Adult Code Sepsis: A Narrative Review of its Implementation and Impact.

This narrative review explores the implementation and impact of sepsis code protocols, an urgent intervention strategy designed to improve clinical outcomes in patients with sepsis. We examined the degree of implementation, activation criteria, areas of implementation, personnel involved, responses after activation, goals and targets, impact on clinical indicators, and challenges in implementation. The reviewed evidence suggests that sepsis codes can significantly reduce sepsis-related mortality and enhance early administration of treatments. However, variability in activation criteria and inconsistent application present ongoing challenges. The review considers the incorporation of newer scoring systems, such as NEWS and MEWS, and the potential integration of machine learning tools for early sepsis detection. It highlights the importance of tailoring implementation to specific healthcare contexts and the value of ongoing training to optimize sepsis response. Limitations include the ongoing controversy surrounding sepsis definitions and the need for standardized, feasible quality indicators. Future research should focus on standardizing activation criteria, improving protocol adherence, and exploring emerging technologies to enhance early sepsis detection and management. Despite challenges, sepsis codes show promise in improving patient outcomes when implemented thoughtfully and consistently across healthcare settings.

Pulse-Wave Velocity, Flow-Mediated Dilation, and Carotid Intima-Media Thickness to Assess Cardiovascular Risk in Population with Metabolic Syndrome.

Pulse-wave velocity (PWV), flow-mediated dilation (FMD), and carotid intima-media thickness (CIMT) are established methods used in research and clinical settings to assess arterial stiffness, endothelial function, and subclinical atherogenesis. These measurements may reflect vascular disease and atherosclerotic progression, which are major causes of adverse cardiovascular events. These methods are particularly valuable in determining cardiovascular dysfunction among populations with different risk factors, such as diabetes mellitus, hypertension, and other metabolic dysfunction-related conditions. They provide a non-invasive and reliable source of information that complements clinical practice. Early detection, risk assessment, and therapeutic decisions regarding cardiovascular disease can be achieved, ultimately contributing to improved patient outcomes. Traditional tools for evaluating cardiovascular disease do not reveal whether metabolic syndrome affects early subclinical cardiovascular disease in patients with obesity. Recent research has highlighted the importance of including arterial stiffness and endothelial function in a comprehensive cardiovascular assessment. Therefore, the aim of the present study is to describe methods that provide information on early subclinical vascular aging, endothelial dysfunction, and atherogenic disease, enabling vascular-targeted risk stratification among populations with obesity and different metabolic profiles.

Corrigendum: Loneliness and global cognitive functioning in racially and ethnically diverse US midlife and older adults.

[This corrects the article DOI: 10.3389/fpsyg.2024.1344044.].

Loneliness and pain among community-dwelling middle-aged and older Black, Latino, and White adults in the United States.

Background: Prior research has demonstrated a strong and independent association between loneliness and pain, but few studies to date have explored this relationship in racially and ethnically diverse groups of midlife and older adults. We drew on the diathesis stress model of chronic pain and cumulative inequality theory to examine the relationship of loneliness and the presence and intensity of pain in a nationally representative sample of Black, Latino, and White adults aged 50 or older in the United States. Methods: Data were from Wave 3 of the National Social Life, Health, and Aging Project (n = 2,706). We used weighted logistic and ordinary least squares regression analyses to explore main and interactive effects of loneliness and race and ethnicity while adjusting for well-documented risk and protective factors (e.g., educational attainment, perceived relative income, inadequate health insurance, perceived discrimination) and salient social and health factors. Results: Almost half (46%) of the participants reported feeling lonely and 70% reported the presence of pain. Among those who reported pain (n = 1,910), the mean intensity score was 2.89 (range = 1-6) and 22% reported severe or stronger pain. Greater loneliness was associated with increased odds of pain presence (AOR = 1.154, 95% CI [1.072, 1.242]) and higher pain intensity (ß = 0.039, p < 0.01). We found no significant interaction effects involving Black participants. However, Latino participants who reported greater loneliness had significantly higher levels of pain (ß = 0.187, p < 0.001) than their White counterparts with similar levels of loneliness. Discussion: Loneliness is an important correlate of pain presence and intensity and may have a stronger effect on pain intensity among Latino adults aged 50 or older. We discuss clinical and research implications of these findings, including the need for more fine-grained analyses of different types of loneliness (e.g., social, emotional, existential) and their impact on these and other pain-related outcomes (e.g., interference). Our findings suggest a need for interventions to prevent and manage pain by targeting loneliness among middle-aged and older adults, particularly Latino persons.

Loneliness and global cognitive functioning in racially and ethnically diverse US midlife and older adults.

Introduction: Few studies have examined the association of loneliness and cognitive functioning in the US. We used two common measures of loneliness and examined their association in a large sample of US Black, Latino, and White adults (ages ≥ 50). Methods: We analyzed Wave 3 of the National Social Life, Health, and Aging Project (N = 2,757). We examined loneliness using one item from the CES-D and the Felt Loneliness Measure (NFLM); cognitive functioning was assessed using the Montreal Cognitive Assessment (MoCA) tool, where higher scores indicated better functioning. We used weighted ordinary least squares regressions to examine the effects of loneliness (CES-D loneliness and NFLM in separate models) on MoCA scores. In exploratory analyses, we examined if these relationships varied by race and ethnicity. We adjusted all models for sociodemographic and other salient factors (e.g., chronic disease, depressive symptoms, living alone). Results: Mean age was 63.49 years, 52% were female, and 9% were Black and 6% Latino persons. Approximately 54% endorsed feeling lonely on at least one measure; 31% (CES-D) and 46% (NFLM). The relationship between loneliness measures was positive and significant, X 2 (1, N = 2,757) = 435.493 p < 0.001. However, only 40% of lonely individuals were identified as lonely on both assessments. CES-D loneliness was inversely (߈ = -0.274, p = 0.032) associated with MoCA scores and this association did not vary by race and ethnicity. Greater NFLM loneliness was positively associated (߈ = 0.445, p < 0.001) with higher MoCA scores for Latino participants only. Discussion: Loneliness appears to be an important predictor of cognitive functioning. However, the association of loneliness and cognitive functioning varied when using the CES-D loneliness item or the NFLM. Future work is needed to understand how loneliness and its clinically relevant dimensions (social, emotional, existential, chronicity) relate to global and individual cognitive domains. Research is needed with racially and ethnically diverse midlife and older adults, particularly to understand our counterintuitive finding for Latino participants. Finally, findings also support the need for research on interventions to prevent cognitive decline targeting loneliness.

Risk Factors for Elder Mistreatment Among Older Korean Americans.

Using data from a sample of older Korean Americans (n = 2,150), we examined the prevalence and associated factors of physical, emotional, and financial mistreatment. Given the importance of contextual factors, we examined the effect of immigration-related (years in the U.S. and acculturation) and interpersonal/community-related (family solidarity, social network, and ethnic community social cohesion) factors in addition to sociodemographic and health-related characteristics. The rate of experiencing physical, emotional, and financial mistreatment during the past year was 3%, 37.9%, and 16.1%, respectively. Younger age and lower family solidarity were common risk factors for emotional and financial mistreatment. The experience of emotional mistreatment was also more likely among females and those with higher level of acculturation, smaller social networks, and lower ethnic community social cohesion. Chronic disease was an additional risk factor for financial mistreatment. The findings suggest targeted prevention and intervention strategies for elder mistreatment.

Community Health Work and Social Work Collaboration: Integration in Health Care and Public Health Settings: A Conceptual Framework.

Community health worker (CHW) and social worker (SW) collaboration is crucial to illness prevention and intervention, yet systems often engage the 2 workforces in silos and miss opportunities for cross-sector alignment. In 2021, a national workgroup of over 2 dozen CHWs, SWs, and public health experts convened to improve CHW/SW collaboration and integration across the United States. The workgroup developed a conceptual framework that describes structural, systemic, and organizational factors that influence CHW/SW collaboration. Best practices include standardized training, delineated roles and scopes of practice, clear workflows, regular communication, a shared system for documentation, and ongoing support or supervision.

Understanding the implementation and sustainability needs of evidence-based programs for racial and ethnic minoritized older adults in under-resourced communities with limited aging services.

BACKGROUND: Evidence-based programs (EBPs) for older adults effectively improve health outcomes. However, there is a limited understanding of the unique needs of service providers as they consider adopting, implementing, and maintaining programs for older minority adults in low-income communities with limited aging services. METHODS: We conducted semi-structured interviews with key informants of community-based organizations (CBOs) to understand implementation and sustainability needs of CBOs within four racial and ethnically diverse Los Angeles County geographic areas. We performed thematic analysis of interview transcripts. RESULTS: Interviews were conducted with representatives from 25 senior-serving agencies providing aging-related EBPs. CBO representatives reported implementing EBPs in 8 domains: Falls Prevention (68%), Mental Health (64%), Caregiver Health (48%), Chronic Disease Management (48%), Diabetes Management (36%), Arthritis Management (28%), Physical Activity (24%), and Multiple Conditions Management (8%). Themes are presented using the six domains of the Bass and Judge framework for factors impacting successful and sustained EBP implementation. CBOs in low-income and diverse communities described unique challenges with tailoring interventions based on local community context (literacy, language), cultural context, and locally available resources (technology, safe community spaces, transportation) and faced resource-intensive administrative burdens through staff turnover, data collection, sustainable funding, and networking. CONCLUSIONS: Serving racial and ethnic communities has unique challenges that require tailored approaches and additional resources to ensure equitable access to EBPs for all communities. We describe suggestions for enhancing the effective adoption of EBPs among service agencies in under-resourced and diverse aging communities serving populations with aging-related health disparities.

Serum protein electrophoresis in European mink (Mustela lutreola): reference intervals and comparison of agarose gel electrophoresis and capillary zone electrophoresis.

BACKGROUND: Knowledge of reference intervals for blood analytes, including serum protein fractions, is of great importance for the identification of infectious and inflammatory diseases and is often lacking in wild animal species. MATERIAL AND METHODS: Serum samples were obtained from European minks enrolled in the breeding program (n = 55). Agarose gel electrophoresis (AGE) and capillary zone electrophoresis (CZE) were used to separate and identify protein fractions. Albumin, α1, α2, ß, and γ-globulins fractions were identified in all mink sera by both electrophoresis methods. Reference intervals (90% CI) were determined following the 2008 guidelines of the Clinical Laboratory Standard Institute. The methods were compared using Passing-Bablok regression, Bland-Altman analysis, and Lin's concordance correlation. RESULTS: A significant bias was found between methods for α1, α2, and γ-globulin. Lin's concordance correlation was considered unacceptable for α1, α2, and ß-globulins. Differences for gender between methods were found for albumin and α2-globuins, which were higher for males than females. γ-globulins were higher for adults than young minks using both methods; however, α1 and α2-globulins were lower. CONCLUSION: Both methods are adequate for identifying serum protein disorders, but the AGE and CZE methods are not equivalent. Therefore, reference intervals for each technique are required.

Skin cancer prevention in extreme sports: Intervention in a 24-h race.

INTRODUCTION: Excessive sun exposure and sunburns are the main preventable causes of skin cancer. The growing popularity of outdoor sports in developed countries has motivated the objective of this work to study the risk of photoexposure and the skin cancer prevention needs of athletes in an extreme race and evaluate an intervention targeted at this population. METHODS: An observational study was conducted during the XXIII edition of the 101 km de Ronda race, which consisted of trail running and mountain biking categories. Environmental and personal dosimetry, monitoring of meteorological conditions, evaluation of the athletes' photoprotection and skin examination habits, a dermatological checkup, and a satisfaction questionnaire were performed. RESULTS: The ultra-endurance race was carried out under adverse conditions (maximum ultraviolet index (UVI) = 9.2, temperatures above 30°C, and relative humidity >35%). The mean effective erythema dose received by race athletes (n = 11) was 2959.2 ± 404.2 J/m2 , equivalent to 29.6 standard erythema doses (SED). The CHACES questionnaire (n = 1145) showed a sunburn rate of 58% and poor protective habits: 62.9% of athletes do not usually use sunscreen and 67.2% do not self-examine their skin. Actinic keratoses (4.7%) and suspicious skin cancer lesions (4.2%) were found in dermatologic screening exams (n = 170). On the satisfaction questionnaire (n = 111), this intervention was rated as excellent (95.5%). CONCLUSION: This research highlights the extreme risk of photoexposure that athletes are subjected to during ultra-endurance competitions. In the same way, it shows the need to carry out interventions aimed at the acquisition of healthy photoprotection habits and skin surveillance in this target group.

Development of a Lived Experience Panel to inform the design of embedded pragmatic trials of dementia care interventions.

BACKGROUND: The National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's Disease and Alzheimer's Related Dementia Clinical Trials (IMPACT) Collaboratory convened a Lived Experience Panel (LEP) to inform the development of research priorities and provide input on conducting embedded pragmatic clinical trials (ePCTs) of dementia care interventions. Given the importance of people with lived experience to dementia research, and the unique considerations of engaging people with dementia, we report on our process for the recruitment, selection, and initial convening of the IMPACT LEP. METHODS: The IMPACT Engaging Partners Team, in partnership with the Alzheimer's Association, sought nominations of individuals with mild cognitive impairment or early-stage dementia, care partners of other people living with dementia (PLWD), and proxy representatives for individuals with mid-to-late stage dementia. The 11-member LEP was composed of individuals with diverse personal experiences in part due to their age, race, ethnicity, gender, sexual orientation, geography, disability, or type of dementia. In its first year, the LEP met with IMPACT's Patient and Caregiver Relevant Outcomes Core and Ethics and Regulation Core. RESULTS: LEP members provided valuable insights and nuanced discussion of issues relevant to ePCTs in dementia care from a broad range of personal experience. Panelists identified key research priorities and provided insight on outcomes often studied by researchers. The LEP also informed investigators' approaches to waivers and modifications of written informed consent and evaluation of minimal risk. Summary reports of the LEP meetings with each Core are available on the IMPACT website. At the end of the first year, changes were made to the composition of the LEP, and opportunities were identified for expanding panelist engagement with IMPACT investigators, as were priorities and scope for future input. CONCLUSIONS: The IMPACT LEP provides a model for engaging PLWD and care partners in the research process as collaborators.

Perceived Anxiousness About COVID-19 and Preventive Behaviors Among Dyads of Older Adults and Family Caregivers.

BACKGROUND AND OBJECTIVES: Adopting preventive behaviors is crucial to avoiding coronavirus disease 2019 (COVID-19) infection, and perceived anxiousness may influence such behaviors among older adults and their caregivers. This study investigated the relationships between perceived anxiousness about COVID-19 and preventive behaviors in older adult-caregiver dyads. RESEARCH DESIGN AND METHODS: A cross-sectional study was conducted using 1,565 older adult-caregiver dyads from the 2020 National Health and Aging Trend Study (NHATS)/National Study of Caregiving (NSOC) COVID-19 Supplements data. Actor-partner interdependence models were estimated to examine the associations between older adults' and family caregivers' perceived anxiousness about COVID-19 and their engagement in personal (e.g., wearing masks, washing hands) and social (e.g., avoiding contact with friends, limiting grocery shopping) preventive behaviors. Separate models were estimated based on older adults' dementia status. RESULTS: We found significant actor effects of anxiousness about COVID-19 on preventive behaviors of both older adults and caregivers in nondementia dyads. The anxiousness about COVID-19 of older adults had significant partner effects on both personal and social preventive behaviors of caregivers, whereas caregivers' anxiousness about COVID-19 only had a significant partner effect on social preventive behaviors of older adults. No significant partner effect was found in dementia dyads. DISCUSSION AND IMPLICATIONS: Our findings highlight the critical role of caregivers in promoting older adults' health behaviors during the COVID-19 pandemic and maintaining mental well-being of older adults. The study also implies future efforts to explore the dyadic relationship of dementia care dyads in promoting health behaviors and mental health.

Successful treatment of sebaceous adenitis with oclacitinib and low-dose prednisolone in a dog.

Finding an effective and well-tolerated treatment for canine idiopathic sebaceous adenitis (ISA) can be challenging. This case report describes an 8-year-old male Rottweiler with ISA successfully treated with a combination of oclacitinib and low doses of prednisolone.

Encontrar um tratamento eficaz e bem tolerado para a adenite sebácea idiopática (ISA) pode ser desafiador. Este relato descreve o caso de um cão Rottweiler macho de oito anos de idade tratado satisfatoriamente com uma associação de oclacitinib e baixas doses de prednisolona.

Encontrar un tratamiento efectivo y bien tolerado frente a la adenitis sebácea idiopática (ISA) puede ser un reto difícil. Este artículo describe el caso de un perro Rottweiler de ocho años tratado con eficacia con una combinación de oclacitinib y dosis bajas de prednisolona.

Trouver un traitement efficace et bien toléré pour l'adénite sébacée idiopathique canine (ASI) peut s'avérer difficile. Ce rapport clinique décrit le cas d'un Rottweiler mâle de 8 ans atteint d'ASI et traité avec succès par une combinaison d'oclacitinib et de faibles doses de prednisolone.

Fatty Acid-Binding Proteins Identification during the Evolution of Metabolic Syndrome: A Raman Spectroscopy-Based Approach.

Excess fat in abdominal deposits is a risk factor for multiple conditions, including metabolic syndrome (MetS); lipid metabolism plays an essential role in these pathologies; fatty acid-binding proteins (FABPs) are dedicated to the cytosolic transport of fat. FABP4, whose primary source is adipose tissue, is released into the circulation, acting as an adipokine, while FABP5 also accompanies the adverse effects of MetS. FABP4 and 5 are potential biomarkers of MetS, but their behavior during syndrome evolution has not been determined. Raman spectroscopy has been applied as an alternative method to disease biomarker detection. In this work, we detected spectral changes related to FABP4 and 5 in the serum at different points of time, using an animal model of a high-fat diet-induced MetS. FABP4 and 5 spectral changes show a contribution during the evolution of MetS, which indicates alteration to a molecular level that predisposes to established MetS. These findings place FABPs as potential biomarkers of MetS and Raman spectroscopy as an alternative method for MetS assessment.

Combining Genetic and Transcriptomic Approaches to Identify Transporter-Coding Genes as Likely Responsible for a Repeatable Salt Tolerance QTL in Citrus.

The excessive accumulation of chloride (Cl-) in leaves due to salinity is frequently related to decreased yield in citrus. Two salt tolerance experiments to detect quantitative trait loci (QTLs) for leaf concentrations of Cl-, Na+, and other traits using the same reference progeny derived from the salt-tolerant Cleopatra mandarin (Citrus reshni) and the disease-resistant donor Poncirus trifoliata were performed with the aim to identify repeatable QTLs that regulate leaf Cl- (and/or Na+) exclusion across independent experiments in citrus, as well as potential candidate genes involved. A repeatable QTL controlling leaf Cl- was detected in chromosome 6 (LCl-6), where 23 potential candidate genes coding for transporters were identified using the C. clementina genome as reference. Transcriptomic analysis revealed two important candidate genes coding for a member of the nitrate transporter 1/peptide transporter family (NPF5.9) and a major facilitator superfamily (MFS) protein. Cell wall biosynthesis- and secondary metabolism-related processes appeared to play a significant role in differential gene expression in LCl-6. Six likely gene candidates were mapped in LCl-6, showing conserved synteny in C. reshni. In conclusion, markers to select beneficial Cleopatra mandarin alleles of likely candidate genes in LCl-6 to improve salt tolerance in citrus rootstock breeding programs are provided.

Older Adult Frequent 9-1-1 Callers for Emergency Medical Services in a Large Metropolitan City: Individual- and System-Level Considerations.

BACKGROUND: High utilizers of 9-1-1 place a substantial burden on emergency medical services (EMS). Results of a retrospective review of records data of the City of Los Angeles Fire Department (LAFD) showed a significant increase in older adult high utilizers of 9-1-1. OBJECTIVE: The objective of this study was to explore individual- and system-level factors implicated in EMS use among older adults, and to provide system recommendations to mitigate overuse. METHODS: A phenomenological study was conducted, drawing from LAFD EMS records between 2012 and 2016 to identify and contact high-utilizing patients older than 50 years, their family, agency representatives, and LAFD personnel. Interviews were recorded, transcribed, and coded and a thematic analysis was completed. RESULTS: We conducted in-depth interviews with 27 participants, including patients (n = 8), their families (n = 6), social service agency representatives (n = 3), and LAFD personnel (n = 10). The following cross-cutting themes emerged: nature of 9-1-1 calls, barriers to access, and changing the system. In addition, LAFD and social service agency representatives identified the role of EMS responders and social agency representatives. Patients and their families agreed that previous encounters and interactions with emergency care responders were relevant factors. CONCLUSIONS: This study described reasons for 9-1-1 calls related to medical and social service needs, including mental health care. Our analysis offers insight from different stakeholders' perspectives on access to medical care and types of barriers that interfere with medical care. All groups shared recommendations to advance access to medical and mental health care.

The Role of Social Isolation on Mediating Depression and Anxiety among Primary Family Caregivers of Older Adults: A Two-Wave Mediation Analysis.

BACKGROUND: Primary family caregivers of older people with chronic care conditions are highly vulnerable to social isolation and psychological strains such as depression and anxiety due to their demanding responsibilities. This study examines how social isolation mediates the relationship between caregiving stress and mental health symptoms of primary family caregivers. METHODS: The analytic sample included 881 primary caregivers of older adults from the 2015 and 2017 National Study of Caregiving (NSOC). Social isolation was measured using a composite structure that includes objective social disconnectedness and subjective loneliness. Two-wave mediation models were estimated to examine longitudinally if social isolation mediated the relationship between caregiving stress (subjective & objective stress) and mental health symptoms (depression & anxiety) of primary caregivers. RESULTS: The study findings indicate that both subjective (ß = 0.32, p < 0.001) and objective stress (ß = 0.21, p = 0.003) have direct effects on depression among primary caregivers. Social isolation was found to only mediate the relationship between objective stress and depression (ß = 0.18, p < 0.001). In contrast, no significant direct and indirect pathway was found in the anxiety model. CONCLUSIONS: The study demonstrates the internal mechanism where objective strains of caregiving make family caregivers socially isolated, which in turn leads to increased symptoms of depression. Future interventions and practices aimed at improving the psychological well-being of family caregivers should prioritize strategies aimed at increasing social engagement, particularly for those with heavy caregiver burdens.

Ultraviolet sun exposure and sun protection behaviors in outdoor rock climbers.

BACKGROUND: Overexposure to sunlight and sunburn are the main preventable causes of skin cancer. Outdoor sports are associated with significant levels of sunlight exposure. AIMS: We sought to quantify the sun radiation exposure received by outdoor rock climbers and assess their sun exposure habits, sun protection behaviors, attitudes, and knowledge regarding skin cancer. METHODS: From April to June 2021, outdoor rock climbers contacted via email completed an online validated self-reported questionnaire on sun related habits, behaviors, attitudes and knowledge. As a pilot trial, ten participants wore a personal dosimeter during two outdoor climbing weekends in May and November 2021. Ambient ultraviolet radiation (UVR) was also recorded. RESULTS: A total of 217 outdoor rock climbers (103 women), mean age 36.8 ± 8.8 years (range 20-70 years) and median climbing practice per week of 8 h (IQR 7.5) were studied. Two in three (65.9%) participants reported at least one sunburn event during the previous rock climbing season. Of the survey respondents, 49.3% reported using sunscreen with SPF ≥ 15, 47% wore sunglasses, and 14.3% indicated they reapplied sunscreen every two hours. The median personal UVR dose measured during the two outdoor climbing weekends analyzed was 5.2 (IQR 1.8) and 8.8 (IQR 1.1) standard erythemal doses, respectively. CONCLUSIONS: The high rates of sunburn, the elevated personal UVR measured and the clearly insufficient sun protection practices followed during rock climbing together with unsatisfactory attitudes towards tanning reveal the need to develop explicit sun protection campaigns and educational strategies to reduce the risk of skin cancer among the athletes studied.

Preparing for pragmatic trials in dementia care: Health equity considerations for nonpharmacological interventions.

Inequities with regard to brain health, economic costs, and the evidence base for dementia care continue. Achieving health equity in dementia care requires rigorous efforts that ensure disproportionately affected populations participate fully in-and benefit from-clinical research. Embedding-proven interventions under real-world conditions and within existing healthcare systems have the potential to examine the effectiveness of an intervention, improve dementia care, and leverage the use of existing resources. Developing embedded pragmatic controlled trials (ePCT) research designs for nonpharmacological dementia care interventions involves a plethora of a priori assumptions and decisions. Although frameworks exist to determine whether interventions are "ready" for ePCT, there is no heuristic to assess health equity-readiness. We discuss health equity considerations, case examples, and research strategies across ePCT study domains of evidence, risk, and alignment. Future discussions regarding health equity considerations across other domains are needed.

A call to address structural barriers to Hispanic/Latino representation in clinical trials on Alzheimer's disease and related dementias: A micro-meso-macro perspective.

Introduction: This perspective paper addresses the US Hispanic/Latino (herein, Latino) experience with regards to a significant public health concern-the underrepresentation of Latino persons in Alzheimer's disease and related dementias (AD/ADRD) clinical trials. Latino individuals are at increased risk for AD/ADRD, experience higher disease burden, and low receipt of care and services. We present a novel theoretical framework-the Micro-Meso-Macro Framework for Diversifying AD/ADRD Trial Recruitment-which considers multi-level barriers and their impact on Latino trial recruitment. Methods: Based on a review of the peer-reviewed literature and our lived experience with the Latino community, we drew from our interdisciplinary expertise in health equity and disparities research, Latino studies, social work, nursing, political economy, medicine, public health, and clinical AD/ADRD trials. We discuss factors likely to impede or accelerate Latino representation, and end with a call for action and recommendations for a bold path forward. Results: In the 200+ clinical trials conducted with over 70,000 US Americans, Latino participants comprise a fraction of AD/ADRD trial samples. Efforts to recruit Latino participants typically address individual- and family-level factors (micro-level) such as language, cultural beliefs, knowledge of aging and memory loss, limited awareness of research, and logistical considerations. Scientific efforts to understand recruitment barriers largely remain at this level, resulting in diminished attention to upstream institutional- and policy-level barriers, where decisions around scientific policies and funding allocations are ultimately made. These structural barriers are comprised of inadequacies or misalignments in trial budgets, study protocols, workforce competencies, healthcare-related barriers, criteria for reviewing and approving clinical trial funding, criteria for disseminating findings, etiological focus and social determinants of health, among others. Conclusion: Future scientific work should apply and test the Micro-Meso-Macro Framework for Diversifying AD/ADRD Trial Recruitment to examine structural recruitment barriers for historically underrepresented groups in AD/ADRD research and care.