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Loneliness is prevalent in adults aged ≥65 years in the United States and is associated with functional decline. The purpose of the current review was to synthesize evidence on the relationship between loneliness and functional decline using Roy's Adaptation Model as a theoretical framework. A comprehensive review of PubMed, Medline, and Embase databases was performed. Inclusion criteria were samples including adults primarily aged >60 years, peer-reviewed, published in the English language, and included a measure for loneliness and function. A total of 47 studies were analyzed. Most studies examined correlates, risk factors, and predictors of loneliness, rather than the relationship between loneliness and function. Evidence suggests there is bidirectionality in the relationship between loneliness and functional decline. Loneliness is associated with functional decline in aging via multiple possible pathways. Further studies are needed to determine causality and biological mechanisms underlying the relationship. [ Research in Gerontological Nursing, xx (x), xx–xx.]

Die Skepsis gegenüber der Demokratie und ihren Institutionen sowie gegenüber den etablierten Medien ist im Freistaat Sachsen besonders gross. Um diesem Problem zu begegnen, ist das Zentrum Journalismus und Demokratie der Universität Leipzig (JoDem) gemeinsam mit dem Zentrum für Lehrer:innenbildung und Schulforschung seit 2020 verstärkt in der Lehramtsausbildung aktiv, um den angehenden Multiplikator:innen der sächsischen Schulen Journalismus- und Demokratiekompetenz zu vermitteln. In diesem Beitrag werden Einblicke in die Konzeption und den Erfolg der Lehrveranstaltungen gegeben. In den Seminaren wird auf eine konsequente Verschränkung von theoretischem Wissen mit praktischem Tun und Erleben gesetzt, etwa mit der Produktion von realen Zeitungsseiten, Radiobeiträgen und Social-Media-Inhalten oder mit dem Einbezug von Elementen des erfahrungsorientierten Demokratietrainings «Betzavta» aus Israel.

Self-injurious thoughts and behaviors (SITB) increase dramatically across adolescence. Despite the prevalence and severity of these outcomes, remarkably little research has elucidated why adolescence represents a particularly high-risk period for the emergence of SITB. Recent theoretical models have posited that SITB may result from failures in biological stress regulation in the context of social stress. However, there is a lack of data examining these associations during the transition to adolescence, a sensitive period of development that is characterized by changes across socio-affective and psychophysiological domains that may interact to heighten risk for SITB. The present study used a prospective longitudinal design among 147 adolescents. We built on advantages offered by the RDoC framework to test the interaction of experiences of social conflict (i.e., parent and peer conflict) with cardiac arousal (i.e., resting heart rate) to predict adolescent non-suicidal self-injury (NSSI) and suicidal ideation (SI) across one year. Longitudinal analyses revealed that while neither greater peer conflict nor higher cardiac arousal at baseline were associated with SITB outcomes at follow-up, adolescents experiencing the combination of greater peer conflict and higher cardiac arousal at baseline showed significant longitudinal increases in NSSI at follow-up. In addition, there were null effects for family conflict and SI outcomes. Findings indicate that youth with greater peer conflict and heightened arousal during the transition to adolescence may be at increased risk for NSSI. Future research should examine these processes at finer timescales in order to elucidate whether these factors are proximal predictors of within-day SITB.

En este artículo analizamos la manera en que los programas sociales del Estado –componentes centrales para la realización de los derechos fundamentales– se han venido implementando bajo el esquema de terciarización posibilitado por la Constitución de 1980, lo que se ha traducido en una precarización de las condiciones de trabajo de quienes los implementan en primera línea. A partir de los resultados de un estudio mixto secuencial exploratorio, sostenemos que sin condiciones de operación dignas para las/os trabajadores que implementan estos programas sociales, difícilmente se podrán garantizar dichos derechos. El trabajo “impago” y el trabajo emocional “sucio”, que aparecen como parte de los hallazgos, configuran una suerte de “fatiga neoliberal” que genera resistencias por parte de las/os implementadores, daña de manera importante a las/os usuarios de los programas y limita la capacidad de la sociedad para promover derechos sociales. Analizamos algunos artículos incluidos en el texto constitucional que fue rechazado en el plebiscito del pasado 4 de septiembre de 2022; y exploramos posibilidades y limitaciones de dicha propuesta en lo que refiere a las condiciones de implementación de los programas sociales, con el propósito de aportar más ampliamente al debate sobre derechos fundamentales en Chile, en tiempos de incertidumbre respecto de un eventual cambio constitucional.

The relation between the autonomic nervous system (ANS) and muscles of the vocal tract is of particular importance when considering the pathomechanism of a functional voice disorder.The aim of this study was to record electrophysiological indicators from the ANS as well as the tone of the external laryngeal muscle and test whether together they could point to an enhanced risk of primary functional voice disorder.The study material consisted of 81 people, 27 of whom were professional opera singers. None reported any voice complaints. The research comprised ENT and phoniatric examination, superficial electromyography (SEMG), and recording of physiological indicators (pulse rate, skin resistance).All subjects had a clear voice with no sign of vocal disability. Endoscopy revealed laryngeal hyperfunction in 26 people. SEMG revealed that the 26 had increased external laryngeal muscle tone during phonation, and this finding correlated with a change in certain electrophysiological indicators HRV, BVP, EDA.We conclude that anomalies in electrophysiological parameters in individuals with subclinical symptoms of functional voice disorder may be at risk of developing fully symptomatic hyperfunctional dysphonia in the future. Vocal training, which differentiates singers and non-singers, is known to have an effect on subclinical hyperfunctional dysphonia.By measuring indicators of hyperfunctional dysphonia, it may be possible to take remedial action before symptomatic dysphonia develops.

The ruptured sinus of Valsalva aneurysm (SVA) can present with dynamic aortic regurgitation (AR). Hemodynamic changes elicited by induction of general anesthesia can lead to dynamic AR in setting of ruptured SVA. Perioperative echocardiography is critical in understanding the etiology of AR and in guiding surgical decision-making. If the aortic valve is structurally normal, AR may resolve following patch repair of the SVA rupture defect. Conventional measures of assessing AR severity are not accurate with continuous left-to-right flow across a ruptured SVA.

A recent medication error at Vanderbilt University Medical Center contributed to the death of a patient. The ensuing criminal indictment of the administering nurse has shaken the medical community. This has led to clinical staff questioning whether they can disclose patient safety incidents without fear of criminal prosecution. However, because of the publicity of this case, hospitals can benefit from the lessons learned and mitigate the risk of this and similar events at their facilities. To uncover the most impactful and relevant safety recommendations, the Vanderbilt case is examined from a systems investigation perspective using the available public information gathered from media reports, the Tennessee Bureau of Investigation report, and Vanderbilt's corrective action plan submitted to CMS. We present an example of how hospitals can benefit from disclosure: Henry Ford Health used the Vanderbilt case study as part of its medication safety continuous improvement initiatives, which are underpinned by available medication safety recommendations from the Institute for Safe Medication Practices. Using this experience and the lessons learned from the Vanderbilt case, a proactive action plan is presented for hospitals nationwide to prevent the recurrence of this medication error. Without disclosure, these analyses and safety recommendations would not have been possible.

Background and ObjectivesClinicians often communicate complex, uncertain, and distressing information about neurologic prognosis to parents of critically ill infants. Although communication tools have been developed in other disciplines and settings, none address the unique needs of the neonatal and pediatric neurology context. We aimed to develop a parent-informed framework to guide clinicians in communicating information about neurologic prognosis.MethodsParents of infants with neurologic conditions in the intensive care unit were enrolled in a longitudinal study of shared decision-making from 2018 to 2020. Parents completed semistructured interviews following recorded family meetings with the health care team, at hospital discharge, and 6 months after discharge. All interviews targeted information about parent preferences for prognostic disclosure. We analyzed the data using a conventional content analysis approach. Two study team members independently coded all interview transcripts, and discrepancies were resolved in consensus. We used NVIVO 12 qualitative software to index and organize codes.ResultsFifty-two parents of 37 infants completed 123 interviews. Parents were predominantly mothers (n = 37/52, 71%) with a median age of 31 (range 19–46) years. Half were Black (n = 26/52, 50%), and a minority reported Hispanic ethnicity (n = 2/52, 4%). Inductive analysis resulted in the emergence of 5 phases of prognostic communication (Approach, Learn, Inform, Give support, and Next steps: ALIGN): (1) Approach: parents appreciated receiving consistent information about their child's neurologic outcome from clinicians who knew their child well. (2) Learn: parents valued when clinicians asked them how they preferred receiving information and what they already knew about their child's outcome prior to information delivery. (3) Inform: parents valued honest, thorough, and balanced information that disclosed prognostic uncertainty and acknowledged room for hope. (4) Give support: parents valued empathic communication and appreciated clinicians who offered real-time emotional support. (5) Next steps: parents appreciated clinicians who connected them to resources, including peer support.DiscussionThe ALIGN framework offers a novel, parent-informed strategy to effectively communicate neurologic prognosis. Although ALIGN represents key elements of a conversation about prognosis, each clinician can adapt this framework to their own approach. Future work will assess the effectiveness of this framework on communication quality and prognostic understanding.

The ability to remember faces is essential for everyday life, with deficits indicative of some neurological conditions. Face recognition ability tasks vary considerably in their design (i.e., use of the same or a different picture for learning and recall and inclusion or exclusion of nonface characteristics), which is known to impact performance levels. However, it is unknown whether these design features cause additional cognitive abilities to be assessed. We preregistered three hypotheses, namely performance on face recognition tasks can best be explained by: (Hypothesis 1) a single general face recognition ability; (Hypothesis 2) a general face recognition ability and an unrelated ability representing one's capacity to ignore external information when recognizing faces; and (Hypothesis 3) a general face recognition ability, a separable unrelated ability to ignore external information, and a third unrelated ability representing one's capacity to recognize faces specifically when different photographs of the same individual are used. During a controlled laboratory session

Two heterozygous missense variants (G1 and G2) of Apolipoprotein L1 (APOL1) found in individuals of recent African ancestry can attenuate the severity of infection by some forms of Trypanosoma brucei. However, these two variants within a broader African haplotype also increase the risk of kidney disease in Americans of African descent. Although overexpression of either variant G1 or G2 causes multiple pathogenic changes in cultured cells and transgenic mouse models, the mechanism(s) promoting kidney disease remain unclear. Human serum APOL1 kills trypanosomes through its cation channel activity, and cation channel activity of recombinant APOL1 has been reconstituted in lipid bilayers and proteoliposomes. Although APOL1 overexpression increases whole cell cation currents in HEK-293 cells, the ion channel activity of APOL1 has not been assessed in glomerular podocytes, the major site of APOL1-associated kidney diseases. We characterize APOL1-associated whole cell and on-cell cation currents in HEK-293 T-Rex cells and demonstrate partial inhibition of currents by anti-APOL antibodies. We detect in primary human podocytes a similar cation current inducible by interferon-γ (IFNγ) and sensitive to inhibition by anti-APOL antibody as well as by a fragment of T. brucei Serum Resistance-Associated protein (SRA). CRISPR knockout of APOL1 in human primary podocytes abrogates the IFNγ-induced, antibody-sensitive current. Our novel characterization in HEK-293 cells of heterologous APOL1-associated cation conductance inhibited by anti-APOL antibody and our documentation in primary human glomerular podocytes of endogenous IFNγ-stimulated, APOL1-mediated, SRA and anti-APOL-sensitive ion channel activity together support APOL1-mediated channel activity as a therapeutic target for treatment of APOL1-associated kidney diseases.

Increasing extracellular levels of serotonin (5-HT) in the brain ameliorates symptoms of depression and anxiety-related disorders, e.g. social phobias and post-traumatic stress disorder. Recent evidence from preclinical and clinical studies established the potential of drugs inducing the release of 5-HT via the 5-HT-transporter. Nevertheless, current 5-HT releasing compounds under clinical investigation carry the risk for abuse and deleterious side effects. Here, we demonstrate that S-enantiomers of certain ring-substituted cathinones show preference for the release of 5-HT ex vivo and in vivo, and exert 5-HT-associated effects in preclinical behavioral models. Importantly, the lead cathinone compounds (i) do not induce substantial dopamine release and (ii) display reduced off-target activity at vesicular monoamine transporter-2 and 5-HT2B-receptors; indicative of low abuse-liability and low potential for adverse events. Taken together, our findings identify these agents as first-in class leads that may prove useful for the treatment of disorders where elevation of 5-HT has proven beneficial.

Quantum tunneling is known to play an important role in the dynamics of systems with nonadiabatic couplings. However, until recently, the time-domain properties of nonadiabatic scattering have been severely under-explored. Using numerically exact quantum methods, we study the impact that nonadiabatic couplings have on the time it takes to tunnel through a barrier. We find that the Wigner phase time is the appropriate measure to use when determining the tunneling flight time also when considering nonadiabatic systems. The central result of the present study is that in an avoided crossing system in one dimension, the nonadiabatic couplings speed up the tunneling event, relative to the adiabatic case in which all nonadiabatic coupling is ignored. This has implications for both the study of quantum tunneling times and for the field of nonadiabatic scattering and chemistry.

The principal component of the protein homeostasis network is the ubiquitin-proteasome system. Ubiquitination is mediated by an enzymatic cascade involving, i.e. E3 ubiquitin ligases, many of which belong to the cullin-RING ligases family. Genetic defects in the ubiquitin-proteasome system components, including cullin-RING ligases, are known causes of neurodevelopmental disorders. Using exome sequencing to diagnose a pediatric patient with developmental delay, pyramidal signs and limb ataxia, we identified a de novo missense variant c.376G>C; p.(Asp126His) in the FEM1C gene encoding a cullin-RING ligase substrate receptor. This variant alters a conserved amino acid located within a highly constrained coding region and is predicted as pathogenic by most in silico tools. In addition, a de novo FEM1C mutation of the same residue p.(Asp126Val) was associated with an undiagnosed developmental disorder, and the relevant variant (FEM1CAsp126Ala) was found to be functionally compromised in vitro. Our computational analysis showed that FEM1CAsp126His hampers protein substrate binding. To further assess its pathogenicity, we used the nematode Caenorhabditis elegans. We found that the FEM-1Asp133His animals (expressing variant homologous to the FEM1C p.(Asp126Val)) had normal muscle architecture yet impaired mobility. Mutant worms were sensitive to the acetylcholinesterase inhibitor aldicarb but not levamisole (acetylcholine receptor agonist), showing that their disabled locomotion is caused by synaptic abnormalities and not muscle dysfunction. In conclusion, we provide the first evidence from an animal model suggesting that a mutation in the evolutionarily conserved FEM1C Asp126 position causes a neurodevelopmental disorder in humans.

Catatonia is a debilitating psychomotor disorder. Previous neuroimaging studies have used small samples with inconsistent results. The authors aimed to describe the structural neuroradiological abnormalities in clinical magnetic resonance imaging (MRI) brain scans of patients with catatonia, comparing them with scans of psychiatric inpatients without catatonia. They report the largest study of catatonia neuroimaging to date.In this retrospective case-control study, neuroradiological reports of psychiatric inpatients who had undergone MRI brain scans for clinical reasons were examined. Abnormalities were classified by lateralization, localization, and pathology. The primary analysis was prediction of catatonia by presence of an abnormal MRI scan, adjusted for age, sex, Black race-ethnicity, and psychiatric diagnosis.Scan reports from 79 patients with catatonia and 711 other psychiatric inpatients were obtained. Mean age was 36.4 (SD=17.3) for the cases and 44.5 (SD=19.9) for the comparison group. Radiological abnormalities were reported in 27 of 79 cases (34.2%) and in 338 of 711 in the comparison group (47.5%) (odds ratio [OR]=0.57, 95% confidence interval [CI]=0.35, 0.93; adjusted OR=1.11, 95% CI=0.58, 2.14). Among the cases, most abnormal scans had bilateral abnormalities (N=23, 29.1%) and involved the forebrain (N=25, 31.6%) and atrophy (N=17, 21.5%).Patients with catatonia were commonly reported to have brain MRI abnormalities, which largely consisted of diffuse cerebral atrophy rather than focal lesions. No evidence was found that these abnormalities were more common than in other psychiatric inpatients undergoing neuroimaging, after adjustment for demographic variables. Study limitations included a heterogeneous control group and selection bias in requesting scans.

The prediction of right heart failure (RHF) after left ventricular assist device (LVAD) implantation remains a challenge. Recently, risk scores were derived from analysis of the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data, the EUROMACS-RHF, and the modified postoperative EUROMACS-RHF. The authors assessed the performance characteristics of these 2 risk score formulations in a continuous-flow LVAD cohort at their institution.A retrospective, observational study.At a tertiary-care academic medical center.Adult patients who underwent durable LVAD implantation between 2015 and 2018.None MEASUREMENTS AND MAIN RESULTS: Early post-LVAD RHF was defined as follows: (1) need for right ventricular assist device, or (2) inotropic or inhaled pulmonary vasodilator support for ≥14 postoperative days. The authors used logistic regression and examined receiver operating characteristic (ROC) curves to evaluate the ability of the 2 risk scores to distinguish between outcome groups. A total of 207 patients met the inclusion criteria. Of the patients, 16% developed RHF (33/207). The EUROMACS-RHF score was not predictive of RHF in the authors' cohort (odds ratio [OR] 1.25; 95% CI [0.99-1.60]; p = 0.06), but the postoperative EUROMACS-RHF CPB score was significantly associated (OR 1.38; 95% CI [1.03-1.89]; p = 0.03). The scores had similar ROC curves, with weak discriminatory performance: 0.601 (95% CI [0.509-0.692]) and 0.599 (95% CI [0.505-0.693]) for EUROMACS-RHF and postoperative EUROMACS-RHF, respectively.In the authors' single-center retrospective analysis, the EUROMACS-RHF risk score did not predict early RHF. An optimized risk score for the prediction of RHF after LVAD implantation remains an urgent unmet need.

The issue of the impacts of the COVID-19 pandemic on the economy is highly topical at a time of gradual economic recovery. The study presents the results of more than a year and a half of empirical research on changes in consumer behaviour patterns of Slovaks obtained through an analysis of their online interactions with the five main representatives of the e-commerce industry. During both pandemic waves B2C and C2B interactions of a sample of more than half a million customers in the Facebook social network environment were systematically recorded. Subsequently, the data were compared with the reference period one year after the historically first lockdown. The results suggest that during the pandemic, customers switched into completely new patterns of consumer behaviour aimed at maximizing benefits. However, as the pandemic progressed, these patterns combined with the pre-pandemic standard behaviour and created a new, relatively stable evolving trend. This economically significant trend must be considered in business practice. Web of Science 70 4 389 368

The discovery of apolipoprotein L1 (ApoL1) has raised important ethical and clinical questions about genetic testing in the context of living and deceased kidney donation. Largely missing from this discussion are the perspectives of those African Americans (AA) most likely to be impacted by ApoL1 testing.We surveyed 331 AA potential and former living kidney donors (LKDs), kidney transplant candidates and recipients, and nonpatients at three United States transplant programs about their ApoL1 testing attitudes.Overall, 72% felt that transplant programs should offer ApoL1 testing to AA potential LKDs. If a potential LKD has the high-risk genotype, 79% felt that the LKD should be allowed to make their own donation decision or participate in shared decision-making with transplant doctors. More than half of the potential LKDs (58%) would undergo ApoL1 testing and 81% of former LKDs would take the test now if offered. Most transplant candidates expressed a low likelihood of accepting a kidney from a LKD (79%) or a deceased donor (67%) with the high-risk genotype.There is strong support among LKDs and transplant patients for ApoL1 testing when evaluating potential kidney donors of African ancestry. Inclusion of AA stakeholders in developing guidelines and educational programs for ApoL1 testing is critical.

A strong bidirectional link between metabolic and psychiatric disorders exists; yet the molecular basis underlying this interaction remains unresolved. Here we explored the role of the brown fat issue (BAT) as modulatory interface, focusing on the involvement of uncoupling protein 1 (UCP-1), a key metabolic regulator highly expressed in BAT, in the control of emotional behavior.Male and female constitutive UCP-1 knockout (KO) mice were used to investigate the consequences of UCP-1 deficiency on anxiety-related and depression-related behaviors under mild thermogenic (23°C) and thermoneutral (29°C) conditions.UCP-1 KO mice displayed a selective enhancement of anxiety-related behavior exclusively under thermogenic conditions, but not at thermoneutrality. Neural and endocrine stress mediators were not affected in UCP-1 KO mice, which showed an activation of the integrated stress response alongside enhanced Fibroblast-growth factor-21 (FGF-21) levels. However, viral-mediated overexpression of FGF-21 did not phenocopy the behavioral alterations of UCP-1 KO mice and blocking FGF-21 activity did not rescue the anxiogenic phenotype of UCP-1 KO mice. No effects of surgical removal of the intrascapular BAT on anxiety-like behavior or FGF-21 levels were observed in either UCP-1 KO or WT mice.We provide evidence for a novel role of UCP-1 in the regulation of emotions that manifests as inhibitory constraint on anxiety-related behavior, exclusively under thermogenic conditions. We propose this function of UCP-1 to be independent of its activity in the BAT and likely mediated through a central role of UCP-1 in brain regions with converging involvement in energy and emotional control.

The current randomized controlled trial investigated the effect of a robotic pet on social and physical frailty in community-dwelling older adults. The intervention group ( n = 107) received a robotic pet and the control group ( n = 113) received usual care following hospital discharge. Social and physical frailty were measured using the Questionnaire to Define Social Frailty Status and the FRAIL questionnaire. Cognitive function and depression were assessed using the Short Portable Mental Status Questionnaire and Geriatric Depression Scale, respectively. Continuous outcomes were compared between groups using t tests or Wilcoxon rank sum tests, as appropriate. Categorical outcomes were compared between groups using chi-square tests or Fisher's exact tests, as appropriate. Main findings showed the robotic pet positively impacted cognitive status in participants who reported they enjoyed engaging with their pet. This finding supported the theoretical premise of the current study that greater engagement with the robotic pet would yield greater improvement in study outcomes. [ Research in Gerontological Nursing, 15 (5), 229–237.]

Unraveling the complex behavior of healthy and disease podocytes by analyzing the changes in their unique arrangement of foot processes, slit diaphragm and the 3D morphology is a long-standing goal in kidney-glomerular research. The complexities surrounding the podocytes' accessibility in animal models and growing evidence of differences between humans and animal systems have compelled researchers to look for alternate approaches to study podocyte behaviors. With the advent of bioengineered models, an increasingly powerful and diverse set of tools is available to develop novel podocyte culture systems. This review discusses the pertinence of various culture models of podocytes to study podocyte mechanisms in both normal physiology and disease conditions. While no one in vitro system comprehensively recapitulates podocytes' in vivo architecture, we emphasize how the existing systems can be exploited to answer targeted questions on podocyte structure and function. We highlight the distinct advantages and limitations of using these models to study podocyte behaviors and screen therapeutics. Finally, we discuss various considerations and potential engineering strategies for developing next-generation complex 3D culture models for studying podocyte behaviors in vitro.

OBJECTIVE: The present study sought to evaluate the psychometric properties and inter-informant agreement of the Self-Injurious Thoughts and Behaviors Interview-Revised (SITBI-R) in adolescents and their parents. METHOD: Suicidal and nonsuicidal adolescents from the community (N =206), ages 12–19 years, were administered the SITBI-R during a lab visit. Approximately half of the adolescents’ parents opted to complete a parent assessment, including the SITBI-R, on behalf of their child. Inter-rater reliability, convergent validity, and inter-informant agreement were assessed. RESULTS: The SITBI-R exhibited overall excellent inter-rater reliability and good convergent validity in adolescents. Parent-adolescent agreement ranged from fair to poor across most outcomes, with parents tending not to report past self-injurious thoughts and behaviors endorsed by their children. CONCLUSIONS: The present study suggests that the SITBI-R can be extended for use with adolescents. Future research should evaluate moderators and implications of parent-adolescent disagreement, particularly with regard to suicide risk.

The use of cardiopulmonary bypass (CPB) is thought to cause delayed cardiac damage. DNA methylation-based liquid biopsies are novel biomarkers for monitoring acute cardiac cell death. We assessed cell-free DNA molecules as markers for cardiac damage after open-heart surgery. Novel cardiomyocyte-specific DNA methylation markers were applied to measure cardiac cfDNA in the plasma of 42 infants who underwent open-heart surgery. Cardiac cfDNA was elevated following surgery, reflecting direct surgery-related tissue damage, and declined thereafter in most patients. The concentration of cardiac cfDNA post-surgery correlated with the duration of CPB and aortic cross clamping. Strikingly, cardiac cfDNA at 6 h predicted duration of mechanical ventilation and maximal vasoactive-inotropic score better than did maximal troponin levels. Cardiac cfDNA reveals heart damage associated with CPB, and can be used to monitor cardiac cell death, to predict clinical outcome of surgery and to assess performance of cardioprotective interventions.

Limited data exist regarding the significance of peripheral arterial disease (PAD) in patients with acute coronary syndrome (ACS).We evaluated 16,922 consecutive ACS patients who were prospectively included in a national ACS registry. The co-primary endpoint included 30 days major adverse cardiovascular event (MACE) (re-infarction, stroke, and/or cardiovascular death) and 1-year mortality.PAD patients were older (70±11 vs 63±13; p0.01), male predominance (80% vs 77%; p=0.01), and more likely to sustain prior cardiovascular events. PAD patients were less likely to undergo coronary angiography (69% vs 83%; p0.001) and revascularisation (80% vs 86%; p0.001). Patients with PAD were more likely to sustain 30-day MACE (22% vs 14%; p0.001) and mortality (10% vs 4.4%; p0.001), as well as re-hospitalisation (23% vs 19%; p=0.001). After adjusting for potential confounders, PAD remained an independent predictor of 30-day MACE (odds ratio [OR], 1.6 [95% confidence interval (CI), 1.24-2.06]). Patients with compared to those without PAD had 2.5 times higher 1-year mortality rate (22% vs 9%; p0.001). Co-existence of PAD remained an independent predictor of 1-year mortality after adjustment for potential confounders by multivariable regression analysis (OR, 1.62; 95% CI, 1.4-1.9). PAD was associated with a significant higher 1-year mortality rate across numerous sub-groups of patients including type of myocardial infarction (ST-elevation myocardial infarction vs non-ST-elevation myocardial infarction), and whether the patient underwent revascularisation.Acute coronary syndrome with concomitant PAD represents a high-risk subgroup that warrants special attention and a more tailored approach.

Clinicians increasingly believe they should discuss costs with their patients. We aimed to learn what strategies clinicians, clinic leaders, and health systems can use to facilitate vital cost-of-care conversations.We conducted focus groups and semi-structured interviews with outpatient clinicians at two US academic medical centers. Clinicians recalled previous cost conversations and described strategies that they, their clinic, or their health system could use to facilitate cost conversations. Independent coders recorded, transcribed, and coded focus groups and interviews.Twenty-six clinicians participated between December 2019 and July 2020: general internists (23%), neurologists (27%), oncologists (15%), and rheumatologists (35%). Clinicians proposed the following strategies: teach clinicians to initiate cost conversations; systematically collect financial distress information; partner with patients to identify costs; provide accurate insurance coverage and/or out-of-pocket cost information via the electronic health record; develop local lists of lowest-cost pharmacies, laboratories, and subspecialists; hire financial counselors; and reduce indirect costs (e.g., parking).Despite considerable barriers to discussing, identifying, and reducing patient costs, clinicians described a variety of strategies for improving cost communication in the clinic.Health systems and clinic leadership can and should implement these strategies to improve the financial health of the patients they serve.