There is 'no cure for caregiving': the experience of women caring for husbands living with Parkinson's disease

BACKGROUND

Parkinson's disease is a progressive neurodegenerative disorder. The majority of the nearly 9 million people living with Parkinson's disease are men. As such, caregiving is often assumed by wives as the disease progresses. However, there is little research about the lived experience of wives as they transition to caregivers.

OBJECTIVE

To describe the lived experience of wife caregivers of male spouses living at home with Parkinson's disease.

METHODS

A descriptive phenomenological study. Semi-structured interviews were recorded and transcribed for analysis in Atlas.ti using Colaizzi's method.

RESULTS

Thirteen women, aged 50 to 83 years, were interviewed. Five themes emerged from the analysis, (1) caregiver who? (2) taking it day by day, (3) not sure what to do next, (4) just too much, and (5) caring is your soul's growth, to support the central theme "there is no cure for caregiving."

CONCLUSION

Transitioning from wife to caregiver was a gradual but difficult process. Although the wife caregivers wanted to be part of the health care team, they remained outsiders. Clinicians need to recognize the wives as care coordinators linking medical management with home care. Policy makers need to develop reimbursement models that provide wife caregivers with support groups, education programs, and telemental health services.

Prognostic value of neutrophil-to-lymphocyte ratio dynamics in patients with septic acute kidney injury: a cohort study

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) has been suggested to be a prognostic marker for various diseases, but whether NLR dynamics (ΔNLR) is related to mortality and disease severity in patients with septic acute kidney injury (AKI) has not been determined.

METHODS

Between August 2013 and August 2021, septic AKI patients at our center were retrospectively enrolled. ΔNLR was defined as the difference between the NLR at septic AKI diagnosis and at hospital admission. The relationship between the ΔNLR and mortality was evaluated by Kaplan-Meier curves, Cox proportional hazards, and cubic spline analyses. The prediction values were compared by area under the receiver-operating characteristic curve (AUROC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) analyses.

RESULTS

Of the 413 participants, the mean age was 63 ± 17 years, and 134 were female (32.4%). According to the median value, patients in the high-ΔNLR group had significantly greater 90-d mortality (74.4% vs. 46.6%, p < 0.001). After adjustment for potential confounders, high ΔNLR remained an independent predictor of 90-d mortality (HR = 2.80; 95% CI = 1.74-4.49, p < 0.001). Furthermore, ΔNLR had the highest AUROC for 90-d mortality (0.685) among the various biomarkers and exhibited an improved NRI (0.314) and IDI (0.027) when incorporated with PCT and CRP. For secondary outcomes, patients with high ΔNLR had increased risk of 30-d mortality (p = 0.004), need for renal replacement therapy (p = 0.011), and developing stage-3 AKI (p = 0.040) according to the adjusted models.

CONCLUSIONS

High ΔNLR is independently associated with increased risk of patient mortality and adverse outcomes. ΔNLR might be utilized to facilitate risk stratification and optimize septic AKI management.

Fruit and vegetable intake, physical activity, and functional fitness among older adults in urban Alaska

Older adults often face barriers to obtaining recommended diet, physical activity, and fitness levels. Understanding these patterns can inform effective interventions targeting health beliefs and behavior. This cross-sectional study included a multicultural sample of 58 older adults (aged 55+ years, M=71.98) living in independent senior housing in urban Southcentral Alaska. Participants completed a questionnaire and the Senior Fitness Test that assessed self-reported fruit and vegetable intake, physical activity, self-efficacy, and functional fitness. T-tests and bivariate correlation analyses were used to test six hypotheses. Results indicated that participants had low physical activity but had a mean fruit and vegetable intake that was statistically significantly higher than the hypothesized "low" score. Only 4.26% of participants met functional fitness standards for balance/agility, and 8.51% met standards for lower-body strength. However, 51.1% met standards for upper-body strength and 46.8% met standards for endurance The results also indicated that nutrition self-efficacy and exercise self-efficacy were positively related to fruit and vegetable intake and physical activity levels, respectively. Interestingly, income was not related to nutrition or activity patterns. These data complicate the picture on dietary and physical activity patterns for older adults in Alaska and offer recommendations for future health promotion activities.

Nails in older adults

As the world's population of adults greater than 60 years old continues to increase, it is important to manage nail disorders that may impact their daily lives. Nail disorders may have significant impact on quality of life due to decreased functionality, extreme pain, or social embarrassment. In this review, we discuss nail disorders affecting older patients, including physiologic, traumatic, drug-induced, infectious, environmental, inflammatory, and neoplastic conditions. Diagnosis of these conditions involves a detailed history, physical examination of all 20 nails, and depending on the condition, a nail clipping or biopsy and/or diagnostic imaging. Nails grow even more slowly in older adults compared to younger individuals, and therefore it is important for accurate diagnosis, and avoidance of inappropriate management and delay of treatment. Increased awareness of nail pathologies may help recognition and management of nail conditions in older adults.

Clinical features and risk factors for pyogenic liver abscess caused by multidrug-resistant organisms: A retrospective study

The incidence rate of pyogenic liver abscess caused by multidrug-resistant bacteria has increased in recent years. This study aimed to identify the clinical characteristics and risk factors for pyogenic liver abscess caused by multidrug-resistant bacteria. We conducted a retrospective analysis of the clinical features, laboratory test results, and causes of pyogenic liver abscesses in 239 patients admitted to a tertiary hospital. Multivariable logistic regression was used to identify risk factors for multidrug resistance. Among patients with pyogenic liver abscesses, the rate of infection caused by multidrug-resistant organisms was observed to be 23.0% (55/239), with a polymicrobial infection rate of 14.6% (35/239). Additionally, 71 cases (29.7%) were associated with biliary tract disease. Patients with pyogenic liver abscesses caused by multidrug-resistant organisms had a significantly higher likelihood of polymicrobial infection and increased mortality (7/44 [15.9%] vs. 3/131 [2.3%]; p = .003). The Charlson Comorbidity Index (adjusted odds ratio [aOR]: 1.32, 95% confidence interval [CI]: 1.06-1.68), hospitalization (aOR: 10.34, 95% CI: 1.86-60.3) or an invasive procedure (aOR: 9.62; 95% CI: 1.66-71.7) within the past 6 months, and gas in the liver on imaging (aOR: 26.0; 95% CI: 3.29-261.3) were independent risk factors for pyogenic liver abscess caused by multidrug-resistant bacteria. A nomogram was constructed based on the risk factors identified. The nomogram showed high diagnostic accuracy (specificity, 0.878; sensitivity 0.940). Multidrug-resistant organisms causing pyogenic liver abscesses have specific characteristics. Early identification of patients at high risk of infection with multidrug-resistant organisms could help improve their management and enable personalized treatment.

Exploring the meaning of a good life for older widows with extensive need of care: a qualitative in-home interview study

INTRODUCTION

Studies of older women's life transitions is rare but gains relevance as the aging population, with older women as the majority, expands.

PURPOSE

To explore the meaning of a good life for older widows with extensive home care needs.

MATERIALS AND METHODS

Semi-structured interviews were carried out with eleven women, aged 80 and over (82-95 years, mean 90) residing at home with extensive care needs (≥4 daily sessions, averaging 2.5-6 hours, mean 3). Data were analysed by reflexive thematic analysis.

RESULTS

The theme "This Day in My Home, the frame of my life" reflects the women's experience of a good life. A good day imbued them with hope, trust and security, carrying them forward with the assurance that night would usher in a new day. However, there were moments when life was merely about navigating daily challenges. During such days, the women felt trapped in time, unsafe and lonely.

CONCLUSION

A day at home may seem static, yet it mirrors life's dynamism, evolving with shifting circumstances. Older widows navigate challenges while maintaining their sense of self, independence, and connection to home. These findings have implications for aged care, recognizing the multifaceted aspects of life and the centrality of home.

Prevalence of monoclonal gammopathy of undetermined significance in Shenzhen, China

BACKGROUND

Data on the prevalence of monoclonal gammopathy of undetermined significance (MGUS) in China are very limited. Our aim was to determine the prevalence and clinical characteristics of MGUS in a large Chinese population.

METHODS

This study included 49,220 healthy people who received serum immunofixation electrophoresis (sIFE) and serum protein electrophoresis (SPE) tests. Serum free light chain ratio, immunoglobulin quantification, and other clinically correlates of MGUS were performed for all patients with M-protein.

RESULTS

A total of 576 MGUS patients were identified by sIFE, with a median age of 58 years and an overall prevalence of 1.17% (95% CI, 1.08-1.27). Among those aged 50 years and older, the prevalence of MGUS was 2.26% (95% CI, 2.04-2.50). The prevalence of MGUS was significantly higher in males than in females (P < 0.05). The median concentration of M-protein was 3.1 g/L, ranging from 0.5 g/L to 25.1 g/L. The M-protein type was IgG in 55.4% of MGUS patients, followed by IgA (31.1%), IgM (9.5%), IgD (0.5%), biclonal (2.3%), and light chain (1.2%). Abnormalities in SPE, FLC ratios, and immunoglobulin levels were observed in 78.3%, 31.1%, and 38.4% of MGUS patients, respectively.

CONCLUSIONS

The prevalence of MGUS is substantially lower in southern China than in whites and blacks.

Chart review study of real-world clinical outcomes in patients with cutaneous T-cell lymphoma treated with extracorporeal photopheresis in the US in 2017-2019

BACKGROUND

Response rates of approved systemic therapies for cutaneous T-cell lymphoma (CTCL) hover near 30%, suggesting unmet need. This study describes real-world treatment patterns and response rates of extracorporeal photopheresis (ECP) in CTCL patients.

METHODS

A chart review was conducted in the United States of adults with CTCL who initiated ECP between January 1, 2017, and February 28, 2019, and received at least three months of ECP treatment as monotherapy or concomitant therapy. Clinical outcomes were collected quarterly for up to 18 months.

RESULTS

The 52 patients were predominantly Caucasian. Half were male; median age was 69 years. Most patients had Sézary syndrome (50%) or mycosis fungoides (36.5%). Nearly 40% of patients had stage IV disease; 33% had lymph node involvement. Nineteen patients (36.5%) achieved response (>50% reduction in BSA affected); median time to response was 6.5 months. The percentage of patients rated as at least minimally improved was 59.5% at 6 months (N = 22), 75.0% at 9 months (N = 24), and 60.0% at 12 months (N = 15) after ECP initiation.

CONCLUSIONS

Despite the ECP treated population in this study being older and having more advanced-stage disease than recent trials, response rates were comparable. These real-world findings support ECP as an effective treatment option for CTCL patients.

Geriatric nutritional risk index is associated with the occurrence of acute kidney injury in critically ill patients with acute heart failure

Background: During the acute heart failure (AHF), acute kidney injury (AKI) is highly prevalent in critically ill patients. The occurrence of the latter condition increases the risk of mortality in patients with acute heart failure. The current research on the relationship between nutritional risk and the occurrence of acute kidney injury in patients with acute heart failure is very limited. Methods: This retrospective cohort study utilized data from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version 2.1) database. We included adult patients with AHF who were admitted to the intensive care unit in the study. Results: A total of 1310 critically ill patients with acute heart failure were included. The AUC of geriatric nutritional risk index (GNRI) (0.694) is slightly superior to that of controlling nutritional status (CONUT) (0.656) and prognostic nutritional index (PNI) (0.669). The Log-rank test revealed a higher risk of acute kidney injury in patients with high nutritional risk (p < 0.001). Multivariate COX regression analysis indicated that a high GNRI (adjusted HR 0.62, p < 0.001) was associated with a reduced risk of AKI during hospitalization in AHF patients. The final subgroup analysis demonstrated no significant interaction of GNRI in all subgroups except for diabetes subgroup and ventilation subgroup (P for interaction: 0.057-0.785). Conclusion: Our study findings suggest a correlation between GNRI and the occurrence of acute kidney injury in patients hospitalized with acute heart failure.

Integrated approach to reducing polypharmacy in older people: exploring the role of oxidative stress and antioxidant potential therapy

Increased life expectancy, attributed to improved access to healthcare and drug development, has led to an increase in multimorbidity, a key contributor to polypharmacy. Polypharmacy is characterised by its association with a variety of adverse events in the older persons. The mechanisms involved in the development of age-related chronic diseases are largely unknown; however, altered redox homeostasis due to ageing is one of the main theories. In this context, the present review explores the development and interaction between different age-related diseases, mainly linked by oxidative stress. In addition, drug interactions in the treatment of various diseases are described, emphasising that the holistic management of older people and their pathologies should prevail over the individual treatment of each condition.

Predicting unplanned hospitalisations in older adults using routinely recorded general practice data

Context: Unplanned hospitalisations represent a hazardous event for older persons. Timely identification of high-risk individuals using a prediction tool may facilitate preventive interventions. Objective: To develop and validate an easy-to-use prediction model for unplanned hospitalisations in community-dwelling older adults using readily available data to allow rapid bedside assessment by general practitioners. Study Design and Analysis: retrospective study Setting or Dataset: general practice electronic health records linked with national administrative data Population Studied: 243,129 community dwelling adults aged 65 years and over Intervention/Instrument: The dataset was geographically split into a development (58.7%) and validation (41.3%) sample. The model was developed using logistic regression with backward selection. The models were validated internally and externally. We evaluated the performance of three different models with increasingly smaller selections of candidate predictors (i.e. optimal, readily-available and easy-to-use model, respectively). Predictive performance was assessed by area under the curve (AUC) and calibration plots. Outcome Measures: unplanned hospital admissions within 6 months. Results: In both samples, 7.6% had at least one unplanned hospitalisation within 6 months. The discriminative ability of the three models was comparable and remained stable after geographic validation. The easy-to-use model included age, sex, prior hospitalisations, pulmonary emphysema, heart failure and polypharmacy. Its discriminative ability after validation was AUC 0.72 [95% confidence interval: 0.72-0.71]. Calibration was good. Conclusions: Our models showed satisfactory predictive ability. Reducing the number of predictors and geographic validation did not impact predictive performance, demonstrating the robustness of the model. We developed an easy-to-use tool that may assist general practitioners in decision-making and targeted preventive interventions.

Injury Risk Functions for the Midsized Male Wrist and Elbow as a Result of Behind Shield Blunt Trauma

Ballistic shields protect users from a variety of threats, including projectiles. Shield back-face deformation (BFD) is the result of the shield deflecting or absorbing a projectile and deforming toward the user. Back-face deformation can result in localized blunt loading to the upper extremity, where the shield is supported by the user. Two vulnerable locations along the upper extremity were investigated-the wrist and elbow-on eight postmortem human subjects (PMHS) using a pneumatic impacting apparatus for investigating the fracture threshold as a result of behind shield blunt trauma (BSBT). Impacting parameters were established by subjecting an augmented WorldSID anthropomorphic test device (ATD) positioned behind a ballistic shield to ballistic impacts. These data were used to form the impact parameters applied to PMHS, where the wrist most frequently fractured at the distal radius and the elbow most frequently fractured at the radial head. The fracture threshold for the wrist was 5663±1386 N (mean±standard deviation), higher than the elbow at 4765±894 N (though not significantly, p = 0.15). The failure impact velocity for wrist impacts was 17.7±2.1 m/s, while for the elbow, the failure impact velocity was 19.5±0.9 m/s. An approximate 10% risk of fracture threshold was identified on the modified WorldSID ATD (no flesh analogue included) to inform future protective standards.

Prediction of depressive symptoms at high age (80+) by psychological, biological and functional factors

BACKGROUND

Late-life depression (LLD) is highly prevalent, especially in people aged 80 years and older. We aimed to investigate predictors and their influence on depressive symptoms in LLD.

METHODS

We analysed data from the NRW80+ study, a population-based cross-sectional study of individuals aged 80 years and older. Data from n = 926 cognitively unimpaired participants were included. We reduced 95 variables to 21 predictors of depressive symptoms by using a two-step cluster analysis (TSCA), which were assigned to one of four factors (function, values and lifestyle, autonomy and contentment, biological-somatic) according to a principal component analysis. A second TSCA with complete data sets (n = 879) was used to define clusters of participants. Using weighted mean composite scores (CS) for each factor group, binary logistic regression analyses were performed to predict depressive symptoms for each cluster and the total population.

RESULTS

The second TSCA yielded two clusters (cluster 1 (n = 688), cluster 2 (n = 191)). The proportion of participants with depressive symptoms was significantly higher in cluster 2 compared to cluster 1 (39 % vs. 15 %; OR = 3.6; 95 % CI 2.5-5.1; p < .001). Participants in cluster 2 were significantly older (mean age 88 vs. 85 years; p < .001), with a higher proportion of women (56 % vs. 46 %; OR = 1.5; 95 % CI 1.1-2.0; p = .016), had a higher BMI (p = .017), lower financial resources (OR = 2.3; 95 % CI 1.6-3.5; p < .001), lower educational level (OR = 1.8; 95 % CI 1.2-2.5; p = .002), higher proportion of single, separated or widowed participants (OR = 1.9; 95 % CI 1.3-2.6; p < .001) and a smaller mean social network (p = .044) compared to cluster 1. Binary logistic regression analyses showed that the weighted mean CS including the autonomy and contentment predictors explained the largest proportion of variance (22.8 %) for depressive symptoms in the total population (Nagelkerke's R2 = 0.228, p < .001) and in both clusters (cluster 1: Nagelkerke's R2 = 0.171, p < .001; cluster 2: Nagelkerke's R2 = 0.213, p < .001), respectively.

LIMITATIONS

The main limitations are the restriction to cognitively unimpaired individuals and the use of a self-rated questionnaire to assess depressive symptoms.

CONCLUSIONS

Psychological factors such as autonomy and contentment are critical for the occurrence of depressive symptoms at higher age, independent of the functional and somatic status and may serve as specific targets for psychotherapy.

Mental health trajectories among the general population and higher-risk groups following the COVID-19 pandemic in Switzerland, 2021-2023

BACKGROUND

Mental health deteriorated in the early stages of the COVID-19 pandemic, but improved relatively quickly as restrictions were eased, suggesting overall resilience. However, longer-term follow-up of mental health in the general population is scarce.

METHODS

We examined mental health trajectories in 5624 adults (58 % women; aged 18-97 years) from the Specchio-COVID19 cohort, using the Generalized Anxiety Disorder scale-2 and the Patient Health Questionnaire-2, administered each month from February to June 2021, and in Spring 2022 and 2023.

RESULTS

Depressive and anxiety symptoms declined during a pandemic wave from February to May 2021 (β = -0.06 [-0.07, -0.06]; -0.06 [-0.07, -0.05]), and remained lower at longer-term follow-up than at the start of the wave. Loneliness also declined over time, with the greatest decline during the pandemic wave (β = -0.25 [-0.26, -0.24]). Many higher-risk groups, including socioeconomically disadvantaged individuals, those with a chronic condition, and those living alone had poorer mental health levels throughout the study period. Women and younger individuals had a faster improvement in mental health during the pandemic wave. Loneliness trajectories were associated with mental health trajectories throughout the study period.

LIMITATIONS

We cannot definitively conclude that the observed changes in mental health were due to experiences of the pandemic.

CONCLUSIONS

While there was a need for additional mental health support during stricter policy responses to COVID-19, overall, mental health improved relatively soon after measures were eased. Nevertheless, the persistence of mental health disparities highlights the need for further efforts from the government and healthcare practitioners to support vulnerable groups beyond the pandemic.

Polygenic markers of survival and longevity in the antioxidant genes PON1, PON2, MTHFR, MSRA, SOD1, NQO1, and CAT in a 20-year follow-up study in the population from the Volga-Ural region

BACKGROUND

Genetic background of healthy or pathological styles of aging and human lifespan is determined by joint gene interactions. Lucky combinations of antioxidant gene polymorphisms can result in a highly adaptive phenotype, providing a successful way to interact with external triggers. Our purpose was to identify the polygenic markers of survival and longevity in the antioxidant genes among elderly people with physiological and pathological aging.

METHODS

In a 20-year follow-up study of 2350 individuals aged 18-114 years residing in the Volga-Ural region of Russia, sex-adjusted association analyses of MTHFR rs1801133, MSRA rs10098474, PON1 rs662, PON2 rs7493, SOD1 rs2070424, NQO1 rs1131341 and CAT rs1001179 polymorphic loci with longevity were carried out. Survival analysis was subsequently performed using the established single genes and gene-gene combinations as cofactors.

RESULTS

The PON1 rs662*G allele was defined as the main longevity marker in women (OR = 1.44, p = 3E-04 in the log-additive model; HR = 0.77, p = 1.9E-04 in the Cox-survival model). The polymorphisms in the MTHFR, MSRA, PON2, SOD1, and CAT genes had an additive effect on longevity. A strong protective effect of combined MTHFR rs1801133*C, MSRA rs10098474*T, PON1 rs662*G, and PON2 rs7493*C alleles against mortality was obtained in women (HR = 0.81, p = 5E-03). The PON1 rs662*A allele had a meaningful impact on mortality for both long-lived men with cerebrovascular accidents (HR = 1.76, p = 0.027 for the PON1 rs662*AG genotype) and women with cardiovascular diseases (HR = 1.43, p = 0.002 for PON1 rs662*AA genotype). The MTHFR rs1801133*TT (HR = 1.91, p = 0.036), CAT rs1001179*TT (HR = 2.83, p = 0.031) and SOD1 rs2070424*AG (HR = 1.58, p = 0.018) genotypes were associated with the cancer mortality.

CONCLUSION

In our longitudinal 20-year study, we found the combinations of functional polymorphisms in antioxidant genes involved in longevity and survival in certain clinical phenotypes in the advanced age.

APOE ε4 allele modifies the associations of toxic metals and their mixture with cognitive impairment among older adults

BACKGROUND

The evidence of interactive effect of the toxic metal (TM) mixture and apolipoprotein E (APOE) ε4 gene on cognitive impairment in older adults is scarce. We aimed to explore whether the associations of single TMs and their mixture with cognitive impairment depend on APOE ε4 in Chinese community-dwelling older people.

METHODS

A total of 1148 older adults from a subset of the baseline survey of a cohort study were included. Blood arsenic (As), cadmium (Cd), lead (Pb), strontium (Sr), and vanadium (V) were detected by inductively coupled plasma mass spectrometry. APOE gene (rs429358, rs7412) polymorphisms were analyzed by the Polymerase Chain Reaction instrument. Mixed effects logistic regression was applied to estimate the relationships of single TMs and APOE genotype with cognitive impairment. Weighted quantile sum (WQS) and Bayesian kernel machine regression (BKMR) models were performed to examine joint impacts of the TM mixture, as well as the interaction of the TM mixture with APOE ε4 genotype on cognitive impairment.

RESULTS

Pb displayed a significant linear association with an increased odds of cognitive impairment after adjustment for covariates (Ptrend = 0.045). While APOE genotype did not show a significant correlation with cognitive impairment. WQS showed that the TM mixture was associated with an increased risk of cognitive impairment by 31.0% (OR=1.31, 95% CI: 0.92, 1.87) while no significance was found. BKMR exhibited a significant linear association between the TM mixture and cognitive impairment. Moreover, both WQS and BKMR indicated that Pb contributed the most to cognitive impairment within the mixture. Significant interactions of Pb or the TM mixture and APOE genotype on cognitive impairment were observed, contributing to 38.1% and 38.2% of total effects, respectively.

CONCLUSIONS

APOE ε4 allele amplifies the associations of single Pb or the TM mixture with cognitive impairment. These findings may help to develop precision prevention.

Long-term exposure to air pollution, greenness and temperature and survival after a nonfatal myocardial infarction

BACKGROUND

Little is known about the impact of environmental exposures on mortality risk after a myocardial infarction (MI).

OBJECTIVE

The goal of this study was to evaluate associations of long-term temperature, air pollution and greenness exposures with mortality among survivors of an MI.

METHODS

We used data from the US-based Nurses' Health Study to construct an open cohort of survivors of a nonfatal MI 1990-2017. Participants entered the cohort when they had a nonfatal MI, and were followed until death, loss to follow-up, end of follow-up, or they reached 80 years old, whichever came earliest. We assessed residential 12-month moving average fine particulate matter (PM2.5) and nitrogen dioxide (NO2), satellite-based annual average greenness (in a circular 1230 m buffer), summer average temperature and winter average temperature. We used Cox proportional hazard models adjusted for potential confounders to assess hazard ratios (HR and 95% confidence intervals). We also assessed potential effect modification.

RESULTS

Among 2262 survivors of a nonfatal MI, we observed 892 deaths during 19,216 person years of follow-up. In single-exposure models, we observed a HR (95%CI) of 1.20 (1.04, 1.37) per 10 ppb NO2 increase and suggestive positive associations were observed for PM2.5, lower greenness, warmer summer average temperature and colder winter average temperature. In multi-exposure models, associations of summer and winter average temperature remained stable, while associations of NO2, PM2.5 and greenness attenuated. The strength of some associations was modified by other exposures. For example, associations of greenness (HR = 0.88 (0.78, 0.98) per 0.1) were more pronounced for participants in areas with a lower winter average temperature.

CONCLUSION

We observed associations of air pollution, greenness and temperature with mortality among MI survivors. Some associations were confounded or modified by other exposures, indicating that it is important to explore the combined impact of environmental exposures.

Risk prediction models of depression in older adults with chronic diseases

BACKGROUND

Detecting potential depression and identifying the critical predictors of depression among older adults with chronic diseases are essential for timely intervention and management of depression. Therefore, risk prediction models (RPMs) of depression in elderly people should be further explored.

METHODS

A total of 3959 respondents aged 60 years or over from the wave four survey of the China Health and Retired Longitudinal Study (CHARLS) were included in this study. We used five machine learning (ML) algorithms and three data balancing techniques to construct RPMs of depression and calculated feature importance scores to determine which features are essential to depression.

RESULTS

The prevalence of depression was 19.2 % among older Chinese adults with chronic diseases in the wave four survey. The random forest (RF) model was more accurate than the other models after balancing the data using the Synthetic Minority Oversampling Technique (SMOTE) algorithm, with an area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC) of 0.957 and 0.920, respectively, a balanced accuracy of 0.891 and a sensitivity of 0.875. Furthermore, we further identified several important predictors between male and female patients via constructed sex-stratified models.

LIMITATIONS

Further research on the clinical impact studies of our models and external validation are needed.

CONCLUSIONS

After several techniques were used to address class imbalance issues, most RPMs achieved satisfactory accuracy in predicting depression among elderly people with chronic diseases. RPMs may thus become valuable screening tools for both older individuals and healthcare practitioners to assess the risk of depression.

General anesthesia is not associated with dementia in older adults with osteoarthritis for hip/knee replacements, a national population-based nested case-control study

BACKGROUND

Dementia is a prevalent neurological condition, yet the relationship between dementia and general anesthesia remains uncertain. The study aimed to explore the association between general anesthesia and dementia using a nationwide population-based database.

METHODS

The study extracted data from Taiwan's national health insurance, which encompassed the records of one million insured residents. A total of 59,817 patients aged 65 years and above, diagnosed with osteoarthritis between 2002 and 2010, were included. Among these patients, 3277 individuals with an initial diagnosis of dementia between 2004 and 2013 were matched with non-dementia patients based on age, gender, and the date of osteoarthritis diagnosis. Following a 1:2 random matching, the case group included 2171 patients with dementia, while the control group consisted of 4342 patients without dementia. The data was analyzed using conditional and unconditional logistic regressions.

RESULTS

No significant differences in the odds of dementia were found between individuals exposed to general and regional anesthesia during hip/knee replacement surgeries (OR = 1.11; 95%CI: 0.73-1.70), after adjusting for age, sex, and co-morbidities. Similarly, there were no significant differences in the odds of dementia based on different durations of anesthesia exposure (General: <2 h: OR = 0.91, 95%CI = 0.43-1.92; 2-4 h: OR = 1.21, 95%CI = 0.82-1.79; >4 h: OR = 0.39, 95%CI = 0.15-1.01; compared to no exposure. Regional: <2 h: OR = 1.18, 95%CI = 0.85-1.62; 2-4 h: OR = 0.9, 95%CI = 0.64-1.27; >4 h: OR = 0.55, 95%CI = 0.15-1.96; compared to no exposure). Likewise, no significant differences were observed in the odds of dementia based on the number of replacement surgeries (twice: OR = 0.74, 95%CI = 0.44-1.23, compared to once).

CONCLUSION

Neither general anesthesia nor regional anesthesia in hip/knee surgery was associated with dementia. Different numbers and durations of anesthesia exposure showed no significant differences in the odds for dementia.

The Efficacy of Hospice-In-Place Care Versus Traditional Inpatient Care

Introduction: The hospice-in-place program at Vanderbilt University Medical Center (VUMC) is available to patients and families who elect for hospice benefits and are too unstable to be transported for hospice care. The goal of this study was to assess the satisfaction of family members of patients who died while hospitalized at VUMC and received hospice-in-place compared to the families of patients who did not receive hospice care. Methods: Next-of-kin satisfaction was measured through the administration of qualitative interviews and quantitative questionnaires. Semi-structured interviews were audio-recorded, and transcripts were analyzed using an iterative inductive-deductive approach to develop a conceptual framework. Participants were also asked to respond to a 10-question satisfaction questionnaire. Results: Forty participants were enrolled: 20 next-of-kin of patients who received hospice-in-place and 20 next-of-kin of patients who passed without hospice. Factors influencing satisfaction were organized into a conceptual framework with three categories: individual-level factors, systems-level factors, and modifying factors. For the questionnaires, the hospice-in-place group had a mean satisfaction score of 4.54 (0.76) out of five, while the non-hospice group had a mean score of 4.14 (1.00). A comparison of the two groups' responses did not show a statistically significant difference (P = 0.06). Discussion: Quantitative findings of this study showed improved satisfaction but were unable to show a significant difference in satisfaction with hospice-in-place compared to traditional care. Questionnaire results suggest that both types of care yield high satisfaction scores and are successfully supporting patients and families. The conceptual framework also adds to the understanding of end-of-life experiences at VUMC.

Adapting the Serious Illness Conversation Guide for Dementia Care

Introduction: Advance care planning (ACP), a critical component of quality dementia care, is underutilized due to lack of clinician comfort and the challenging nature of ACP in this context. The Serious Illness Conversation Guide (SICG) is a well-validated clinician-facing tool, developed with patient and clinician input, to facilitate ACP. The aim of this project was to adapt the SICG for dementia for the first time to promote high-quality ACP. Methods: This study uses a mixed-methods approach to adapt the SICG tool for use in dementia care. Experts with relevant clinical, ethical, and topical knowledge were interviewed to develop alterations to the SICG for dementia care. Patients and caregivers were shown a mock interview of the adapted SICG for dementia (SICG-D) to elicit feedback. Results: 8 relevant experts were interviewed. Adaptations included topical alterations to make the conversation more applicable to dementia as well as alterations to the structure of the conversation to accommodate the patient-caregiver dyad. Twenty interviews were conducted with 14 patients and 18 caregivers (either together or separately). A thematic content analysis of interview transcripts demonstrated positive impressions of the tool. In anonymous survey results, 94% reported a positive impression of the conversation and 89% endorsed incorporation of the adapted guide into dementia healthcare. Conclusion: This paper presents the SICG-D, an adapted version of the SICG for use in dementia care. This guide leverages the strengths of the SICG to promote values-based ACP conversations and has been adapted to better facilitate patient-caregiver-clinician triadic communication.

INSM1 is a useful neuroendocrine marker to differentiate pancreatic serous cystadenoma from pancreatic well-differentiated neuroendocrine tumors in cytology and surgical specimens

INTRODUCTION

Differentiating pancreatic serous cystadenoma (SCA) from well-differentiated neuroendocrine tumors (WDNETs) based on histomorphology is critical yet challenging, particularly in small biopsy samples. Our study aimed to examine the expression profile of INSM1 in cytologic and surgical resection specimens from pancreatic SCA to evaluate its potential as a discriminative marker against pancreatic WDNET.

METHODS

We characterized INSM1 immunohistochemistry in 34 patients with pancreatic SCA, comprising 23 surgical resections and 11 cytology specimens. As a control, we used 28 cytology specimens from pancreatic WDNET. Clinical information was retrieved through a review of electronic medical records.

RESULTS

All 11 pancreatic SCA cytology specimens and 15 of 23 pancreatic SCA surgical resections exhibited absent INSM1 immunostaining. Each of the remaining eight surgical resection specimens demonstrated 1 % immunoreactivity. In contrast, 27 out of 28 (96 %) pancreatic WDNET cytology specimens were positive for INSM1 immunostaining, with a median immunoreactivity of 90 % and a range of 30-90 %. Overall, INSM1 immunostains perform similarly to chromogranin and synaptophysin in pancreatic SCA.

CONCLUSIONS

The results indicate that INSM1 immunohistochemistry staining may serve as a useful neuroendocrine marker to differentiate pancreatic SCA from pancreatic WDNET in clinical practice. To our knowledge, this represents the first large-scale study to evaluate INSM1 immunostaining in surgical and cytology specimens from pancreatic SCA.

Depth of invasion analysis to predict acral melanoma outcomes

BACKGROUND

Acral melanoma is a subtype with worse outcomes. The Breslow micrometric measurement is the most critical parameter in planning treatment and predicting outcomes. However, for acral lentiginous melanoma, the value of the Breslow thickness is a matter of debate. Depth of Invasion (DOI) is a well-established measure for staging oral squamous cell carcinoma.

OBJECTIVE

This study compared DOI and Breslow thickness for predicting acral melanoma outcomes.

METHODS

We performed a retrospective cross-sectional study of 71 acral melanoma lesions subjected to sentinel lymph node biopsy at one Brazilian referral center.

RESULTS

Cox model univariate analysis showed that both DOI and Breslow thickness predicted melanoma specific survival (HR 1.12; p = 0.0255 and HR 1.144; p = 0.0006, respectively), although Kaplan Meier curve was only significant for Breslow (χ2 = 5.792; p = 0.0161) and not for DOI (χ2 = 0.2556; p = 0.6132). Sentinel lymph node status and presence or absence of ulceration also predicted specific survival in patients with acral melanoma (χ2 = 6.3514; p = 0.0117 and χ2 = 4.2793; p = 0.0386, respectively). Multivariate analysis, however, demonstrated that Breslow depth was the only independent parameter for predicting acral melanoma specific survival (HR 1.144; p = 0.0006).

CONCLUSION

Even though Breslow thickness remains the main predictor for survival in acral melanoma, it is not a perfect parameter. The introduction of DOI in this context opens new perspectives for predicting acral melanoma outcomes.