Publications

• Conservative Management is customized CKD care, symptom management, and support to navigate care across the CKD trajectory through end of life.
• Conservative management is defined by shared decision-making and interdisciplinary teamwork in alliance with patients and care partners.
• Implementation of conservative management hinges on each practice's logistical considerations and resource availability.

Conservative management is holistic and whole-person care for people with kidney failure. This care pathway is often a good choice for patients who prioritize independence, quality of life, and avoidance of burdens associated with life prolonging therapies such as dialysis. This Kidney Health Guidance document aims to provide evidence-based clinical guidance for best practices in conservative management care delivery. Conservative management comprises three components including customized CKD care, symptom management, and smooth navigation of care transitions. This Kidney Health Guidance describes the application of these three components across the illness trajectory, including the role of shared decision-making, care partner engagement, and interdisciplinary collaboration. Practical strategies are outlined for health care professionals to integrate conservative management care delivery into practice.

Early life adversity confers lifelong health risk, and mindfulness-based interventions (MBIs) show promise for mitigating risk. This trial evaluated feasibility and acceptability of remote mindfulness and coping interventions among emerging adults who recalled childhood trauma with the goal to inform an efficacy trial examining stress-related health outcomes. Eighty-one healthy adults (ages 18–29) who recalled physical, emotional, or sexual abuse during childhood were enrolled. Participants were randomly assigned to 2-week mindfulness or coping comparison interventions and completed lab-based and ambulatory assessments at preintervention, postintervention, and one-month follow-up. Primary outcomes included measures of feasibility and acceptability. Global psychosocial outcomes were secondary. Enrollment and retention targets were reached; of 891 people recruited, 81 were eligible and enrolled, and 88% completed the trial. The intervention programs met benchmarks for feasibility, acceptability, and safe implementation. Participants completed 95% of intervention lessons and 59% of daily life practice prompts, and 93% reported positive treatment expectancies. Three mindfulness participants (8%) showed substantial increases in mental health symptoms. No serious adverse events were reported, but 53% of participants had challenging emotional experiences during the training. The assessment protocol was feasible, with 87% of ambulatory assessments and 99% of blood samples collected. There were no group differences on feasibility/acceptability outcomes. Participants in both groups showed medium-sized improvements on global mental health and mindfulness measures. Two-week remote mindfulness and control interventions were feasible and acceptable among adults exposed to childhood trauma. Further work is warranted to evaluate whether MBIs can offset health risk.

Despite numerous calls to action, palliative care remains inadequately integrated into pulmonary–critical care medicine (PCCM) practice and is de-emphasized in PCCM education. Barriers to specialty palliative care demonstrate a clear need for efficient and effective primary palliative care delivered by PCCM clinicians with advanced training. This American Thoracic Society Workshop Report builds on our policy statement on the proactive integration of palliative care in serious respiratory illness with 2 goals: (1) Develop a scalable “PalliPulm” framework to improve palliative care education and practice in PCCM and (2) inform palliative care–focused education and training programs in PCCM to guide future initiatives. We convened an interdisciplinary and interprofessional group of experts between May 2024 and February 2025 over 4 phases: (1) hybrid workshop; (2) virtual breakout groups; (3) nominal group technique and rapid qualitative analysis; and (4) workshop report development. We identified core primary palliative care skills that PCCM trainees and clinicians should obtain and prioritized the most essential skills—that is, symptom management, serious illness communication, and caregiver support in ambulatory settings and serious illness communication, symptom management, palliative care fundamentals, and end of life care in inpatient settings. We describe pragmatic ways to integrate palliative care into PCCM education and offer advanced educational resources. We provide recommendations for framing palliative care to patients and caregivers, illustrate ways to deliver culturally appropriate palliative care, and offer a path for the future of PalliPulm. This report guides PCCM leaders, trainees, and clinicians to establish scalable PalliPulm educational and practice initiatives and improve its integration into practice.

BACKGROUND: Oral anticancer medications are standard care for cancer. Medication adherence influences health outcomes, but valid, reliable measures assessing self-reported medication adherence are limited. Psychometric properties of the PROMIS® Medication Adherence Scale (PMAS) were evaluated in patients prescribed oral anticancer medications for multiple myeloma.

METHODOLOGY: This was a secondary analysis from a longitudinal observational study examining medication adherence, symptoms, quality of life, and financial hardship among individuals prescribed oral anticancer medications for multiple myeloma. PMAS measured self-reported medication adherence. Self-report and medical record data assessed participant characteristics and adherence correlates. Objective medication adherence indices were generated from continuous electronic event monitored data. Internal consistency reliability was estimated using Cronbach's alpha. Dimensionality was assessed with confirmatory factor analysis. Construct validity was assessed considering adherence correlates. Spearman rank-order correlations summarized associations between PMAS and electronic event monitored data.

RESULTS: PMAS items had limited variability, with high adherence over time. Reliability of PMAS scores was adequate (T1 α = 0.82, 95% CI: 0.75, 0.87; T2 α = 0.84, 95% CI: 0.78, 0.89). Confirmatory factor analysis fit was better for sub-scales (Medication Beliefs and Knowledge and Medication Taking Behaviors) than Total scale, particularly for the Medication Beliefs and Knowledge subscale. Adherence correlates were observed as expected between PMAS and age, self-reported cognitive function, symptom severity, and depression. Weak/moderate positive associations were found between PMAS and electronic event monitored data.

CONCLUSIONS: Reliability, two-factor dimensionality, and construct validity were supported, with some evidence of concurrent criterion validity with electronic event monitored adherence data. Additional validation testing is needed to support findings. Evidence supports the feasibility of longitudinal oral anticancer medication adherence assessment monitoring using PMAS.

PURPOSE: HER2-low breast cancer is treatment-relevant, but whether it is clinically distinct from HER2-0 disease remains unclear. We evaluate metastasis-free interval (MFI), first metastatic site, and survival after metastasis among HER2 classes in metastatic breast cancer.

METHODS: We retrospectively examined patients with metastatic breast cancer classified as HER2-0, HER2-low, or HER2-positive. Analyses included the chi-square test of independence, Welch one-way ANOVA, Kaplan-Meier estimation, and binary and ordinal logistic and Cox regression models.

RESULTS: Among 1,599 patients, 647 (40.5%) had HER2-0 tumors, 672 (42%) had HER2-low tumors, and 280 (17.5%) had HER2-positive tumors. HER2-positive tumors had the shortest MFI compared with HER2-low and HER2-0 tumors (median 2.7 vs. 3.3 vs. 3.7 years, respectively; p = 0.002) and lower odds of late recurrence (≥ 5 years) compared with HER2-0 tumors (OR 0.39, 95% CI 0.22-0.68). HER2-low and HER2-0 tumors had similar metastatic timing. First metastatic site differed across HER2 groups in unadjusted analyses, although HER2 status was not independently associated with bone-only or CNS-only presentation in adjusted binary models. In adjusted Cox regression, HER2-low disease (HR 0.85, 95% CI 0.74-0.97) and HER2-positive disease (HR 0.73, 95% CI 0.60-0.88) were associated with lower hazard of death compared with HER2-0 disease.

CONCLUSION: HER2-positive disease was associated with earlier metastatic recurrence but more favorable post-metastatic survival. HER2-low disease had modestly improved post-metastatic survival but otherwise resembled HER2-0 disease in metastatic timing and adjusted metastatic presentation. These findings support HER2-low status for outcome stratification but suggest it may not independently define a distinct metastatic pattern.

CLINICAL TRIAL NUMBER: Not applicable.

BACKGROUND: Goals of care (GOC) discussions are critical conversations between patients, families, and clinicians to ensure medical treatment aligns with patients' values/preferences, especially in the context of serious illness. Despite their importance in enhancing patients' quality of life (QOL) and aligning care plans with values/preferences, GOC discussions occur infrequently due to systemic, clinician, and patient-level barriers. We sought to conduct an updated review of the literature highlighting recent interventions aimed at improving GOC discussions, as summarizing these advancements could help inform clinical practice.

METHODS: We conducted a robust, systematic narrative review to analyze clinical trials from 2010 to 2025 focused on improving GOC discussions among seriously ill patients (defined as individuals with life-limiting illness). Eligible studies included randomized and nonrandomized trials that reported patient-level outcomes. We identified relevant articles by searching PubMed, Web of Science, CINAHL, and Embase databases, extracting data regarding study design, setting, sample, intervention details, and outcomes (mapped in a tabular format to facilitate comparison).

RESULTS: We identified 41 eligible studies conducted in diverse settings (n = 21, 51.2% across hospitals) and serious illness types (n = 21, 51.2% across multiple serious illness), predominantly from the United States (n = 31, 75.6%). Most studies were randomized controlled trials (n = 28; 68.3%), focusing on patient, clinician, system, or combined interventions to enhance GOC discussions. Patient-focused interventions increased readiness and documentation but showed mixed results on clinical outcomes, such as QOL. Clinician and system interventions improved documentation and conversation quality but had inconsistent impacts on healthcare utilization. Combined interventions showed improvements in communication but not consistently in QOL or healthcare utilization.

CONCLUSIONS: This review highlights the robustness and diversity of GOC interventions, emphasizing the trade-offs between scalability, depth, and patient-centeredness. While interventions appeared to increase GOC discussions and documentation, their impact on downstream patient and caregiver outcomes remains limited. Future research should refine measures and quality indicators to better capture the impact of GOC discussions on patient and family well-being, while considering proximal process outcomes and downstream health outcomes.

BACKGROUND: Gender diverse adolescents and young adults (AYA) experience disproportionately high rates of sexual violence victimization (SVV), suicidal thoughts and behaviors (STBs), and adverse mental health outcomes. Limited qualitative research has explored how acute SVV influences mental health and STBs among this population.

AIMS: This study aimed to explore how acute SVV influences STBs and mental health among gender diverse AYAs.

METHODS: This qualitative study was conducted from June to July 2025. Seventeen gender diverse young adults aged 21 to 24 years participated in semi-structured interviews exploring experiences of sexual violence, STBs, coping strategies, minority stress, support systems, and mental health outcomes. Interviews were analyzed using thematic analysis with constant comparison. Two reviewers achieved substantial interrater reliability (κ = .808).

RESULTS: Five themes captured the impact of sexual violence on identity, mental health, and relationships. Participants described erosion of self-worth, internalized stigma, and loss of trust following sexual violence. Psychological outcomes included depression, anxiety, posttraumatic stress disorder symptomatology, and STBs, often intensified by discrimination, racism, and transphobia. Interpersonal effects included fear of intimacy and social withdrawal. Disclosure and help-seeking were shaped by distrust; however, supportive confidants and online communities facilitated emotional validation. Participants described a range of coping strategies, from avoidance and substance use to creative and goal-directed activities.

CONCLUSION: Acute SVV is associated with substantial impacts on psychological functioning and suicide risk among gender-diverse AYA. Trauma-informed, person-centered interventions are needed to support adaptive coping and improve mental health outcomes.

BACKGROUND: Sleep disturbance is a core feature of bipolar disorder (BD) and often precedes mood recurrence, particularly in youth. Smartphone-based mobile sensing offers a scalable alternative to objective sleep measurement via actigraphy, but its validity in youths with BD is unclear.

METHODS: Analyses included adolescents and young adults (ages 14-25) with BD-I/II from the PROMPT-BD study with at least four days of concurrent actigraphy and mobile sensing. Actigraphy-derived sleep metrics were compared with smartphone-derived proxies. Agreement was evaluated using root mean squared error (RMSE) and mixed-effects models. Zero-inflated negative binomial models examined associations between actigraphy-derived and mobile-sensing derived wake after sleep onset (WASO). Sensitivity analyses tested robustness to missing data, smartphone use patterns, sleep window definitions, operating system, presence of mood symptoms and anxiety, and weekend effects.

RESULTS: Mobile sensing showed strong convergence with actigraphy for sleep timing and duration. RMSEs were <21 minutes for onset, offset, midsleep, and TST, with strongest agreement for midsleep (RMSE = 14.8 minutes). Mobile sensing slightly overestimated sleep duration and estimated earlier timing, and underestimated WASO. Greater WASO significantly increased the odds of detecting any via mobile sensing; mobile sensing proxies were sensitive to the presence of nocturnal wakefulness but did not provide an accurate estimate of the extent of sleep fragmentation. Findings were robust across sensitivity analyses.

CONCLUSIONS: Passive smartphone-derived sleep metrics approximated actigraphy-based estimates of sleep timing and duration in youth with BD. Given the widespread availability of smartphones in this population, this supports their potential as scalable tools for monitoring circadian disruption and informing early intervention.

BACKGROUND: Best Case/Worst Case (BC/WC) is a communication tool to support nephrologists and older adults with advanced chronic kidney disease with decisions about dialysis. We compared the effectiveness of training nephrologists to use BC/WC versus usual care on receipt of palliative care, quality of life (QOL), quality of communication, dialysis initiation, and death.

PARTICIPANTS AND SETTING: From February 2021 to December 2023, we enrolled patients at 10 US sites who were ≥ 60 years, had an estimated glomerular filtration rate (eGFR) ≤ 24 mL/min/1.73m2, with estimated survival ≤ 18 months, and were considering dialysis initiation in the outpatient setting. We randomized nephrologists to intervention or usual care.

METHODS: In this cluster randomized trial, we followed patients for up to 2 years using chart review and patient and caregiver surveys. The primary outcome was receipt of palliative care within 12 months of patient enrollment.

RESULTS: We enrolled 68 nephrologists (36 intervention) and 268 patients (105 intervention). On intention-to-treat analysis, receipt of palliative care within 12 months did not significantly differ between groups (hazard ratio (HR) 0.94, 95% Confidence Interval (CI), 0.59-1.52; p = 0.812). Patients of intervention nephrologists were more likely to initiate dialysis (HR, 1.50, 95% CI, 1.00-2.25; p = 0.048) and report worse QOL throughout the study (FACIT-Pal effect estimate, -6.51; 95% CI, -12.20, -0.81; p = 0.025; FACT-G effect estimate, -4.78; 95% CI, -8.35, -1.22; p = 0.010). We found no significant differences in intensity of treatment at the end of life, quality of communication, or on-study death between groups.

CONCLUSION: Training nephrologists to use the BC/WC communication tool does not significantly affect receipt of palliative care or other measurable clinical outcomes.

TRIAL REGISTRATION: NCT04466865 (URL: clinicaltrials.gov/study/NCT04466865), registered 07/07/2020.

BACKGROUND: It is difficult for patients to make informed decisions about kidney failure unless they know all their treatment options. Conservative management is an important option infrequently presented alongside other kidney failure treatments by nephrologists.

METHODS: We conducted a randomized pilot trial testing the feasibility and acceptability of a communication tool, called Conservative Kidney Management Jumpstart Tool, in assisting nephrologists with discussing conservative management with their patients. We recruited patients aged ≥75 years with stage 4 or 5 chronic kidney disease in the greater Seattle area between April 2023-May 2025. Patients were randomized in 1:1 fashion to either their nephrologists receiving the Tool to use with them at their next clinic visit (intervention) or usual care (control). Our primary outcome and feasibility measure was patient-reported discussion of conservative management during the clinic visit. Our secondary outcome and acceptability measure was change in patients' satisfaction with their nephrologist's serious illness communication skills (using the Quality of Communication Scale, with higher scores indicating higher quality) before and after the visit. We performed an intent-to-treat analysis of the primary endpoint using a chi-square test. We used paired-samples t-tests to assess within-patient changes in the secondary endpoint.

RESULTS: We randomized 74 patients (age 80±1, 19% women, 69% White) to either the control (n=37) or intervention (n=37) group. Patients whose nephrologists received the Tool were more likely to discuss conservative management during their clinic visit (60% vs. 19%, p=0.001) than patients in the control group. Patients whose nephrologists received the Tool rated their nephrologist's communication skills at 7.5±2.1 before the visit and 9.0±1.7 after the visit (p<0.001) as compared with 7.8±1.9 and 7.9±1.8 (p=0.54), respectively, among patients in the control group.

CONCLUSIONS: The Tool was feasible and acceptable to patients, promoting patient-nephrologist discussion of conservative management and improving patients' satisfaction with their nephrologist's communication skills.