However, both groups did not have a different pulmonary function (p = .25) and the proportion of readmission within 28 days (p = .50). This study shows that the symptom management program can reduce dyspnea and severity during activities and improve the quality of life. Older people suffer from chronic obstructive pulmonary disease, especially when experiencing dyspnea. Therefore, it is crucial to have a symptom management program for older patients, especially a program developed to respond to changes in the aging process and the limitations of older people. This developed program was age-friendly to deal with symptoms and improve quality of life. However, this program should be explored in typical situations without the effects of the coronavirus disease (COVID-19) pandemic. In addition, more extensive population-based studies and randomized controlled trials should be adopted to increase credibility and ensure generalization.Older adults have limitations from their aging process and chronic disease, so developed interventions must pay attention and concern to their aging degeneration and needs. This study aims to study the effects of a symptom management program on selected health outcomes among older people with chronic obstructive pulmonary disease. The quasi-experimental research included the 15 older patients in the control group receiving routine nursing care, while the other 15 in the experimental group received a 4-week symptom management program. First, the general information was analyzed using descriptive statistics. Next, the average health outcomes were analyzed using independent and dependent t-tests, Mann–Whitney U Test, and Wilcoxon Signed Ranks Test. In addition, the readmission rate was compared using Fisher’s Exact Test. Results revealed that most of the older patients were men (96.7%), aged 60–88 years , with a smoking history (93.3%). The improvements were found in dyspnea . Many processes, such as destroying parts of the lungs, secretions blocking the airway, and inflammation and swelling of the respiratory mucosa, narrow the airways, leading to breathing difficulties1. Based on world statistics, COPD is a significant public health problem and a primary disease affecting the quality of life, which causes suffering, disability, and mortality2. The statistics from all countries across the globe found that COPD is the third leading cause of death in the world in 20222. According to statistics in Thailand in 2020, COPD was the sixth leading cause of death, with more than three million cases, an average of six per minute. In addition, more than one million patients are admitted to hospitals due to exacerbation, commonly found among older people, people with smoking habits, or those living in highly air-polluted areas3. In older people, it was also found that COPD was a significant disease causing disability and death. The mortality rate also substantially increased in this population, making this disease an area of concern for researchers and healthcare providers2.Chronic obstructive pulmonary disease (COPD) is a disorder in the lungs’ small airways. It leads to restriction and resistance to airflow in and out of the lungs, especially among older adults with their aging process related to organ and functional degeneration and long-term exposure to COPD risk factors4. The significant risk factors for COPD are smoking, pollution, chemical substances, and dust in the air5. Studies found that older people are exposed to the main risk factors for a long time due to inappropriate health behaviors, such as smoking and secondhand smoke. Moreover, their occupations cause them to be exposed to pollution, chemical substances, and dust in the air, causing many older people to suffer from COPD6. Other factors were the respiratory system and lung tissue changes with age4. In this regard, the decline in the respiratory structure among older people affects the strength of the respiratory muscles, ventilation balance, resistance to airflow, the retraction ability of the chest and lungs, and self-defense mechanisms of the respiratory tract, resulting in a decrease in lung volume, secretion retention, and an increase in the work of breathing9. Owing to these factors, the incidence of COPD in older people was higher than in other ages, and the GOLD stage of COPD among older patients is usually more advanced. Since the mean age of COPD diagnosis was 40 years, and the life expectancy of Thai people was 79, these patients often suffer from multimorbidity and polypharmacy burden along with living with COPD diagnosis for a longer time when compared with other age groups6.Older adults are at risk for COPD of both the significant risk factors and changes in older adults according to the aging process5. In some cases, older patients cannot control or manage their symptoms, causing respiratory failure that quickly leads to disability and death. As for the emotional and psychosocial effects, it was found that the loss of existing abilities caused older adults to have less self-esteem and high perceived pressure, anxiety, fear, anger, or sometimes getting furious for no reason. In addition, depression can be found in older patients with COPD10.Older people suffer from symptoms induced by the disease pathology when diagnosed with COPD. Older people have severe symptoms and many physical, mental, emotional, and social impacts. Regarding the physical aspect, the common symptom in older patients is dyspnea. It was found that older patients with COPD would experience dyspnea when exercising or doing activities. As for the psychological aspect, older patients suffer from shortness of breath or a feeling of dying. They cannot live everyday life like ordinary people, so it is necessary to limit daily routines, exercise, work, and activities that lower the quality of life of older patients with COPD11. COPD treatment aims to relieve symptoms, prevent exacerbation, maintain pulmonary function, and promote quality of life. Disease preventions include inhalers and oxygen therapy in case of breathing difficulties. This treatment will start with an oxygen cannula at 1–2 L/min. In addition, studies have shown that a low oxygen supply during exercise enables patients to have better exercise tolerance. Symptoms exacerbation prevention can be done by reducing risk factors, such as smoking, secondhand smoke exposure, infection, and behaviors inappropriate with the disease. Pulmonary function maintenance focuses on avoiding risk factors, especially quitting smoking or changing occupations and exposure to precipitating factors, such as dust, smoke, and pollution, to stop or slow the pathology and disease progression. Finally, quality of life promotion is trying to maintain the ability to perform daily activities and socialize as before11. Because care and treatment for patients with COPD focus on self-care, symptom management, and behavioral modification, nurses play an essential role in providing care, advice, and encouragement to this population. Then older people can take care of themselves at home, carry out daily activities as usual, and have a good quality of life12.Currently, care and treatment for patients with COPD are mostly symptomatic treatment, elimination of the cause or precipitating factor, and palliative care13 and Volpato et al.14 have showed that interventions reducing inspiratory neural drive and regional lung hyperinflation and promoting breathing pattern and pulmonary blood flow can improve dyspnea and its psychological effects. These interventions included oxygen therapy, opiates, bronchodilators, inspiratory muscle training, combined exercise training, psychotherapy, self-management, relaxation therapy, music therapy, and pulmonary rehabilitation. Based on the literature review on intervention studies, researchers also developed many interventions for managing and caring for patients with COPD. However, these studies were conducted in adult patients or mixed-age groups. We realized that the pathogenesis, risk factors, and skills in perceiving information, learning, and understanding among older people might be limited and different from those of adults16. The aging process causes some degeneration of organ function and impairment, affecting health education for older people. These impairments include vision, hearing, attention, concentration, and less ability to remember information. Then, the provision of health education or knowledge needs to be specific in line with the limitations and requirements of older people18, and the previous interventions might be ineffective with older patients, especially Thai older patients who have specific lifestyles and contexts such as occupations relate to risk factors, foods and drinks, activities in daily, types of exercise and culture. Therefore, gerontology experts recommend that teaching older people should take a short time, be divided into sessions, and consist of explanations and practices. Practices must be simple and uncomplicated in a suitable place, and repeated teaching and training sessions should be provided. The teaching style considering the context and culture of older people should be concerned with using the proper media, large visible text, simple language, and age-friendly colors to be seen easily and clearly. In addition, teaching materials should be available for older people to take home and review18. To the best of our knowledge and based on our review, the existing nursing care methods or programs have not yet consistently responded to older people’s requirements and limitations. Consequently, developing a program specific to older people’s requirements and limitations is necessary.The reviews by O'Donnell et al.To study the effects of a symptom management program on selected health outcomes, including dyspnea and its severity during activities, pulmonary function, quality of life, and readmission rate within 28 days among older patients with COPD.After attending the program, dyspnea, its severity during activities, pulmonary function, the quality of life, and the proportion of readmission within 28 days will be improved in older patients when compared with before attending the program and a control group.19 and a study by Chantaro20. The alpha level was set at 0.05 a priori with a power of 0.90 and an effect size of 0.768. Based on the calculation, 12 hospitalized older adults were needed for this study. However, 20% of participant dropouts were added to obtain an adequate sample. A sample of 15 participants for each group would meet the statistical criteria, and the total participants for this study were 30 hospitalized older adults.The sample size was calculated using the equation of SchlesselmanIn this quasi-experimental research with a two-group pretest–posttest design and a double-blind study, the participants were older adults aged 60 years and over, diagnosed with COPD by the physician using signs and symptoms, history of exposure to risk factors and spirometer test, and received treatment at the outpatient department of a medium-sized hospital in the northeastern region of Thailand. The participants were selected according to the inclusion criteria to assign the older patients to the experimental and control groups, totaling 15 patients each. The drawing was made to determine the order of study. The drawing result was to start conducting the study in the control group. After completing the outcome assessment process in this group, the experimental group conducted the study. The principal researcher provided the symptom management program, and the research assistant collected the data. Then, the results of the study were analyzed. In this regard, those who collected and analyzed the data did not know which participants were the experimental or the control groups to prevent bias in conducting the study and analyzing the results. Finally, there was no dropout for this study, so 30 patients were included for data analysis. In conducting this study, we confirmed that all process was performed in accordance with relevant guidelines/regulations and the Declaration of Helsinki, and informed consent was obtained from all participants and/or their legal guardians.There were seven criteria including (1) Older men and women aged 60 years and over with COPD, (2) They are in the remission phase, (3) No signs and symptoms limiting their ability to practice exercises during this study, including low blood pressure, chest pain, and cardiac arrhythmia, (4) Have no depression, screened by a two questions (PHQ-2 or 2Q) screening test at the time of this study, (5) No cognitive impairment, assessed by the Thai Mental State Examination (TMSE), (6) No hearing and vision impairment and be able to communicate in Thai, and 7) Be voluntary and willing to cooperate in the study.Patients who participated in a similar symptom management program within six months, experienced symptoms exacerbation during the program, and attended the program less than 80 percent were excluded from this study.The principal researcher selected the participants according to the inclusion criteria, comprising older patients with COPD who visited the outpatient department at a medium-sized hospital in the northeastern region of Thailand from late June to September 2021. After screening and passing the criteria, the research assistants asked participants to participate in this study. They voluntarily participated in this study by signing the informed consent. To avoid cross-contamination of the program, the principal researcher randomly arranged the sequence of the study. As a result, the study was conducted earlier in the control group in June and July. This group received routine care, including vital signs and health assessment, review of signs and symptoms, treatments, and recommendations related to their health problems. After that, the study was conducted in the experimental group in August and September. The experimental group received the same routine care as the control group, plus the symptom management program. The research assistants collected data for the pretest before starting the program, and the posttest would be made 28 days after the completion of the program. Data collection continued until the required number of 30 patients was obtained, consisting of 15 patients in each group. The adhering record sheet monitored the adherence rate. The principal researcher phoned the older participants for 4 weeks, and their family members helped verify their adherence. Finally, all participants adhere to the program over 95%.. Moreover, a step-by-step of the program was also provided , symptom management (What are the symptom management strategies?), and symptom outcomes (What is the patient's expected outcome?). Health education mainly consists of knowledge of COPD, factors related to exacerbation and prevention, treatment, dyspnea management, and pulmonary function promotion. In addition, pulmonary function promotion included breathing exercises, effective cough, medication use, energy conservation, and smoking cessation. The principal researcher provided health education individually for 30 min in the private room of the outpatient department. Then, patients had an opportunity to ask questions and receive more explanations, and a handbook was also given for this step. A handbook is a guidebook for providing health education, sizing 10 × 15 inches, totaling 15 pages, consisting of pictures and content. This handbook mainly used bold and large text, clear fonts and images, and age-friendly colors visible to older people, such as black, red, orange, and dark yellow, on a white background—the handbook's contents consist of definition, pathophysiology, complications, and treatment.Teaching health education was based on the teaching plan to provide knowledge on COPD and self-management skills following the symptom management program provided by Dodd et al.Symptom management training and monitoring is a practicing symptom management skill, i.e., self-management of dyspnea among older patients with COPD, consisting of breathing exercises, purse lip breathing, abdominal and diaphragmatic breathing, effective cough, medication use, and energy conservation. Three exercises, including the breathing exercise, energy conservation, and effective cough, will be practiced for 45 min. The practice will be done in a well-ventilated room with no noise. There are chairs to rest and staff to assist in practice. Then, the patients practiced at home for 4 weeks, and a checklist was provided and monitored by phone call.22, the Peak Expiratory Flow Rate (PEFR), the COPD Assessment Test (CAT), and the readmission record form.The evaluation will be conducted 4 weeks after participating in the program. For this evaluation, the instrument included the Dyspnea Visual Analogue Scale (DVAS) based on the assessment form of BoonsawatThe symptom management program for older patients with COPD is provided belowded Fig. .We start23 and a Thai Mental State Examination (TMSE) with a sensitivity of 82% and a specificity of 70%24. The 2Q has two questions, and the response items were “Yes” or “No.” The TMSE includes 11 questions about orientation for time and place, registration, attention/calculation, recall, naming, repetition, verbal and written command, writing, and visuoconstraction. The participants will get the score when they respond with the right answer, and score rank from 11 to 30. Patients who answered “no” for both questions of 2Q and had a score of TMSE higher than 23 indicated they had no depression and cognitive impairment and were ready for this study.Screening forms for assessing readiness included a depression screening form (2Q) with a sensitivity of 97.30% and a specificity of 45.60%The instrument for conducting the study was a symptom management program and handbook developed by the principal researcher from the literature review. First, the three experts, a medical professor specializing in COPD, a nurse professor, and a registered nurse specializing in caring for older patients with COPD, reviewed and provided recommendations for program development. After that, the principal researcher revised the program and handbook according to the experts' recommendations. Then, this program was implemented with five older patients with similar qualifications to the participants. We found the program suitable, understandable, and easy to follow, and it takes little time. In addition, the handbook is short, concise, and uses simple language, with large text and transparent images, which are easily readable and portable. Only two problems with the font size and three illustrations need to be clarified due to the file and printing quality. The principal researcher adjusted the font size to be larger and changed the image using the original file so that it did not get blurry when enlarged before using it in the actual study. The content validity index (CVI) from the three experts for this program was 1.0. This pilot was published in Thai and was entitled "Effects of symptoms management program on health outcomes among older people with chronic obstructive pulmonary disease, Nongwauso Hospital, Udonthani Province: A pilot study.The research instrument for data collection included five instruments.25. The DVAS was a straight line 100 mm in length. The participants were asked to make a line indicating their dyspnea. The score rank from 0 to 100. The more the score, the more they suffer from dyspnea.The Dyspnea Visual Analogue Scale (DVAS) is a highly accurate instrument COPD patients widely use. The concurrent validity was determined from the current condition  to find the relationship between the measured scores and the instrument’s external criterion, namely, PEFR (Peak Expiration Flow Rate), which measures the maximal expiratory flow. Based on a study among 16 patients with asthma, the metric scores correlate with airway obstruction as 0.8526. The reliability of the assessment form for severity during activities was 0.84. This assessment had one item with five severity levels (0–4) when 0 refers to no exertion during activity, but 4 indicates exertion when performing only activity daily.The assessment form for severity during activities was measured by requiring older patients with COPD to estimate the 5-level severity of the symptoms. This instrument was widely used in research and practice among patients with COPD. It was developed from the Modified Medical Research Council Dyspnea Score (mMRC) of the Global Initiative for Chronic Obstructive Lung Disease (GOLD)The record of readmissions within 28 days is to record the number of times the older patients were admitted to receive treatment for exacerbation of dyspnea or COPD complications within 28 days after the study. The reason for readmission does not include treatment for other causes, such as falls and fainting due to low sugar levels. The three experts assessed this form, and CVI was 1.0. The number of readmissions was used to compare between groups. The more older patients are often readmitted, the poorer they can control their health condition.27. As for the mouthpiece, it is a disposable type. Therefore, only one mouthpiece was used per patient. The result from a pulmonary function measured was a liter per second. The more liters per second they get, the more they have effective pulmonary function.The instrument for pulmonary function assessment is called the Wright Peak Flow Meter or Peak Flow Meter of GlaxoSmithKline Company. This instrument has been certified by industrial product standards and passed reliability testing before being used in the study. It was the accuracy of ± 5% of the readable value or ± 0.20 L/s28, this assessment test has a reliability value of 0.87. The CAT included eight questions with six response items (0–5), of which 0 had no symptoms but 5 had severe symptoms. The score ranks from 0 to 40. The less they get the score, indicating a low impact of the disease on these patients, and they have a high quality of life.COPD Assessment Test (CAT) of GOLD 2019 was used to measure the quality of life among COPD Patients. This questionnaire was translated into Thai by GlaxoSmithKline Company and was widely used. According to the study by ChanthaThe adherence record sheet was used to monitor the percentage of adherence in program activities. The record sheet includes all activities and a checklist. If older patients perform each activity in the program that they were trained at the hospital, the principal researcher checks on the provided list. This monitoring was done by a weekly telephone check and verified by the participant’s family members. The three experts assessed this form, and CVI was 1.The principal researcher developed the research program from a literature review. Three experts in three professional fields verified the content: a medical professor, a nurse professor, and a registered nurse. All experts were involved in the care and treatment of older adults and COPD. The feasibility and acceptability of the program were conducted among five older adults with the same health problem as the target group of this study. The results were already published in Thai. The outcome evaluator and statistician did not know whether they were in control or experimental groups. During the data collection, the research team carefully double-checked the data to ensure its correctness and completeness. Finally, the principal researcher registered a study protocol and strictly followed the protocol to reduce bias and increase the validity and reliability of this study.The research received approval from the Khon Kaen University Ethics Committees for Human Research based on the Declaration of Helsinki and the International Conference on Harmonization (ICH) Good Clinical Practice Guidelines. The research project code was HE632103. Every research process adhered to the ethical principles of researching human subjects, including respect for persons, beneficence, and justice. The principal researcher explained the research project to the participants and gave time for decision-making and the right to make decisions without affecting the treatment process. Moreover, the patients could withdraw from the study whenever they wanted and continue to receive standard care for COPD patients. Finally, the control group would receive the symptom management program after finishing this study if needed.Before generating the data analysis, assumptions were tested, including normality and homogeneity, and parametric and non-parametric statistics were applied based on the results. The participants' general characteristics data were analyzed using descriptive statistics. The mean scores between groups were compared using Independent T-test and Mann–Whitney U Test. The mean scores within groups were compared using the Dependent T-test and Wilcoxon Signed Ranks Test. The proportion of readmissions within 28 days was compared using Fisher’s Exact Test. Finally, an adjusted analysis was provided when finding the experimental and control group participants’ general characteristics and based line outcomes different. Fortunately, these differences were not found in this study, and an adjusted analysis was not conducted.The participants consisted of 30 patients who ultimately attended the program, over 95%. Most of them were men (96.7%) aged between 60 and 69 years (46.7%) . There were 100.0% Buddhists, 66.7% were married, and 86.7% graduated from primary school. The occupation of 60.0% was a farmer. Most families' monthly income was between 3000 and 10,000 baht, and 60.0% had adequate income/ no savings. Most of them used the universal coverage scheme (86.6%), and 96.7% had no problems with medical expenses. They were 93.3% smoking history, and 90.0% quit smoking (Table Most participants had been diagnosed with COPD for 6 years or longer (70.0%), and the GOLD stage was stage 1 (63.3%). In the past year, 70.0% had never been hospitalized. At present, most of them have received inhalers (66.7%). Most of the symptoms in the past month were dyspnea, thick phlegm, and chronic cough, which accounted for 56.7%, 53.3%, and 50.0%, respectively. The most frequently chosen method of managing dyspnea was the inhaler (96.6%) , the severity of symptoms during activities , and the quality of life  between experimental and control groups. However, pulmonary function was not different  , the severity of symptoms during activities , the pulmonary function , and quality of life  were improved in the experimental group   in the control group and no older patients in the experimental group visiting the hospital within 28 days. After using Fisher’s Exact Test, it was found that the proportion of readmissions within 28 days among older patients in control and experimental groups was not different (0) Table .Table 4C14. Dyspnea is caused by a breakdown in the regular interaction between the respiratory system's dynamic response and the inspiratory neuronal desire to breathe. By lessening the neuromechanical dissociation of the respiratory system, therapeutic therapies such as bronchodilators, exercise training, ambulatory oxygen, inspiratory muscle training, and opiates can alleviate dyspnea13, meaning successful management needs a combination of interventions14. This program included several breathing exercises promoting lung function and respiratory muscle. Breathing exercises can also promote ventilation and gas exchange. Health education and self-management prevent the patient from engaging in unhealthy behaviors that might stimulate symptom exacerbations; meanwhile, energy conservation helps them relieve fatigue. Finally, the effective cough and medication use included in this program supports the patient in clearing the airway from secretion and promoting bronchodilatation, resulting in dyspnea and its severity reduction.Findings confirmed that the symptom management program could relieve dyspnea and severity during activities. The capacity imbalance theory can be used to explain the physiological bases for reducing dyspnea and its severity21, consisting of symptom experience, symptom management strategies, and symptom outcomes. The symptom experience—older patients mainly experienced dyspnea, perceiving the symptom as severe and life-threatening. Symptom management strategies –The most important was to give inhalers and breathing therapies. This program showed a tutorial on giving inhalers, and the handbook clearly explained the processes with illustrations. The management outcomes showed that dyspnea and its severity during activities substantially decreased. Maricoto et al.29 found that a program that taught older patients how to use inhaler devices would enable patients to use them accurately and effectively and help significantly reduce COPD exacerbations, especially dyspnea.Moreover, this program helped relieve dyspnea and severity because the principal researcher developed the program based on the literature review and evidence-based analysis. This symptom management program integrated multiple activities, including teaching, practicing, and giving a handbook for reviewing, which all jointly stimulated learning skills. In addition, activities in the program were carried out step by step based on the symptom management model of Dodd et al.16. Older people have different characteristics from adults4, so they require specific care. The accessibility to older people must be specific and consistent with their limitations, such as changes in vision and hearing, reduced energy reserves, easy fatigue, and a decrease in cognitive ability, i.e., having less concentration and reduced memorization ability18. As a result, previous programs may have limitations and may not be suitable for older people30.The program’s design in this study is specific to the requirements and limitations of older people, so it helps older people learn quickly and achieve positive outcomes. The principles of health education or teaching for older people need to apply multiple strategies and adjust strategies to meet the requirements of older people to enhance teaching efficiency18. As older adults had reduced memorization ability, the program was designed to have practices to enhance skills and ability to manage the symptoms independently. Moreover, repetitive self-practice would enable practitioners to learn effectively, understand reasons, and achieve sustainable learning18. Participation in the teaching and practice process would promote learning, memorization, and practicing with confidence18. As a result, the older patients who participated in the program had less dyspnea and severity during activities. Accordingly, Chantaro's study of the effects of a self-management program on dyspnea among patients with COPD revealed that their symptoms after attending the self-management program were better than those who received routine nursing care20.Therefore, this symptom management program was designed considering font size, illustrations, and color. Moreover, this provided knowledge and practice related to the Thai context and culture. Teaching procedures and periods were not too long. The stimuli transmitted through the five senses, namely, the ears, eyes, nose, tongue, and skin, produce more learning outcomes than stimuli transmitted through one sense only. The practice helped turn the abstract into concrete for better understanding31.This study found that although pulmonary function in the experimental group after participating in the program was significantly better than before joining the program, it was not different from that of the control group. This program included pulmonary function promotion and dyspnea self-management; however, the program's short duration might not clearly demonstrate the significant results between the two groups. This result is because pulmonary function improvement or rehabilitation requires a certain period to see the improvement. As shown in this study, the duration was approximately 4 weeks, so it caused minor differences. The results of this study differ from the study of Chouythoa, which explored the effects of a self-management program for 6 weeks, which was 2 weeks longer than this study10. The study by Xiao and Zhuang found that regular physical activity/exercise by walking helped raise functional capacities, such as walking endurance, fatigue, pulmonary function, shortness of breath, mental health, and quality of life32. Maricoto et al. conducted a systematic review and meta-analysis of eight studies on older people. They concluded that the most powerful practice to reduce dyspnea exacerbations was the practice of using an inhaler and simulation equipment. After attending the program, the rate of exacerbation was reduced. At the same time, the quality of life tended to increase after attending the program33.The symptom management program for older patients with COPD encouraged the patients who participated in the program to have a better quality of life. Older patients who received the symptom management program had quality of life scores of less than 10, which indicated a low impact of the disease on these patients. Proper management of exacerbations coupled with the promotion of pulmonary function is essential to improve the patient's quality of life as it would help reduce the symptoms of dyspnea and increase the ability of older patients to do daily activities as usual. This newly developed program was designed to enable older people to manage dyspnea, improve pulmonary function, and prevent exacerbations. If the pulmonary function could be enhanced, the severity of dyspnea decreased, and the incidence of exacerbations could be controlled, older patients could live everyday life and have a better quality of life. Accordingly, Duangseang's study on managing dyspnea among older patients with COPD found that patients who could effectively manage dyspnea would achieve high happiness scores and life satisfaction34 study, which found that only one patient who received the triple therapy program had an exacerbation. Hung’s study on the effects of a hospital-to-home transition care program revealed that a program could help reduce the readmission rate35. The results mentioned above differed from this study, possibly because the hospital-to-home transition care program took longer, had more participants (212 persons), and used multidisciplinary teams to care for patients, resulting in apparent differences between the experimental and control groups. However, our study found no differences, possibly due to the small sample size and short study period. In addition, during the COVID-19 outbreak, this situation may cause older patients to be worried about receiving services as they were afraid to be at risk of contracting COVID-19 from hospitalization. Then, they did not decide to visit the hospital if they did not experience the worst symptoms. Another explanation was a policy to prevent the spread of COVID-19 by giving medication or receiving treatment at a sub-district health-promoting hospital instead of visiting a hospital37. Therefore, this may affect decision-making in receiving treatment at the hospital.This study found no difference in readmission rates. Older patients who attended the program had no readmissions within 28 days, but only one older patient who received routine care was readmitted. The results of this study are similar to Li et al.’sThis study was conducted on mild and moderate-severity patients (GOLD levels 1 and 2) during the remission phase, not other groups with high and very high severity (GOLD levels 3 and 4), who often suffer and burden along with a longer time living with COPD diagnosis. Therefore, the study could not represent the entire population and limited use of the research findings in higher severity groups. Participants who attend this program have no hearing and visual impairment. These inclusion criteria make the participants less representative of older patients and limit generalization. In addition, almost all of the participants in this study were men. Therefore, it may not reflect the study’s results in the female population. In this case, future studies should be conducted among older women likely to be exposed to secondhand smoke. Finally, the small sample size, the short study period, and the COVID-19 epidemic may cause older patients to worry about deciding to receive services at the hospital. Therefore, this study could not show an apparent difference in readmission rates.The study on the effects of this symptom management program among older patients with COPD was conducted on 30 older patients. There were 15 patients in the experimental group receiving the symptom management program and 15 patients in the control group receiving routine nursing care. Outcomes were measured after attending the program for 28 days. The results revealed that the symptom management program could reduce dyspnea and its severity during activities and increase the quality of life. Therefore, the program should be applied to maximize efficiency and effectiveness in caring for older patients with COPD. However, this study may only partially reflect results due to the COVID-19 outbreak, which affects the healthcare service policies and the decision-making of older patients to receive healthcare services in case of an exacerbation. Therefore, this program should be explored in typical situations again, and outcomes should be measured over a more extended period. In addition, more extensive population-based studies and randomized controlled trials should be adopted to increase credibility and ensure generalization.


Traditionally, lymphovascular invasion (LVI) has represented one of the foremost pathological features of malignancy and has been associated with a worse prognosis in different cancers, including breast carcinoma. According to the most updated reporting protocols, the assessment of LVI is required in the pathology report of breast cancer surgical specimens. Importantly, strict histological criteria should be followed for LVI assessment, which nevertheless is encumbered by inconsistency in interpretation among pathologists, leading to significant interobserver variability and scarce reproducibility. Current guidelines for breast cancer indicate biological factors as the main determinants of oncological and radiation therapy, together with TNM staging and age. In clinical practice, the widespread use of genomic assays as a decision-making tool for hormone receptor-positive, HER2-negative breast cancer and the subsequent availability of a reliable prognostic predictor have likely scaled back interest in LVI’s predictive value. However, in selected cases, the presence of LVI impacts adjuvant therapy. This review summarizes current knowledge on LVI in breast cancer with regard to definition, histopathological assessment, its biological understanding, clinicopathological association, and therapeutic implications. Together with local invasion, one of the main defining characteristics of cancer is its spread capability, resulting in metastases. Notably, metastatic disease is the leading cause of death in cancer patients . Before The College of American Pathologists (CAP) recommends assessing and reporting LVI in all Cancer Protocols, the “gold standard” in cancer reporting . MoreoveCurrently, the therapy of BC patients is mainly dictated by well-established biological biomarkers, including estrogen receptors (ER), progesterone receptors (PR), HER2, and the Ki-67 proliferation index, together with TNM staging and age. However, the presence of LVI may impact the indication for adjuvant therapy . SpecifiIn this review paper, we critically summarize the state of the art on the main aspects of LVI in BC, its histological characteristics and possible pitfalls, its biological understanding, clinicopathological associations, and therapeutic implications.For a long time, the presence of LVI has been identified on an optical microscope, described by pathologists, and recognized as a histopathological feature of malignancy and metastasis potential . LVI, alSpecifically, the CAP advises reporting the occurrence of LVI in resection specimens since BC is known to spread through the vascular pathway, like many other malignancies . MoreoveThe assessment of LVI is a time-consuming task with considerable interobserver variability and low reproducibility ,15. As aThe assessment of LVI is routinely performed on hematoxylin–eosin-stained preparations, for which detailed histological criteria have been proposed and recommended for the diagnosis of LVI in breast pathology  4,6].,6.4,6].LVI evaluation is more trustworthy in breast parenchyma outside, but close to, invasive carcinoma margins due to the difficulty in distinguishing true LVI from retraction artifact, mainly encountered within the tumor (see below) . In addiHistologically, the tumor emboli do not exactly shape the space they are in, leaving an intravascular empty space. Sometimes, this space is partially or completely occupied by fibrin clots and erythrocytes adhering to the tumor emboli, a consistent feature of the blood vessel LVI, or lymph content, composed of pinkish-stained homogenous material, more consistent with lymphatic channels . In partEndothelial cells, which appear as a thin monolayer of cells with inconspicuous flat cytoplasm and homogenous elongated nuclei that can protrude in the vessel lumen, must line tumor emboli in LVI. Then, in breast parenchyma, usually small blood vessels (an arteriole and a venule), as well as a nerve trunk, are often found in close proximity to the LVI, although this finding is variable and inconsistent .Cutaneous LVI is particularly relevant due to its strict association with the clinical entity of inflammatory breast carcinoma . HistoloAlthough there is a lack of agreement about the precise criteria for classifying LVI, the St. Gallen International Expert Consensus Conference recommendations advocate quantifying LVI . In ordeIn the breast, LVI has been reported in combination with carcinoma but also with benign proliferative diseases. Specifically, one study by Eusebi and Azzopardi found non-neoplastic breast tubules within the artery or the venous wall in 5 of 50 consecutive cases of sclerosing adenosis . In addiDuring specimen processing, tissue retraction creates artifactual clefts around nests of invasive and in situ carcinoma that can mimic LVI. Such retraction or shrinkage artifacts can be difficult to differentiate from true lymphovascular lumens . InitialExceptionally, breast carcinomas, as well as lymphomas, show a peculiar pattern of infiltration as the result of permeation of the pseudoangiomatous stromal hyperplasia (PASH), which simulates extensive LVI . ImmunohImmunohistochemical staining can aid in the identification and confirmation of LVI. The current wide availability of antibodies specific for antigens differentially expressed in small vessels allows for the identification of lymphatic channels, the distinction of blood capillaries, and the resolution of tricky morphologic dilemmas. Historically, many studies have described the utility of factor VIII, CD34, CD31, and Ulex europaeus agglutinin I in the identification of LVI endothelial cells . HoweverAgain, the significant attenuation of the stretched endothelial cytoplasm in dilated lymphatic channels may be responsible for the apparent false-negative immunostaining of lymphatic endothelial cells . Taking LVI is a complex process composed of many steps. Initially, cancer cells must breach the epithelial basement membrane, invade the stroma, and reach the underlying vessel spaces . These vEpithelial-to-mesenchymal transition (EMT), an evolutionarily conserved cellular program important for both physiological and pathological processes, including embryogenesis, wound healing, and tissue repair, plays a key role in carcinoma invasion . SeveralAn additional key player in cancer invasion is the extracellular matrix (ECM) . In cancSeveral lymphangiogenic factors are released by BC and stromal cells. Specifically, the most critical are VEGF-C and VEGF-D, which bind their receptor VEGFR-3 and stimulate lymphatic endothelial cells . Both VEOnce cancer cells reach the vessel wall, they must penetrate the perivascular cells, basement membrane, and endothelial cell layer. There is evidence that different mechanisms other than protease-mediated invasion contribute to cancer cell intravasation: (1) mechanical forces such as interstitial fluid pressure or contractile stress ,55; (2) Several studies have been conducted on neoplastic LVI in invasive breast carcinoma. Clinically, LVI has been consistently associated with younger patients ,64,65,66Then, LVI has been strongly associated with larger tumor size, higher histologic grade, and higher T staging ,72. InteBased on increasing and consistent evidence, the presence of LVI indicates a worse prognosis for BC patients. LVI, in particular, has been shown to significantly predict the presence of lymph node metastases, including those in sentinel lymph nodes ,72,74,76Recent research has investigated the relationship between LVI and major predictive biological markers. LVI was found more frequently in tumors that were hormone receptor (HR)-negative, HER2-positive, and had a higher Ki-67 proliferation index . AccordiAn interesting issue regards LVI in heredo–familial BC. Since young women have a higher incidence of LVI than older women ,64,65,66BRCA1-related BCs. Their expectation was the absence or scarcity of LVI in such cancers, mainly for supposed biological reasons [BRCA1-related BCs are usually characterized by pushing borders, which they say is not a favorable condition for easily reaching vessels. However, this subjective statement is not supported by consistent scientific data and is disproved by one previous study that identified LVI as significantly associated with nonstellate tumors [BRCA1-related cancers are more often of a medullary-like histotype in comparison with sporadic BC, and such a histotype is usually characterized by little LVI. Despite these assumptions, the results showed LVI occurring in BRCA1-related BCs as often as in sporadic ones (25% versus 20.6%), leading to the conclusion that these BC cells could be able to overcome the apparent barrier to reaching vessels [Van Voss et al. analyzed and discussed the presence of LVI in 28  reasons . First, e tumors . Second, vessels .BRCA1 mutation carriers than in BRCA2 and non-carriers  in a cohort of 302 patients, of which 75 were mutation carriers [BRCA1- and BRCA2-related BCs, others showed instead a higher proportion, especially in BRCA1 mutation carriers. Only one report described LVI as occurring more often in BRCA2-related than in BRCA1-related or sporadic BCs  [Furthermore, in a recent study, Atcı et al. showed a higher prevalence of LVI in carriers . The autctively) .TP53 germline mutation carriers. LVI was described in comparison to other patient subgroups with early onset of BC [TP53 mutation carriers, a higher percentage than BRCA1 (14.5%), BRCA2 (24.8%), and sporadic BC in young patients (19.9%). Curiously, LVI was found as being as common in TP53 carrier BC as it was in HER2-amplified BC (34.6%). These results are not consistent with some previous findings, where much higher percentages of LVI were observed in BRCA1- and BRCA2-related BC subgroups [The COPE study analyzed the characteristics of BC in et of BC . LVI occubgroups .Despite the fact that the negative prognostic value of LVI is well known, and that many studies have been conducted on its predictive value for better therapy choices, its inclusion in the decision-making process for BC standard care has not been adequately defined and is not acknowledged in most guidelines . More reIn an adjuvant setting, a recent large French multicenter retrospective cohort study of over 17,000 patients found that LVI was an independent negative prognostic factor for DFS, OS and metastasis-free survival in all eBC patients, except both G3 and Luminal A-like BC treated with adjuvant CT. The authors concluded by considering a possible LVI positive predictive value for chemotherapy in certain subsets of eBC [The introduction of genomic assays in clinical practice for HR-positive, HER2-negative BCs and the subsequent availability of a reliable prognostic tool could have scaled back interest in LVI-predictive value, making it less relevant, if not outdated, in the adjuvant clinical setting. Nevertheless, a new role for LVI as a parameter to employ in addition to genomic assays, especially when the scores are positioned in a gray zone for chemotherapy choice, has produced new updated studies. Regarding this, Makower et al. assessed the complementary role of LVI as an adjunct to a 21-gene recurrence score (RS) . AccordiMoreover, Mutai et al. analyzed a potential correlation between LVI and higher 21-gene RS . Such a RPL37A gene, which encodes for the ribosomal protein L37a, which is also present in the Endopredict® assay). For the other assays, however, only some correspondence with genes from the same family was found (two genes for PAM50 and one for both OncotypeDx® and Mammaprint®).Another related issue is the association between LVI and the presence of genes correlated with LVI among those included in the clinically available genomic assays. In this contest, Klahan et al. applied bioinformatics to investigate the mechanisms underlying LVI in BC patients, describing a very large number of genes differentially expressed between LVI-positive and LVI-negative BC patients, including 37 down-regulated and 49 up-regulated genes . When sup < 0.01) [A field of more actual interest could be the LVI’s prognostic and predictive value in the neoadjuvant setting. The identification of LVI after neoadjuvant chemotherapy (NAC) seems to correlate with a worse outcome in many studies. Liu et al. described results from their retrospective analysis of 166 women treated with NAC . In thei < 0.01) . When LV < 0.01) . A conco < 0.01) . LVI was < 0.01) .A larger cohort study of 1033 BCs confirmed the role of LVI in addition to other prognostic scores . ParticuLVI represents a major feature of biological aggressiveness among carcinomas. Coherently, strong evidence showed that LVI in BCs is associated with more aggressive clinicopathological characteristics, such as larger tumor size, higher histologic grade, higher T staging, and axillary lymph node metastasis. Importantly, LVI is an independent negative prognostic factor associated with local recurrence and distant metastasis as well as worse DFS and OS, even in lymph node-negative patients.In clinical practice, the emergence of genomic assays as decision-making tools for adjuvant chemotherapy in early-stage HR-positive, HER2-negative BC patients have waned interest in LVI’s predictive power. However, sometimes genomic assays are not conclusive, and additional reliable prognostic parameters for chemotherapy selection could acquire relevance. In this situation, further studies on the potential use of LVI as an adjunct are wanted. Notably, genomic assays are expensive, burdening healthcare costs and causing socioeconomic disparities. Regardless, LVI is clinically important since it influences radiotherapy indications.Given the strong prognostic power of LVI, standardized methods of LVI routine assessment with more reproducible outcomes are required to implement LVI use to better risk-stratify BC patients at no additional cost.


Both creativity and responsibility are important higher-order skills to develop to meet the challenges of the Anthropocene, and both are related to attentional states of consciousness and to ethics. Meditation is a set of practices that trains attentional and emotional regulation. A few studies have shown that different kinds of meditation can foster different kinds of creative thinking, and others have begun to investigate the effect of the combination of meditation and ethics on ethical characteristics . Here, we present a nonrandomized trial with an active control group among second-year science university students (n = 84) to test the effect of the secular Meditation-Based Ethics of Responsibility (MBER) program on creative potential, self-reported awareness, and sense of one’s own responsibility. The results show a large effect of the program on sense of one’s own responsibility and convergent and divergent creative writing tasks, both in conceptual–semantic and engineering-like verbal ideation. They also suggest that convergent conceptual–semantic thinking might moderate the effect of the MBER program on the awareness and sense of one’s own responsibility. This work opens up new research and educational perspectives linked to necessary behavioral changes in the Anthropocene. Thus, democratic solutions are an ethical matter that imply (i) individuals feeling committed and being involved in acting ethically and (ii) new and efficient solutions. How can education foster such change to more ethical modes of functioning? This is the general issue that we address here.In the time of the Anthropocene, warning signals indicating the urgency of changing our modes of functioning are increasing. The latest report from the Intergovernmental Panel on Climate Change (IPCC) highlights the growing vulnerability of human beings, natural species, and regions of the world to global warming, undoubtedly caused by human activity . LimitinCreativity  and ethiN.B.: We consider abilities as one of the three dimensions of skill, along with knowledge and dispositions  of creativity have been noted , whereasAlso, in different types of ethics, for example virtue ethics  and orgaNotice that in the field of ethics, the term “creativity” is quite rarely mentioned. It is explicitly mobilized in the ethics of authenticity, where it refers to an innovative way of living the contingency of one’s own choices and actions . HoweverNow, as far as educational needs in the Anthropocene are concerned, skills such as responsibility and creativity are more lacking than mental intelligence, which is already a major focus of our Western schools . So, howBoth the higher-order skills of creativity , whereas the two first establish ethical principles, and the last half deals with meditation or meditation-triggered states of consciousness  Does the MBER program increase creativity scores ? H1: Yes, it does.(Q2) Does the program increase responsibility scores ? H2: Yes, it does.(Q3) Does the program decrease responsibility scores on a subsection of the population identified according to their initial creativity score and thus have “unwanted effects”? H3: No, it does not.(Q4a) Is there a correlation between creativity and responsibility scores at the pretest measurement? (Q4b) Do the creativity scores mediate or moderate the effect of the program on responsibility? We expected that creativity scores on the pretest would mediate or moderate the effect of the program on responsibility scores at the post-test (H4b). Also, we hypothesized that creativity scores were independent of responsibility scores , because the latter should also rely on other necessary dimensions .We designed a 25 h mindfulness-based program called MBER derived from an existing program, which was itself based on early forms of MBSR  and 36  participants in the experimental and control groups, respectively (n = 84). We kept participants who did not completely fill in all relevant measures.We conducted a quasi-experimental study (pretest/post-test with control group) with young adults (n = 105) in the context of a French faculty of “hard” sciences. The MBER program was part of the students’ curricula as a module of “general knowledge”, which they could choose among other modules. The experimental group was composed of university science students who chose the MBER module, whereas the control group consisted of students who chose other 25 h modules of “general knowledge” related to the hard sciences but not to ethics, creativity, or meditation. Because the students chose their optional module through an online procedure, we had the means to contact them only after this choice. It was thus not possible to assign them randomly to a group. Inclusion criteria were to agree freely to take part anonymously in the study and, for the analyses of the experiment, to complete both pretest and post-test measures. Anonymity was guaranteed, and data between pretest and post-test were matched using an anonymous code created by each participant in an imposed manner, based on data to which we did not have access to . Twenty participants were absent at the post-test. They did not significantly differ from the remaining participants in age and sex. Also, one participant was removed from the analysis because her responses appeared to be an extreme outlier for the majority of variables . Finally, we retained 48  and post-test , we calculated a global verbal creativity score (labeled “creativity” in the tables) which had satisfying internal reliabilities, both at the pretest (Cronbach’s α = 0.71) and the post-test (Cronbach’s α = 0.77).Each individual score is the mean of these four notations. The interjudge reliabilities of the 4 creativity subscores at pretest and post-test range, according to Fleiss’s Kappa, from 0.22 (fair) to 0.45 (moderate), with an average of 0.37 (sd = 0.07). Given the satisfactory bivariate correlations between the 4 scores of creativity, both at pretest  and occurred before the administration of the questionnaire, which included other self-reported scales that are not presented here . The title of the questionnaire sheet was “questionnaire to be completed as part of a scientific study of modules of general knowledge”, and then it was written that “this questionnaire is divided into sections on different themes” (the themes were vague and indicated as subtitles). Then, we conducted the statistical analyses using SPSS Statistics 20.0.0 software. Moderation and meditation analyses were conducted using the Hayes’ module of SPSS.We first assessed the means of the variables of interest in the experimental and control groups .Initial creativity scores were below the central point of the scale (<4), whereas responsibility pretest scores were above it (>3.5). Therefore, the first ones had more room for improvement than the second, on average.As both groups did not a priori present the same motivation to learn meditation and, moreover, had different sex ratios, we controlled the pretest scores thanks to a one-way between-groups analysis of covariance . So, theThe program showed large effect sizes on both variables: Awareness and Sense of One’s Own Responsibility (through SOOR) and verbal creative potential , significant at a level below 0.003. AOOR is the only variable for which we observed no significant change below the threshold of 5%. All the changes that are significant show medium to large effect sizes and are in the expected direction (rising on average between the pretest and the post-test). These results show a strong effect of the MBER program on indicators of creativity and responsibility, suggesting its efficiency on both skills (H1 and H2).As the relationships between creativity and responsibility have not been studied earlier, we explored them, keeping in mind that our measure of responsibility is preliminary.First, the correlations between all scores and subscores for all participants of the pretest indicated that only creative potential scores are significantly intercorrelated . This teWe then assessed if it would be plausible for creativity scores to have the unwanted effect of negatively affecting the evolution of the responsibility scores between the pretest and the post-test in a sub-section of the experimental group .p = .74—and the most important rises (large effects) concern the creativity scores among the participants who initially had the lowest scores. This effect is specific to the experimental group, because no significant increase in these scores is observed in any median split half of the control group. It is striking to note that the only scores that do not increase significantly at the 5% threshold are the scores of responsibility among the participants who have the initially lowest creativity scores . This suggests that creativity might moderate the effect of the MBER program on responsibility.We did not observe such an unexpected effect in either of the groups characterized by their initial amount of creativity . The meap less than .06)  .p = .091). However, when this initial score is higher (3.17 or 4.57), the rise in the responsibility score becomes significant (p < .001). This result suggests that the initial score of convergent conceptual–semantic creativity might moderate the effect of the MBER program on Awareness and Sense of One’s Own Responsibility, but this should be confirmed in another study.We also tested if pretest creativity scores might mediate the effect of MBER program on responsibility post-test scores, and it did not yield any significant result.We conducted a nonrandomized actively controlled experiment in order to assess the impact of the MBER program on indicators of creativity and responsibility and to explore the potential relationships between both variables.In the context of our study, our first hypothesis (H1) is largely supported, because we observe large size significant effects of the MBER program on convergent and divergent, both conceptual–semantic and engineering-like creative potentials . Indeed,Our H2 hypothesis was only partially confirmed: the effect of the MBER program on the SOOR subscore was of the same type and magnitude as the ones measured for creativity, but AOOR did not significantly change after the program.The SOOR items concentrate on the ethical intention : to feel concerned by the impact of one’s own actions on the world and to be motivated to orient one’s own actions towards a better impact. To our knowledge, these are the first empirical data of this sort, and the closest study is one which showed that an 8-day online short ethically oriented meditation training enhanced a measure of prosociality , as compared with more classical online mindfulness training . So, theIn the past two months, I became more aware of the consequences of my [functioning]”.The AOOR items express the awareness of one’s own functioning and actions and of their consequences on oneself and the world: either the program did not increase this awareness or there is a methodology issue here. This first interpretation tends to contradict what the students expressed in informal written feedback that we collected , 2022. A“Primum non nocere” (first do no harm) is Hippocrates’ first oath. In this vein, we verified the absence of unwanted effects of the program on responsibility depending on initial creativity scores. Participants with the lowest initial creativity made the most progress on this score ; so, allAs far as our H4 hypotheses are concerned, we supposed that responsibility requires some kind of creativity and that on the contrary, creativity does not require responsibility. Both sets of variables were not significantly correlated with each other . So, H4aSome preliminary results suggest that convergent conceptual–semantic creativity might moderate the effect of the MBER program on responsibility : a minimSo, overall, further investigation might be conducted that would overcome some limits of the present study .This study offers some preliminary explorations of the relationships between creativity and responsibility. It supports the power of the MBER program to foster convergent and divergent verbal ideation coupled with writing (a verbal creativity that we consider as a motor and higher-order cognitive skill; In conclusion, it seems that a misconception of human functioning, prevalent in society and even among some scientists , suggestIndeed, it is the technoscientific enterprise , with it


Post-traumatic stress (PTSD) disorder is a mental health condition that can occur after experiencing or witnessing a traumatic event. The 27-F earthquake that struck Chile in 2010 was one such event that had a significant impact on the mental health of the population. A study was conducted to investigate the prevalence of PTSD and its associated factors among survivors of this earthquake. The study was a longitudinal design, involving a sample of 913 patients aged 18 to 75 years who attended 10 Primary Care Centers in Concepción, Chile. The Composite International Diagnostic Interview (CIDI) was used to assess both depressive episodes (DE) and PTSD before and after the earthquake. The study also involved genotyping studies using saliva samples from the participants, specifically focusing on the Val66Met and 5-HTTLPR polymorphisms. Statistical analysis was performed to examine the association between different variables and the presence of PTSD. These variables included demographic factors, family history of psychiatric disorders, DE, childhood maltreatment experiences, and critical traumatic events related to the earthquake. The results showed that the incidence of post-earthquake PTSD was 11.06%. No significant differences were found between the groups of participants who developed post-earthquake PTSD regarding the Val66Met or 5-HTTLPR polymorphisms. However, a significant association was found between the concomitant diagnosis of DE and the development of post-earthquake PTSD. The presence of DE doubled the risk of developing post-earthquake PTSD. The number of traumatic events experienced also had a statistically significant association with an increased risk of developing post-earthquake PTSD. The study’s limitations include the potential interference of different DE subtypes, the complexity of quantifying the degree of earthquake exposure experienced by each individual, and events entailing social disruption, such as looting, that can profoundly influence distress. In conclusion, the study found that PTSD following the 27-F earthquake in Chile was associated with a concomitant diagnosis of DE and the number of traumatic events experienced. The study did not find a significant association between PTSD and the Val66Met or 5-HTTLPR polymorphisms. The researchers recommend that mental health professionals should prioritize the detection and treatment of concomitant depressive episodes and exposure to critical traumatic events in survivors of disasters. They also suggest that further research is needed to better understand the relationship between genetic factors and post-disaster PTSD. Chile, given its geographical location, is a territory that is under constant threat from natural disasters . In factOn the morning of February 27th, an earthquake occurred. It acted as the primary precipitating event for two subsequent disasters that occurred in rapid succession. A devastating tsunami affected and destroyed approximately 450 kilometres . This waMajor traumatic events play a key role in the development of post-traumatic stress disorder (PTSD) . Major tAdverse experiences or traumatic stressors in childhood, adolescence, or adulthood have been widely linked to PTSD . Child mIn neurobiological terms, PTSD’s pathophysiology, progression, and maintenance involve multiple factors, presenting many questions . PTSD coA single nucleotide polymorphism (SNP) called Val66Met  exists in the BDNF gene on 11p13. It lead to altered BDNF packaging and reduced release-dependent activity . Val66MeTraumatic events have been described to increase serotonin release in some brain regions . The 5-HConsequently, the presence of these alleles would increase the risk of developing stress-related disorders, including PTSD . This stA longitudinal study of a sample of patients, aged 18 to 75 years, who attended 10 Primary Care Centres in Concepción, Chile.n = 2466) completed the 12-month follow-up  was used in the study . It asseDuring the PREDICT-FONDEF study, a comprehensive set of environmental risk factors for PTSD was collected . These risk factors were compiled using an inventory from the PREDICT-Europe Project and were also based on known risk factors from earlier literature . This inAccording to the authors, all procedures used in this study and the 2008 revision of the 1975 Helsinki Declaration adhere to the ethical guidelines set forth by the pertinent national and institutional human experimentation committees. All procedures involving patients or human subjects received approval from the Ethics Committee of the Faculty of Medicine at the Universidad de Concepción. An informed consent form was signed by each person who consented to participate, which has been fully anonymized and cannot be identified through the manuscript .® 200 PRO NanoQuant spectrophotometer . Finally, DNA integrity was confirmed by agarose gel electrophoresis.Saliva samples were obtained, preserved, and transported using a DNA collection kit . DNA was then extracted using the salt precipitation method. The DNA concentration was then quantified using an InfiniteIt was typed by restriction enzyme-based PCR (BsaA I). Specifically, the oligonucleotide partitions, sense F-1F (5′-ATCCCGGTGAAAGAAAGCCCTAAC-3′) and antisense F-1R (5′-CCCCTGCAGCCTTCTTCTTTTGTGTAA-3′) were used to amplify a PCR fragment 673 bp in length. The PCR fragments were then digested with the restriction enzyme BsaA I . Specifically, this enzyme produces 3 fragments of 275, 321, and 77 bp when guanine is present at nucleotide 1249. In contrast, when cytosine is present at this position, 2 fragments of 321 and 352 bp are produced. Finally, the digested PCR products were separated on a 1.2% agarose gel.Genotyping of 5-HTTLPR for short and long alleles was performed by PCR . These aversus lower-risk alleles for developing psychiatric disorders about each gene . Consequently, the number of maltreatment forms was taken into account, irrespective of their type. Regarding the experience of the earthquake, a variable representing critical traumatic events associated with the earthquake was included. This variable encompassed the death of a family member, being trapped under rubble, suffering serious or life-threatening physical injuries, and damage to or loss of housing.α = 0.05 was considered for all analyses. Specifically, RStudio version 2.15.2  and PTSD risk, multivariate logistic regression analyses were performed. These models were built hierarchically based on theoretical reasoning. The first two models included only genetic risk factors, independently and with their interaction. The subsequent model incorporated additional biological variables, followed by a model including psychosocial factors. Finally, the last model encompassed the catastrophe model (A significance level of n 2.15.2  was usedhe model .n = 101) incidence of post-earthquake PTSD. Of the PTSD cases, 83.2% (n = 84) were female and 16.8% (n = 17) were male (p = 0.375). A total of 117 subjects (12.8%) experienced critical traumatic events associated with the earthquake while only 19 of those (18.8%) developed post-earthquake PTSD (p = 0.079). The mean number of traumatic events experienced was 2.2 (+/ −1.7) for those who developed PTSD, compared to 1.2 (+/ −1.3) for those who did not(p < 0.001).p = 0.419 and p = 0.344, respectively). The study did not find any statistically significant differences when considering the number of forms of childhood maltreatment (p = 0.459), biological sex (p = 0.375), and level of schooling (p = 0.590).After analyzing the genetic data, no significant differences were found between the groups of participants who developed post-earthquake PTSD about the Val66Met or 5-HTTLPR polymorphisms or the combination of their alleles  (p > 0.05). The same was observed when examining the interaction between both alleles and the development of PTSD (p = 0.949), as well as for sex (p = 0.313) and age (p = 0.345).To investigate the possible association between post-earthquake PTSD and various variables, a regression analysis was performed with increasing complexity, as depicted in p = 0.013), but not for the number of forms of maltreatment experienced in childhood (p = 0.610). The presence of DE doubles the risk of developing post-earthquake PTSD . When variables associated with the earthquake are added to the model, the significant association between the concomitant diagnosis of DE and the development of post-earthquake PTSD is maintained, doubling the risk of developing post-earthquake PTSD .When incorporating psychosocial variables, a statistically significant association was found between the concomitant diagnosis of DE and the development of post-earthquake PTSD (p = 0.079). However, the number of traumatic events experienced had a statistically significant association with an increased risk of developing post-earthquake PTSD . Thus, the number of traumatic events is a factor that increases the risk of developing post-earthquake PTSD by 1.65 times.It is important to note that the experience of a critical traumatic event associated with the earthquake was not statistically significant in the development of post-earthquake PTSD , with no significant difference from the literature’s reported prevalence of PTSD (9 to 11%) for those who have been exposed to a traumatic event . Before When comparing prevalence rates of PTSD between studies, it is important to consider several factors such as the timing of the stressful event. For example, a study on the 27-F disaster conducted by the Chilean government 3 to 4 months after the earthquake reported a national prevalence of 11.1%, with higher rates in the Province of Concepción (28.4%) and lower rates in regions unaffected by the earthquake (4.4%) . AnotherThere may be several factors that account for variations in the prevalence of post-earthquake PTSD reported in different studies, including differences in timing and the magnitude of exposure to the disaster. For instance, the Nepal earthquake of April 25, 2015, has been the subject of several studies, highlighting differences in prevalence rates depending on the timing and context of exposure. One study focusing on certain districts in the Kathmandu Valley found a prevalence of post-earthquake PTSD of 15.9% at 6 months , while aIn Chile, 73.6% of children reportedly experience physical or emotional violence from their parents or relatives . NeverthNumerous studies have identified a higher prevalence of PTSD among women ; howeverp = 0.013). This risk was marginally reduced when accounting for the experience of the seismic event in the logistic regression model . Notwithstanding, a concomitant DE diagnosis still doubled the risk of developing post-earthquake PTSD at 12 months. It is crucial to consider the potential that numerous individuals were not diagnosed with DE at the time of the 27-F, and that the disaster merely exacerbated their symptoms, in conjunction with the concurrent development of post-earthquake PTSD.In the present study, we observed that a concomitant diagnosis of DE was significantly associated with an elevated risk of developing post-earthquake PTSD .It is imperative to emphasize that while DE can manifest as highly heterogeneous conditions, encompassing various subtypes such as anxious, melancholic, psychotic, or suicidal ideation, our study did not differentiate between these subtypes. This limitation arose from methodological constraints and the relatively small number of evaluated individuals who developed PTSD. A significant aspect to acknowledge is that the earthquake transpired during the early morning hours (03:38 AM), resulting in the earthquake and its ensuing events being experienced in a communal or familiar context, encompassing family gatherings, shared meals, and mutual support among neighbours. This scenario fosters coping strategies at both individual and collective levels. Our study’s findings highlight that the experience of a single critical traumatic event associated with the earthquake did not constitute a significant variable. Conversely, witnessing more than one critical traumatic event linked to the earthquake emerged as a significant factor, escalating the risk of developing earthquake-induced PTSD by 1.65 times  Variable created to group the number of forms of maltreatment experienced in childhood, independent of the type of maltreatment . (**) Death of a family member, Being trapped under rubble, Having physical injuries that required hospitalisation or were life-threatening, Severe damage to the dwelling or total loss.Click here for additional data file.10.7717/peerj.15870/supp-2Supplemental Information 2Click here for additional data file.


Intrinsically disordered proteins and regions of proteins (IDPs/IDPRs) are proteins that do not have a well-defined three-dimensional structure and have been linked to neoplastic development. Our study aimed to evaluate the presence of intrinsic disorder in PRAME and the role these structureless regions have in PRAME( +) Class 1 UM.The PReferentially expressed Antigen in MElanoma 2P2) platform, IUPred, FuzDrop, fIDPnn, AUCpred, SPOT-Disorder2, and metapredict V2 allowed us to evaluate the potential functional disorder of PRAME. Additionally, we used the Search Tool for the Retrieval of Interacting Genes (STRING) to analyze PRAME's potential interactions with other proteins.A bioinformatics study to characterize PRAME’s propensity for the intrinsic disorder. We first used the AlphaFold tool to qualitatively assess the protein structure of PRAME. Then we used the Compositional Profiler and a set of per-residue intrinsic disorder predictors to quantify the intrinsic disorder. The Database of Disordered Protein Prediction , a disorder-promoting amino acid. PRAME was found to have an average disorder score of 16.49%  across six per-residue intrinsic disorder predictors. Our IUPred analysis revealed the presence of disorder-to-order transition (DOT) regions in PRAME near the C-terminus of the protein (residues 475–509). The D2P2 platform predicted a region from approximately 140 and 175 to be highly concentrated with post-translational modifications (PTMs). FuzDrop predicted the PTM hot spot of PRAME to be a droplet-promoting region and an aggregation hotspot. Finally, our analysis using the STRING tool revealed that PRAME has significantly more interactions with other proteins than expected for randomly selected proteins of the same size, with the ability to interact with 84 different partners .Our structural analysis showed that PRAME contains intrinsically disordered protein regions (IDPRs), which are structureless and flexible. We found that PRAME is significantly enriched with serine  are localized to regions of high levels of disorder. PRAME has a complex protein–protein interaction (PPI) network that may be secondary to the structureless features of the polypeptide. Our findings contribute to our understanding of UM and suggest that IDPRs and DOT regions in PRAME may be targeted in developing new therapies for this aggressive cancer.Video AbstractThe online version contains supplementary material available at 10.1186/s12964-023-01197-y. Uveal melanoma (UM) is the most common primary intraocular tumor . The neoGene expression profiling (GEP) has been developed to assess the risk of metastasis for UM. GEP allows clinicians to group UM into either Class 1 (low-grade metastatic risk) or Class 2 (high-grade metastatic risk) based on their molecular profiles . Class 1Our group has studied ocular malignancies and characterized proteins involved in ocular surface squamous neoplasia, conjunctival melanoma, and uveal melanoma . We are Intrinsically disordered proteins (IDPs) and intrinsically disordered protein regions (IDPRs) are proteins and the regions of proteins that do not adopt a well-defined three-dimensional structure and instead are disordered but maintain function . These fOur study focused on the intrinsic disorder phenomenon and its association with PRAME expression and its association with uveal melanoma. To accomplish this, we conducted a disorder-based bioinformatics analysis that utilized publicly available databases and computational tools to probe PRAME for intrinsically disordered protein regions.https://uniprot.org; date last accessed: Dec 26, 2022) [The Universal Protein Resource (UniProt) is a protein database with information related to function, taxonomy, subcellular location, disease associations, post-translation modifications, expression profiles, interaction networks, structure, protein families, and sequences  . The seaThe UniProt entries for PRAME also contain structural information. There are computational and experimental-based structures  housed on the UniProt server. We selected the “AlphaFoldDB” entry. AlphaFold is the most up-to-date and accurate computational method to predict protein structure –21.http://www.cprofiler.org/; accessed on December 26, 2022) [Cx is the content of a given residue in a query protein  and Corder is the content of the same residue in the PDB Select 25.We sought to quantify the elements of intrinsic disorder in PRAME. We utilized the Compositional Profiler to measure the relative proportion of specific amino acids in each protein (available at: https://ridao.app) was used to yield bulk predictions for the PONDR family of predictors  as well as IUPred-Long and IUPred-Short. The remaining predictions were obtained using local installations of the respective predictors—flDPnn, AUCpreD, SPOT-Disorder2, and metapredict V2. Each predictor used in this work takes a primary sequence as input and yields a measure of intrinsic disorder propensity, referred to as the disorder score, for each amino acid contained therein. Disorder scores range from 0 to 1, where 0 is the most ordered measurement and 1 is the most disordered. Taken as a whole, the complete set of disorder scores for a given sequence constitute a disorder profile.The intrinsic disorder of PRAME was quantified on a per-residue basis using a set of ten well-established disorder predictors, namely: PONDR® VLS2 , 24, PONUsing the disorder profile of PRAME we computed the percent of predicted disordered residues (PPDR) for a given predictor, er cases . Further2P2) platform  [2P2 platform integrates IUPred [2P2 server provides the Structural Classification of Proteins (SCOP) [https://www.ebi.ac.uk/interpro/search/sequence/, accessed on December 12, 2022) [2P2also predicts disorder-based binding sites with the ANCHOR algorithm [2P2platform also predicts possible posttranslational modifications (PTMs) using the outputs of the PhosphoSitePlus [Disorder-related functionality of PRAME was evaluated with the Database of Disordered Protein Prediction  . The D2Ps IUPred , PONDR® s IUPred , PONDR® s IUPred , 24, PrDs IUPred , PV2 [34s IUPred , allowins (SCOP) , 39, SUPs (SCOP) , and Int2, 2022) . D2P2alslgorithm . ANCHOR-lgorithm . FinallySitePlus .https://iupred3.elte.hu/; accessed on November 17, 2022) [The IUPred3 platform was the final step in quantifying intrinsic disorder within PRAME  , 45, 46.https://fuzdrop.bio.unipd.it/predictor; accessed on December 27, 2022) [Additional functional information on human PRAME was retrieved using the FuzDrop platform  . This to7, 2022) , 49. Fuz7, 2022) .https://string-db.org/; accessed on November 17, 2022). STRING is a quality-controlled database that utilizes experimentally and computationally derived data to detail functional interactions between proteins [To further understand the protein–protein interactions of PRAME, the amino acid sequences were used as inputs for The Search Tool for the Retrieval of Interacting Genes (STRING)  at residues 116–145, 207–231, 232–258, 259–294, 295–320, 321–352, 353–371, 377–404, and 405–429. There is also a region (residues 416–509) that mediates the interaction with a retinoic acid receptor alpha (RARA).The 3D structure of PRAME modeled by AlphaFold Fig.  demonstrAfter visualization of the IDPRs in PRAME within the AlphaFold-modeled structure, we aimed to quantify these regions. We first constructed a normalized amino acid composition profile for PRAME Fig. . In the After determining the amino acid composition of PRAME, we aimed to quantify the intrinsic disorder on a per-residue basis. We used PONDR® VLXT , PONDR® 2P2 platform  and disorder-based binding potential. PRAME’s D2P2 output , 3 ubiquitination sites, 2 acetylation sites, and 2 phosphorylation sites.To assess the functionality of the intrinsic disorder in PRAME, we used the Dorm Fig. . The D2Pput Fig.  demonstrWe next sought to understand further PRAME’s ability to under disorder-to-order transition (DOT). To assess whether this protein can undergo conformational reorganization following changes in the redox state of its environment , the IUPred’s redox tool was utilized. We identified one segment of PRAME that is predicted to be moderately disordered in the reduced state and undergoes a transition to a highly ordered state in the oxidized form . This redox-related DOT of PRAME is near the C-terminus of the protein  Fig. .Fig. 5EvLLPS), where proteins capable of spontaneous LLPS are classified as droplet-driving proteins, whereas proteins that need some additional interactions to form droplets are classified as clients. As per FuzDrop, LLPS drivers are proteins with the overall pLLPS ≥ 0.60, whereas proteins with lower overall pLLPS but containing droplet-promoting regions (DPRs) defined as consecutive residues with pLLPS≥ 0.60 will likely serve as droplet-clients [The propensity of a given protein to undergo liquid–liquid phase separation (LLPS) can be evaluated computationally with FuzDrop . One of -clients . Fig. 6 Another important advantage of FuzDrop is its capability to find aggregation hot-spots, defined as residues/regions that may promote the conversion of the liquid-like condensed state into a solid-like amyloid state, capable of undergoing both ordered and disordered binding modes that can drive this process , 49. Fig9 and Ser16), suggesting that the functionality of this region can be regulated by posttranslational modifications.Finally, FuzDrop provides an outlook of the probability of a protein having residues/regions with cellular context-dependence  . Fig. 6 p-value < 1.0 × 10–16). At a STRING model confidence of high  in the network, and the number of interactions was approximately the same as what was expected for a randomly selected set of proteins of the same size .Our analysis has elucidated that intrinsic disorder is embedded into the structure of PRAME. The last step in our disorder-based bioinformatics analysis was focused on understanding how the intrinsic disorder may apply to the binding capabilities of PRAME. Our STRING analysis demonstrated that PRAME has multiple binding partners Fig. . Figure To the best of our knowledge, this work is the first to elucidate the presence of potentially functional intrinsically disordered protein regions (IDPRs) in PRAME. Our findings reveal the intrinsically disordered protein segments and regions where disorder is present within PRAME. This highlights the potential role these regions have in PRAME’s function that could be a possible focus for the development of immunotherapies. We show here that PRAME has several IDPs, some of which are relatively long. Furthermore, we demonstrate that these structureless regions are associated with dynamic portions of the protein and that PRAME has a complex PPI network. Our findings must be considered when evaluating the underlying molecular processes that drive the biological behavior of PRAME( +) Class 1 uveal melanoma.p-value < 0.05), which is partly due to the presence of nine leucine-rich repeats embedded in its sequence. Of the disorder-promoting residues, PRAME was significantly enriched with serine . Note that at least two of those (Ser9 and Ser16) were also identified as phosphorylation sites, indicating that they are likely functional hotspots for the protein. PRAME’s average disordered score was 16.49%, classifying it as a moderately disordered and flexible protein.The AlphaFold model of PRAME qualitatively demonstrated the presence of several IDPRs . Our quantitative analysis indicated that PRAME was most enriched with leucine  in PRAME. These amino acid sites are vital to the protein’s function and are concentrated in areas of high levels of disorder . The concentration of PTMs in intrinsically disordered regions are known to produce a range of regional structural effects , 56. ThePRAME may promote tumor progression through the inhibition of differentiation, growth arrest, and apoptosis induced by retinoic acid . ThroughOur study brings new considerations in the molecular behavior of PRAME. Our group’s and other studies have shown that IDPs and IDPRs are associated with different ocular malignancies, including UM , 22, 23.Among the most intriguing recent developments in the field of the molecular biology of the cell is the recognition of the abundant presence of MLOs. MLOs are subcellular structures formed by proteins and other macromolecules not enclosed by a lipid bilayer. These liquid droplet-like entities are formed through the process LLPS, where parts of the homogeneous solution of a cell separate to form two distinct phases. LLPS represent an ideal stress-response mechanism that allows for the spatio-temporal organization of macromolecular components in living cells and are extremely sensitive to even minute variations of the environment  –66. Our Our study does not come without its limitations. We used databases and bioinformatics tools, and this approach does not represent a comprehensive nor an exhaustive investigation into the molecular behavior of PRAME. We aimed to analyze the intrinsic disorder qualitatively and quantitatively in PRAME and make a presumption on how intrinsic protein disorder may play a role in the pathogenesis of UM. Further work modeling these disordered segments through molecular dynamic simulations or docking analysis would be the next steps to target these regions further effectively. If these efforts were focused on in-vitro disorder-based drug discovery efforts, it may lead to the most success. Consequently, we could develop a novel immunotherapy targeting the intrinsic disorder in PRAME, which may be identified and eventually translated to direct care of PRAME( +) UM patients. These findings are strictly theoretical; however, our findings establish a necessary biological framework for targeting PRAME.Through this study, we have demonstrated that intrinsically disordered protein regions are likely involved in functionality of PRAME and could be related to its pathogenesis in UM. Further investigation will be necessary to translate these findings into patient care. Modern drug discovery and therapeutic target development are grounded in structure and order-based assumptions. We are taking a different aim than that paradigm and believe these drug discovery campaigns must also be built on the assumption that proteins have inherent flexibility, thus altering the therapeutic development process. This study represents an exciting take on immunotherapy development. Successful efforts to target the intrinsically disordered-based proteins of PRAME may reduce rates of metastasis and poor outcomes in Class 1 uveal melanomas.PRAME plays an important role in tumor biology and has been identified as a biomarker for Class 1 UM. PRAME( +) Class 1 tumors are associated with higher rates of metastasis and, thus, worse prognosis. Our study demonstrates that intrinsically disordered protein regions are present in PRAME. IDPRs in PRAME likely have a role in its functionality and protein–protein interactions. We show that intrinsically disordered protein regions or disorder-to-order transition regions in PRAME are likely important for the functionality of the protein and could be targeted when developing immunotherapies for this protein. Future studies should further validate our findings to better elucidate the role of IDPRs in PRAME for the treatment of Uveal Melanoma.Additional file 1: Figure S1. PRAME amino acid sequence. Shown in FASTA format, the protein sequence represents PRAME canonical form. The protein contains 509 residues.