Invisibilização e preconceitos velados: barreiras para o acesso aos serviços de atenção básica pela população trans / Invisibilization and veiled prejudices: barriers to access to primary care services for the transgender population / Invisibilización y prejuicios velados: barreras para el acceso de la población trans a los servicios de atención primaria

Introdução: No processo de edificação da Política Nacional de Saúde Integral LGBT+, a Atenção Básica ganha importante destaque, pois deveria funcionar como o contato preferencial dos usuários transgênero (trans). Objetivo: Investigar quais as percepções dos profissionais da Atenção Básica quanto às situações de vulnerabilidade enfrentadas pelas pessoas trans, bem como pesquisar os impedimentos que eles consideram existir na busca dessa população por acesso a esses serviços. Métodos: Utilizou-se uma abordagem qualitativa por meio de entrevistas semiestruturadas com 38 profissionais de saúde atuantes das Estratégias Saúde da Família de dois municípios do interior do estado de São Paulo. O material obtido foi submetido à análise de conteúdo de Bardin. Resultados: Os resultados apontaram para o desconhecimento quanto aos reais empecilhos que dificultam o acesso e seguimento de pessoas trans nos serviços de saúde. Observou-se ainda a manutenção de preconceitos e ideias que reforçam estereótipos ligados ao tema e que se estendem ao exercício da profissão. Isso se relaciona diretamente com a falta da abordagem de assuntos relacionados à sexualidade humana na graduação desses profissionais, além da falta de atualização quanto ao tema, o que impacta a qualidade do serviço que é ofertado à população em estudo. Conclusões: As normativas e portarias já existentes precisam ser efetivamente postas em prática, fazendo-se imperativas a ampliação e difusão do conhecimento a respeito da temática trans no contexto dos serviços públicos de saúde, o que pode servir como base para subsidiar a formação dos profissionais que atuam nesse setor, bem como políticas públicas efetivas.

Introduction: In the process of creating the National LGBT+ Comprehensive Health Policy, primary care has important prominence as it must work as the preferential contact of transgender (trans) users. Objective: To investigate the perceptions of primary care professionals about the vulnerability situations faced by trans persons and also hindrances they consider existing in this population's search for access to these services. Methods: A qualitative approach was used through semi-structured interviews with 38 health care professionals working in the Family Health Strategy of two cities in the countryside of the state of São Paulo. The material obtained was submitted to analysis of Bardin content. Results: The results pointed to a lack of knowledge about real hindrances that obstruct the access to and follow-up by health services for trans persons. It was also observed the maintenance of prejudices and ideas that reinforce stereotypes connected to the matter and extend to the practice of professionals. It is directly related to the lack of approach of issues related to human sexuality in the education of those professionals, in addition to lack of update about it, which impacts the quality of service offered to the population under study. Conclusions: The standards and ordinances already existing need to be effectively practiced, being crucial the extension and spread of knowledge about trans matters in the context of public health services. It can be the basis for subsidizing the education of professionals who work in this field, as well as effective public policies.

Introducción: En el proceso de edificación de la Política Nacional de Salud Integral LGBT+, la Atención Básica tiene importante destaque, pues debería funcionar como contacto preferente de los usuarios transgénero (trans). Objetivo: Investigar las percepciones de los profesionales de Atención Básica sobre las situaciones de vulnerabilidad que enfrentan las personas trans, así como investigar los impedimentos que consideran que existe en la búsqueda de esta población por el acceso a estos servicios. Métodos: Se utilizó un abordaje cualitativo por medio de entrevistas semiestructuradas con 38 profesionales de salud actuantes de las Estrategias de Salud de la Familia de dos municipios del interior del estado de São Paulo. El material obtenido fue sometido a análisis de contenido de Bardin. Resultados: Los resultados apuntaron al desconocimiento sobre los reales obstáculos que dificultan el acceso de personas trans a los servicios, además del segmento de los cuidados en las unidades. Se observó además que se mantienen los prejuicios e ideas que refuerzan estereotipos vinculados al tema y que se extienden al ejercicio de la profesión. Esto se relaciona directamente a la falta da abordaje de asuntos relacionados a la sexualidad humana en la graduación de estos profesionales, además de la falta de actualización sobre el tema, lo que impacta en la calidad del servicio que se ofrece a la población en estudio. Conclusiones: Las normas y ordenanzas ya existentes deben ser efectivamente puestas en práctica, por lo que es imperativo ampliar y difundir el conocimiento sobre la temática trans en el contexto de los servicios públicos de salud, que pueda servir de base para apoyar la formación de profesionales que actúan en este sector, así como políticas públicas efectivas.

Relação entre apoio social e sono de pessoas idosas cuidadoras em vulnerabilidade social / Relationship between social support and sleep of elderly caregivers in social vulnerability / Relación entre apoyo social y sueño de adultos mayores cuidadores con vulnerabilidad social

Objetivo: analisar a relação entre apoio social e qualidade do sono de pessoas idosas que cuidam de outros idosos em ambiente de vulnerabilidade social. Método: estudo transversal realizado com 65 cuidadores entrevistados por meio de instrumento de caracterização, Índice de Katz, Escala de Lawton e Brody, Índice de Qualidade do Sono de Pittsburgh e Escala de Apoio Social do Medical Outcomes Study, com dados analisados com testes de comparação e de correlação. Resultados: a maioria eram mulheres, cônjuges do idoso cuidado e possuíam sono de má qualidade. Observou-se correlação fraca e inversa entre má qualidade do sono e a dimensão interação social positiva (Rho=-0,27; p=0,028). Identificou-se relação significativa entre: apoio material e disfunção diurna (p=0,034); apoio afetivo e eficiência do sono (p=0,026); interação social positiva e qualidade subjetiva do sono (p=0,001) e disfunção diurna (p=0,008). Conclusão: Quanto maior a interação social positiva, melhor é a qualidade do sono.

Objective: to analyze the relationship between social support and sleep quality of elderly individuals who care for other elderly individuals in a socially vulnerable environment. Method: a cross-sectional study conducted with 65 caregivers interviewed using a characterization instrument, Katz Index, Lawton and Brody Scale, Pittsburgh Sleep Quality Index, and Medical Outcomes Study Social Support Scale, with data analyzed using comparison and correlation tests. Results: the majority were women, spouses of the elderly being cared for, and had poor sleep quality. A weak and inverse correlation was observed between poor sleep quality and the positive social interaction dimension (Rho=-0.27; p=0.028). Significant relationships were identified between: material support and daytime dysfunction (p=0.034); emotional support and sleep efficiency (p=0.026); positive social interaction and subjective sleep quality (p=0.001), as well as daytime dysfunction (p=0.008). Conclusion: The higher the positive social interaction, the better the sleep quality.

Objetivo: analizar la relación entre el apoyo social y la calidad del sueño de personas mayores que cuidan de otras personas mayores en entornos socialmente vulnerables. Método: estudio transversal realizado con 65 cuidadores entrevistados mediante un instrumento de caracterización, Índice de Katz, Escala de Lawton y Brody, Índice de Calidad del Sueño de Pittsburgh y Escala de Apoyo Social del Medical Outcomes Study, los datos fueron analizados mediante pruebas de comparación y correlación. Resultados: la mayoría eran mujeres, cónyuges del adulto mayor que recibe el cuidado y tenían mala calidad del sueño. Se observó una correlación débil e inversa entre la mala calidad del sueño y la dimensión de interacción social positiva (Rho=-0,27; p=0,028). Se identificó que había relación significativa entre: apoyo material y disfunción diurna (p=0,034); apoyo afectivo y eficiencia del sueño (p=0,026); interacción social positiva y calidad subjetiva del sueño (p=0,001) y disfunción diurna (p=0,008). Conclusión: Cuanto mayor sea la interacción social positiva, mejor será la calidad del sueño.

The relationship between emotional inhibition, emotional deprivation, failure, vulnerability to harm schema, and severity of symptoms among patients with obsessive-compulsive disorder.

OBJECTIVE: Assess the relationship between emotional inhibition, emotional deprivation, failure, vulnerability to harm schema, and severity of symptoms among obsessive-compulsive disorder. METHODS: A descriptive correlational study was conducted on 30 patients with obsessive-compulsive disorder who were recruited to complete the Yale-Brown Obsessive-Compulsive Scale, Young Schema Questionnaire-Long Form. RESULTS: The results of the study indicate that 66.6% of the 30 subjects exhibited high levels of OCD symptom severity, with a mean score of 33.20 ± 4.67. In terms of early maladaptive schemas, 60% of subjects displayed severe emotional deprivation, 66.7% showed severe emotional inhibition, and 83.3% had severe failure schemas. A strong positive correlation was found between failure schemas and OCD symptoms (r = 0.697, p < 0.001). However, what truly impressed the researchers was the predictive power of the failure schema. It was the only significant predictor of OCD symptoms (Beta = 0.992, p < 0.001), explaining 55.2% of the variance. CONCLUSION: The study underscores the crucial influence of early maladaptive schemas on the severity of obsessive-compulsive disorder symptoms in individuals with obsessive-compulsive disorder. It proposes that considering early maladaptive schemas, such as emotional self-awareness, failure, and vulnerability to harm, can aid in gauging the severity of obsessive-compulsive disorder symptoms. Moreover, the study's findings are of significant importance to mental health professionals, researchers, and individuals involved in the treatment and management of obsessive-compulsive disorder, as they provide a deeper understanding of the condition and suggest practical approaches for its management.

Integrating social, climate and environmental changes to confront accelerating global aging.

INTRODUCTION: The global increase in the aging population presents critical challenges for healthcare systems, social security, and economic stability worldwide. Although the studies of the global rate of aging have increased more than four times in the past two decades, few studies have integrated the potential combined effects of socio-economic, climatic, and environmental factors. METHODS: We calculated the geographic heterogeneity of aging population growth rates from 218 countries between 1960 and 2022. Public databases were then integrated to assess the impacts of seven global stressors: socio-economic vulnerability, temperature, drought, seasonality, climate extremes, air pollution, and greening vulnerability on growth rates of aging population (a totally 156 countries). Linear regression models were primarily used to test the statistically significant effects of these stressors on the rate of aging, and multiple model inference was then used to test whether the number of stressors exceeding specific thresholds (e.g., > 25, 50, and 75%) was consistently significant in the best models. The importance of stressors and the number of stressors exceeding thresholds was verified using random forest models for countries experiencing different population aging rates. RESULTS: Our analysis identified significant heterogeneity in growth rates of aging population globally, with many African countries exhibiting significantly lower aging rates compared with Europe. High socio-economic vulnerability, increased climate risks (such as high temperature and intensive extreme climate), and decreased environmental quality were found to significantly increase growth rates of the aging population (P < 0.05). The positive combined impacts of these stressors were diminished at medium-high levels of stressors (i.e., relative to their maximum levels observed in nature). The number of global stressors exceeding the 25% threshold emerged as an important predictor of global aging rates. Demographic changes in regions with relatively rapid aging (e.g., Africa and Asia) are more sensitive to climate change (e.g., extreme climate and drought) and the number of global stressors, and regions with low to medium rates of aging (e.g., Europe and the Americas) are more sensitive to socio-economic vulnerability and environmental stability (e.g., drought, green fragility and air pollution). CONCLUSIONS: Our findings underscore that policy tools or methods must be developed that consider the holistic dimension of the global factor. Further investigations are essential to understand the complex interactions between multiple stressors and their combined effects on global aging.

Examining the association between psychological resilience and chronic versus discrete stressors among individuals who use opioids in Baltimore, Maryland.

INTRODUCTION: Psychological resilience has emerged as a key construct of interest in the study of substance use. However, very few studies have examined resilience among individuals who are actively using drugs. Furthermore, many studies of psychological resilience have focused on individual-level factors. This study addresses the call for a more 'ecological' approach to the study of resilience by exploring how socio-structural vulnerabilities may shape individuals' assessment of their own ability to cope. METHODS: The Peer Harm Reduction of Maryland Outreach Tiered Evaluation study conducted a cross-sectional survey of people who used opioids in Baltimore, Maryland, USA (n = 565). Resilience was measured using the 10-item Connor-Davidson Resilience Scale. We used linear regression to examine the association between resilience and stressors commonly encountered by individuals who use drugs, including both chronic, enduring stressors (e.g., homelessness, food insecurity) and discrete, event-based stressors (e.g., overdose, arrest). RESULTS: We observed a negative relationship between self-reported resilience and chronic stressors. Specifically, individuals who reported experiencing three (ß = -4.08; p = 0.002) or four (ß = -4.67; p = 0.008) types of chronic stress had significantly lower resilience scores. Additionally, we found that an unmet need for mental health treatment was associated with reduced resilience (ß = -1.74; p = 0.040) and greater educational attainment was associated with increased resilience (ß = 2.13; p = 0.005). DISCUSSION AND CONCLUSIONS: Overlapping experiences of socio-structural vulnerability, as well as access to mental health care, may influence how individuals who use drugs evaluate their own resilience. Interventions that seek to promote the resilience of this population should focus on addressing structural drivers of marginalisation and barriers to mental health treatment.

[Frailty, dependence, and unwanted loneliness in elderly. A review of the health plans]. / Fragilidad, dependencia y soledad no deseada en personas mayores. Una revisión de planes de salud.

OBJECTIVE: The health plan is a guiding tool for territorial health planning where the proposed objectives and measures should prioritize vulnerable groups. The aim of this study was to identify if the Regional Government health plans in Spain included measures related to frailty, dependence and unwanted loneliness aimed at elderly. METHODS: Institutional websites were scanned to identify the most recent health plan of each Regional Government. Information concerning the diagnosis, objectives, specific programs and types of measures on the three domains: frailty, dependence and loneliness was extracted manually. The search was performed on 10 July 2023. RESULTS: Sixteen health plans published between 2010 and 2023 were identified. Twelve of these had incorporated intervention measures on frailty, fourteen on dependence and eight on loneliness, with a considerable heterogeneity. Only eight Regional Governments provide for measures to detect and assess frailty. Aragón, Castilla-La Mancha, Cataluña, Extremadura, País Vasco, Principado de Asturias, Comunidad Foral de Navarra and Comunitat Valenciana were the Regional Governments that presented objectives in the three domains. CONCLUSIONS: The measures proposed by the Regional Governments on frailty, dependence and unwanted loneliness are highly heterogeneous. In the same manner that exists for frailty, it is recommended to stablish a consensus including dependency and unwanted loneliness. Surprisingly, the measures focus more on late stages (dependence) than on prevention (frailty). This study could serve the Regional Governments to in-depth review their health plans, and to examine the actions carried out in other regions to improve the quality of their proposals.

OBJECTIVE: El plan de salud es el instrumento director de la planificación en salud de un territorio, donde los objetivos y medidas planteados deben priorizar a los colectivos más vulnerables. El objetivo de este estudio fue conocer si se incluían medidas sobre la fragilidad, dependencia y soledad no deseada en los planes de salud dirigidos a personas mayores de las comunidades autónomas (CC. AA.) españolas. METHODS: Se realizó una búsqueda en los sitios web institucionales para identificar el plan de salud más reciente de cada comunidad autónoma. Se extrajo manualmente la información sobre el diagnóstico, los objetivos, los programas específicos y los tipos de medidas en tres ámbitos: fragilidad, dependencia y soledad. La búsqueda se completó el 10 de julio de 2023. RESULTS: Se localizaron dieciséis planes de salud publicados entre los años 2010 y 2023. De ellos, doce incorporaban medidas de intervención en fragilidad, catorce en dependencia y ocho en soledad no deseada, observándose mucha heterogeneidad entre ellos. Solo ocho CC. AA. contemplan medidas de detección y valoración de la fragilidad. Las CC. AA. con objetivos en los tres ámbitos fueron Aragón, Castilla-La Mancha, Cataluña, Extremadura, País Vasco, el Principado de Asturias, Comunidad Foral de Navarra y la Comunitat Valenciana. CONCLUSIONS: Las medidas relacionadas con fragilidad, dependencia y soledad no deseada son heterogéneas entre CC. AA. De la misma forma que existe en fragilidad, se recomienda establecer un consenso que incluya dependencia y soledad no deseada. Sorprende que las medidas inciden más en fases tardías (dependencia) que en prevención (fragilidad). Este estudio puede ayudar a las CC. AA. a hacer una profunda revisión de su plan de salud, así como consultar las acciones realizadas en otros territorios para mejorar la calidad de sus propuestas.

Association of non-HDL cholesterol with plaque burden and composition of culprit lesion in acute coronary syndrome. An intravascular ultrasound-virtual histology study.

OBJECTIVE: Lipids play key role in coronary atherosclerosis. The role of non-high-density lipoprotein cholesterol (non-HDL-C) in atherosclerotic plaques using intravascular imaging remains unclear. This study aimed to assess its relationship with coronary plaque features using intravascular ultrasound (IVUS) in acute coronary syndrome (ACS). METHODS: A total of 601 patients divided into two groups: normal non-HDL-C≤130 mg/dl (n = 410) and high non-HDL cholesterol >130 mg/dl (n = 191). IVUS performed before coronary intervention. RESULTS: Mean age 53.18 ± 12.29 years. No significant differences in hypertension, diabetes, and smoking between groups. Plaque burden was significantly higher among normal versus high non-HDL-C groups (79.59 ± 9.98 % vs. 81.61 ± 5.39 %; p = 0.001). At minimal luminal site, fibrofatty percentage was higher in normal non-HDL-C group (p = 0.027), while necrotic core greater in high non-HDL-C group (p = 0.033). Segmental analysis, necrotic core was significantly higher in percentage (p = 0.006) and volumes (p = 0.011) in normal versus high non-HDL-C groups. Total cholesterol (r = 0.099, p = 0.015), LDL-C (r = 0.081, p = 0.046), triglycerides (r = 0.083, p = 0.041),and non-HDL-C (r = 0.099, p = 0.015) positively correlated with plaque burden. Total cholesterol (r = 0.115, p = 0.005), LDL-C (r = 0.107, p = 0.009), and non-HDL-C (r = 0.105, p = 0.010) positively correlated with necrotic core volume. Linear regression analysis showed age and non-HDL-C as predictors of higher plaque burden. Multiple linear regression analysis; age, body mass index, and non-HDL-C were predictors of larger necrotic core volume. CONCLUSION: Non-HDL-C levels were positively associated with plaque burden, measure of extent of atherosclerosis. It is closely associated with and is a predictor of necrotic core volume; a marker of plaque vulnerability. This IVUS study demonstrates potential role of non-HDL-C in causation of plaque in ACS.

Is naloxone where it needs to be? Using spatial analytics to examine equitable distribution of community-based naloxone sites.

BACKGROUND: One of the most effective harm reduction services for preventing opioid overdose deaths is naloxone. Given the ongoing opioid crisis, which has led to a surge in overdose deaths across the country, expanding access to naloxone is critical. Community-based naloxone distributions sites in Palm Beach County can increase access to naloxone. However, several rural and disadvantaged regions rarely have any type of access to naloxone. The purpose of this descriptive paper is to examine the spatial distribution of and evaluate equitable accessibility to community-based naloxone sites in Palm Beach County. METHODS: We examined health equity in the distribution of community-based naloxone sites using a mixed-methods approach with ArcGIS Pro version 3.0, which is a geographic information system (GIS) software used for mapping, spatial analysis, and data visualization. RESULTS: The Belle Glade region was identified as the location most adversely affected with health inequities and limited accessibility to naloxone distribution sites, as it ranked in the 100 % percentile for all social vulnerability index (SVI) themes. The 30-minute drive-time area calculated a county service area of 1885.3 km2 (km2), which covers about 34 % of the 478.0 km2 land area of census tracts. Drive-time areas did not account for periods of heavier traffic such as during rush hour. Maximum distances during heavier traffic may be smaller, thus decreasing accessibility to naloxone distribution sites. CONCLUSION: There is a need for effective policy-led strategies tailored to expanding our understanding of the challenges that are experienced by the individuals in need of naloxone and encountered by the distribution sites themselves, as accessible naloxone is crucial for preventing nonfatal and fatal overdoses and ensuring timely emergency responses in vulnerable communities.

Vulnerability, social value and the equitable sharing of benefits from research: beyond the placebo and access debates.

The vulnerability of research participants is a critical topic for the 2024 revision of the Declaration of Helsinki, with the proposal to include "social value. " However, this proposal has been withdrawn and the relationship between the two concepts has not been clarified. This paper attempts to clarify: (1) the recent reform for the ethical inclusion of vulnerable study participants to promote diversity; (2) the social value, prerequisite for everyone, especially for those who are vulnerable and the most in need; (3) the requirements for promoting the inclusion of vulnerable participants, in particular the review of the norms for placebo-controlled trials and post-trial access; (4) finally, the direction of research ethics reform to achieve social value and equitable global health.

Analyzing the Social Vulnerability Index With Metabolic Surgery.

INTRODUCTION: The social vulnerability index (SVI) is a census tract-level population-based measure generated from 16 socioeconomic and demographic variables on a scale from 1 (least) to 100 (most) vulnerable. This study has three objectives as follows: 1) to analyze multiple ways of utilizing SVI, 2) compare SVI as a group measure of marginalization to individual markers, and 3) to understand how SVI is associated with choice of surgery in metabolic surgery. METHODS: We retrospectively identified adults undergoing Roux-en-Y gastric bypass and gastric sleeve in 2013-2018 National Surgical Quality Improvement Program data from a single academic center. High SVI was defined as >75th percentile. Low SVI was coded as <75th percentile in measure 1 and < 25th percentile in measure 2. Chi-square and Mann-Whitney U tests were utilized for categorical and continuous variables, respectively. Multivariable regression models were performed comparing SVI to marginalized status as a predictor for type of metabolic surgery. RESULTS: We identified 436 patients undergoing metabolic surgery, with a low overall morbidity (6.1%). Complication and readmission rates were similar across comparator groups. The logistic regression models had similar area under the curve, supporting SVI as a proxy for individual measures of marginalization. CONCLUSIONS: SVI performed as well as marginalized status in predicting preoperative risk. This suggests the validity of using SVI to identify high risk patients. By providing a single, quantitative score encompassing many social determinants of health, SVI is a useful tool in identifying patients facing the greatest health disparities.

Evaluating the Association Between Social Vulnerability and Outcomes of Heart Transplantation in the United States.

INTRODUCTION: The Social Vulnerability Index (SVI) is a tool that was developed by the Centers for Disease Control and Prevention to help identify communities that are at risk of harm from social, economic, or environmental factors. This study evaluates the association between SVI and outcomes of adult heart transplantation (HT) in the United States. METHODS: The United Network for Organ Sharing registry was used to identify all isolated adult (≥18 y) HT recipients and their home address zip codes between 2010 and 2021. Recipients were classified into three SVI risk groups: low risk (SVI: <0.33), intermediate risk (SVI: 0.33-0.65), and high risk (SVI: ≥0.66). Kaplan-Meier analysis was used to estimate recipient survival probability based on SVI risk. Multivariable Cox proportional hazard models were built to evaluate the association of SVI with 1- and 5-y mortality. RESULTS: A total of 22,400 recipients distributed over 9753 zip codes were included. Unadjusted 1-y survival rates in the three risk groups were as follows: low risk: 90.5%, intermediate risk: 91.1%, high risk 90.9%, and Log-rank P = 0.550 and 5-y survival rates were as follows: low risk: 80.8%, intermediate risk: 78.6%, high risk: 76.1%, and Log-rank P < 0.001. Compared to low-risk recipients, risk-adjusted 1-y mortality hazard ratio was 1.02 (0.92-1.14, P = 0.657) for intermediate risk and 1.09 (0.95-1.24, P = 0.222) for high-risk recipients. Risk-adjusted 5-y mortality hazard ratio was 1.07 (0.99-1.16, P = 0.095) for intermediate-risk recipients and 1.17 (1.06-1.28, P = 0.002) for high-risk recipients. CONCLUSIONS: Social vulnerability is associated with HT outcomes. The Centers for Disease Control and Prevention SVI may be a useful tool in identifying at-risk geographic areas where targeted efforts may be prudent for reducing disparities in HT outcomes.

Perspectives on advance research directives from individuals with mild cognitive impairment and family members: a qualitative interview study.

Background: Advance research directives (ARDs) provide a promising way to involve individuals with mild cognitive impairment (MCI) in research decisions before they lose the capacity to consent. At the same time, the views of people with MCI on ARDs are underexplored. This study assesses the perceptions of people with MCI and family members on the benefits and challenges associated with ARDs. Aims: The aim of this study was to investigate the perspectives of individuals with MCI and family members of individuals with MCI on ARDs. We focus specifically on willingness to participate in nontherapeutic research, understanding of ARDs and the ethical considerations involved. Methods: Thirteen open-ended, face-to-face interviews were conducted using a semi-structured format. Seven interviews were conducted with individuals with MCI, and six with family members of individuals with MCI. The narratives were transcribed verbatim and qualitative content analysis was carried out. Results: Research participation and ARDs were viewed positively, largely based on altruistic motives and the desire to contribute to society. The participants recognized the potential advantages of ARDs in reducing the decision-making burden on family members and maintaining personal autonomy. They also highlighted challenges in comprehending ARDs and navigating the complexities surrounding potential conflicts between current preferences versus preferences described in an ARD. Conclusions: ARDs were predominantly seen as valuable instruments that enable individuals with MCI to participate in research. This study provides insights into the reasons why affected individuals are interested in drafting ARDs. These insights can guide the development of supportive interventions that are tailored to assist individuals with MCI and their families in navigating ARD processes.

Advancing cancer therapy: new frontiers in targeting DNA damage response.

Genomic instability is a core characteristic of cancer, often stemming from defects in DNA damage response (DDR) or increased replication stress. DDR defects can lead to significant genetic alterations, including changes in gene copy numbers, gene rearrangements, and mutations, which accumulate over time and drive the clonal evolution of cancer cells. However, these vulnerabilities also present opportunities for targeted therapies that exploit DDR deficiencies, potentially improving treatment efficacy and patient outcomes. The development of PARP inhibitors like Olaparib has significantly improved the treatment of cancers with DDR defects (e.g., BRCA1 or BRCA2 mutations) based on synthetic lethality. This achievement has spurred further research into identifying additional therapeutic targets within the DDR pathway. Recent progress includes the development of inhibitors targeting other key DDR components such as DNA-PK, ATM, ATR, Chk1, Chk2, and Wee1 kinases. Current research is focused on optimizing these therapies by developing predictive biomarkers for treatment response, analyzing mechanisms of resistance (both intrinsic and acquired), and exploring the potential for combining DDR-targeted therapies with chemotherapy, radiotherapy, and immunotherapy. This article provides an overview of the latest advancements in targeted anti-tumor therapies based on DDR and their implications for future cancer treatment strategies.

Surgical subspecialist distribution and Social Vulnerability Indices in the inland empire.

Background: Access to surgical specialty care differs based on geographic location, insurance status, and subspecialty type. This study uses the Inland Empire as a model to determine the relationship between Social Vulnerability Indices (SVIs), surgeon sex, and surgical subspecialty distribution. Methods: 823 census tracts from the Centers for Disease Control's (CDC) SVI 2018 database were compared against 992 surgeons within 30 distinct subspecialties. This data was retrieved from the American Medical Association's (AMA) 2018 Physician Masterfile. Spearman's bivariate and multiple regression were used to compare the relationship between SVI and number of surgical subspecialists within each census tract. Results: There were approximately 3.34 male and 0.35 female surgeons per census tract (t(267) = 7.74, p < 0.001). Significant inverse relationships existed between Cosmetic surgery, Urology and Minority status/language (ρ = -0.131 [95 % CI -1.000 to -0.028], p = 0.016; ρ = -0.142 [95 % CI -1.000 to -0.039], p = 0.010, respectively); General surgery, Socioeconomic status (ρ = -0.118 [95 % CI -1.000 to -0.014], p = 0.027), and Household composition/disability (ρ = -0.203 [95 % CI -1.000 to -0.102], p < 0.001); Hand surgery and Socioeconomic status (ρ = -0.114 [95 % CI -1.000 to -0.010], p = 0.031); Otolaryngology, Housing type/transportation (ρ = -0.102 [95 % CI -1.000 to 0.001], p = 0.047), and Overall Social Vulnerability (ρ = -0.105 [95 % CI -1.000 to -0.001], p = 0.043). Multiple regression analyses reinforced these findings. Conclusions: This study concludes that social vulnerability is predictive of, and significantly linked to, differences in distribution of surgical subspecialty and surgeon gender. Future research should investigate recruitment of a diverse surgical workforce, infrastructural barriers to care, and differences in quality of care. Key message: Our work demonstrates complex relationships between surgical subspecialist distribution, surgeon gender, and a census tract's various Social Vulnerability Indices. Thus, this research can serve to continue educating surgeons and other healthcare providers about the importance of social determinants of health in the construction of healthcare policy and practice, as well as incentivizing equitable recruitment of a diverse population of surgeons.

Substance Use During Pregnancy.

Pregnancy is a period of transition with physical changes in the maternal body but also mental and psychological ones. This phase may be accompanied by symptoms of anxiety, depression or irritability, which are part of non-pathological adaptation mechanisms. These symptoms can, however, be intense and constitute real psychiatric syndromes, particularly when the woman presents vulnerability factors. While fetal exposure to alcohol and other drugs is one of the leading preventable causes of developmental delay and birth defects in newborns, substance use during pregnancy is common, particularly in Europe. There is no amount and no time during pregnancy where consuming alcohol and other substances of abuse is safe. This narrative review reflects the point of view of the obstetrician, the constraints of his therapeutic framework with its limitations of time, training and tools to detect and manage substance-related disorders. Validated detection questionnaires are poorly adapted to obstetric practice; detection and first brief interventions can be delegated to save time but at the risk of reducing the involvement of the obstetrician. The combined management of pregnancy and addictions by a psychiatrist and an obstetrician comes up against different frameworks and working deadlines in the two disciplines.

Livelihood vulnerability to climate change health impacts among Amhara Sayint district community, northeastern Ethiopia: A composite index approach.

Climate change significantly impacts public health, affecting nearly everyone across the globe and contributing to approximately 10% of global mortality. Ethiopia is particularly vulnerable to the changing climate attributed impacts due to economic, and social determinants. While research on climate change is expanding, it often prioritizes its effects on agriculture. The impacts from public health perspective are frequently overlooked. We address this shortcoming by evaluating the vulnerability of the community in the district of Amhara Sayint, Amhara, northeastern Ethiopia, to the health impacts of climate change, and identifying factors involved. Data was collected using a community-based cross-sectional approach, involving 605 randomly selected households between July Twenty and September Five, 2022. The data collection process utilized a validated and pilot-tested questionnaire, which was administered through face-to-face interview with the aid of Kobo Collect toolbox. The community's vulnerability was assessed using the IPCC's framework of vulnerability. Household's Vulnerability status was then classified into three levels according to their Livelihood Vulnerability Index (LVI) score. A partial proportional oddsapproach of ordinal logistic regression model was used to identify factors associated with vulnerability to climate change attributed health impacts. Among the 605 respondents, 48% (95% CI: 44.1, 52.1) were identified as vulnerable, and about 4.6 % (95% CI: 3, 6.6) were classified as highly vulnerable. Wealth status (AOR1 = 1.8; 95 % CI: 1.2, 2.8), educational status (AOR1 = 2.8; 95% CI: 1.1, 7.3), marital status (AOR2 = 4.7, 95% CI: 1.6, 13.4), and home crowdedness (AOR2 = 2.9, 95% CI: 1.1, 8.1) significantly associated with vulnerability. Over half of the residents in the district wereeither being vulnerable or highly vulnerable to climate change attributed health impacts. Therefore, prioritizing prevention and preparedness along with conducting spatial analysis to identify high-risk areas for timely intervention, is essential.

Geospatial approach to pluvial flood-risk and vulnerability assessment in Sunyani Municipality.

Historically, and in recent times, efforts have been to understand, predict, analyze, and quantify floods and their impacts in various countries of the globe. Although recent scientific advances have introduced approaches to assessing the risks presented by flooding, little studies have been carried out in the Sunyani Municipality of Ghana for generating a pluvial flood-risk and vulnerability map for risk identification, resilience, emergency preparedness, and urban spatial planning. In this study, five parameters that influence both pluvial and fluvial flooding were assessed to map flood-prone areas within the Sunyani Municipality. These are precipitation, drainage density, LULC, elevation, and slope, which were integrated in GIS. Using an AHP, weights were assigned to each parameter based on its level of influence on flooding. The findings reveal that 21.32 % of the Sunyani Municipality lies within a highly flood-prone area, 39.65 % in a flood-prone area, while 28.06 % and 10.97 % in slightly flood-prone and not flood-prone areas respectively. Built-up areas close to watersheds with lower elevations and larger drainage density are the places that are highly flood-prone. Some towns within the highly flood-prone and flood-prone areas are Abesim, Newtown, Nkwarbeng, Baakoniaba, Kootokrom, and Penkwase. Highly valued infrastructure such as schools, churches, and hospitals have also been found within these highly flood-prone areas. These findings can aid the government and relevant stakeholders in disaster risk management to be better informed, and to effectively plan and prevent flood challenges in the Sunyani Municipality. Moreover, urban spatial planners in the study setting can consider incorporating the flood hazard maps generated from this study into their spatial plans for proactive physical developments.

Hospital-Based Preparedness Measures for CBRNE Disasters: A Systematic Review.

Chemical, Biological, Radiological or Nuclear and Explosive (CBRNe) disasters have historically caused significant fatalities and posed global threats. The inadequate preparedness of hospital equipment for CBRNe incidents underscores the urgent need for hospitals to modernize and standardize their equipment to effectively manage these high-risk situations. The purpose of this systematic review was to examine hospital-based preparedness measures for CBRNe incidents. The PRISMA guidelines were followed for this review. A comprehensive search of English-language peer-reviewed literature from January 2010 to 2023 was conducted, identifying 2191 items from PubMed, ScienceDirect, EBSCO, and Google Scholar. The modified ROBINS-I instrument was used to assess bias, ensuring the reliability and validity of the studies. Data synthesis was conducted jointly by both authors. After eliminating duplicates and reviewing abstracts, 124 studies remained. Upon full-text examination, only 20 studies met the criteria for inclusion in this review. The review identified three key interrelated domains of preparedness: personal, technological, and structural measures. Most studies emphasized decontamination, Personal Protective Equipment (PPE), and detection, while the management of deceased bodies, transportation, and Points of Dispensing (PODs) were largely overlooked. These findings may assist hospital administrators and policymakers in enhancing their facilities' readiness for CBRNe emergencies.

Crispr-mediated genome editing reveals a preponderance of non-oncogene addictions as targetable vulnerabilities in pleural mesothelioma.

Pleural mesothelioma (PM) is an aggressive cancer with limited treatment options. In particular, the frequent loss of tumor suppressors, a key oncogenic driver of the disease that is therapeutically intractable, has hampered the development of targeted cancer therapies. Here, we interrogate the PM genome using CRISPR-mediated gene editing to systematically uncover PM cell susceptibilities and provide an evidence-based rationale for targeted cancer drug discovery. This analysis has allowed us to identify with high confidence numerous known and novel gene dependencies that are surprisingly highly enriched for non-oncogenic pathways involved in response to various stress stimuli, in particular DNA damage and transcriptional dysregulation. By integrating genomic analysis with a series of in vitro and in vivo functional studies, we validate and prioritize several non-oncogene addictions conferred by CDK7, CHK1, HDAC3, RAD51, TPX2, and UBA1 as targetable vulnerabilities, revealing previously unappreciated aspects of PM biology. Our findings support the growing consensus that stress-responsive non-oncogenic signaling plays a key role in the initiation and progression of PM and provide a functional blueprint for the development of unprecedented targeted therapies to combat this formidable disease.

Increased Stillbirth Rates and Exposure to Environmental Risk Factors for Stillbirth in Counties with Higher Social Vulnerability: United States, 2015-2018.

INTRODUCTION: Exposure to unfavorable environmental conditions during pregnancy, such as extreme heat and air pollution, has been linked to increased risk of stillbirth, defined as fetal mortality at or after 20 weeks' gestation, however no studies have examined its association with social vulnerability. We examined associations between county-level stillbirth rates, environmental risk factors for stillbirth, and social vulnerability in the United States. METHODS: This ecologic study linked county-level data from three nationwide datasets on stillbirths (National Vital Statistics System), environmental conditions (North American Land Data Assimilation System and Environmental Protection Agency), and social vulnerability (Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index). Poisson and negative binomial models were fit to the variables and produced rate ratios to estimate associations among stillbirth rates, environmental risk factors, and social vulnerability. RESULTS: Social vulnerability was positively associated withn stillbirth rates, annual average number of extreme heat days, and ambient concentration of particulate matter ≤ 2.5 µm in diameter (PM2.5). The average number of days that ozone and PM2.5 each exceeded regulatory standards were not associated with stillbirth rates or social vulnerability. A positive association between average annual PM2.5 concentration and stillbirth rates was detected; no other significant associations between environmental risk factors and stillbirth rates were observed. DISCUSSION: We found evidence of associations between social vulnerability and stillbirth rates, and between social vulnerability and environmental risk factors for stillbirth at the county level. Further research could inform understanding of how social vulnerability impacts the relationship between environmental exposures and stillbirth risk.