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 AND AIMS: Daily movement behaviors are typically analyzed in isolation, ignoring their inherent competition for time within the 24-hour day. We examined whether the 24-hour composition of sleep, sedentary time, and physical activity was associated with liver stiffness in adults with steatotic liver disease (SLD) METHOD: This cross-sectional analysis used NHANES 2017-2018 data from 1,080 adults with SLD (889 MASLD, 101MetALD, and 90 ALD). Sleep, sedentary time, moderate-to-vigorous physical activity (MVPA), and other waking activity were modelled using isometric log-ratio coordinates in survey-weighted regression with log-transformed liver stiffness measurement (LSM). Isotemporal substitution analyses estimated LSM changes from reallocating 30 minutes between behaviors.

RESULTS: In MASLD, a greater sedentary time relative to active behaviors was associated with 5.79% higher LSM (95% CI 1.14-10.66%; p=0.027) after sociodemographic adjustment, attenuating after cardiometabolic adjustment (3.73%; p=0.086). Greater sleep relative to all other behaviors was independently associated with 15.55% lower LSM (95% CI -27.33% to -1.86%; p=0.044), persisting after full adjustment (-14.38%, 95% CI -25.58% to -1.49%; p=0.047). Replacing 30 minutes of sedentary time with sleep was associated with a larger LSM reduction (-1.69%, 95% CI -2.98% to -0.39%; p=0.011) than replacement with MVPA (-0.83%, 95% CI -1.32% to -0.33%; p=0.001). Among former drinkers, sedentary-to-sleep reallocation was associated with 2.24% lower LSM (95% CI -3.78% to -0.67%; p=0.005); among low drinkers, sedentary-to-MVPA reallocation was associated with 1.32% lower LSM (95% CI -2.19% to -0.44%; p=0.004). No substitution was significant in MetALD or ALD.

CONCLUSIONS: The 24-hour self-reported movement behavior composition is associated with liver stiffness in MASLD, with sedentary and sleep balance showing associations in opposite directions. This supports a personalized, whole-day approach to behavioral counseling in MASLD management.

Opioid therapy is a key component of palliative care delivery but may sometimes be associated with complications such as nonmedical opioid use (NMOU) behavior. Clinicians are encouraged to adopt risk-mitigation strategies to minimize NMOU while optimizing opioid prescribing practices. Urine drug testing (UDT) is usually implemented in palliative care (PC) settings to mitigate such risks, but its role is not well-defined. In this article, a group of PC specialists with specific clinical and research interests and expertise in UDT offers 10 tips regarding the current evidence surrounding UDT, its appropriate application, interpretation of results, and the utilization of test results within the PC context. The goal is to inform practicing PC clinicians regarding the use of UDT in routine opioid therapy.

INTRODUCTION: Extremely preterm birth (< 28 weeks' gestation) increases chronic kidney disease (CKD) risk. However, among those born extremely preterm, the prevalence of abnormal kidney health during adolescence and its perinatal predictors remain poorly defined.

METHODS: Adolescents from the Extremely Low Gestational Age Newborn -Environmental influences on Child Health Outcomes (ELGAN-ECHO) cohort (14 US hospitals) were assessed for abnormal kidney health defined as ≥ 1 indicator-chronic kidney disease in children (CKiD) U25 estimated glomerular filtration rate (eGFR) < 90 ml/min per 1.73 m2, blood pressure (BP) ≥ 120/80 mm Hg, or microalbuminuria > 30 mg/g.Five feature selection methods screened perinatal covariate predictors using a 60 to 40 training-test split. Multiple imputation addressed missing data in sensitivity analyses. Area under the curve (AUC) was the primary performance metric.

RESULTS: Of the 675 adolescents (mean age 18 years), 354 (52%) had a classifiable kidney health status, as follows: 188 with all 3 measurements and 166 with partial measurements showing ≥ 1 abnormality. The prevalence of abnormal kidney health was 66% among complete cases (125/188) and 82% among all determinate cases (291/354). In the full cohort, prevalence ranged from 43% to 91% (bounding estimates accounting for missing data). Individual measurements revealed 30.5% with reduced eGFR, 42% with elevated BP, and 9% with microalbuminuria. Across all methods, perinatal covariates achieved random test-set discrimination (AUC: 0.48-0.55) for abnormal kidney health prediction, compared with training set AUCs of 0.66-0.72.

CONCLUSION: Abnormal kidney health is highly prevalent after extremely preterm birth, underscoring the importance of protocolized longitudinal kidney health surveillance throughout childhood to enable early identification of CKD and elevated BP in children born extremely preterm. The perinatal factors we examined did not meaningfully predict kidney health abnormalities and variable importance did not translate to individual-level prediction in this cohort.

Patients who present after suicide attempts (SA) may experience a wide range of clinical trajectories, from full medical recovery to irreversible neurologic injury, multiorgan failure, or death. Although suicide prevention, risk assessment, and psychiatric treatment after a SA are well represented in the literature, comparatively little guidance exists for palliative care (PC) clinicians consulted after an SA. Care after SA lies at the intersection of critical care, psychiatry, and ethics, and raises distinctive challenges in prognostication, decisional capacity, decisions about life-sustaining treatment, and support for families and clinicians. This manuscript uses the case of Mr. A, a patient with a self-inflicted gunshot wound and uncertain neurologic prognosis, to describe a PC-informed framework for PC clinicians caring for patients after SA. In collaboration with psychiatry, ethics consultants, and the primary team, PC clinicians can help integrate medical and psychiatric prognosis, avoid anchoring on the attempt as evidence of stable values, support families struggling with guilt and stigma, manage distressing symptoms, and guide ethically grounded decision-making.

At-home administration of oral anticancer medications (OAM) limits interactions with healthcare providers, therefore limiting opportunities for symptom management, posing threats to medication adherence. Individuals diagnosed with multiple myeloma (MM) experience symptoms from both disease- and treatment-related factors. Proteins Beta-2 Microglobulin (B2M) and Lactate Dehydrogenase (LDH) are routinely used in disease monitoring, yet their associations with symptoms and regulation via DNA methylation (DNAm) in individuals with MM have not been investigated. This study explored relationships among LDH and B2M proteins; DNAm of genes B2M, LDHA, LDHB; and symptoms in patients prescribed OAMs for MM. This was a 6-month, longitudinal, exploratory analysis. Symptoms were assessed using self-reported measures. Protein levels were extracted from medical records. DNAm of B2M, LDHA, and LDHB promoter regions were quantified via pyrosequencing of peripheral blood samples. Linear mixed modeling explored cross-sectional and longitudinal associations. Significant cross-sectional associations were identified between fatigue, LDHA and B2M DNAm, and B2M protein (p < .02); pain and LDHA and B2M DNAm (p < .05); gastrointestinal disturbances and LDHA DNAm and LDH protein (p < .05); shortness of breath and LDHA DNAm (p < .04); and depression and LDH protein (p < .04). Longitudinal interaction effects were significant for B2M DNAm and fatigue (p < .05), LDHA and B2M DNAm and pain (p < .04), and LDH protein and depression (p < .04). Prognostic proteins B2M and LDH and their gene-level DNAm patterns were significantly associated with symptoms in individuals taking OAMs for MM. These preliminary findings support further exploration of multi-omics pathways underlying symptoms to inform symptom identification and management strategies.

Moderate-to-severe cancer pain is frequently managed with prescription opioids. However, there are many barriers to guideline-concordant prescription opioid management, including stigma surrounding prescription opioids. The goal of this concept mapping study was to work directly with patients to identify actionable treatment targets to inform future behavioral intervention development that can ultimately improve cancer pain management. Investigators were particularly interested in exploring patient perspectives on opioid stigma interventions, given the lack of existing strategies in this area. Investigators conducted concept mapping with 20 patients with advanced cancer pain who endorsed at least one aspect of opioid stigma. Participants responded to a broad focal prompt: "What kinds of supports and problems should people know about when using prescription opioids to treat cancer pain?" Findings revealed 5 "clusters": 1) pain and opioid management; 2) prescription opioid stigma; 3) clinician attitudes about prescription opioids; 4) support and resources; and 5) insurance and pharmacy issues. Salient discussion focused on strategies to improve internalized stigma and reducing stigmatizing clinician attitudes. Future research should develop and test easily accessible multicomponent, contact-based, and/or internalized stigma interventions that integrate psychoeducation and shared decision-making. PERSPECTIVE: This article presents important, actionable intervention targets for improving cancer pain management, with a specific emphasis on addressing opioid stigma. Findings can be used to inform future intervention development efforts that improve patient and clinician skills, including multicomponent, contact-based, and/or internalized stigma interventions, improved psychoeducation, and shared decision-making.