Post Death Research Articles

Central nervous system multiple myeloma: A real-world multi-institutional study of the Greek Myeloma Study Group.

Central nervous system (CNS) involvement is a rare and aggressive complication of multiple myeloma (MM). We identified 54/4352 MM patients (1.2%), who developed CNS-MM between 2000 and 2022. A matched-control group of MM patients without CNS-MM was used for comparisons. Median age was 63 years. Median time to CNS-MM was 28 months; 6/54 experienced CNS-MM at MM diagnosis. Abnormal lactate dehydrogenase (LDH), high-risk cytogenetics, and extramedullary involvement (EMI), that is, soft tissue plasmacytomas and/or plasma cell leukemia (PCL), were more frequent in CNS-MM versus controls (p < .05); 13/54 had PCL at CNS-MM. The majority had leptomeningeal infiltration (LMI) (66%); 26% had CNS-MM without systemic myeloma; EMI was the strongest predictor for CNS-MM (OR: 6.3). Median overall survival (OS) of CNS-MM patients versus controls was 43 months (95% CI: 32-54) versus 60 months (95% CI: 38-82) (p < .001); treatment of CNS-MM included mainly bortezomib/thalidomide/chemotherapy whereas 20% received novel drugs/immunotherapy combinations; 28 patients underwent cerebrospinal fluid infusions; EMI was the strongest negative predictor for post CNS-MM OS (p = .005; HR: 2.9). Treatment after 2016 predicted significantly for OS (p = .002; HR: 0.27). Median post CNS-MM OS was 4 months (95% CI: 2.6-5.4); in patients treated after 2016 median OS was 12 months. In conclusion, we have demonstrated in this large real-world series that survival of CNS-MM remains poor; however, there is a positive impact of treatment after 2016, related to the efficacy of modern anti-myeloma therapy; EMI significantly increases the probability to develop CNS-MM and the risk of post CNS-MM death, indicating a potential need for CNS prophylaxis for those patients.

Examining the association of physical activity and mortality among recently hospitalized older adults with dementia

IntroductionThis study aimed to examine the association between physical activity one month post discharge and mortality over the first-year post discharge among recently hospitalized older adults with dementia. MethodsFor this descriptive sub-study, among 42 participants, we obtained physical activity data via accelerometry at one month post discharge and death status via phone call at 6 months and 1 year post discharge. We performed logistic regression. ResultsWe found that participants’ amount of time spent in physical activity one month post hospital discharge was not statistically significantly associated with mortality within the first-year post hospital discharge (OR=.996, CI=.992,1.000; p=.053). However, we did observe a strong trend. ConclusionsGiven the small sample of participants, this trend is salient and should be examined in a larger sample. The results highlight a specific patient profile, recently hospitalized older adults with dementia, that would greatly benefit from physical activity interventions.

Infection Burden and Timing in the First Year After Pediatric Allogeneic Hematopoietic Cell Transplantation: A Single-Center Experience

Abstract Background Infection is a leading cause of morbidity and non-relapsed mortality (NRM) after allogeneic hematopoietic cell transplant (allo-HCT). This study aimed to describe the contemporary epidemiology of infections, overall survival (OS) as well as NRM at 1 year post pediatric allo-HCT. Methods Retrospective review of laboratory-confirmed infections among patients who underwent first allo-HCT from January 2014 to December 2020 at a single, quaternary pediatric hospital. Cytomegalovirus (CMV), Adenovirus (AdV), Epstein-Barr virus (EBV) and Human Herpes Virus-6 (HHV-6) weekly viral surveillance was performed on blood using polymerase chain reaction until day +100. We reviewed Clostridioides difficile, bacterial blood stream infections (BSIs), and fungemia until 1 year post allo-HCT or death. Results During the six-year study period, 146 subjects underwent allo-HCT at a median age of 8.75 years (IQR 2.6-14.28), predominantly males (58%) with hematologic malignancies (60%), and bone marrow as stem cell source (71%). Matched unrelated donors were used in 53% after myeloablative conditioning in 62%. A total of 126 patients (86%) experienced at least one infection, primarily with DNA viral infections (n=113, 77%). EBV DNAemia occurred in 50%, CMV in 30%, HHV-6 in 23%, and AdV in 17%. The time to first DNAemia detection post HCT was 15 days for CMV (IQR 6-28.5), 20 days for AdV (IQR 6-89), 22 days for HHV-6 (IQR 17-31), and 55 days for EBV (IQR 41-92.5). Bacterial BSIs were identified in 37% (54/146) of patients at a median of 12.5 days post-HCT (IQR 5-146.3), 80% (43/54) experienced a single episode, while 20% (11/54) had multiple episodes, resulting in 68 BSIs total. Among all BSIs, 38% (26/68) were classified as mucosal barrier injury laboratory confirmed bloodstream infections, while 59% (40/68) as central line associated BSIs. In total, 89 pathogens were identified. Gram-negative pathogens (GN) were predominant in 56% (50/89) of the isolates, with lactose fermenters representing 72% (36/50). Gram-positive pathogens (GP) accounted for 44% (39/89), primarily Staphylococcus species (36%, 14/39, predominantly Staphylococcus aureus in 10 cases) and Viridans Group Streptococcus (31%, 12/39). Clostridioides difficile was detected by PCR in 19% (27/146), with a median onset of 54 days post-HCT (IQR 19-125). Fungemia occurred on 3% (4/146) at a median of 150 days post-HCT (IQR 40.23 - 226.8), 3 had candidemia and 1 had fusariosis. The overall mortality rate at 1 year was 15% (22/146), with a median time from transplant to death of 188 days (IQR 44-233.5) and documented active infection at the time of death in 41% (9/22). Only the presence of fungemia showed a significantly difference in OS (25% vs 87%, p &amp;lt; 0.0001) and NRM (50% vs 5.6%, p &amp;lt; 0.001) Conclusions Infections occurred frequently in our cohort affecting 86% (126/146), most commonly as viral DNAemia [77% (113/146)] with EBV &amp;gt; CMV &amp;gt; HHV-6 &amp;gt; AdV, followed by bacterial BSI [37% (54/146)] with GN (56%) vs GP (44%). Despite CLABSI prevention efforts, CLABSI occurred 40 (59%) of total bacterial BSI episodes. Despite the higher frequency of bacterial and viral infections, only fungemia was significantly associated with decreased OS and higher NRM.

The COVID-19 Pandemic: Bereavement Experiences Between Hospital and Home Deaths in Palliative Care

BackgroundAustralian COVID-19 public health measures reduced opportunities for people to communicate with healthcare professionals and be present at the death of family members/friends. AimTo understand if pandemic-specific challenges and public health measures during the COVID-19 pandemic impacted end-of-life and bereavement experiences differently if the death, supported by palliative care, occurred in a hospital or at home. DesignA cross-sectional online survey was completed by bereaved adults during 2020–2022. Analyses compared home and in-patient palliative care deaths and bereavement outcomes. Additional analyses compared health communication outcomes for those identified as persons responsible or next of kin. Setting/participantsOf 744 bereaved people; 69% (n = 514) had a death in hospital and 31% (n = 220) at home. ResultsThe COVID-19 public health measures influenced people's decision to die at home. Compared to hospital deaths, the home death group had higher levels of grief severity and grief-related functional impairment. Only 37% of bereaved people received information about bereavement and support services. 38% of participants who were at least 12 months postdeath scored at a level suggestive of possible prolonged grief disorder. Levels of depression and anxiety between the two groups were not significantly different. ConclusionsThese findings highlight the need for health services to recognize bereavement as fundamental to palliative and health care and provide pre- and post death grief and bereavement care to ensure supports are available particularly for those managing end-of-life at home, and that such supports are in place prior to as well as at the time of the death.

Update Analysis of Central Nervous System Multiple Myeloma Prognosis and Survival: A Real-World Multi-Institutional Study of the Greek Myeloma Study Group

Central Nervous System Multiple Myeloma (CNS-MM) is a rare but aggressive complication of MM, and its treatment remains an unmet clinical need. Herein we present a real-world national analysis of incidence, characteristics, prognostic factors and outcome of a large cohort of patients with CNS-MM. We evaluated 53 patients with CNS-MM (M/F: 23/30; median age: 59, range: 20-96 years; IgG: 27, IgA: 10, light-chain: 11, non-secretory: 4, IgD: 1; ISS1: 22, ISS2: 13, ISS3: 18; RISS1: 15, RISS2: 22, RISS3: 16) out of 4352 MM patients (1.2%), who were treated within the Greek Myeloma Study Group centers from 2000 to 2022 (23% of patients were diagnosed after 2016). A control group of MM patients matched for age, gender, and stage (ISS/RISS) who were treated during the same period was used for comparisons. Presence of soft tissue plasmacytomas (STP) and/or plasma cell leukemia (PCL; circulating plasma cells, cPCs: ≥5%) was determined and analyzed as extramedullary involvement (EMI). Median time to CNS-MM from MM diagnosis was 28 months (range 0-149 months); 6/53 (11.3%) patients experienced CNS-MM at initial MM diagnosis. Clinical manifestations of CNS-MM included visual disturbances/diplopia: 32%, paresis/paraplegia: 22%, lethargy/confusion: 37%, headache: 22%, cranial nerve palsy: 13% and dysarthria: 11%. PCL was present in 16/53 (30%) CNS-MM patients, while 29/53 (54.7%) CNS-MM patients had bone and/or STP vs. 13/53 matched controls (p=0.001); EMI was found in 24/53 (45%) patients with CNS-MM vs. 4/53 (7%) in controls (p&amp;lt;0.001). 35/53 (66%) CNS-MM patients had leptomeningeal infiltration (LMI) and 34% had intraparenchymal lesions. Median number of cells in the cerebrospinal fluid (CSF) was 60/μL (range 10-2550) and almost all of them (80%, range: 20-100%) were clonal plasma cells. Out of 53 CNS-MM patients, 14 (26.4%) had only CNS involvement without marrow infiltration by PCs; 51% had ≥1 high-risk molecular features (i.e., del17p, t4:14, t14:16, 1q+), and this was marginally higher vs. controls (36%; p=0.15). CD56 negative marrow PCs did not differ between groups (33% vs. 37%). A binary logistic regression analysis demonstrated that EMI was the strongest prognostic factor for the development of CNS-MM (p=0.01; HzR: 5.7). Median number of lines of treatment before the development of CNS-MM was 2 (range 0-9). First line anti-myeloma treatment in patients who developed CNS-MM included conventional chemotherapy (CT) or thalidomide-based regimens in 19 patients, bortezomib-based triplets in 27 and daratumumab-based regimens (DBR) in 7; this did not differ from controls. Overall response rate (ORR) in first-line therapy was similar between CNS-MM and controls (85% for both groups; CR 41% vs. 36%, respectively). After a median follow-up of 150 months post-MM diagnosis (95% CI: 107-192), 46 CNS-MM patients (87%) deceased (MM progression: 34, infection/sepsis: 10, cerebral hemorrhage: 2). Median overall survival (OS) of CNS-MM patients vs. matched controls from initial MM diagnosis was 43 months (95% CI: 31-54) vs 60 months (95% CI: 34-86) (p=0.002; Figure). Regarding CNS-MM therapy, 17 patients received IMiD-based regimens and 26 received PI-based regimens, 6 received CT and 4 received DBR. Patients with CNS-MM and marrow infiltration by PCs displayed an ORR of 31% only; CNS symptoms improved in 74% of all patients. Median OS of CNS-MM patients from the time of CNS involvement was 4 months (95% CI: 2.6-5.3), and it was longer in 12 patients treated after 2016 [18 months (95% CI: 7-29) vs. 2 months (95% CI: 1-3)]. Cerebrospinal fluid (CSF) infusions were performed in 28 patients (53%); 9 patients (19%) underwent radiotherapy. A multivariate analysis showed that EMI, either at diagnosis or during MM course, was the strongest negative predictor for post CNS-MM OS (p=0.008; HR: 3.4 95% CI: 1.4-8.0). Moreover, LMI was a negative predictor (p=0.02; HR: 2.7, 95% CI: 1.2-6.3) for OS, whereas treatment after 2016 had a positive impact (p=0.02; HR: 0.28, 95% CI: 0.12-0.8); CSF infusions did not affect OS. In conclusion, our analysis representing one of the largest real-world series of CNS MM patients after 2016, showed that, OS of CNS-MM remains poor however, there is a positive impact of treatment after 2016, reflecting the efficacy of modern anti-myeloma therapy; EMI strongly predicts for CNS-MM and induces a 3-fold increase in the probability of post CNS-MM death indicating a potential need for CNS prophylaxis in these patients.

Nursing students experiences of end-of-life care.

Undergraduate nursing students spend a significant amount of time in clinical placements where they are involved in care at the end of a person's life and care after death. While their role is to provide compassionate care, some students feel wholly unprepared. The aim of this qualitative study was to explore student nurses' experiences of care in death, dying and post death care, and to explore how students can be better prepared to provide such care. This is a qualitative descriptive study that is concerned with the subjective reality of participant's experiences. Six themes were developed from the analysis: first encounters with death and dying; preparedness; mentoring and support received; the caring role; striving to cope; working with families and working through COVID-19. Students described their experience of placements in end-of-life care as challenging, yet were also able to adopt ways to develop as compassionate practitioners.

MENTAL DISORDERS AND LIVER TRANSPLANTATION: A 2-YEAR COHORT STUDY.

Psychosocial assessment is a key component in evaluation for liver transplantation and may affect survival rates and outcomes. The primary aim of this study was to investigate the impact of previous mental disorders and impulsivity on the 2-year surviving rate after liver transplantation. We performed a prospective cohort study assessing end-stage liver disease individuals with and without psychiatric comorbidities for 2 years post-transplant. Psychiatric diagnosis was carried out through Mini-Plus 5.0.0 and impulsivity by using Barratt Impulsiveness Scale in the pre-transplant phase. We followed patient's status for 2 years after transplantation. The main outcome was death. We used a logistic regression to evaluate the association of psychiatric comorbidities with death and performed a survival analysis with Kaplan-Meier and Cox regression models. Between June 2010 and July 2014, 93 out of 191 transplant candidates received transplants. From the 93 transplant patients, 21 had psychiatric comorbidities and 72 had not. 25 patients died during the study. The presence of psychiatric comorbidities (P=0.353) and high impulsivity (P=0.272) were not associated to 2-year post transplant death. This study found no evidence that the presence of mental disorders and impulsivity worsened prognosis in post-liver transplantation.

1282P An interim report on the piloting of care of the dying patient guidance in an acute hospital

Palliative care is delivered in specialist inpatient units, in the community and in the acute hospital. Optimizing treatment provision to a dying patient in the acute setting can be challenging. A form to provide guidance to teams in the acute hospital managing a patient at end of life has been developed. The aim of this guidance is to improve patient management at end of life and improve outcomes for the patient and their loved ones. This form was piloted on an oncology and geriatrics ward in a 600-bed acute hospital for a period of 6 weeks. A retrospective audit was completed on the forms of patients who had died in the 6-week pilot period. Form users provided feedback on the usefulness of the form highlighting any areas for improvement they noted. There were 18 deaths in total in the 6-week period. Forms were completed for 50% of patients. The portion of the form to be completed before a patient died demonstrated significantly higher compliance (89%) compared to the portion to be completed post death (11%). 78% recorded whether death notification to the coroner was required, 67% noted that family had been advised that the patient was dying. The consideration of referral to the palliative care team was documented in 67% of forms. Only 22% noted that chaplaincy had been advised. Only 11% recorded considering bereavement support through either social work or chaplaincy referral. 11% noted that the GP had been advised of the patients’ death. User feedback was positive in relation to the use of the guidance with users finding it very helpful as a reference point in end-of-life situations. Many medical teams in the acute hospital have little experience of managing a dying patient. This form provides useful guidance going forward and should improve patient and family outcomes. A 50% form completion rate indicates that more awareness of the form and its purpose is required. The lack of completion of the post death section is attributable to the removal of patient notes from wards shortly post death. This is an area which requires attention to ensure important post death support is provided to families and to ensure GPs are informed of the death of their patient in hospital. The aim is to implement this document across the hospital and potentially nationwide.

196. Clinical characteristics of 98 patients presenting with hematogenous spinal osteomyelitis: An observational study

<h3>BACKGROUND CONTEXT</h3> Most spinal infection occurs in the wake of invasive procedures, wherein flora have been directly inoculated into the spine and its surrounding soft tissues. Hematogenous infections, on the other hand, result from bacterial spread from a distant site. Staphylococcus aureus is the most common cause of hematogenous spinal infections, and most cases resolve with a 6-week course of antibiotics. However, some patients, especially those that present with concurrent epidural abscess and neurological embarrassment, require debridement of the site and potential structural stabilization. Since very few studies report the clinical characteristics of patients requiring surgery or succumbing to this disease state, this study aims to detail our series of patients with hematogenous spinal osteomyelitis. <h3>PURPOSE</h3> To report clinical characteristics of patients with hematogenous spinal osteomyelitis <h3>STUDY DESIGN/SETTING</h3> Retrospective study. <h3>PATIENT SAMPLE</h3> A total of 98 patients with hematogenous vertebral osteomyelitis. <h3>OUTCOME MEASURES</h3> Preoperative (preop) and postoperative (postop) courses of antibiotics, surgery, reoperation, length of hospital stay, postop sequelae and death. <h3>METHODS</h3> The medical records of patients presenting to two tertiary care centers from January 2014 to January 2021 with hematogenous spinal osteomyelitis were abstracted using ICD-10 codes M46.20 to M46.59. We collected age, sex, body mass index (BMI), comorbidities, affected spinal region, microbiological details, type and duration of pre- and postop antibiotics, length of hospital stay (LOS), reoperation and mortality. Long-term antibiotics were those in use > 6 months. <h3>RESULTS</h3> A total of 98 consecutive patients presenting with hematogenous vertebral osteomyelitis were included. Demographically, the mean age was 62±10 years; 61.2% (n-=60) were male; mean BMI was 29.2±10.4. Most of the infections occurred in the lumbar region (44.2%), followed by the thoracic spine (37.9%), more than two spinal regions (9.5%) and cervical spine (8.4%). Biopsy was performed in 94.1% and returned positive cultures in 93.4%. Of the cultures taken, gram positive bacteria accounted for 69.2%, gram negative in 16.7%, and fungus in 2.6%. 11.5% of cultures returned no growth. 76 (77.6%) patients underwent surgery while 22 (22.4%) were treated with antibiotics only. Of the 76 undergoing surgery, 34.2% underwent secondary surgeries due to a heavy wound burden of necrotic tissue and pus or the failure of multimodal care including antibiotics and debridement. 51.6% of the patients had been prescribed antibiotics preoperatively, with a mean course of 37.2±25.7 days. Postoperative antibiotics were prescribed to all patients, with a mean length of 70.2 days. Mean LOS was 17.9±15.3 days. Additionally, 51.6% of the patients were prescribed long-term antibiotic therapy. The overall death rate was 3.1% (n=3). All 3 patients underwent surgery. Demographic and clinical characteristics of the deceased patients include a mean age of 64 years, majority male (66.7%), who had major comorbidities such as diabetes, anemia, obstructive lung disease and hypertension. Major cause of death was septic shock. Major post-infection sequelae occurred in 24.5% (n=24) of patients. Patients suffering sequelae had a mean age of 69.3 years, were mostly male (83%) and carried major comorbidities including diabetes, anemia, hypertension and renal disease. The most common sequelae were major motor weakness, wound dehiscence and meningitis. <h3>CONCLUSIONS</h3> This study describes the clinical characteristics of patients presenting with hematogenous spinal osteomyelitis, their treatment course and outcomes. As in other sites of infection, the presence of major comorbidities (diabetes, hypertension and renal failure) appear to increase the risk of developing post infection sequalae and death. Our population included patients hospitalized in a tertiary care center with spinal osteomyelitis. They were therefore more likely to carry concomitant diagnoses such as epidural abscess, resulting in a high rate of surgical intervention. A future study with a larger sample size utilizing logistic regression would be able to identify significant risk factors both for hematogenous infection itself and for failure of non-operative and initial operative care. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

PB1758: TWENTY-ONE YEARS’ EXPERIENCE OF THE EORTC 58951 PROTOCOL FOR THE TREATMENT OF CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA IN THE SOUTH OF TUNISIA

Background: Childhood acute lymphoblastic leukemia (ALL) is a hematologic malignancy with high rate of cure. Aims: We report the experience of the clinical hematology department of Sfax-Tunisia for the treatment of childhood ALL with the EORTC 58951 protocol. Methods: From January 2000 to December 2020, we retrospectively studied the outcome of childhood ALL aged less 16 years, treated with the EORTC 58951 pediatric protocol. For those patients we studied the leukemia characteristics (sex ratio, white blood cell counts WBC, blast’s phenotype, cytogenetic abnormalities) and response to treatment: response to prophase, remission rate, risk group stratification, treatment related mortality (TRM) (induction and post induction death) and survival (overall survival OS and event free survival. Results: From January 2000 to December 2020, 284 children were treated with the EORTC 58951 protocol. Medium age was 7 years (range: 1 to 15 years). Sex ratio M/F was 1.53. WBC counts more than 100 G/L were observed respectively in 41, 44 and 15% of cases. The blast’s phenotype was B in 70%. Cytogenetic abnormalities were noted in 37% of cases. A good response to prophase was noted in 80% and complete remission in 92% of cases. The EORTC risk group stratification was Low Risk (LR) in 5%, Average Risk1 (AR1) in 39%, Average Risk2 (AR2) in 25% and Very High Risk (VHR) in 31%. TRM was 10%: induction rate death was 6% and post-induction rate death was 4%. Twenty-eight patients from VHR group with sibling familial donor underwent allograft. The relapse rate was 29% of all patients in remission; 4% for LR group, 39% for AR1 group, 18% for AR2 group and 39% for VHR group. At a follow up of 126 months, OS and EFS at 10 years were respectively 61% and 56%. Summary/Conclusion: At diagnosis, childhood ALL in our study had poor characteristics particularly higher rate of T phenotype of blasts, higher rate of leukocytosis more than 100 G/L, higher rate of VHR therapeutic group and higher rate of cortico-resistant regarding occidental series. Despite the acceptable results concerning remission rate but survival rates remain lower than those observed in the literature, this is explained mainly by the high rate of relapse (29% vs ≃15%). It can be improved our results by detecting high risk patient with MRD study especially for AR1 risk group and doing allograft for VHR patients.

Intensive care nurse’s perceptions on barriers impeding the provision of end of life care in the intensive care setting: a quantitative analysis

Background: Intensive care nurses look after the most critically ill patient population with the highest mortality rate on a daily basis. Whilst research to date has highlighted and provided some insights into the current provision of end of life care, further research is much needed to improve the efficacy of nurses existing practice. Objective: To investigate the specific barriers and contextual characteristics that nurses experience within the Intensive Care Unit environment. Study Methods: The National Questionnaire of Critical Care Nurses Regarding End of Life Care was used to collect quantitative and qualitative data to answer the research questions. This study was conducted in a major intensive care unit located in a tertiary public hospital in metropolitan Western Australia. Results: The respondent rate was 67.31%. Obstacles with the highest perceived intensity score (PIS) reported by participants involved issues around the communication and practice of end of life care including family interaction. The ranges of mean scores for supportive behaviours were much higher than the ranges for obstacles. These supportive behaviours included allowing family members to have adequate time alone with the patient after death, and families being taught how to engage with the dying patient. Conclusion: The findings reflect that the most intense and frequently occurring obstacles are consistent with past research. A perceived negative end of life care experience by the nurse was found to negatively impact the nurse’s psychological and physiological health. The research demonstrates the need for a stronger multidisciplinary patient centred approach. It is envisaged that the findings will support the review and development of appropriate guidelines to support nurses caring for intensive care patients in the initial and progressive phases of end of life care. What is already known about this topic? ICU patients have the highest incidence of mortality in the acute care setting with one in four patients dying in an ICU, accounting for 15% of all hospital deaths annually. This patient population presents nurses with a set of unique, yet significant challenges related to increased rate of mortality. There is a significant amount of existing literature that has explored moral distress amongst nurses, particularly in relation to end of life care. What this paper adds: This research suggests that there continues to be obstacles that impede critical care nurse’s ability to facilitate EOLC in the ICU setting. The participants of this study highlighted the need for stronger emphasis being placed on decision making processes, communication, and standardised practice. The most supportive behaviours reported were associated with practice that could be initiated by the nurse such as, allowing family members adequate time with their loved one pre and post death, and teaching family members how to act and engage with their loved ones during this time.

Caregivers' Loss of the Dyadic Experience After Their Care Partner's Death

One emerging dyadic concept is the experience of family caregivers when their care partner dies and their dyadic relationship comes to an end. This study qualitatively examined and characterized the loss of the dyadic experience for the caregiver after the death of their care partner. Data was accrued as part of a randomized clinical trial in 29 older hospice caregivers. Iterative thematic analysis focused on dyadic processes before, during and post death. Using two relational parameters from Relational Turbulence Theory resulted in a preliminary characterization of a new concept - dyadic dissolution as a cognitive and affective process whereby a remaining member of a dyad experiences relational uncertainty and partner interference while adapting (or not) to the death of their care partner. Findings suggest that asking several open-ended questions about the dyadic relationship will enable assessment for any continuing impact of relational uncertainty and partner interference on bereaved caregivers.

Nurse-facilitated reflective exercise post patient death in the ICU: a best practice implementation project.

ICUs are stressful environments where patient care is complex and demanding; death is not an unusual outcome. Nurses can become emotionally distressed from experiencing multiple, unexpected, or traumatic patient deaths. Performing a reflective exercise immediately post death is one coping strategy which encourages healthcare staff and family to debrief their feelings in a timelier manner. The aim of this project was to educate the nurses in the ICU with emotional coping skills pertaining to the effects of patient deaths. The objective was to implement a nurse-guided reflective exercise following each patient death in three adult ICUs in a quaternary academic medical center. The current change project used the Joanna Briggs Institute's Getting Research into Practice and Practical Application of Clinical Evidence Systems for auditing and strategy development. After standardizing the reflective exercise procedure, teaching methods were employed to support implementation. One follow-up audit measured compliance with completing a reflective exercise for all deaths occurring in the three ICUs. Contextual data were collected for completed exercises including type of death and words to describe nurses' emotions. The reflective exercise script was revised and the standard procedure posted to the intranet for easy access. All ICU nurses received education on the use of this reflective exercise. For each of the two ICUs where this practice was new, compliance with nurses initiating and completing a reflective exercise was at a rate of 17 and 2%, respectively. For the ICU where reflective exercise was reintroduced, compliance was 30%. All deaths included in this study were anticipated (e.g., patient on comfort care) and calm, with the exception of one post cardiac arrest death. Despite multipronged teaching for why, when, and how to use reflective exercise, there was minimal success in completing reflective exercises in the two units where the practice was new. This outcome was most likely due to higher than anticipated levels of needed support or the unpredictability of frequency of deaths on each unit. However, the main achievement was having the Minute of Silence procedure with a standardized script readily available at all times for nursing staff. Reimplementation success in the other ICU was attributed to more recently established reflective practices. Further exploration of barriers, such as type of death, and re-education are essential strategies to bolster and sustain practice and to provide support for our nursing staff to prevent emotional distress.

Abstract P571: Effects of Renal Insufficiency on Congestive Heart Failure and Coronary Artery Disease Burden in Patients Undergoing Elective Percutaneous Coronary Intervention

Background: We investigated coronary artery disease (CAD) burden and rates of death and stroke in stable patients with renal insufficiency undergoing elective percutaneous coronary intervention (PCI). Methods: Data from 2015 NY state Angioplasty registry was utilized. There were 33,508 PCI recipients (65+/-11 years old; 32% females, 40% with diabetes, 6.4% with COPD, 6.9% with history of CHF, and 8.25% with peripheral artery disease) without history of recent myocardial infarction (MI in less than 24 hours), shock, or prior coronary artery bypass surgery. Patients were divided according to the glomerular filtration rate (GFR) status consistent with the National Kidney Foundation classification: 24% had a GFR more than 90 ml/min (group G1) , 49% GFR of 60-89 (G2), 15% GFR of 45-49 (G3a), 6.9% GFR 30-44 (G3b), 2% GFR of 15-29 (G4), and 4% with GFR of less than 15 ml/min (G5). Results: With decline in GFR, prevalence of CHF increased significantly. CHF was present in 3.6% of G1 patients undergoing elective PCI, 4.49% of G2, 10.20% of G3a, 17% of G3b, 22.26% of G4 and 22.20% of G5 patients (P&lt;0.0001). With decline in GFR, CAD burden was also significantly increased. Left main or three vessel CAD was present in 19.39% of G1 patients undergoing elective PCI, 19.13% of G2, 22.62% of G3a, 25.83% of G3b, 29% of G4 and 27.8% of G5 patients (p&lt;0.001). Furthermore, advanced kidney disease was associated with increased rates of post elective PCI stroke and death. Specifically, post PCI stroke occurred in 0.11% of G1 patients, 0.13% of G2, 0.33% of G3a, 0.27% of G3b, 0.7% of G4, and 0.6% of G5 patients (p&lt;0.001). Similarly, post elective PCI mortality occurred in 0.16% in G1 patients, 0.19% in G2, 0.41% in G3a, 1.04% in G3b, 1.22% in G4 and 1.49% in G5 patients (p&lt;0.0001). After adjustment for co-morbidities such as diabetes, CVD, and COPD, risk of post PCI stroke and death was significantly increased by 3.528 (95%CI 1.866-6.671, p&lt;0.0001) in patients with GFR less than 15 ml/min. Conclusion: In patients undergoing elective PCI, renal insufficiency is associated with increased rates of post-procedural death and stroke as well as increased prevalence of CHF. Additional research is needed to decrease risk of elective interventions in this vulnerable group of CAD patients.

P50.10 Intravenous (IV) versus IV/oral route of etoposide administration: impact on real-world SCLC survival outcomes

Platinum-etoposide doublet (PE) is the recommended first-line (1L) chemotherapy for small cell lung cancer (SCLC). Evidence shows that oncology patients prefer oral treatment to IV. This study compared outcomes between 1L intravenous (IV), and IV followed by oral (IV/oral) route of etoposide administration in real-world SCLC patients in Alberta, Canada. SCLC patients who were diagnosed between 2010 and 2016 and completed 1L etoposide at an academic tertiary cancer centre, (Tom Baker Cancer Centre) were included. Data were retrieved from the Glans-Look database excluding those with mixed histology. Outcomes explored included, a] overall survival, (OS), the time in months from diagnosis date to death/last contact, b] tumor objective response rate (ORR), the complete and partial responses as defined by the RECIST v1.1 criteria, using diagnostic imaging reports within 4-8 weeks post 1L or as reported in oncologist progress notes, and c] 1L-related toxicity rate, derived from progress notes, graded using the CTCAE criteria (version 5). Also measured was the progression free survival (PFS): time difference in months from diagnosis date to first progression post 1L or death, whichever occurs first. Comparison between IV/oral and IV groups was performed using Fisher’s Exact (point estimates), Log-Rank tests (Kaplan-Meier survival estimates) and Cox proportional hazard model (survival outcome predictors). A priori statistical significance was p < 0.05. Analyses were performed using SPSS statistical software (version 25). There were 222 patients, 1L was mostly PE [93%] employing etoposide in combination with cisplatin [61%] or carboplatin [32%]. 168 [76%] were IV/oral group. Median age was 66 years, 132 [60%] female, and 138 [62%] had extensive stage SCLC (ES). Performance status (ECOG) was 0-2 in 112 (51%), ≥3 in 9 (4%) and unknown in 101 (46%) patients. IV and IV/oral patients have similar characteristics, but compared to IV/oral, the IV group had less limited stage disease (LS), [p=0.28]. 100 patients experienced grade 3 or 4 toxicities, mainly neutropenia [83%]. The rates were similar for IV/oral versus IV group, p= 0.36. Stratified by stage however, toxicity from IV was greater in LS than ES patients [60 vs 39%]. Overall, ORR for IV/oral versus IV group was 71% vs 66%, [p=0.85]. Within stage, ORR was 79 vs. 89% in LS [p< 0.01] and 58 vs 71% in ES [p=0.23], IV/oral relative to IV group. There was no statistically significant difference in PFS or OS with IV/oral relative to IV groups [PFS: 14 vs 12 months for LS; both 6 months for ES; OS: 32 vs 25 mo. for LS; 12 vs 14 mo. for ES]. Predictors of favorable survival include presence of grade 3 or 4 toxicity in LS [HR= 0.45, p=0.03] and second-line chemotherapy receipt in ES [HR= 0.46, p<0.01]. Consistent with previous reports, we found high oral treatment rate in real-world SCLC patients and no statistically significant differences in SCLC survival outcomes comparing IV/oral versus IV group. Future studies may explore why severe chemotherapy-related toxicity (grade 3 or 4) in LS patients predicts favorable survival.

Caregivers' Loss of the Dyadic Experience after Their Care Partners' Death.

Little is known about the experience of family caregivers when their care partner dies and their dyadic relationship comes to an end. This study qualitatively examined and characterized the loss of the dyadic experience for the caregiver after the death of their care partner. Data was accrued as part of a randomized clinical trial in 29 older hospice caregivers. Iterative thematic analysis focused on dyadic processes before, during and post death. Using two relational parameters from Relational Turbulence Theory resulted in a preliminary characterization of a new concept-dyadic dissolution as a cognitive and affective process whereby a remaining member of a dyad experiences relational uncertainty and partner interference while adapting (or not) to the death of their care partner. Findings suggest that asking several open-ended questions about the dyadic relationship will enable assessment for any continuing impact of relational uncertainty and partner interference on bereaved caregivers.

High throughput estimates of Wolbachia, Zika and chikungunya infection in Aedes aegypti by near-infrared spectroscopy to improve arbovirus surveillance

Deployment of Wolbachia to mitigate dengue (DENV), Zika (ZIKV) and chikungunya (CHIKV) transmission is ongoing in 12 countries. One way to assess the efficacy of Wolbachia releases is to determine invasion rates within the wild population of Aedes aegypti following their release. Herein we evaluated the accuracy, sensitivity and specificity of the Near Infrared Spectroscopy (NIRS) in estimating the time post death, ZIKV-, CHIKV-, and Wolbachia-infection in trapped dead female Ae. aegypti mosquitoes over a period of 7 days. Regardless of the infection type, time post-death of mosquitoes was accurately predicted into four categories (fresh, 1 day old, 2–4 days old and 5–7 days old). Overall accuracies of 93.2, 97 and 90.3% were observed when NIRS was used to detect ZIKV, CHIKV and Wolbachia in dead Ae. aegypti female mosquitoes indicating NIRS could be potentially applied as a rapid and cost-effective arbovirus surveillance tool. However, field data is required to demonstrate the full capacity of NIRS for detecting these infections under field conditions.

In-hospital Outcome of Percutaneous Coronary Intervention among Very Elderly Patients with Ischemic Heart Disease in a Dedicated Cardiac Hospital

Background: Cardiovascular disease, and ischemic heart disease (IHD), is a major cause of morbidity and mortality in the very elderly patients (&gt;80 years) worldwide. These patients represent a rapidly growing cohort presenting for percutaneous coronary intervention (PCI), now constituting more than one in five patients treated with PCI in real-world practice. Furthermore, they often have greater ischemic burden than their younger counterparts, suggesting that they have greater scope of benefit from coronary revascularization therapy. The elderly usually has higher prevalence of co morbidities and more often experience complications during and after revascularization procedures. Our aim was to evaluate clinical outcomes of PCI in patients older than 80 years, compared to their younger counterparts.&#x0D; Materials and methods: From July 2017 to July 2018 we included 212 patients with IHD purposively in Cardiology department of National Institute of Cardiovascular Diseases undergone PCI who were divided into 2 groups according to age: e” 80 years (n = 74) and &lt; 80 years (n = 138). Baseline clinical characteristics, indications for coronary intervention, in hospital outcomes were obtained. Study endpoint were Renal impairment, MI, LVF, emergency revascularization and death.&#x0D; Results: Very elderly patients were more frequently male (86%) and nonsmoker at present (41% vs. 63%, p=0.003), had higher prevalence of hypertension (60% vs. 50%, p&lt;0.13), and more often presented with NSTEMI (54% vs. 23%, p&lt;0.001). Elderly group had higher incidence of TVD and LM disease (36% vs. 26% and 9.5% vs. 2.9%, p=0.07) and more incidence of ostial (16.2% vs.5.1%,p=0.007) and calcified lesions (31.1% vs. 14.5%, p=0.004). Procedural success (TIMI III) were high in both groups, but still lower in the elderly as compared to younger group (95% vs. 97%, p=0.65). Very elderly patients had higher incidence of post PCI bleeding, CIN, MI, LVF and death (9.5% vs.6.1%, 8.2% vs.3.7%, 6.8% vs.5.8%, 9.5% vs. 5.1% and 5.4%vs.3.6%,p=0.07), whereas emergency revascularization were higher in younger group (5.4% vs. 6.5%, p=0.07).&#x0D; Conclusion: Very elderly patients aged ≥80 years face more vascular site complications during PCI, usually have more LM and TVD with more ostial and calcified lesions in comparison with younger group. Though procedural success is similar with younger group, they face more post PCI CIN, LVF and MI. Repeat revascularization was higher in younger group.&#x0D; Bangladesh Heart Journal 2020; 35(1) : 61-65

Spouses bereaved by suicide: A population-based longitudinal cohort comparison of physician-diagnosed mental disorders and hospitalized suicide attempts

BackgroundThis study compares a longitudinal population-based sample of spouses bereaved by suicide and those bereaved by other sudden deaths to determine if suicide-bereaved spouses (SBS) experience greater rates of physician-diagnosed mental disorders. Methods: First, married individuals whose spouse died by suicide, sudden natural death (SND) and unintentional injury (UI) were compared to non-bereaved matched cohorts to determine if there were differences in mental disorder rates between bereavement groups and non-bereaved matches. Second, SBS (n = 365), spouses bereaved by SND (n = 1000), and spouses bereaved by UI (n = 270), were compared using inverse probability treatment weighting and generalized estimating equations to calculate relative rates of mental disorders 5 years before/after death. Outcomes: All bereaved cohorts had higher rates of mental disorders compared to non-bereaved cohorts. SBS had the greatest rate of depression post-bereavement (50·96%), followed by UI (38·52%) and SND (33·70%) spouses. When comparing bereavement cohorts, a significant group-by-time interaction (P = 0·047) revealed the rate change for depression was significantly different between suicide and UI-bereaved spouses, with SBS having higher rates of depression before bereavement. SBS had increased rates of any mental disorder both pre (ARR = 1·35, 95% CI = 1·03-1·18, P<·05) and post spousal death (ARR = 1·24, 95% CI = 1·03-1·45, P<·05) when compared to UI spouses signifying pre-existing mental disorders. Post-bereavement, SBS had greater rates of depression only when compared to SND-bereaved spouses (ARR = 1·31, 95% CI = 1·10-1·55, P<·01). Interpretation: SBS have the greatest rates of depression and any mental disorder before the death of their spouse, suggesting suicide bereavement may be unique. Sudden spousal bereavement is a vulnerable time for mental disorders.

Scatter plot analysis of malleable variables in the post death era of George Floyd

Scatter plot analysis of malleable variables in the post death era of George Floyd