Validation of the Pandemic Grief Risk Factors and Its Relationship With Work-Related Stress and Grief Reaction Among Healthcare Workers Who Witnessed Patient Deaths

BACKGROUND

The Pandemic Grief Risk Factors (PGRFs) was developed as a self-report tool to compile a comprehensive list of unique risk factors related to grief when experiencing a coronavirus disease 2019 (COVID-19) loss. We explored the reliability and validity of the PGRF among healthcare workers who witnessed their patients' deaths during the COVID-19 pandemic. Further, we examined whether the general severity of PGRF may have been associated with work-related stress and pandemic grief reactions.

METHODS

An online survey was conducted among tertiary hospital healthcare workers (doctors and nursing professionals) who had witnessed the deaths of patients they cared for. Pandemic Grief Scale for healthcare workers, the Stress and Anxiety to Viral Epidemics-3 items, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7 responses were collected.

RESULTS

In total, 267 responses were analyzed. The single-factor structure of the Korean version of the PGRF showed a good fit for the model. The scale demonstrated good internal consistency and convergent validity with other depression and anxiety rating scales. The mediation analysis revealed that work-related stress directly influenced pandemic grief reactions positively, and depression, anxiety, and general severity of grief risk factors partially mediated the association positively.

CONCLUSION

Among healthcare workers who witnessed the deaths of their patients due to COVID-19, the Korean version of the PGRF was valid and reliable for measuring the overall severity of PGRF. The PGRF can be used to identify individuals at risk for dysfunctional grief.

Pandemic Grief and Suicidal Ideation in Latin American Countries: A Network Analysis

This study aimed to characterize the network structure of pandemic grief symptoms and suicidal ideation in 2174 people from eight Latin American countries. Pandemic grief and suicidal ideation were measured using the Pandemic Grief Scale and a single item, respectively. Network analysis provides an in-depth characterization of symptom-symptom interactions within mental disorders. The results indicated that, "desire to die," "apathy" and "absence of sense of life" are the most central symptoms in a pandemic grief symptom network; therefore, these symptoms could be focal elements for preventive and treatment efforts. Suicidal ideation, the wish to die, and the absence of meaning in life had the strongest relationship. In general, the network structure did not differ among the participating countries. It identifies specific symptoms within the network that may increase the likelihood of their co-occurrence and is useful at the therapeutic level.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

COVID-19 Bereavement in Ten Latin American Countries: Measurement Invariance of the Pandemic Grief Scale and Its Relation to Suicidal Ideation

The present study aimed to evaluate the cross-cultural measurement invariance of the Pandemic Grief Scale (PGS) in ten Latin American countries. A total of 2,321 people who had lost a family member or other loved one due to COVID-19 participated, with a mean age of 34.22 years old (SD = 11.99). In addition to the PGS, a single item of suicidal ideation was applied. The unidimensional model of the PGS had adequate fit in most countries and good reliability estimates. There was evidence of measurement invariance by country and gender. Also, a one-point increase in the PGS was associated with an almost twofold increase in the odds of suicidal ideation. Scores greater than or equal to 4 on the PGS are proposed as a cut off to identify individuals with suicidal ideation. Strong evidence of the cross-cultural validity of the PGS is provided.

Assessment of Obsessive Thoughts About COVID-19 in 7 Latin American Countries: Structure and Measurement Invariance of the Obsession With COVID-19 Scale

The present study aimed to evaluate the measurement invariance of the Obsession with COVID-19 Scale (OCS) among seven Latin American countries: Bolivia, Brazil, Cuba, El Salvador, Guatemala, Paraguay, and Uruguay. Although the OCS has been used in several countries and languages, there is a need for approaches that better integrate the cross-cultural equivalence of the scale. A total of 3185 people participated in the study. The results indicated the presence of a unidimensional structure and good reliability indices for the OCS in each country. The alignment method indicated that the OCS is an invariant measure of COVID-19 obsession among the populations of seven Latin American countries. The findings based on IRT analysis indicated that all OCS items had adequate discrimination and difficulty parameters. The findings contribute to the understanding of the internal structure of the scale in different countries at the same time, something that has been pending evaluation.

A Psychometric Analysis of the Spanish Version of the Grief Impairment Scale: A Screening Tool of Biopsychosocial Grief-Related Functional Impairment in a Salvadoran Sample

The objective of this study was to translate and psychometrically evaluate a Spanish version of the Grief Impairment Scale (GIS) using a sample of bereaved adults from El Salvador (N = 579). The results confirm the unidimensional structure of the GIS, and solid reliability, item characteristics, and criterion-related validity, where the GIS scale significantly and positively predicts depression. However, this instrument only showed evidence of configural and metric invariance between different sex groups. Overall, these results support the Spanish version of the GIS as a psychometrically sound screening tool for health professionals and researchers to use in their clinical work.

Pandemic grief in El Salvador: factors that predict dysfunctional grief due to a COVID-19 death among Salvadoran adults

Thousands of people have died of COVID-19 in El Salvador. However, little is known about the mental health of those who are mourning the loss of a loved one to COVID-19. Therefore, the objective of this study was to examine the dysfunctional grief associated with COVID-19 death among Salvadoran adults. A sample of 435 Salvadorans (M = 29 years; SD = 8.75) who lost a family member or loved one to COVID-19 completed a digital survey using the Google Forms platform, during April 2 and 28, 2022. The results revealed that 35.1% reported clinically elevated symptoms of dysfunctional grief and among those mourners, and 25.1% also exhibited clinical levels of coronavirus anxiety. A binary logistic regression revealed that predictor variables such as COVID-19 anxiety (p = .003), depression (p = .021), and COVID-19 obsession (p = .032) were significant (χ² = 84.31; Nagelkerke R² = .242) and predict a 24.2% chance of dysfunctional bereavement.

Personality and Grief-Related Panic Attacks: Analysis of Neuroticism, Worry, and Anxiety Sensitivity

Grief-related panic attacks (GRPAs) are a relatively common yet debilitating psychological reaction to loss, the mechanisms of which remain poorly understood among scholars. The purpose of this study was to identify the personality traits that underlie GRPAs in a sample of 314 bereaved adults. The results indicate that GRPAs were relatively common (55.4%) and that anxiety sensitivity uniquely predicted both frequency and impairment associated with these kinds of attacks, while taking into account the effects of neuroticism, trait worry, grief, and gender. Findings suggest that anxiety sensitivity may be a risk factor for GRPAs and magnified grief for some mourners. Clinical implications and future directions are discussed.

Brazilian Adaptation of the Coronavirus Anxiety Scale: A Psychometric Investigation of a Measure of Coronaphobia

This study examined the psychometric properties of a Brazilian adapted version of the Coronavirus Anxiety Scale (CAS-BR) in a sample of adults in Brazil. Confirmatory factor analyses demonstrated that the CAS-BR produces a reliable (α = .84), unidimensional construct whose structure was shown to be invariant across gender, race, and age. However, some items of the CAS-BR were stronger indicators of the coronavirus anxiety construct for women and younger adults. Although the CAS-BR demonstrated evidence of discrimination ability for functional impairment (AUC = .77), Youden indexes were low to identify a clinical cut-score. Construct validity was demonstrated with correlations between CAS-BR scores and measures of functional impairment, generalized anxiety, and depression. Exploratory analyses revealed that CAS-BR total scores were higher among women and participants with a history of anxiety disorder. These findings are consistent with previous investigations and support the validity of CAS-BR for measuring coronavirus anxiety with Brazilian adults.

Validation of the healthcare workers' version of the Pandemic Grief Scale among frontline nursing professionals during the COVID-19 pandemic in Korea

Introduction

Nurses have been repeatedly exposed to unexpected death and grief during COVID-19 pandemic, and it is necessary to provide grief support for the nurses who have experienced the loss of patients to COVID-19. We aimed to explore the reliability and validity of the Pandemic Grief Scale (PGS) for Healthcare Workers among frontline nursing professionals working in COVID-19 inpatient wards whose patients may have died.

Methods

An anonymous online survey was performed among frontline nursing professionals working in COVID-19 wards in three tertiary-level general hospitals in Korea between April 7 and 26, 2021. In total, 229 from participants who confirmed they had witnessed death of patients were employed for the statistical analysis. The survey included demographic characteristics and rating scales, including the Korean version of the PGS for Healthcare Workers, the Fear of COVID-19 scale, the Generalized Anxiety Disorder-7 items, and the Patient Health Questionnaire-9 items.

Results

The single-factor structure of the Korean version of the PGS for Healthcare Workers showed good fits for the model. The scale had good internal consistency and convergent validity with other anxiety and depression scales.

Conclusion

The Korean version of the PGS of Healthcare Workers was valid and reliable for measuring grief reactions among nursing professionals facing the pandemic. It will be helpful in evaluating the grief reaction of the healthcare workers and providing them with a psychological support system.

Red State, Blue State, Purple State; Higher and Increasing Blue COVID-19 Anxiety Rate

The present study investigated COVID-19 Anxiety Scale (CAS) scores for participants from blue states, red states, and purple states across 276 days ranging from April 18, 2020 to January 23, 2021. The CAS scores increased with knowing and caring for an individual with COVID-19, following social distancing guidelines, hours talking and thinking about COVID-19, hypochondria, neuroticism, depression, anxiety, stress, negative PANAS, and time, whereas they decreased with positive PANAS. More importantly, the CAS scores were higher for participants from blue states than for participants from purple states, and the positive relation between CAS scores and time was only significant for participants from blue states. We connected media events that occurred concurrently for high CAS scores overall and for high CAS scores for participants from blue states. The spikes in CAS ratings occurred along with COVID-19 contagion, partisan reactions to protests for slain African Americans (e.g., George Floyd), and the 2020 presidential election.

Spirituality Influences Emotion Regulation During Grief Talk: The Moderating Role of Prolonged Grief Symptomatology

A growing body of research demonstrates that religion greatly affects people's adjustment to loss. However, little is known about the influence of religiosity on emotion regulation during grief. The present study attempts to fill this void in the literature by examining the predictive relationship between variables assessing facets of religiosity and emotion regulation during an interview about loss in a sample of bereaved adults. The results demonstrated that religiousness, spirituality, and negative religious coping were correlated with emotion reactivity following an interview. Spirituality's influence was also found to be moderated by prolonged grief symptoms, as spirituality predicted more adaptive emotion regulation among those with low-to-mild levels of prolonged grief symptomatology, but not among participants with elevated prolonged grief disorder (PGD) symptoms. These findings support the beneficial effects of religion in bereavement adjustment as well as its limits.

Air Pollution Levels Outside the Capital's Maternity Hospitals

Introduction The World Health Organisation has identified air pollution as the single biggest environmental threat to human health. There is growing evidence in the literature that air pollution is associated with negative outcomes in pregnancy. The purpose of this study was to measure pollution levels in the immediate surroundings of the three Dublin maternity hospitals by measuring fine particulate matter &lt;2.5 micrometres (PM2.5). Methods Data pertaining to levels of PM2.5 at the three Dublin maternity hospitals were obtained from Pollutrack's records for the time period 25/6/2021-2/12/2021. Results were compared to the 2021 WHO Air Quality Guidelines. Results Average PM2.5 levels were 9μg/m³ around the National Maternity Hospital, 10μg/m³ around the Coombe Hospital and 13μg/m³ around the Rotunda Hospital. Levels were higher during the day, weekdays and in December. No matter when the PM2.5 levels were measured, results were higher than those recommended by the World Health Organisation's Air Quality Guideline. Discussion Air pollution levels across Ireland's capital city are higher than recommended by the WHO. This is concerning for the public and in particular for the pregnant population. Going forward, further research is required on the relationship between levels of air pollutants and adverse pregnancy outcomes in Dublin.

Measurement of Risk Factors Associated With bereavement Severity and Deterioration by COVID-19: A Spanish Validation Study of the Pandemic Grief Risk Factors

The present study translated and evaluated the psychometric evidence of the Pandemic Grief Risk Factors (PGRF) in a sample of 363 people from the general population of Peru who suffered the death of a loved one by COVID-19 (63-4% women and 36.6% men, where 78.5% were between 18 and 29 years old). The findings indicated that the PGRF is a unidimensional and reliable measure. The PGRF items can differentiate between individuals with different levels of risk factors and thus cover a wide range of the latent construct. Also, a greater sense of distress for each of the risk factors for pandemic grief is necessary to answer the higher response categories. Risk factors significantly and positively predict COVID-19-associated dysfunctional grief. The results indicated that the PGRF in Spanish is a measure with adequate psychometric properties to measure risk factors for pandemic grief.

Grief Impairment Scale: A biopsychosocial measure of grief-related functional impairment

Though most mourners are resilient, a minority of the bereaved experience disabling grief accompanied by clinically significant impairment in important areas of functioning. Although impairment measures exist, they have notable limitations in the context of bereavement. Therefore, the objective of this study was to develop and evaluate the Grief Impairment Scale (GIS), which was designed to identify the impact of grief on biopsychosocial functioning. The resulting 5-item scale, which was based on 363 adults who are struggling with grief, demonstrated solid reliability, factorial validity, and convergent and divergent validity with correlations with measures of impairment, prolonged grief, and psychological distress. The GIS also measures grief-related functioning equivalently across demographic groups and satisfactorily discriminates between persons with and without impairment using an optimized cut score of ≥ 9 (79% sensitivity and 74% specificity). These results provide preliminary support for the GIS as a flexible tool for clinical research and practice.

Implementing Medical Student Teaching on Gynaecological Healthcare of Transgender Patients

Introduction Transgender people have specific healthcare needs and experience difficulty in accessing health services. Medical students should receive teaching on general and gynaecological healthcare issues in this population. Our aim was to assess medical students' knowledge of healthcare needs of transgender people before and after a newly implemented teaching session on transgender healthcare. Method A mixed-method study was carried out over a three month period in a university obstetric and gynaecology hospital in Dublin. A one-hour teaching session was developed and delivered to final year medical students. Students completed a survey before and after receiving the lecture. Results Seventy-one students completed the pre-lecture survey and forty-three completed the post-lecture survey. Pre-lecture, 64 students (90%) reported some-to-no understanding of healthcare issues of transgender people, and only 13 (18%) reported understanding gynaecological issues faced by transgender people. Post-lecture, 41 (95%) had a better understanding of health issues faced by this population and 40 (93%) had a better understanding of gynaecological health issues faced. Most students (81%) wanted further teaching on the topic. Conclusion A one-hour teaching session was effective at improving student knowledge of care of transgender people. This teaching could be expanded to all Irish medical schools. Going forward, the teaching could be adapted for post-graduate obstetric and gynaecology teaching.

Unfinished business and self-blaming emotions among those bereaved by a COVID-19 death

In view of the mounting death toll of COVID-19 worldwide and the complicating circumstances that commonly accompany such losses, we studied the grief experiences of 209 adult mourners who lost a loved one to coronavirus with a focus on self-blaming emotions and unresolved issues with the deceased. We found universal endorsement of one or more forms of self-blame (guilt, regret, shame) or unfinished business (UB), with over one-third of mourners endorsing all four experiences. Those having a closer relationship to the deceased reported both greater distress over UB and more intense and dysfunctional grief symptomatology. Strikingly, unresolved conflict, a major dimension of UB, accounted for nearly 40% of the unique variance in problematic grief, which bore no relation to time since the loss.

Bereavement in Pakistan during the COVID-19 pandemic: Psychometric analysis of the Pandemic Grief Scale-Urdu Version (PGS-UV)

With nearly 4 million deaths worldwide, COVID-19 has resulted in a great loss of life. For many of the bereaved, the grieving process has been especially difficult due to COVID-19 spatial distancing procedures and the traumatic circumstances of this particular form of loss. Consequently, a large number of the world's bereaved are experiencing dysfunctional levels of grief. To assess such grief, the Pandemic Grief Scale (PGS) was created to identify those affected who may benefit from professional support. This study aimed to psychometrically analyze the properties of the Urdu version of the scale, among a sample of 272 Pakistanis who lost a loved one to COVID-19 from March to June 2021. Results revealed that the scale was found to be a reliable and valid tool for assessing dysfunctional pandemic grief for both men and women. However, unique gender differences were found. Additional research should further confirm the psychometric properties of the PGS on other culturally diverse samples.

Social isolation and the mitigation of coronavirus anxiety: The mediating role of meaning

This study examined core belief violation and meaning making as mechanisms mediating the relationship between adherence to social isolation policies for mitigating coronavirus transmission and reduced coronavirus anxiety (CA). Adherence to social isolation policies (social distancing, sheltering in place, and cessation of long-distance travel), use of nonsocial precautionary measures (handwashing, wearing a mask), core belief violation, meaning made of the COVID pandemic, and CA were assessed in a sample of 408 North Americans. Process analysis revealed that adhering to social isolation policies predicted lower levels of CA and that this effect was largely mediated by conservation of core beliefs (e.g., in predictability, control, and self-agency) and ability to make meaning of the pandemic. In contrast, exclusive reliance on nonsocial protections such as handwashing and mask wearing was associated with high levels of CA. These results suggest that social isolation policies support the integrity of adherents' meaning systems, thereby mitigating distress, which carries useful implications for both policy and psychological intervention.

The Psychometric Properties of the Stress and Anxiety to Viral Epidemics-6 Items: A Test in the U.S. General Population

Objectives: Many individuals around the world are suffering from psychological distress due to the COVID-19 outbreak. The aim of this study is to explore the validity and reliability of the English version of Stress and Anxiety to Viral Epidemics-6 (SAVE-6), which measures the anxiety response of the general population to the viral epidemic. Methods: A cross-sectional web-based study with self-reporting measures was conducted. A total of 314 United States residents were recruited via online platform in exchange for payment. The participants were asked to an anonymous questionnaire, collecting information on demographics, psychiatric history, SAVE-6, Patient Health Questionnaire-4 (PHQ-4), and the Coronavirus Anxiety Scale. Results: The result from confirmatory factor analysis (CFA) demonstrated that a single-factor model [χ ( 9 ) 2 = 11.53, p = 0.24] yielded excellent fit for all of indices [χ2/df ratio = 1.28; CFI = 1.00; TLI = 1.00; SRMR = 0.02; RMSEA = 0.03 (0.00, 0.07; 90% CI)] and yielded strong internal consistency reliability (Cronbach's α = 0.88). The results from multigroup CFAs showed that there were no gender differences [ Δ χ ( 6 ) 2 = 3.20, p = 0.78, ns] and no race differences [ Δ χ ( 6 ) 2 = 3.60, p = 0.73, ns] between the models, along with excellent model fits. Conclusions: The results of this study support the reliability and validity of SAVE-6 with strong psychometric properties for the English version of the U.S. population.

Risk factors for dysfunctional grief and functional impairment for all causes of death during the COVID-19 pandemic: The mediating role of meaning

The COVID-19 pandemic, coupled with significant social changes due to legislative and public health requirements, has changed the way in which people experience grief. We examined whether dysfunctional grief symptoms, disrupted meaning, risk factors, and functional impairment differed between people bereaved from COVID-19 and from other natural or violent causes in this same period. A sample of 409 participants (67.73% male; M = 37.54 years) completed an online survey in June 2021. There were no statistically significant differences between the three groups on any of the outcome variables; all three groups manifested clinical levels of functional impairment equal to or greater than bereaved groups diagnosed with complicated or prolonged grief disorder prior to the pandemic. Disrupted meaning partially mediated the relationship between risk factors on the one hand and functional impairment and dysfunctional grief symptoms on the other. Findings indicate that deaths during COVID-19, rather than deaths from COVID-19, may precipitate symptoms of significant clinical concern.

Assessment of Dysfunctional Grief due to Death from COVID-19 in Peru: Adaptation and Validation of a Spanish Version of the Pandemic Grief Scale

This study evaluated the psychometric properties of the Pandemic Grief Scale (PGS), using Classical Test Theory (CTT) and Item Response Theory (IRT) methods, in a sample of 458 people who have suffered the loss of a loved one due to the COVID-19 pandemic. The Pandemic Grief Scale, Patient Health Questionnaire-2 (PHQ-2), the two-item Generalized Anxiety Disorder Scale (GAD-2), and a single item on suicidal ideation were used. The unidimensional model had good fit and reliability; furthermore, convergent validity was demonstrated based on the relationships between dysfunctional grief, anxiety symptoms, depression, and suicidal ideation. Additionally, a higher presence of dysfunctional grief is required to answer using the higher response categories. The evidence of validity and reliability of the PGS in its Spanish version, using traditional and modern methods, is confirmed in Peru.

Validating the Coronavirus Anxiety Scale in a Colombian sample

The present instrumental study evaluated the psychometric properties of the Coronavirus Anxiety Scale with 421 Colombian adults in full lockdown of coronavirus. The reliability was excellent, obtained through the Cronbach's Alpha coefficient (α = 0.83). The results of the confirmatory factor analysis identified satisfactory indicators for the scale's one-dimensional model. The correlations obtained in the discriminant analysis of the items have a moderate level of correlation with values between 0.74 and 0.81. These findings demonstrate that the Coronavirus Anxiety Scale is a valid and reliable instrument to evaluate dysfunctional anxiety related to coronavirus in Colombian population.

Growth performance, real-time gizzard pH and calcium solubility in the gut of broiler chickens is dependent on the interaction between dietary calcium concentration and limestone particle size

1.The purpose of this study was to determine the effect of limestone particle size and dietary Ca concentration on performance, real-time gizzard pH, and Ca and P solubility in the gastrointestinal tract of 21d broiler chickens.2. A total of 576, one-day-old Ross 308 male broilers were randomly allocated among 4 treatments, with 8 replicate pens, and 18 birds per pen. Treatments were arranged as a 2 × 2 factorial consisting of two particle sizes of limestone (coarse, CL, 1200 µm; fine, FL, 44 µm) and two Ca concentrations (9.6 or 6.0 g/kg). On d 19 and 20, four birds per treatment were administered Heidelberg pH capsules and readings monitored for 3 h.3. Reducing Ca concentration from 9.6 to 6.0 g/kg had no effect on d 21 weight gain or FCR of birds fed CL; however, feeding FL at 9.6 g/kg Ca increased weight gain by 10% and reduced FCR by 5% compared to FL at 6.0 g/kg Ca (P < 0.001).4. Average gizzard pH readings ranged from pH 0.67 to 3.01 across all treatments. Birds fed CL at 6.0 g/kg Ca had lower average gizzard pH compared to birds fed 9.6 g/kg Ca, while birds fed FL at 6.0 g/kg Ca had higher gizzard pH than birds fed CL at both Ca concentrations, but was comparable to birds fed FL at 9.6 g/kg Ca (P < 0.001).5. For birds fed CL at 6.0 g/kg Ca, soluble Ca in the gizzard was approximately 40% lower (P < 0.05) than all other treatments, and reduced by 44% (P < 0.05) in the small intestine compared with birds fed FL at 6.0 g/kg Ca.6. These findings demonstrated that the effect of Ca concentration on gizzard pH, Ca solubility and broiler performance was dependent on limestone particle size and suggested that solubility per se had little relevance to performance.

Circumstances of the death and associated risk factors for severity and impairment of COVID-19 grief

This study examined the relationship between reactions of the bereaved to conditions of the pandemic and severity of their grief and levels of impairment. A total of 831 American adults who lost a loved one to COVID-19 responded to validated measures of dysfunctional grief and functional impairment, as well as items assessing unique complications associated with the pandemic (e.g. resentment toward doctors, social isolation). In combination, circumstantial risk factors accounted for 59% of the variance in social impairment and fully 71% of the variance in pandemic grief, leading to the development of an inventory of Pandemic Grief Risk Factors (PGRF), which displayed a unified factor structure, high reliability and strong convergent validity. Implications for psychological screening and intervention for those bereaved by COVID-19 are briefly noted.

The Utility of the Pandemic Grief Scale in Identifying Functional Impairment from COVID-19 Bereavement

Background: Meeting the needs of people bereaved by COVID-19 poses a substantial challenge to palliative care. The Pandemic Grief Scale (PGS) is a 5-item mental health screener to identify probable cases of dysfunctional grief during the pandemic. Objective: The PGS has strong psychometric and diagnostic features. The objective was to examine the incremental validity of the PGS in identifying mourners at risk of harmful outcomes. Design: A cross-sectional survey design involving sociodemographic questions and self-report measures of pandemic grief, generalized anxiety, depression, post-traumatic stress, separation distress, functional impairment, meaning-making difficulties, and substance use coping. Setting/Subjects: A sample of people bereaved through COVID-19 (N = 1065) in the United States. Results: Fully 56.6% of participants scored above the cut score of ≥7 on the PGS for clinically dysfunctional pandemic grief and 69.7% coped with their loss using drugs or alcohol for at least several days in past two weeks. PGS scores were not associated with time since loss. Hierarchical multiple regression models demonstrated that the PGS uniquely explained variance in functional impairment, meaning-making difficulties, and substance use coping, over relevant background factors, bereavement-related psychopathology, and separation distress. In the final model, the standardized regression coefficients for the PGS were 2-15 times larger than for the other competing measures in explaining each of the three outcomes. Conclusions: The findings underscore the clinical utility of this short and easy-to-use measure in identifying risk of deleterious outcomes across a range of functional and behavioral domains.

Pandemic grief in Poland: adaptation of a measure and its relationship with social support and resilience

Millions of people are mourning the death of a loved to COVID-19. According to previous studies, the circumstances of coronavirus disease-related deaths may lead to dysfunctional grief. The purpose of this study was to introduce the Polish adaptation of the Pandemic Grief Scale (PGS) as well as to assess the relationship between dysfunctional grief due to a COVID-19 death, resilience and perceived social support. The adaptation was carried out on a general population sample of 286 individuals aged 18-54 years, with the evaluation being performed on a group comprising 214 people aged 18-78 years, who lost a loved one during the pandemic. The Polish version of PGS revealed a single-factor structure with strong internal consistency (α = 0.89). The PGS scores were associated with measures of complicated grief (Inventory of Complicated Grief), depression (Kutcher Adolescent Depression Scale) and lower resilience (Resilience Scale 14), which confirmed the scale's convergent validity. No relation between PGS scores and health behaviors (Inventory of Health Behaviors) was observed, which confirmed the scale's discriminant validity. The results of the bootstrapping technique revealed that resilience mediates the relationship between perceived social support (Multidimensional Scale of Perceived Social Support) and dysfunctional grief (total mediation). The results of this study suggest the need for practitioners to focus on resilience-enhancing interventions and perceived social support in order to improve mental health in people who lost their loved ones during the new coronavirus pandemic.

Psychological Risk Factors of Functional Impairment After COVID-19 Deaths

CONTEXT

People bereaved from COVID-19 report higher levels of grief than people bereaved from natural causes. The full impact of this onslaught of grief will not be known for some time. Ensuring high-quality bereavement care in the context of COVID-19 presents unprecedented challenges to end-of-life care.

OBJECTIVES

We aimed to determine how psychological symptoms explain functional impairment.

METHODS

A sample of people bereaved through COVID-19 (N = 307) in the United States completed demographic questions and self-report measures of neuroticism; symptoms of depression, generalized anxiety, posttraumatic stress, separation distress, and dysfunctional grief; and functional impairment due to a COVID-19 loss.

RESULTS

Most participants' scores were in the clinical ranges for generalized anxiety, depression, dysfunctional grief, and functional impairment. Functional impairment scores were not associated with age, gender, and time since loss but were associated with being diagnosed with COVID-19, having received professional help with the loss, and a close relationship to the deceased. A logistic regression model showed that, after controlling for covariates, the odds of functional impairment significantly increased by 27% for higher scores in separation distress, 25% for higher scores in dysfunctional grief, and 13% for higher scores in posttraumatic stress.

CONCLUSION

People bereaved because of COVID-19 are at risk of functional impairment, especially if they have symptoms of separation distress, dysfunctional grief, and/or posttraumatic stress. Attention to identifying and treating functional impairment may be important in facilitating grieving persons' full participation in social and economic life during and after the pandemic.

Validation of the Brazilian Portuguese version of the Obsession with COVID-19 Scale (BP-OCS) using a large University Sample in Brazil

We aimed to validate a Brazilian Portuguese version of the Obsession with COVID-19 Scale (BP-OCS) using a large sample of university students in Brazil (N = 1454). The scale showed solid psychometric characteristics in terms of internal consistency (α = .78), test-retest reliability (ICC = .86), factorial validity (PAF and CFA support), and construct validity. Additionally, BP-OCS scores were found to be higher among females, participants with diagnosed depression, anxiety, and self-reported anxiety. These findings suggest that the BP-OCS is a reliable and valid measure of persistent and disturbed thinking about COVID-19 for Brazilian university students.

Pandemic Grief Scale: A screening tool for dysfunctional grief due to a COVID-19 loss

Millions of people are grieving the loss of someone who died of COVID-19. However, there have been no screening tools developed to identify individuals who may be suffering from dysfunctional grief during the pandemic. Therefore, the objective of this study was to develop and evaluate the properties of the Pandemic Grief Scale (PGS), which is a brief mental health screener to identify probable cases of dysfunctional grief associated with a COVID-19 death. This 5-item scale, which was based on 831 adults who lost someone to COVID-19, demonstrated solid reliability (αs = 0.86), factorial validity (PCA and CFA support), and construct validity with strong correlations with suicidal ideation and substance use coping. The PGS measures COVID-19 grief equivalently across demographic groups, and discriminates well between persons with and without dysfunctional grief using an optimized cut score of ≥ 7 (87% sensitivity and 71% specificity). An alarming 66% of the sample scored in the clinical range. The PGS also demonstrates incremental validity by explaining 18% additional variance in functional impairment due to a COVID-19 loss beyond measures of depression and generalized anxiety. These results support the PGS as an efficient and valid screening tool for clinical research and practice during a pandemic.

Validation of the Korean version of the obsession with COVID-19 scale and the Coronavirus anxiety scale

In response to the current COVID-19 pandemic, the Obsession with COVID-19 scale (OCS) and the Coronavirus Anxiety Scale (CAS) were developed as screening tools for dysfunctional anxiety associated with the coronavirus. These scales have not yet been validated in the East Asia. The present study examined the validity of the OCS and the CAS with a sample of 329 Korean adults. We found that the OCS-Korean and CAS-Korean showed good psychometric properties and construct validity. Developing such valid screening tools across different cultures is vital for health practitioners and scholars alike during global infectious disease outbreaks.

Coronaphobia among healthcare professionals in Mexico: A psychometric analysis

The present study examined the validity of the coronaphobia phenomenon with healthcare professionals using a psychometric approach. Using SurveyMonkey, an adapted version of the Coronavirus Anxiety Scale-Healthcare version (CAS-HC) was administered to 231 adult healthcare professionals in Mexico. Confirmatory factor analysis demonstrated that dysfunctional coronavirus anxiety symptoms cohered into a reliable, single factor structure of coronaphobia. A receiver operating characteristic curve analysis indicated that the classification features of the CAS-HC were strong, but supported a less stringent cut-score for this population. Construct validity was supported by the positive correlations between the CAS-HC and measures of depression and generalized anxiety, while known groups validity was found with high CAS-HC scores exhibited by those working in emergency rooms, triage, and intensive care units. The findings collectively support the coronaphobia construct with healthcare professionals, and the finding that over one third of the participants in the study scored in the clinical range on this measure points to the critical importance of assessing and alleviating this form of distress in this vulnerable but indispensable workforce.

Fear and Psychopathology During the COVID-19 Crisis: Neuroticism, Hypochondriasis, Reassurance-Seeking, and Coronaphobia as Fear Factors

The COVID-19 pandemic has generated a rise in psychological distress worldwide. Although fear appears to be a major contributing factor, there has been no systematic research to determine which specific facets of fear predict psychopathology during the coronavirus crisis. The present study is the first to examine which fear factors uniquely predict clinical levels of depressive symptoms and generalized anxiety. Data were collected from 256 adults in the United States recruited from Amazon's Mechanical Turk (MTurk) during the coronavirus pandemic. The results from logistic regression analyses demonstrated that neuroticism, coronaphobia, and hypochondriasis were fear factors that predicted pandemic-related psychopathology in adults. These findings suggest that mental health professionals should screen individuals for this set of fear factors when choosing appropriate assessments and interventions for treating people who are suffering during the crisis.

Clinically significant fear and anxiety of COVID-19: A psychometric examination of the Coronavirus Anxiety Scale

The present study examined the psychometric properties of the Coronavirus Anxiety Scale (CAS) using an online survey of 398 adult Amazon MTurk workers in the U.S. Confirmatory factor analyses demonstrated that the CAS measures a reliable (α = 0.92), unidimensional construct with a structure that was shown to be invariant across gender, race, and age. Construct validity was demonstrated with correlations between CAS scores and demographics, coronavirus diagnosis, history of anxiety, coronavirus fear, functional impairment, alcohol/drug coping, religious coping, hopelessness, suicidal ideation, as well as social attitudes (e.g., satisfaction with President Trump). The CAS also demonstrated solid discrimination ability for functional impairment (AUC =0.88), while the original cut score of ≥9 (76% sensitivity and 90% specificity) showed the strongest diagnostic effectiveness among scores. Overall, these findings are largely consistent with the results of the first CAS investigation and support the validity of this mental health screener for COVID-19 related research and practice.

Incremental validity of coronaphobia: Coronavirus anxiety explains depression, generalized anxiety, and death anxiety

The adverse psychological effects of COVID-19 have increased globally. Moreover, the psychological toll may be worsening for this health crisis due to the growing numbers of mass deaths and unemployment levels. Coronaphobia, a relatively new pandemic-related construct, has been shown to be strongly related to functional impairment and psychological distress. However, the extent to which coronaphobia is uniquely accountable for the psychological distress experienced during the COVID-19 crisis has not been systematically investigated. The current study examined this question of incremental validity using online data from 453 adult MTurk workers in the U.S. The results of a series of hierarchical multiple regression analyses demonstrated that coronaphobia explained additional variance in depression, generalized anxiety, and death anxiety, above sociodemographics, COVID-19 factors, and the vulnerability factors of neuroticism, health anxiety, and reassurance-seeking behaviors. These findings suggest that health professionals should be aware of coronaphobia as this expression of pandemic-related stress has reliably demonstrated incremental validity in accounting for major indicators of psychological distress.

Factorial validity of the Urdu version of the Obsession with COVID-19 Scale: Preliminary investigation using a university sample in Pakistan

The psychological toll of the COVID-19 pandemic is being felt by people around the world. Persistent and disturbed thinking about the disease appears to be contributing to this mental health concern. Although the Obsession with COVID-19 Scale (OCS) has been shown to be a reliable and valid instrument in the U.S., it has not been examined with in Pakistan. The current study addressed this problem by examining the validity of an Urdu translated version of the OCS using online survey data from 240 university students and teachers in Pakistan. The results showed that the OCS exhibited factorial validity, as well as measurement invariance for gender. However, the OCS also showed limited evidence of construct validity in terms of showing weak positive correlations with the total scale and social dysfunction and self-confidence subscales of the General Heath Questionnaire and no correlation with the depression and anxiety subscale (GHQ-12). These findings suggest that further research is necessary before the Urdu version of the OCS is widely adopted in Pakistan.

Persistent Complex Bereavement Disorder Symptoms Predict Grief Interview Emotions

This study examined persistent complex bereavement disorder (PCBD) symptoms' ability to predict emotional reactions of 69 bereaved adults who participated in grief interviews. The results supported the predictive validity of PCBD symptoms for both self-report and behavioral observation measures of sadness but with only one behavioral measure of happiness. Furthermore, PCBD symptoms uniquely predicted sadness in all but one measure of that emotion while accounting for symptoms of depression, posttraumatic stress, and separation anxiety. Because interviews are the primary method of psychological evaluation for clinicians, these findings collectively support the validity of the PCBD construct.

Does the DSM-5 grief disorder apply to owners of deceased pets? A psychometric study of impairment during pet loss

This study aimed to validate the DSM-5 grief disorder construct to owners of deceased pets using a sample of 395 adults who were impaired during bereavement. Confirmatory factor analyzes indicated that the grief symptoms cohered into the symptom clusters proposed by the DSM-5, which were driven by a higher-order factor and were equivalent across gender. Grief disordered individuals exhibited more depression, loneliness, sleep difficulties, negative religious coping, and alcohol/drug coping compared to the rest of the sample. These findings support the application of the DSM-5 model of grief to owners of deceased pets.

Coronavirus Anxiety Scale: A brief mental health screener for COVID-19 related anxiety

Mental health concerns of people impacted by the coronavirus pandemic have not been adequately addressed. The objective of this study was to develop and evaluate the properties of the Coronavirus Anxiety Scale (CAS), which is a brief mental health screener to identify probable cases of dysfunctional anxiety associated with the COVID-19 crisis. This 5-item scale, which was based on 775 adults with anxiety over the coronavirus, demonstrated solid reliability and validity. Elevated CAS scores were found to be associated with coronavirus diagnosis, impairment, alcohol/drug coping, negative religious coping, extreme hopelessness, suicidal ideation, as well as attitudes toward President Trump and Chinese products. The CAS discriminates well between persons with and without dysfunctional anxiety using an optimized cut score of ≥ 9 (90% sensitivity and 85% specificity). These results support the CAS as an efficient and valid tool for clinical research and practice.

Abstract P4-06-23: Feasibility of sygeneic mice models of breast cancer for research of immune checkpoint blockades

Background: With the increasing success of immune checkpoint blockades for cancer treatment, we increasingly need well-characterized preclinical models. Syngeneic mice models (with a fully competent immune system) have advantages that they are easily established and cost less, though they do not reflect genetic complexity of human tumors. We evaluated feasibility of syngeneic mice models of breast cancer by analyzing efficacy of immune checkpoint blockade and dynamic change of tumor immune microenvironment.

Methods: We used syngeneic mice model of JC, 4T1, and EMT6 cells, which are all murine triple negative breast cancer in BALB/c mice. At the time when subcutaneous tumors reach at 50˜100mm^3, each mice models were divided into 2 groups for treatment versus no-treatment control. In the treatment group, mice version of anti-PD-1 antibody was intraperitoneally injected (q 3 days, x 6). Anti-tumor efficacy was monitored by measuring tumor volume. 'Tumor response' was defined as a case with tumor volume less than that of control group by a standard error at a determined time point. Immune microenvironment was evaluated by measuring serum cytokines (IL-2, IL-6, IL-10, IFNγ, and TNFα) with legendplex and immune cells (CD3, CD4, CD8, CD56, and FOXP3) of peripheral blood with FACS before injection of PD-1 blockade, after 1st injection, and when euthanized. Tumor-infiltrating immune cells were evaluated with FACS, when euthanized.

Results: The tumor response rate to PD-1 blockade was highest in the 4T1 model (54.5%, 6/11) compared to JC model (40%, 4/10) or EMT6 model (36.4%, 4/11). Bleeding 3 times and tumor obtainment when euthanized in each mouse were feasible for profiling of cytokines and immune cells. Although before treatment with PD-1 blockade, CD3+T cells in peripheral blood were slightly lower in 4T1 model (18.3±8.1%) than JC model (24.6±4.7%) or EMT6 model (27.9±6.3%), after injection of one dose of PD-1 blockade, CD3+T cells increased 1.5 times in 4T1 model (18.3% to 27.3%), whereas those CD3+T cells decreased slightly in JC model and EMT6 model. Dynamic changes were not observed in other subsets of peripheral immune cells in all 3 models. Serum TNFα (with statistical significance) and IFNγ (with borderline significance) were higher in responders than in non-responders or no-treatment control.

Conclusions: Syngeneic mice models of breast cancer were feasible to investigate immune checkpoint blockades and monitor dynamic change of immune microenvironment. In this regard, such models may be used to evaluate immune checkpoint blockade-based combination therapy as well.

Citation Format: Moon YW, Park N, Hur J, Pandey K, Cho YB, Kim SK, Lee SA, Son GW, Jo JM, An H-J. Feasibility of sygeneic mice models of breast cancer for research of immune checkpoint blockades [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-23.

Persistent complex bereavement symptoms explain impairments above depression, posttraumatic stress, and separation anxiety: an incremental validity study

The present study examined the incremental validity of persistent complex bereavement disorder (PCBD) symptoms using an on-line survey of 255 bereaved college students. A series of hierarchical multiple regression analyses examined the extent to which PCBD symptoms explained unique variance in different domains of life impairment, beyond symptoms of depression, posttraumatic stress, and separation anxiety. The results supported the incremental validity of PCBD symptoms for fear of future losses, sleep impairment, and work/social impairment. However, PCBD symptoms did not account for loneliness scores. These findings collectively support the validity and clinical utility of the DSM-5's PCBD construct.