± 18.6 mL min^-1 /1.73 m² and mean ECF of 16.1 ± 3.6 L. Over a median follow-up of 5.3 [IQR: 3.0;7.4] years, ECF increased by 136 [95%CI 106;167] mL per year on average, whilst diuretic prescription and 24-hour urinary sodium excretion remained stable. ESKD occurred in 324 (20.4%) patients, and 185 (11.6%) patients died before ESKD. A higher current value of ECF was associated with increased hazards of ESKD (adjusted hazard ratio [aHR]: 1.12 [95%CI 1.06;1.18]; P < 0.001 per 1 L increase in ECF), and death before ESKD (aHR: 1.10 [95%CI 1.04;1.17]; P = 0.002).

CONCLUSIONS

The current value of ECF was associated with the risks of ESKD and mortality, independent of multiple potential confounders, including kidney function decline. This highlights the need for a close monitoring and adjustment of treatment to avoid fluid overload in CKD patients.

Enhancing Shared Decision Making in a Chronic Population. Use of an Advance Directive Decision Aid for Patients with Heart Failure and Their Caregivers

Background

Heart failure (HF) is a costly, progressive, symptomatic, and deadly condition affecting more than 6 million people in the United States. Despite evidence that advance care planning (ACP), including completion of an advance directive (AD), enhances decision-making quality and patient experience, completion rates remain low. ACP decision aids have been shown to improve the quality of decisions in other chronic illnesses, yet few have been tested in the HF population.

Purpose

This pilot study was designed to test the feasibility and acceptability of an Advance Directive Decision Aid (ADDA) in hospitalized patients with HF and their designated caregivers. The secondary aim was to describe the levels of decisional conflict (DC) and decisional regret (DR) associated with participating in ACP discussions and consideration of completing an AD.

Methods

Convenience sampling was used to recruit 30 dyads (patients with HF and their designated caregivers) from an academic medical center. Feasibility was assessed by tracking the enrolled, ineligible, and refusal rates, in addition to the time to deliver the intervention. Acceptability was assessed via completion of a follow-up survey and participation in an exit interview. The dyads were evaluated for DC and DR following delivery of the ADDA.

Results

For enrolled patients, mean age was 56.5 years (SD = 12.17), 73% were Caucasian, most were male (66.6%), 54% were diagnosed with HF <1 year, and 70% were NYHA IV. Patients that were ineligible or refused participation were similar in sociodemographic data to the enrolled sample, though the refusal sample was significantly younger (56.5 years vs 49.47 years; p = 0.011). The ADDA took 2-5 minutes to complete. 80% of dyads found the ADDA to be acceptable and would recommend the ADDA to others. Dyads also reported that the ADDA assisted decision making to complete an AD. Dyads expressed similar amounts of DC; however, caregivers were found to have significantly more DR compared to patients (p = 0.008). In qualitative analysis, both patients and caregivers reported decreased anxiety and gratitude about ACP discussions. Enrolled patients expressed a sense of relief in participating in ACP discussions, though continued to endorse a sense of “impending death” if they completed an AD. Only 8 of 30 patients completed an AD at the conclusion of the study.

Conclusions

This pilot study revealed that the ADDA was feasible in clinical practice and acceptable to patients and caregivers. Younger patients were more likely to refuse the ADDA and caregiver regret was higher among caregivers than patients after viewing the ADDA. Patients remain fearful that completing an AD means death is imminent. Future research needs to be directed at breaking down the barrier to completing an AD and increasing completion rates, engaging the younger aged HF population, and understanding and decreasing caregiver regret.

Association between Palliative Care Consultation and Advance Palliative Care Rates: A Descriptive Cohort Study in Patients at Various Stages in the Continuum of Chronic Kidney Disease

Background: Despite evidence that advance care planning (ACP) benefits patients with serious illnesses, there is a dearth of information about "who" is referred for palliative care (PC) consultation, the rate of PC consultation, and the outcomes of referrals in patients with advanced chronic kidney disease/end-stage kidney disease (aCKD/ESKD). Objectives: (1) To describe patient characteristics associated with PC consultations and (2) to determine the frequency and outcome of PC consultation on documented ACP discussions for patients with aCKD/ESKD. Methodology/Design: This is retrospective observational electronic health record cohort review. Settings: University of Virginia (UVA) hospital, clinics, and dialysis units. Participants: Patients were studied along two time intervals. Time period January 1, 2015 to June 30, 2017 included all patients admitted to UVA during that time period with estimated glomerular filtration rate (eGFR) <60 mL/minute. Time period January 1, 2018 to March 31, 2019 included two cohorts: patients with eGFR <15 mL/minute who had died during study period excluding those who withdrew from dialysis and those who were dialysis dependent and withdrew from dialysis. Results: Aside from higher rates of PC consultation in patients with heart failure, none of the demographic and comorbidity data studied affected whether or not a patient is referred to PC in patients with aCKD/ESKD. PC consultation rates were low among all patients studied: 14.7% in patients with eGFR <60 mL/minute, 28.9% in dialysis patients withdrawing from dialysis, and 57.1% in terminally ill patients with eGFR <15 mL/minute. In all cohorts, PC consultations were associated with improved ACP. Conclusion: PC consultation is significantly associated with better end-of-life outcomes with more completion of ACP and hospice referral in patients with aCKD/ESKD. PC consultation rates remain low. Even in terminally ill patients with more aCKD, >40% were never seen by PC. Until policies and curricula better prepare nephrologists to independently address ACP, collaboration between nephrologists and PC specialists is recommended.

Characterization of Biostable Atomic Layer Deposited (ALD) Multilayer Passivation Coatings for Active Implants

The next generation of flexible, electrically active implants, such as brain implants or retina chips require a flexible, biostable as well as biocompatible passivation, ensuring a degradation-free usage for long time periods on the order of several years. Until today, these passivations are prepared mostly by polyimides or parylene, both of which are water vapor permeable to a certain degree. To remedy this deficiency, Atomic Layer Deposited (ALD) thin films are characterized regarding their electrical passivating features under conditions of accelerated aging, such as elevated temperatures in a liquid environment. The initial electrical passivation by various ALD deposited multilayers, combining alternating thin Al₂O₃ and TiO₂ layers is the goal of this research as well as the stability of these layers under induced degradation. Such layers, in combination with a parylene passivation, would ensure a water vapor impermeable and biocompatible coating.

A longitudinal mixed methods study describing 4th year baccalaureate nursing students' perceptions of inclusive pedagogical strategies

BACKGROUND

Creating inclusive learning environments-those in which all students thrive-is a priority as nursing educators are charged with preparing a diverse workforce to care for a diverse patient population. Yet, faculty are hindered by a dearth of evidence-based pedagogical strategies to promote inclusion.

PURPOSE

This longitudinal mixed methods study uniquely addresses this evidence gap by describing relationships among inclusive pedagogical strategies and student outcomes in 81 4th-year baccalaureate nursing students.

METHODS

Across the academic year, students participated in two focus groups and completed surveys at three timepoints on classroom and clinical belongingness, self-confidence and satisfaction with learning, and self-efficacy in the clinical setting.

RESULTS

Students' reports of satisfaction and confidence in learning, clinical self-efficacy, and clinical belongingness were significantly higher when they characterized their learning environment as inclusive. Underrepresented students, however, reported significantly lower classroom and clinical belongingness at all three survey timepoints and shared examples of unaddressed breaches in inclusivity which undermined confidence and belongingness. Focus group participants evaluated pedagogical strategies and highlighted faculty's pivotal role in creating inclusive learning environments.

CONCLUSION

Inclusive pedagogical strategies may increase students' sense of belongingness, satisfaction and confidence in learning, and self-efficacy. Study results may assist faculty and inform future interventions.

Impact of sex and glucose-lowering treatments on hypoglycaemic symptoms in people with type 2 diabetes and chronic kidney disease. The French Chronic Kidney Disease - Renal Epidemiology and Information Network (CKD-REIN) Study

AIM

To describe current practices of glucose-lowering treatments in people with diabetes and chronic kidney disease (CKD), the associated glucose control and hypoglycaemic symptoms, with an emphasis on sex differences.

METHODS

Among the 3033 patients with CKD stages 3-5 recruited into the French CKD-REIN study, 645 men and 288 women had type 2 diabetes and were treated by glucose-lowering drugs.

RESULTS

Overall, 31% were treated only with insulin, 28% with combinations of insulin and another drug, 42% with non-insulin glucose-lowering drugs. In CKD stage 3, 40% of patients used metformin, 12% at stages 4&5, similar for men and women; in CKD stage 3, 53% used insulin, similar for men and women, but at stages 4&5, 59% of men and 77% of women used insulin. Patients were reasonably well controlled, with a median HbA1c of 7.1% (54mmol/mol) in men, 7.4% (57mmol/mol) in women (P=0.0003). Hypoglycaemic symptoms were reported by 40% of men and 59% of women; they were not associated with the estimated glomerular filtration rate, nor with albuminuria or with HbA1c in multivariable analyses, but they were more frequent in people treated with insulin, particularly with fast-acting and pre-mixed insulins.

CONCLUSION

Glucose-lowering treatment, HbA1c and hypoglycaemic symptoms were sex dependent. Metformin use was similar in men and women, but unexpectedly low in CKD stage 3; its use could be encouraged rather than resorting to insulin. Hypoglycaemic symptoms were frequent and need to be more closely monitored, with appropriate patient-education, especially in women.

Nanoparticle-Based Mucosal Vaccines Targeting Tumor-Associated Antigens to Human Dendritic Cells

The induction of effective T cell-mediated immune responses is the main objective of vaccination against cancer. T cell responses are initiated by dendritic cells (DCs) as the most potent antigen-presenting cells. Designing vaccines for efficient delivery of tumor antigens to these cells in immunogenic fashion is, therefore, a major task in tumor immunology. In this human-based in vitro study we investigated the suitability of different polymeric nanoparticles (NPs) for delivering the tumor-associated antigen Her2/neu to DCs for induction of T cell responses by mucosal vaccination. The natural polymer chitosan and novel functionalized PLGA-based polymers were used for NP production. All NPs were efficiently taken up by DCs. Her2/neu delivered by NPs was more efficiently processed and presented by DCs than the soluble protein and induced more vigorous CD4+ and CD8+ T cell proliferation, and cytotoxic T cells. Testing the suitability of this platform for mucosal vaccination, NPs were applied to the apical side of an intestinal epithelium model and found to be efficiently transported across the epithelial layer to become available to basolateral DCs. Thus, chitosan and PLGA-based NPs are efficient carriers for delivery of antigens to DCs for induction of T cell-based immunity, and suitable for mucosal vaccine formulations.

The OsteoLaus Cohort Study

Eine indirekte Beurteilung der Mikroarchitektur (MA) ist in der täglichen Praxis anhand des TBS (Trabecular Bone Score) näherungsweise möglich. Das Ziel der OsteoLaus-Kohorte besteht darin, klinische Risikofaktoren und Informationen aus der DXA (Knochenmineraldichte [BMD], TBS und Wirbelkörperfrakturerkennung [VFA]) zu kombinieren, um Frauen mit hohem Frakturrisiko leichter zu erkennen. Wir nahmen 631 Frauen im mittleren Alter von 67,4 ± 6,7 J. und mit einem BMI von 26,1 ± 4,6 auf. Es bestand eine schwache Korrelation zwischen BMD und Zentrums-gematchtem TBS (r2 = 0,16). Die Prävalenz von Wirbelfrakturen (VFx) Grad 2/3, größeren osteoporotischen (OP) Frakturen und allen OP-Frakturen betrug 8,4 %, 17,0 % bzw. 26,0 %. Alters- und BMI-adjustierte OR (nach abnehmender SD) lagen bei 1,8 (1,2–2,5), 1,6 (1,2–2,1) bzw. 1,3 (1,1–1,6) für BMD und 2,0 (1,4–3,0), 1,9 (1,4–2,5) bzw. 1,4 (1,1–1,7) für TBS. Die TBS OR (nach abnehmender SD), adjustiert nach Alter, BMI und Wirbelsäulen-BMD, für VFx Grad 2/3, größere und alle OP-Frakturen betrugen 1,7 (1,1–2,7), 1,6 (1,2–2,2) bzw. 1,3 (1,0–1,7). Nur 35 bis 44 % der Frauen mit OP-Frakturen hatten eine BMD <−2,5 SD oder einen TBS < 1.200. Durch Kombination eines BMD < −2,5 SD oder TBS < 1,200 werden 54 bis 60 % der Frauen mit OP-Fraktur erkannt. Somit können wir anhand von VFA, BMD und TBS aus einem einfachen und strahlenarmen Röntgenverfahren, der DXA, Zusatzinformationen gewinnen, die für den Patienten im Praxisalltag von Nutzen sind.

Clinical practice guidelines of the French Association for Supportive Care in Cancer and the French Society for Psycho-oncology: refusal of treatment by adults afflicted with cancer

PURPOSE

The study's purpose was to develop practical guidelines for assessment and management of refusal of treatment by adults afflicted with cancer.

METHODS

The French Association for Supportive Care in Cancer and the French Society for Psycho-oncology gathered a task force that applied a consensus methodology to draft guidelines studied predisposing situations, the diagnosis, regulatory aspects, and the management of refusal of treatment by adults afflicted with cancer.

RESULTS

We propose five guidelines: (1) be aware of the conditions/profiles of patients most often associated with refusal of treatment so as to adequately underpin the care and support measures; (2) understand the complexity of the process of refusal and knowing how to accurately identify the type and the modalities of the refused treatments; (3) apply a way to systematically analyze refusal, thereby promoting progression from a situation of disaccord toward a consensual decision; (4) devise procedures, according to the legal context, to address refusal of treatment that safeguards the stakeholders in situations of sustained disaccord; and (5) know the indications for ethical collective decision-making.

CONCLUSION

The quality of the relationship between patients and health professionals, and the communication between them are essential components involved in reaching a point of consent or refusal of treatment. A process of systematic analysis of refusal is recommended as the only way to ensure that all of the physiological, psychological, and contextual elements that are potentially involved are taken into account.

Process and impact of an advance care planning intervention evaluated by bereaved surrogate decision-makers of dialysis patients

BACKGROUND

Few studies have examined the process and impact of an advance care planning intervention experienced by surrogate decision-makers of dialysis patients.

AIM

To explore the perspectives of the bereaved surrogates of dialysis patients on the process and impact of an advance care planning intervention and to compare the perceived impacts of the intervention between African Americans and Whites.

DESIGN

Qualitative interviews and thematic analysis.

SETTING/PARTICIPANTS

24 bereaved surrogates of patients from outpatient dialysis centers were interviewed. Both patients and surrogates had been participants in a larger efficacy study and had received an advance care planning intervention, SPIRIT (Sharing Patient's Illness Representations to Increase Trust).

RESULTS

Two themes related to the process of SPIRIT were as follows: (1) SPIRIT provided a welcome opportunity to think about and discuss topics that had been avoided and (2) SPIRIT helped patients and surrogates to share their feelings. Four themes of the SPIRIT's impact were as follows: (1) SPIRIT was an eye-opening experience, acquiring knowledge and understanding of the patient's illness and end-of-life care, (2) SPIRIT helped strengthen relationships between patients and surrogates, (3) SPIRIT helped surrogates feel prepared during the time leading up to end-of-life decision-making, and (4) SPIRIT helped surrogates have peace of mind during and after actual end-of-life decision-making. Themes related to SPIRIT's impact on feeling prepared for end-of-life decision-making and the actual decision-making experience more frequently occurred in African Americans than in Whites.

CONCLUSION

Our data may help explain the beneficial effects of SPIRIT on surrogates, but future trials should include data on control surrogates' perspectives.

The lumbar spine age-related degenerative disease influences the BMD not the TBS: the Osteolaus cohort

We evaluated the influence of degenerative disease and fractured vertebra on lumbar spine bone mineral density (BMD) and trabecular bone score (TBS) in 1500 women aged 50-80 years. TBS was not affected by a degenerative disease. While BMD increases after 62.5 years, TBS continues to decline. TBS should play a leading role in lumbar spine evaluation.

INTRODUCTION

After menopause, lumbar spine (LS) BMD and TBS values decrease. Degenerative disease (DD) increases with age and affect LS BMD. The aim of this study was to measure changes in LS BMD and TBS in women 50 to 80 years old, taking into account the impact of fractured vertebrae and DD.

METHODS

LS BMD, TBS, and vertebral fracture assessment were evaluated in the OsteoLaus cohort (1500 women, 50-80 years old). The exams were analyzed following ISCD guidelines to identify vertebrae with fractures or DD (Vex).

RESULTS

1443 women were enrolled: mean age 66.7 ± 11.7 years, BMI 25.7 ± 4.4. LS BMD and TBS were weakly correlated (r2 = 0.16). The correlation (Vex excluded) between age and BMD was +0.03, between age and TBS -0.34. According to age group, LS BMD was 1.2 to 3.2% higher before excluding Vex (p < 0.001). TBS had an insignificant change of <1% after excluding Vex. LS BMD (Vex) decreased by 4.6% between 52.5 and 62.5 years, and increased by 2.6% between 62.5 and 77.5 years. TBS (Vex excluded) values decreased steadily with age with an overall loss of 8.99% between 52.5 and 77.5 years. Spine TBS, femoral neck, and total hip BMD gradually decreased with age, reaching one SD between the oldest and youngest group.

CONCLUSIONS

TBS is not affected by DD. While BMD increases after 62.5 years, TBS continues to decline. For lumbar spine evaluation, in view of its independence from DD, TBS should play a leading role in the diagnosis in complement to BMD.

Determining Consistency of Surrogate Decisions and End-of-Life Care Received with Patient Goals-of-Care Preferences

BACKGROUND

Care consistent with preferences is the goal of advance care planning (ACP). However, comparing written preferences to actual end-of-life care may not capture consistency of care with preferences.

OBJECTIVE

We evaluated four additional types of consistency, using prospective data on written preferences and active clinical decision making by patients and their surrogates.

METHODS

Secondary analysis of data was done from a trial of an ACP intervention for patient-surrogate dyads. Forty-five patients died during the trial and comprised the sample for the analysis. Sources of data included patients' preferences in a written goals-of-care tool, medical record reviews, and two-week postbereavement interviews with surrogates to complement medical record reviews.

RESULTS

Twenty-four patients (53.3%) received care consistent with written preferences and 11 (24.4%) inconsistent with written preferences. The remaining 10 patients (22.2%) died suddenly with no opportunity for treatment decision making. Eleven (24.4%) were able to participate in decision making with their surrogates; of those, 9 (81.8%) received care consistent with their expressed preferences. Twenty-two patients were incapacitated and thus the surrogate made treatment decisions alone; of those, 18 (81.8%) made decisions consistent with the patient's written preference.

CONCLUSIONS

Simply comparing documented preferences for end-of-life care and medical records of care delivered does not adequately reflect the process of ACP and treatment decision making at the end of life. To understand consistency between preferences and end-of-life care, investigators need data on written and real-time expressed preferences.

A randomized controlled pilot trial to improve advance care planning for LVAD patients and their surrogates

OBJECTIVES

To examine feasibility, acceptability and preliminary effects of an advance care planning (ACP) intervention, SPIRIT-HF, in LVAD patients and their surrogates.

BACKGROUND

LVADs may improve HF symptoms but they are not curative. Thus, ACP is needed to prepare patients and surrogates for end-of-life (EOL) decision-making.

METHODS

Bridge to transplant and destination therapy LVAD patient-surrogate dyads were randomized to either SPIRIT-HF or usual care. Percentages of eligible dyads who were enrolled and completed the study determined feasibility. Analysis of interviews with SPIRIT dyads determined acceptability. Group comparisons of dyad congruence, patient's decisional conflict, and surrogate's decision-making confidence determined preliminary effects.

RESULTS

Of 38 eligible dyads, 29 (76%) were enrolled, randomized, and completed the study. The 14 intervention dyads characterized SPIRIT-HF as beneficial. All dyads demonstrated improvement in outcomes. However, SPIRIT-HF dyads tended toward greater congruence on patient EOL treatment goals.

CONCLUSIONS

SPIRIT-HF is feasible and acceptable. Results will inform future trials.

CD44 functions in Wnt signaling by regulating LRP6 localization and activation

Wnt reception at the membrane is complex and not fully understood. CD44 is a major Wnt target gene in the intestine and is essential for Wnt-induced tumor progression in colorectal cancer. Here we show that CD44 acts as a positive regulator of the Wnt receptor complex. Downregulation of CD44 expression decreases, whereas CD44 overexpression increases Wnt activity in a concentration-dependent manner. Epistasis experiments place CD44 function at the level of the Wnt receptor LRP6. Mechanistically, CD44 physically associates with LRP6 upon Wnt treatment and modulates LRP6 membrane localization. Moreover, CD44 regulates Wnt signaling in the developing brain of Xenopus laevis embryos as shown by a decreased expression of Wnt targets tcf-4 and en-2 in CD44 morphants.