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Objectives: Anticipatory grief is associated with post-bereavement grief; however, reports on the influence of pre-loss depression are limited. Therefore, we investigated the association between the anticipatory grief of family members and post-loss and post-depression grief adjusted for pre-loss depression. Methods: This cohort study included the family members of dying patients with cancer. Questionnaires were distributed to them during hospitalization in four inpatient palliative care units from 2016 to 2017. We also administered follow-up questionnaires after their bereavement in 2018. The pre-bereavement questionnaire consisted of three items from the Anticipatory Grief Scale for Families Caring for a Terminally Ill Person for assessing anticipated grief and the Patient Health Questionnaire 9 for assessing depression. The Brief Grief Questionnaire was used to assess post-loss grief. Results: We distributed 181 pre-bereavement questionnaires to the family members; 112 (62%) responded to the pre-bereavement survey, out of which 71 (63%) responded to the post-bereavement survey. Anticipatory grief was significantly associated with pre-loss (ρ = 0.37, ρ < 0.001) and post-loss (ρ = 0.24, P = 0.009) depression and marginally associated with post-loss grief (ρ = 0.15, P = 0.10). Pre-loss depression was also significantly associated with post-loss depression (ρ = 0.50, P < 0.001) and post-loss grief (ρ = 0.41, P < 0.001). However, anticipatory grief was not significantly associated with post-loss depression (P = 0.35) and post-loss grief (P = 0.65) after adjusting for pre-loss depression. Significance of Results: Bereaved families who experienced anticipatory grief had worse post-bereavement depression. However, this association was not statistically significant after adjusting for pre-bereavement depression. Post-bereavement depression may be in a continuum with pre-loss depression, and anticipatory grief does not independently affect post-loss reactions.

Background: Antipsychotics and benzodiazepines are prescribed for hyperactive delirium despite their side effects and lack of supportive evidence. Valproic Acid (VPA) improves agitation without QTc prolongation, excessive sedation, and parkinsonism. However, high quality evidence for this is lacking in delirium. Methods: This retrospective study involved hospitalized patients seen by Palliative medicine from 10/1/2019 to 4/17/2020 who received VPA for at least 24 hours for hyperactive delirium. Patients were excluded if VPA was used for seizures or bipolar disorder. We hypothesized that VPA improves agitation and thus reduces the use of opioids, antipsychotics, and benzodiazepines. Results: Twenty patients, 50% women, and a median age of 81.5 years were treated. Nine had cancer, five dementia and two had strokes. The median daily VPA dose was 831.6 mg (IQR 671.4 -1016.4). Due to the small numbers, we did not find a statistically significant differences in benzodiazepine, opioid, or antipsychotic use on days 1, 2, or 3. VPA was used as monotherapy in 10 patients, with no additional antipsychotic or benzodiazepines needed. Eleven patients were on comfort care measures at the time of VPA initiation. Ten died in the hospital. Three were discharged home, and seven transferred to a skilled nursing facility. Discussion: This study explored the use of VPA in palliative care. VPA may be effective in treating aggitation. Randomized controlled trials are needed to validate VPA benefits in treating agitated delirium.

IntroductionBlunt trauma to the external iliac artery (EIA) is rare but potentially fatal. Endovascular stent-graft placement is used to control hemorrhage and restore limb perfusion. However, the safety profile and potential complications associated with stent-graft treatment are not well documented. We report a case of EIA injury following blunt trauma complicated by stent-graft deployment into a false lumen, successfully managed with an endovascular rescue technique.Case ReportAn 88-year-old man sustained blunt pelvic trauma with active extravasation from the left EIA. Initially, a covered stent-graft was deployed, which inadvertently caused arterial occlusion due to placement within a false lumen. A rescue procedure was performed using an endovascular approach, where a guidewire was advanced through the perigraft space and snared to establish a pull-through technique. Over this, a second stent-graft was deployed within the perigraft space, restoring flow through the true lumen. Follow-up computed tomography images confirmed successful recanalization and persistent exclusion of the false lumen.ConclusionThis case highlights the potential for stent-graft misplacement in EIA trauma and the importance of ensuring access to the true lumen. Accessing the perigraft space and placing an additional stent-graft represents a new therapeutic approach to achieve recanalization in similar complex vascular injuries.

Obesity appears to be associated with improved health outcomes in patients with sepsis, a phenomenon termed the obesity paradox. However, the potential influence of varying operational definitions of obesity on clinical outcomes within this paradox remains inadequately characterised. This scoping review aimed to identify, analyse, and synthesise the methodological approaches to obesity definition employed in sepsis research. A systematic literature search was conducted in August 2023 across MEDLINE, Embase, CINAHL, and CENTRAL databases. This review included original articles, systematic reviews, and meta-analyses reporting on adult patients with both obesity and sepsis. After removing 60 duplicates, 430 citations were screened, and 68 met the inclusion criteria. Among studies on the obesity paradox, 90.5% supporting and 88.6% refuting it employed body mass index-based definitions, with approximately three-quarters using retrospective designs. Studies supporting the obesity paradox identified patients with obesity as younger, predominantly female, and with higher comorbidity rates. In contrast, studies refuting the paradox reported more diverse age and sex distributions, yet consistently noted elevated chronic disease prevalence in patients with obesity. Both groups found similar or higher illness severity scores among patients with obesity. The lack of methodological rigour in obesity definitions within clinical research may contribute to the obesity paradox. Future studies should critically evaluate measurement methods and definitional variability to clarify their impact on clinical outcomes.

ObjectiveVascular closure devices (VCDs) are frequently employed to achieve hemostasis at the femoral puncture site, offering an alternative to traditional manual compression. However, a rare yet significant complication is common femoral artery (CFA) occlusion caused by suture-mediated VCDs. The optimal management of this complication remains unclear, with open surgical repair traditionally regarded as the standard of care. This paper aims to share our clinical experience in managing CFA occlusions caused by suture-mediated VCDs and to introduce our preferred endovascular treatment strategy.MethodsAt our institution, approximately 250 femoral artery hemostasis procedures using suture-mediated VCDs are performed annually. Over the past 10 years, we encountered 6 cases of CFA occlusion following the use of such devices. This corresponds to an incidence rate of approximately 0.24%. In all cases, endovascular management was selected as the primary treatment modality over open surgical intervention. Our endovascular approach consisted of initial balloon angioplasty, with adjunctive stenting performed when residual stenosis exceeded 50%.ResultsEndovascular treatment was technically successful in all 6 cases, with no major procedural complications. The mean degree of stenosis prior to balloon angioplasty was 91.9%, including 3 cases of long segmental occlusion. Balloon angioplasty alone was sufficient in 4 cases, while the remaining 2 required additional stenting to address significant residual stenosis. Final angiography demonstrated an average residual stenosis of 25.1%. During the follow-up period (mean duration: 37.8 months), no patients reported symptoms of lower extremity ischemia.ConclusionThis case series highlights the feasibility and efficacy of endovascular management as a first-line approach for CFA occlusion caused by suture-mediated VCDs. When diagnosis is delayed, long segmental occlusion with considerable thrombus burden may limit the effectiveness of balloon angioplasty alone, necessitating adjunctive stenting. Therefore, timely diagnosis and intervention are essential to optimize outcomes in these cases.

Orthodox Jewish patients with terminal illnesses have unique goals and desires, often driven by halakha (Jewish law and ethics) and cultural norms. We conducted a quality improvement project investigating the baseline perceptions and experiences of medical professionals who care for Orthodox Jewish patients with terminal illnesses. The survey included health care professionals who cared for Orthodox Jewish patients as part of Intensive Care Unit (ICU), Oncology, or Palliative Care and Hospice teams. The three main elements of the survey included respondent demographics, multiple choice selections, and a free-text section. A total of 73 medical professionals responded to the survey. Several important findings were noted. Compared to the general population, Orthodox Jewish patients with terminal illnesses are more likely to request aggressive measures at end-of-life and are less likely to have completed advanced directives and health care power of attorney documentation. They also do not always have a rabbinic authority involved in decision-making. Health care professionals highlighted strong religious and community support as positive elements of caring for this population and recommend that medical teams establish early and direct communication with rabbinic authorities for those patients for whom a rabbi's involvement is desired. These data inform ongoing next steps to improve the quality of care for these patients and their families.

There is an emerging need to provide high-quality pediatric palliative care and end-of-life care to children, adolescents, and young adults with life-limiting illnesses. Currently, there are no standardized quality measures supporting pediatric palliative care and end-of-life care patient outcomes. The aim of this literature review was to explore current quality measures utilized in pediatric palliative care and end-of-life care among pediatric patients with life-limiting illnesses within the conceptual framework of Comfort Theory. A comprehensive review of relevant articles resulted in 15 articles that met criteria and were evaluated. Included studies focused on pediatric patients with life-limiting illnesses receiving palliative care or end-of-life care. Articles related to children with acute illness, trauma, or accidental death were excluded. Emergent themes among quality measures were categorized into 7 domains: (a) Alleviation of distressing symptoms, (b) Structures and processes of care, (c) Health care utilization, (d) Location of death and bereavement care, (e) Patient and family experiences, (f) Psychological and spiritual care, and (g) Cultural, ethical, and legal considerations. These domains support the physical, psychospiritual, sociocultural, and environmental contexts of Comfort Theory. Quality measure research, development, and standardization should focus within the 7 domains identified for the promotion of comfort, equity, and accessible care.

BackgroundAortic dissection following endovascular aneurysm repair (EVAR) may be iatrogenic or a de-novo event. This study aims to systematically review all cases of dissection following EVAR to identify complications specific to each scenario and develop a management algorithm depending on the clinical presentation.MethodsA comprehensive literature search of MEDLINE, Embase, and CENTRAL databases was performed for all studies relating to dissection following EVAR or fenestrated/branched EVAR (F/BrEVAR). Data collected included timing (differentiating iatrogenic and de-novo events), entry tear location, endograft involved, complications, management, and subsequent outcomes. Due to limited data availability, descriptive data was collected and outcomes compared depending on dissection type and timing. Risk of bias was assessed using a standardised tool for case reports.Results46 patients in 37 studies were included. Complications included endograft compression (52.2%), endoleak (15.2%), and rupture (13.0%). Compression was less likely in endografts with proximal fixation (41.9%), compared to those without (69.2%). Type A dissection after EVAR required cardiac surgery with a high mortality (20.0%). In Type B dissection, 2 cases were diagnosed intra-operatively during F/BrEVAR, 1 died. 8 were diagnosed <4 weeks post-operatively, all managed medically with no complications or mortality. 31 were diagnosed >4 weeks, with mortality of 25.8% and high rates of endograft compression (58.1%), endoleak (16.1%), and rupture (19.4%).ConclusionAortic dissection following EVAR may cause endograft compression, endoleak, or rupture, with significant mortality. Complications are more frequent following Type A dissection and late Type B dissection. Early Type B dissection may be amenable to medical management.

Body mass index (BMI) on its own is a poor diagnostic and staging tool for obesity because it does not measure health status. The newly published Lancet Clinical Obesity Criteria (LCOC) for defining clinical obesity distinguish preclinical and clinical obesity based on organ or tissue dysfunction. The King's Obesity Staging System (KOSS) goes further and incorporates biomedical, psychosocial, and economic factors while offering a practical, holistic, and health domain-specific assessment of obesity's impact. This paper compares and maps the LCOC against the KOSS to highlight their complementary aspects, strengths, and potential for integration. By combining the LCOC philosophical framework with the practical patient-centred approach of the KOSS, we propose a unified model that enhances diagnostic ability and allows the clinician to track the impact of any obesity treatment. This integrated framework advances obesity management, addressing both medical, functional, and broader psychosocial challenges.

BackgroundThirty-day hospital readmissions are a critical healthcare quality metric used to evaluate hospital performance and patient outcomes. Vascular surgery readmission rates are among the highest and most costly. Accurate data on patient readmissions is essential for improving care quality and reimbursement processes. The accuracy of readmission data, often derived from quality metric programs like NSQIP and Vizient, is challenged by misclassification or improper capture of readmissions.MethodsWe conducted a single-institution retrospective analysis using the NSQIP and Vizient registries to identify patients who underwent vascular surgery between 2018 and 2023 and were subsequently readmitted to our institution within 30 days. Demographic, procedural, and readmission data were reviewed to identify factors associated with procedure-related vs non-procedure related readmissions. Logistic regression was employed to determine variables that significantly predicted procedure-related readmissions.ResultsAmong 2375 vascular surgery operations captured by NSQIP and Vizient during the study period, 219 patients (9.2%) were readmitted within 30 days. Of these, 89 (40.6%) were procedure-related and 130 (59.4%) were non-procedure-related. Baseline demographics, comorbidities, and perioperative characteristics were largely similar between groups, although patients with non-procedure-related readmissions were more likely to be functionally dependent (39.2% vs 22.5%, P = 0.009) and current smokers (30.8% vs 20.2%, P = 0.08). In multivariable logistic regression, functional dependence (OR 0.41, 95% CI 0.19-0.88, P = 0.022) and current smoking within 1 year (OR 0.48, 95% CI 0.23-0.99, P = 0.047) were independently associated with lower odds of procedure-related readmission, suggesting that these patients are more likely to return for medical decompensation rather than surgical complications.ConclusionsVascular surgery readmissions are frequent and costly, and factors such as functional health status and pre-existing complications should be considered in prevention strategies. Accurate documentation and coding, combined with targeted transitional care interventions, will be essential to reduce unnecessary readmissions and to ensure fair institutional benchmarking under current quality metric programs.