Emotional Distress and Compassionate Responses in Palliative Care Decision-Making Consultations

Background: Seriously ill hospitalized patients and their loved ones are frequently faced with complex treatment decisions laden with expressions of emotional distress during palliative care (PC) consultations. Little is known about these emotional expressions or the compassionate responses providers make and how common these are in PC decision-making conversations

Genome-wide meta-analysis uncovers novel loci influencing circulating leptin levels

Leptin is an adipocyte-secreted hormone, the circulating levels of which correlate closely with overall adiposity. Although rare mutations in the leptin (LEP) gene are well known to cause leptin deficiency and severe obesity, no common loci regulating circulating leptin levels have been uncovered. Therefore, we performed a genome-wide association study (GWAS) of circulating leptin levels from 32,161 individuals and followed up loci reaching P <10(-6) in 19,979 additional individuals. We identify five loci robustly associated (P <5 x 10(-8)) with leptin levels in/near LEP, SLC32A1, GCKR, CCNL1 and FTO. Although the association of the FTO obesity locus with leptin levels is abolished by adjustment for BMI, associations of the four other loci are independent of adiposity. The GCKR locus was found associated with multiple metabolic traits in previous GWAS and the CCNL1 locus with birth weight. Knockdown experiments in mouse adipose tissue explants show convincing evidence for adipogenin, a regulator of adipocyte differentiation, as the novel causal gene in the SLC32A1 locus influencing leptin levels. Our findings provide novel insights into the regulation of leptin production by adipose tissue and open new avenues for examining the influence of variation in leptin levels on adiposity and metabolic health.Peer reviewe

Comparative Analysis of New Legislation in Florida, Illinois, and Wisconsin on Do-Not-Resuscitate Orders in Non-Hospital Settings

This article focuses on the history and application of the newest type of end-of-life decision-making documents

Distress due to prognostic uncertainty in palliative care: frequency, distribution, and outcomes among hospitalized patients with advanced cancer.

BACKGROUND: Prognostic uncertainty is common in advanced cancer and frequently addressed during palliative care consultation, yet we know little about its impact on quality of life (QOL). OBJECTIVE: We describe the prevalence and distribution of distress due to prognostic uncertainty among hospitalized patients with advanced cancer before palliative care consultation. We evaluate the association between this type of distress and overall QOL before and after palliative care consultation. DESIGN: Observational cohort study. SETTING & PARTICIPANTS: Hospitalized patients with advanced cancer who receive a palliative care consultation at two geographically distant academic medical centers. MEASUREMENTS: At the time of enrollment, before palliative care consultation, we asked participants: Over the past two days, how much have you been bothered by uncertainty about what to expect from the course of your illness? (Not at all/Slightly/Moderately/Quite a Bit/Extremely). We defined responses of Quite a bit and Extremely to be indicative of substantial distress. RESULTS: Two hundred thirty-six participants completed the baseline assessment. Seventy-seven percent reported being at least moderately bothered by prognostic uncertainty and half reported substantial distress. Compared with others, those who were distressed by prognostic uncertainty (118/236) reported poorer overall QOL before palliative care consultation (mean QOL 3.8 out of 10 vs. 5.3 out of 10, p = \u3c 0.001) and greater improvement in QOL following consultation (Adjusted difference in mean QOL change = 1.1; 95% confidence interval = 0.2, 2.0). CONCLUSIONS: Prognostic uncertainty is a prevalent source of distress among hospitalized patients with advanced cancer at the time of initial palliative care consultation. Distress from prognostic uncertainty is associated with lower levels of preconsultation QOL and with greater pre-post consultation improvement in the QOL

Absence of JC polyomavirus in stool samples of patients with multiple sclerosis despite high anti-JCV antibodies in serum

Background: Natalizumab is an effective treatment for relapsing multiple sclerosis (MS). During therapy, individualsare at increased risk of developing progressive multifocal leukoencephalopathy (PML). So far, therelevant reservoir for PML-type JC polyomavirus (JCV) remains elusive. We here tested if the detection of JCVDNAin stool of persons with MS treated with natalizumab could be a future tool for PML risk assessment.Methods: The presence of JCV-DNA in stool, urine, and whole blood of MS patients treated with natalizumab andknown serum anti-JCV antibodies index values (IV) was studied. Different DNA extraction methods, real-time(RT) and droplet digital (dd) PCR techniques were compared. JCV isolates were screened for PML-associatedvariants by sequencing.Results: Thirty MS patients treated with natalizumab were screened. For 21 patients, blood, stool, and urinesamples were available. These patients were stratified according to their serum anti-JCV antibody IV (high (>1.5,n = 12); medium (1.5–0.9, n = 2); low (<0.9, n = 1); negative (n = 6)). JCV-DNA could not be detected in thewhole blood or stool samples. Four urine samples had measurable JCV-DNA, ranging from 1.71×104–1.07×108international units (IU)/mL detected by RT-PCR, corresponding to 4.62×104–9.85×106 copies/mL measured byddPCR. All JCV variants were wild-type and derived from patients with high antibody IV.Conclusion: Stool-specific DNA extraction methods provided the highest quality of DNA, while the sensitivity ofddPCR and RT- PCR was comparable. Our findings do not support assessing stool samples for PML risk stratificationin persons with MS. Further studies are needed to explore where PML-associated viral variants arise

Parents' Initial Perceptions of Multidisciplinary Care for Pediatric Chronic Pain

Chronic and recurrent pain is experienced by many children and adolescents. Treatment of chronic pain using a multidisciplinary approach has been found to be effective for treatment of chronic pain. Parent satisfaction with treatment and treatment providers highly correlates to children’s treatment adherence. Parents of children treated at a multidisciplinary chronic pain clinic were interviewed following their initial appointment. Parents reported high satisfaction with treatment team members and with the treatment plan. Parents also reported appreciation of multidisciplinary structure, the high level of expertise of the team members, and the team members’ genuine interest in treating their children. This increase in satisfaction when compared to previous treatment is important since increases in satisfaction may correlate with a reduction in experiences of chronic pain. Parents reported high satisfaction with interactions with treatment team members and with the treatment plan provided for their children. Parents had appreciation of multidisciplinary team structure and the high level of expertise of the team members. This increase in satisfaction when compared to treatment from previous providers is important since increases in satisfaction may correlate with an increase in children’s treatment adherence and a reduction in experiences of chronic pain