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Background: Patients with cirrhosis have significant morbidity and mortality, as well as substantial symptom burden. Objective: We investigated the relationship between symptom burden and inpatient health care utilization among patients with cirrhosis. Methods: Adult patients with cirrhosis being evaluated for or awaiting liver transplantation at an academic institution in the United States completed the Edmonton Symptom Assessment Scale (ESAS), a validated symptom evaluation tool with total scores ranging from 0 to 90. The outcomes of interest were emergency department (ED) visits, nonelective hospitalizations, hospital days, intensive care unit (ICU) admissions, and 30-day readmissions within 6 months. Adjusted incidence rate ratios (IRRs) were used to examine the relationship between ESAS scores and outcomes. Results: Of 233 patients (43% female, median age 61), the median total ESAS score was 16 (interquartile range 6–30). Higher total scores on the ESAS were associated with increased ED visits, hospitalizations, hospital days, and ICU days (all p

The informal caregiver plays a critical role in supporting patients with various end-stage diseases throughout the solid organ transplantation journey. Caregiver responsibilities include assistance with activities of daily living, medication management, implementation of highly specialized treatments, transportation to appointments and treatments, and health care coordination and navigation. The demanding nature of these tasks has profound impacts across multiple domains of the caregiver's life: physical, psychological, financial, logistical, and social. Few interventions targeting caregiver burden have been empirically evaluated, with the majority focused on education or mindfulness-based stress reduction techniques. Further research is urgently needed to develop and evaluate interventions to improve caregiver burden and outcomes for the patient-caregiver dyad.

OBJECTIVES Although patients with cirrhosis often experience debilitating symptoms, few are referred for palliative care. Frailty is increasingly incorporated in liver transplantation evaluation and has been associated with symptom burden in other populations. We hypothesized that frail patients with cirrhosis are highly symptomatic and thus are likely to benefit from palliative care. METHODS Patients with cirrhosis undergoing outpatient liver transplantation evaluation completed the Liver Frailty Index (grip strength, chair stands and balance) and a composite of validated measures including the Edmonton Symptom Assessment Scale, distress and quality of life (QOL) measures. RESULTS Of 233 patients (median age 61 years, 43% women), 22% were robust, 59% prefrail and 19% frail. Overall, 38% of patients reported ≥1 severe symptoms based on preestablished Edmonton Symptom Assessment Scale criteria. Higher frailty categories were associated with increased prevalence of pain, dyspnea, fatigue, nausea, poor appetite, drowsiness, depression and poor well-being (test for trend, all P < 0.05). Frail patients were also more likely to report psychological distress and poor QOL (all P < 0.01). In univariate analysis, each 0.5 increase in liver frailty index was associated with 44% increased odds of experiencing ≥1 severe symptoms [95% confidence interval (CI), 1.2-1.7, P < 0.001], which persisted (odds ratio, 1.3, 95% CI, 1.0-1.6, P = 0.004) even after adjusting for Model for End Stage Liver Disease-Sodium, ascites, hepatic encephalopathy and age. CONCLUSION In patients with cirrhosis, frailty is strongly associated with physical/psychological symptoms, including pain and depression and poor QOL. Frail patients with cirrhosis may benefit from palliative care co-management to address symptoms and improve QOL.

Background: Multimorbidity and pain are both common among older adults, yet pain treatment strategies for older patients with multimorbidity have not been well characterized. Objectives: To assess the prevalence and relationship between multimorbidity and opioid prescribing in hospitalized older medical patients with pain. Methods: We collected demographic, morbidity, pain, and analgesic treatment data through structured review of the electronic medical records of a consecutive sample of 238 medical patients, aged ≥65 years admitted between November 2014 and May 2015 with moderate-to-severe pain by numerical pain rating scale (range 4–10). We used the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) to assess multimorbidity and cumulative illness burden. We examined the relationship between morbidity measures and opioid prescribing at hospital discharge using multivariate regression analysis. Results: The mean age was 75 ± 8 years, 57% were female and 50% were non-White. Mean CIRS-G total score was 17 ± 6, indicating high cumulative illness burden. Ninety-nine percent of patients had multimorbidity, defined as moderate-to-extremely severe morbidity in ≥2 organ systems. Sixty percent of patients received an opioid prescription at discharge. In multivariate analyses adjusted for age, race, and gender, patients with a discharge opioid prescription were significantly more likely to have higher cumulative illness burden and chronic pain. Conclusion: Among older medical inpatients, multimorbidity was nearly universal, and patients with higher cumulative illness burden were more likely to receive a discharge opioid prescription. More studies of benefits and harms of analgesic treatments in older adults with multimorbidity are needed to guide clinical practice.

Background: Advance care planning allows patients to share their preferences for medical care with the aim of ensuring goal-concordant care in times of serious illness. The morbidity and mortality of the COVID-19 pandemic has increased the importance and public visibility of advance care planning. However, little is known about the frequency and quality of advance care planning documentation during the pandemic. Aim: This study examined the frequency, quality, and predictors of advance care planning documentation among hospitalized medical patients with and without COVID-19. Design: This retrospective cohort analysis used multivariate logistic regression to identify factors associated with advance care planning documentation. Setting/participants: This study included all adult patients tested for COVID-19 and admitted to a tertiary medical center in San Francisco, CA during March 2020. Results: Among 262 patients, 31 (11.8%) tested positive and 231 (88.2%) tested negative for SARS-CoV-2. The rate of advance care planning documentation was 38.7% in patients with COVID-19 and 46.8% in patients without COVID-19 ( p = 0.45). Documentation consistently addressed code status (100% and 94.4% for COVID-positive and COVID-negative, respectively), but less often named a surrogate decision maker, discussed prognosis, or elaborated on other wishes for care. Palliative care consultation was associated with increased advance care planning documentation (OR: 6.93, p = 0.004). Conclusion: This study found low rates of advance care planning documentation for patients both with and without COVID-19 during an evolving global pandemic. Advance care planning documentation was associated with palliative care consultation, highlighting the importance of such consultation to ensure timely, patient-centered advance care planning.

Hepatocellular carcinoma (HCC) is a highly morbid and prevalent cancer globally. While high quality evidence for mortality benefit of HCC surveillance is lacking, early detection of HCC is likely beneficial as prognosis is highly correlated with tumor stage. High risk populations, including patients with cirrhosis and subgroups with Hepatitis B, should undergo surveillance with ultrasound ± alpha-fetoprotein (AFP) at 6-month intervals. In addition, emerging data suggest that patients with Hepatitis C cirrhosis who achieve sustained virologic response should continue surveillance. Further research is needed to determine the value of surveillance in patients with nonalcoholic fatty liver disease in the absence of cirrhosis or with advanced fibrosis of other etiologies. Newer biomarkers and models such as Lens culinaris agglutinin-reactive fraction of AFP, des-γ-carboxy prothrombin, and the GALAD score are increasingly utilized in the diagnosis and prognostication of HCC. The role of these biomarkers in surveillance is still under investigation but may potentially offer a more practical alternative to traditional image-based surveillance. Despite recommendations from multiple professional society guidelines, many at-risk patients do not receive HCC surveillance due to barriers at the patient, clinician, and health care system levels. Strategies such as implementing patient navigation services, educating clinicians about surveillance guidelines, and creating automated outreach systems, may improve surveillance rates and ultimately reduce morbidity and mortality from HCC.

Objectives To investigate the prevalence, characteristics, and management of pain in older hospitalized medical patients. Design Medical record aggregate review. Setting Tertiary care hospital. Participants Individuals aged 65 and older admitted to the medicine service between November 28, 2014, and May 28, 2015. Measurements Demographic characteristics, comorbidity burden, pain characteristics, and analgesics during index hospitalization were assessed in individuals with moderate to severe pain (≥4 on 0–10 Numeric Pain Rating Scale). Results Of 1,267 patients admitted to the medicine service, 248 (20%) had moderate to severe pain on admission (mean age 75 ± 8, 57% female, 50% white). During hospitalization, most participants received opioids (80%) and acetaminophen (74%), and few received nonsteroidal antiinflammatory drugs (9%). Participants with chronic pain had less reduction in pain intensity score from admission to discharge than those without a history of chronic pain (mean change score 3.7 vs 4.9, p=.002) and were more likely to receive opioids, adjuvant analgesics, and other analgesics (all p

Background Adult congenital heart disease (ACHD) patients with moderate or great defect complexity are at risk for premature death. Although early engagement in advance care planning (ACP) is recommended, previous research suggests that it seldom occurs. Methods This study investigated ACHD patient preferences for ACP and factors that impact preferences. ACHD patients completed an ACP preferences questionnaire, the Hospital Anxiety and Depression Scale and a measure of attachment styles. Results Of 152 ACHD patients (median age 33years, 50% female), 13% reported previous ACP discussions with providers and 21% had completed advance directives. On a 0–10 scale, the median rating for the importance of discussing ACP with providers was 7; 18years was identified as the most appropriate age to initiate this dialogue. Higher ratings for the importance of discussing ACP with providers was observed in patients who were female ( p =0.03), had lower disease complexity ( p =0.03), and had elevated anxiety symptoms ( p =0.001); elevated anxiety remained significant in a multivariable model. Interest in receiving information about life expectancy (61% overall) was greater among patients with lower disease complexity ( p =0.04) and a history of ≥2 cardiac surgeries ( p =0.01); disease complexity remained significant in a multivariable model. Conclusions As a group, ACHD patients value the opportunity for ACP discussions and prefer earlier communication. Although some clinicians might avoid ACP discussions in patients who are generally more anxious or have less complex CHD, such avoidance does not appear to be warranted.

Post-traumatic stress disorder (PTSD) is associated with adverse outcomes and increased mortality in cardiac patients. No studies have examined PTSD in the adult congenital heart disease (ACHD) population. The objectives of this study were to assess the prevalence of self-reported symptoms of PTSD in patients with ACHD and explore potential associated factors. Patients were enrolled from an outpatient ACHD clinic and completed several validated measures including the Impact of Event Scale-Revised, PTSD Checklist-Civilian Version, and the Hospital Anxiety and Depression Scale. Clinical data were abstracted through medical data review. A total of 134 participants (mean age 34.6 ± 10.6; 46% men) were enrolled. Of the 127 participants who completed the Impact of Event Scale-Revised, 14 (11%) met criteria for elevated PTSD symptoms specifically related to their congenital heart disease or treatment. Of the 134 patients who completed PTSD Checklist-Civilian Version, 27 (21%) met criteria for global PTSD symptoms. In univariate analyses, patients with congenital heart disease-specific PTSD had their most recent cardiac surgery at an earlier year (p = 0.008), were less likely to have attended college (p = 0.04), had higher rates of stroke or transient ischemic attack (p = 0.03), and reported greater depressive symptoms on the Hospital Anxiety and Depression Scale (7 vs 2, p

BackgroundAdults with congenital heart disease face psychological challenges although an understanding of depression vs. anxiety symptoms is unclear. We analyzed the prevalence of elevated symptoms of anxiety and depression and explored associations with demographic and medical factors as well as quality of life.MethodsAdults with congenital heart disease enrolled from an outpatient clinic completed the Hospital Anxiety and Depression Scale and two measures of quality of life: the Linear Analogue Scale and the Satisfaction with Life Scale. Medical data were obtained by chart review.ResultsOf 130 patients (median age = 32 years; 55% female), 55 (42%) had elevated anxiety symptoms and 16 (12%) had elevated depression symptoms on subscales of the Hospital Anxiety and Depression Scale. Most patients with elevated depression symptoms also had elevated anxiety symptoms (15/16; 94%). Of 56 patients with at least one elevated subscale, 37 (66%) were not receiving mental health treatment. Compared to patients with 0 or 1 elevated subscales, patients with elevations in both (n=15) were less likely to be studying or working (47% vs. 81%; p=0.016) and reported lower scores on the Linear Analogue Scale (60 vs. 81, ppConclusionsAmong adults with congenital heart disease, elevated anxiety symptoms are common and typically accompany elevated depressive symptoms. The combination is associated with unemployment and lower quality of life. Improved strategies to provide psychosocial care and support appropriate engagement in employment are required.

OBJECTIVE To investigate the experiences and communication preferences of adult patients with congenital heart disease (CHD) in the domains of employment, insurance, and family planning. DESIGN Patients ≥ 18 years of age completed a questionnaire about experiences and communication preferences regarding employment, health insurance, and family planning. RESULTS Of 152 patients (median age = 33 years, 50% female, 35% with CHD of great complexity), one in four reported work-related problems due to CHD and a quarter also recalled a previous gap in health insurance. Of females, 29% experienced an unplanned pregnancy. The median importance of discussion ratings (on a 0-10 scale) were 3.5 (employment), 6.0 (insurance), and 8.0 (family planning). Few patients recalled discussions about employment (19%) or health insurance (20%). Over half recalled discussions about family planning, although males were less likely to have had these discussions than females (24% vs 86%, P

BACKGROUND: Unrelieved pain is associated with adverse outcomes among older adults. While previous studies found a high prevalence of pain among community dwelling older adults, the occurrence of pain among older patients in the hospital is not well understood. The objective of this study was to investigate the prevalence, characteristics and management of pain in older hospitalized medical patients. METHODS: To determine the prevalence of moderate to severe pain (i.e., pain of ≥ 4 on the 0 to 10 Numeric Pain Rating Scale), medical record aggregate review was conducted on patients ≥ 65 years of age admitted to the medicine service at a tertiary hospital between 11/28/2014 – 5/28/2015. Demographic characteristics, comorbidity burden, pain characteristics, and analgesics during the index hospitalization were assessed on moderate to severe pain patients only. RESULTS: Of 1267 patients admitted to the medicine service, 248 (20%) had moderate to severe pain on admission. Mean age was 75 ± 8 years, 57% were female, and 50% were white. During hospitalization, most patients received opioids (80%) and acetaminophen (74%), and few received nonsteroidal anti-inflammatory drugs (9%). Compared to those without a history of chronic pain, patients with chronic pain experienced a lower reduction in pain intensity score from admission to discharge (mean change score 3.7 vs. 4.9, p=0.002) and were more likely to receive opioids, adjuvant analgesics, and other analgesics (all p

Inadequate treatment of pain is a known risk factor for delirium among older adults. However, little is known about pain management among hospitalized older adults with delirium. We sought to investigate the role of pain and pain management in the development of delirium among older adults with moderate to severe pain admitted to the medicine service. Medical record review was conducted on adults ≥ 65 years admitted to the medicine service at an urban hospital between November 2014 and May 2015 with moderate to severe pain defined by the Numerical Pain Rating Scale score: 4 – 10. Of 254 patients with moderate to severe pain on admission, 41 (16%) were diagnosed with delirium during their hospitalization. Compared to patients without delirium, those with delirium were more likely to be age ≥ 75 years (59% vs. 42%, p=0.05), have a history of dementia (29% vs. 7%, p

BACKGROUND: South Africa's Western Cape has experienced a dramatic increase in methamphetamine ("meth") use over the past decade. There is concern that meth may further fuel the HIV epidemic in this country because of its association with risky sexual behaviors. This study describes the prevalence of meth use and its relation to HIV sexual risk behaviors among patrons of alcohol-serving venues. METHODS: Participants (N=3328) were surveyed in 12 venues in a mixed race township. Logistic regression models were used to examine the relations between meth use and sexual risk behaviors, and structural equation models were used to test whether meth use mediates the relationship between childhood sexual abuse and current sexual risk. RESULTS: Meth use in the past 4months was more common among Coloured than Black persons (10.5% vs. 3.5%). Meth users were more likely than non users to use marijuana, inhalants, and injection drugs, have a history of childhood sexual and/or physical abuse, and experience and/or perpetrate intimate partner violence. Among both men and women, meth use was associated with greater odds of engaging in sexual risk behaviors, and meth use partially mediated the relationships between childhood sexual abuse and all sexual risk behaviors. CONCLUSIONS: Meth users in this setting are at increased risk for HIV due to their greater likelihood of engaging in sexual risk behaviors and being in violent relationships. There is an urgent need to provide targeted HIV prevention and substance abuse treatment to meth users living in townships in Cape Town. Language: en

With nearly 33 million global citizens living with HIV or AIDS, the need for a highly qualified, competent nursing workforce is critical. With the recent increase in global funding to expand access to antiretroviral therapy, there have been considerable efforts to improve the capacity of nurses to initiate and maintain antiretroviral therapy while evaluating its effectiveness, monitoring for side effects, reducing the incidence of drug–drug interactions (including drug interactions related to therapies provided by traditional healers), promoting adherence to therapies, and providing management of symptoms. Therefore, using a participatory action approach, nursing leaders from six sub-Saharan African countries collaborated to develop the essential nursing competencies related to HIV and AIDS. These competencies can help to guide preservice education related to HIV and AIDS, to strengthen in-service or capacity-building programs designed for already qualified nurses, and to guide policy and regulatory reform in the context of task-shifting, task-sharing, and scope of nursing practices. This is an online Supplement to the Journal of the Association of Nurses in AIDS Care. Visit www.nursesinaidscarejournal.org for easy navigation. A Supplement Preview was published in the January/February 2011 issue, Volume 22, Number 1. The Supplement Preview and Online Supplement are supported by grant number U92HA07230 from the U.S. Department of Health and Human Services, Health Resources and Services Administration, funded by the President's Emergency Plan for AIDS Relief.

Context: Aberrant cellular oxygen sensing is a leading theory for development of pheochromocytoma (PHEO) and paraganglioma (PGL). Objective: The objective of the study was to test the hypothesis that chronic hypoxia in patients with cyanotic congenital heart disease (CCHD) increases the risk for PHEO-PGL. Design/Setting/Participants: We investigated the association between CCHD and PHEO-PGL with two complementary studies: study 1) an international consortium was established to identify congenital heart disease (CHD) patients with a PHEO-PGL diagnosis confirmed by pathology or biochemistry and imaging; study 2) the 2000–2009 Nationwide Inpatient Survey, a nationally representative discharge database, was used to determine population-based cross-sectional PHEO-PGL frequency in hospitalized CCHD patients compared with noncyanotic CHD and those without CHD using multivariable logistic regression adjusted for age, sex, and genetic PHEO-PGL syndromes. Results: In study 1, we identified 20 PHEO-PGL cases, of which 18 had CCHD. Most presented with cardiovascular or psychiatric symptoms. Median cyanosis duration for the CCHD PHEO-PGL cases was 20 years (range 1–57 y). Cases were young at diagnosis (median 31.5 y, range 15–57 y) and 7 of 18 had multiple tumors (two bilateral PHEO; six multifocal or recurrent PGL), whereas 11 had single tumors (seven PHEO; four PGL). PGLs were abdominal (13 of 17) or head/neck (4 of 17). Cases displayed a noradrenergic biochemical phenotype similar to reported hypoxia-related PHEO-PGL genetic syndromes but without clinical signs of such syndromes. In study 2, hospitalized CCHD patients had an increased likelihood of PHEO-PGL (adjusted odds ratio 6.0, 95% confidence interval 2.6–13.7, P < .0001) compared with those without CHD; patients with noncyanotic CHD had no increased risk (odds ratio 0.9, P = .48). Conclusions: There is a strong link between CCHD and PHEO-PGL. Whether these rare diseases coassociate due to hypoxic stress, common genetic or developmental factors, or some combination requires further investigation.

An efficient tin-free reductive photochemical carboxymethylation of olefins with α-alkylthioacetates is developed, which (a) is an experimentally simple technique furnishing substituted derivatives of fatty acids in moderate to good yields, (b) is compatible with polar/protic functional groups and solvents, (c) does not require a special reducing reagent, (d) is fairly insensitive to the presence of dissolved oxygen and, generally, does not require degassing prior to irradiation. The critical feature of the mechanism in the “reluctance” of short-lived MeS • to group-transfer, resulting in hydrogen abstraction from the media.

With nearly 33 million global citizens living with HIV or AIDS, the need for a highly qualified, competent nursing workforce is critical. With the recent increase in global funding to expand access to antiretroviral therapy, there have been considerable efforts to improve the capacity of nurses to initiate and maintain antiretroviral therapy while evaluating its effectiveness, monitoring for side effects, reducing the incidence of drug-drug interactions (including drug interactions related to therapies provided by traditional healers), promoting adherence to therapies, and providing management of symptoms. Therefore, using a participatory action approach, nursing leaders from six sub-Saharan African countries collaborated to develop the essential nursing competencies related to HIV and AIDS. These competencies can help to guide preservice education related to HIV and AIDS, to strengthen in-service or capacity-building programs designed for already qualified nurses, and to guide policy and regulatory reform in the context of taskshifting, task-sharing, and scope of nursing practices.

An efficient tin-free reductive photochemical carboxymethylation of olefins with α-alkylthioacetates is developed, which (a) is an experimentally simple technique furnishing substituted derivatives of fatty acids in moderate to good yields, (b) is compatible with polar/protic functional groups and solvents, (c) does not require a special reducing reagent, (d) is fairly insensitive to the presence of dissolved oxygen and, generally, does not require degassing prior to irradiation. The critical feature of the mechanism in the “reluctance” of short-lived MeS • to group-transfer, resulting in hydrogen abstraction from the media.

Michael V. Relf, PhD, RN, ACNS-BC, AACRN, FAAN Julia Mekwa, PhD, RN, RM Cynthia Chasokela, PhD(c), MEd, BScN, SRN, RMN, SCM Christina Booth, BA Lisa Deng, Student R. Kevin Mallinson, PhD, RN, AACRN, FAAN Keabitsa Ramantele, BSEd, RN, RM Elizabeth Letsie, BSEd, RN, RM Jasintha Mtengezo, MPH, BScN, UCM, DipN Winnie Nhlengethwa, PhD, RN, SRM, FNP, SRH Dorothy Powell, EdD, RN, FAAN Adele Webb, PhD, RN, AACRN, FAAN Tony Diesel, BA Cur (Admin & Education), Dipl (Gen Nursing), Dipl (Psychiatric Nursing), RN Amanda Liddle, DrPH, RN, FAAN Michael V. Relf, PhD, RN, ACNS-BC, AACRN, FAAN, is an associate professor and assistant dean for Undergraduate Education, Duke University School of Nursing, Durham, NC. Julia Mekwa, PhD, RN, RM, Head of Department, Department of Nursing Science, University of Zululand, Republic of South Africa. Cynthia Chasokela, PhD(c), MEd, BScN, SRN, RMN, SCM, Director of Nursing Services/Chief Nursing Officer, Ministry of Health and Child Welfare, Zimbabwe. Christina Booth, BA, Duke University, Durham, NC. Lisa Deng, Student, Duke University, Durham, NC. R. Kevin Mallinson, PhD, RN, AACRN, FAAN, Assistant Professor, Department of Nursing, Georgetown University School of Nursing & Health Studies, Washington, DC. Keabitsa Ramantele, BSEd, RN, RM, President, Botswana Nurses Association, Botswana. Elizabeth Letsie, BSEd, RN, RM, Chairperson, Lesotho Nursing Council, Lesotho. Jasintha Mtengezo, MPH, BScN, UCM, DipN, Director of Education Programs, Nurses and Midwives Council of Malawi, Malawi. Winnie Nhlengethwa, PhD, RN, SRM, FNP, SRH, Rector, Nazarene Higher Education Consortium & Principal, Nazarene College of Nursing, Swaziland. Dorothy Powell, EdD, RN, FAAN, Associate Dean, Global and Community Health Initiatives, Duke University School of Nursing, Durham, NC. Adele Webb, PhD, RN, AACRN, FAAN, Executive Director, Association of Nurses in AIDS Care, Akron, OH. Tony Diesel, BA Cur (Admin & Education), Dipl (Gen Nursing), Dipl (Psychiatric Nursing), RN, Regional Director, Nurses SOAR! Durban, Republic of South Africa. Amanda Liddle, DrPH, RN, FAAN, Project Director, Nurses SOAR! Georgetown University, School of Nursing and Health Studies, Washington, DC.