Invasive vs. conservative management of older patients with non-ST-elevation acute coronary syndrome: individual patient data meta-analysis.

BACKGROUND AND AIMS: Older patients with non-ST-elevation acute coronary syndrome (NSTEACS) are less likely to receive guideline-recommended care including coronary angiography and revascularization. Evidence-based recommendations regarding interventional management strategies in this patient cohort are scarce. This meta-analysis aimed to assess the impact of routine invasive vs. conservative management of NSTEACS by using individual patient data (IPD) from all available randomized controlled trials (RCTs) including older patients. METHODS: MEDLINE, Web of Science and Scopus were searched between 1 January 2010 and 11 September 2023. RCTs investigating routine invasive and conservative strategies in persons >70 years old with NSTEACS were included. Observational studies or trials involving populations outside the target range were excluded. The primary endpoint was a composite of all-cause mortality and myocardial infarction (MI) at 1 year. One-stage IPD meta-analyses were adopted by use of random-effects and fixed-effect Cox models. This meta-analysis is registered with PROSPERO (CRD42023379819). RESULTS: Six eligible studies were identified including 1479 participants. The primary endpoint occurred in 181 of 736 (24.5%) participants in the invasive management group compared with 215 of 743 (28.9%) participants in the conservative management group with a hazard ratio (HR) from random-effects model of 0.87 (95% CI 0.63-1.22; P = .43). The hazard for MI at 1 year was significantly lower in the invasive group compared with the conservative group (HR from random-effects model 0.62, 95% CI 0.44-0.87; P = .006). Similar results were seen for urgent revascularization (HR from random-effects model 0.41, 95% CI 0.18-0.95; P = .037). There was no significant difference in mortality. CONCLUSIONS: No evidence was found that routine invasive treatment for NSTEACS in older patients reduces the risk of a composite of all-cause mortality and MI within 1 year compared with conservative management. However, there is convincing evidence that invasive treatment significantly lowers the risk of repeat MI or urgent revascularisation. Further evidence is needed from ongoing larger clinical trials.

"Who's there?": Depicting identity in interaction.

Social robots have limited social competences. This leads us to view them as depictions of social agents rather than actual social agents. However, people also have limited social competences. We argue that all social interaction involves the depiction of social roles and that they originate in, and are defined by, their function in accounting for failures of social competence.

The Association between Mortality and Distance to Treatment Facility in Patients with Muscle Invasive Bladder Cancer.

PURPOSE: Regionalization of bladder cancer treatment is suggested to improve quality of care. As an unintended consequence some patients travel farther for care with unknown implications on outcomes. We characterized the relationship between distance and overall mortality in patients with invasive bladder cancer and those who underwent radical cystectomy. MATERIALS AND METHODS: We performed a retrospective cohort study using NCDB (National Cancer Database) from 2004 to 2012 to identify patients with muscle invasive bladder cancer (cT2a-T4 N0 M0). We also extracted a subgroup of patients who underwent radical cystectomy. Multivariate Cox proportional hazards and multinomial logistic regression analyses were performed in each group, controlling for demographic, clinical, hospital and geographic factors. RESULTS: For 34,729 patients with muscle invasive bladder cancer traveling farther for treatment was associated with a lower probability of overall mortality (referent less than 12.5 miles, 12.5 to 49.9 miles HR 0.96, 95% CI 0.92-0.99 and 50 to 249.9 miles HR 0.91, 95% CI 0.86-0.96). This was significant for patients with cT2 disease and those treated at academic centers (p ≤0.05). For 11,059 patients who underwent radical cystectomy this trend did not reach significance. However, longer distance was associated with surgery at a high volume institution and receipt of neoadjuvant chemotherapy (each p <0.001). CONCLUSIONS: Patients who traveled farther for bladder cancer treatment did not experience inferior survival outcomes and traveling to academic institutions was associated with reduced mortality. For patients who undergo cystectomy this relationship was equivocal, although longer distance was associated with receiving neoadjuvant chemotherapy or surgery at a high volume facility. These findings may reflect a complex association of regionalization of bladder cancer care with patient individual health and health care seeking behavior.

Cognitive impairment and outcomes in older adults with non-ST-elevation acute coronary syndrome.

OBJECTIVE: This study aimed to explore the prognostic impact of cognitive impairment on the long-term risk of major adverse cardiovascular events (MACEs) in older patients with non-ST-elevation acute coronary syndrome (NSTEACS) undergoing invasive treatment. METHODS: Patients aged ≥75 years with NSTEACS undergoing an invasive strategy were included in the multicentre prospective study (NCT01933581). Montreal Cognitive Assessment was used to evaluate cognitive status at baseline (scores ≥26 classified as normal, <26 as cognitive impairment). Long-term follow-up data were obtained from electronic patient care records. The primary endpoint was MACE as a composite of all-cause deaths, reinfarction, stroke/transient ischaemic attack, urgent revascularisation and significant bleeding. RESULTS: 239 patients with baseline cognitive assessment completed long-term follow-up. Median age was 80.9 years (IQR 78.2-83.9 years) and 62.3% were male. On 5-year follow-up, there was no significant difference in the occurrence of MACE between the cognitively impaired group and the normal cognition group (p=0.155). Cognition status was not associated with MACE (HR 1.37 (95% CI 0.96 to 1.95); p=0.082). However, there was significantly more deaths (p=0.005) in those with cognitive impairment. Kaplan-Meier survival analysis (log-rank p=0.003) and Cox regression analysis (aHR 1.85 (95% CI 1.11 to 3.08); p=0.018) revealed increased risk of all-cause mortality, even after adjusting for frailty and GRACE (Global Registry of Acute Coronary Events) score. CONCLUSION: Cognitive impairment in older patients with NSTEACS undergoing an invasive strategy was associated with long-term all-cause mortality. Routine cognitive screening may aid risk stratification and further studies are needed to identify how this should influence management strategies and individual decision-making in this patient group. TRIAL REGISTRATION NUMBER: NCT01933581.

Self-Repair Increases Referential Coordination.

When interlocutors repeatedly describe referents to each other, they rapidly converge on referring expressions which become increasingly systematized and abstract as the interaction progresses. Previous experimental research suggests that interactive repair mechanisms in dialogue underpin convergence. However, this research has so far only focused on the role of other-initiated repair and has not examined whether self-initiated repair might also play a role. To investigate this question, we report the results from a computer-mediated maze task experiment. In this task, participants communicate with each other via an experimental chat tool, which selectively transforms participants' private turn-revisions into public self-repairs that are made visible to the other participant. For example, if a participant, A, types "On the top square," and then before sending, A revises the turn to "On the top row," the server automatically detects the revision and transforms the private turn-revisions into a public self-repair, for example, "On the top square umm I meant row." Participants who received these transformed turns used more abstract and systematized referring expressions, but performed worse at the task. We argue that this is due to the artificial self-repairs causing participants to put more effort into diagnosing and resolving the referential coordination problems they face in the task, yielding better grounded spatial semantics and consequently increased use of abstract referring expressions.

Differences in treatment and clinical outcomes in patients aged ≥75 years compared with those aged ≤74 years following acute coronary syndromes: a prospective multicentre study.

OBJECTIVE: This study describes the differences in treatment and clinical outcomes in patients aged ≥75 years compared with those aged ≤74 years presenting with acute coronary syndrome (ACS) and undergoing invasive management. METHODS: A large-scale cohort study of patients with ST-elevation/non-ST-elevation myocardial infarction (MI)/unstable angina underwent coronary angiography (January 2015-December 2019). Patients were classified as older (≥75 years) and younger (≤74 years). Regression analysis was used to yield adjusted risks of mortality for older versus younger patients (adjusted for history of heart failure, hypercholesterolaemia, peripheral vascular disease, chronic obstructive pulmonary disease, ischaemic heart disease, presence of ST-elevation MI on presenting ECG, female sex and cardiogenic shock at presentation). RESULTS: In total, 11 763 patients were diagnosed with ACS, of which 39% were aged ≥75 years. Percutaneous coronary intervention was performed in fewer older patients than younger patients (81.2% vs 86.2%, p<0.001). At discharge, older patients were prescribed less secondary-prevention medications than younger patients. Median follow-up was 4.57 years. Older patients had a greater risk of in-hospital mortality than younger patients (adjusted OR (aOR) 2.12, 95% CI 1.62 to 2.78, p<0.001). Older patients diagnosed with ST-elevation MI had greater adjusted odds of dying in-hospital (aOR 2.47, 95% CI 1.79 to 3.41, p<0.001). Older age was not an independent prognostic factor of mortality at 1 year (adjusted HR (aHR) 0.95, 95% CI 0.82 to 1.09, p=0.460) and at longer term (aHR 0.98, 95% CI 0.87 to 1.10, p=0.684). CONCLUSIONS: Older patients are discharged with less secondary prevention. Patients aged ≥75 years are more likely to die in-hospital than younger patients.

Running Repairs: Coordinating Meaning in Dialogue.

People give feedback in conversation: both positive signals of understanding, such as nods, and negative signals of misunderstanding, such as frowns. How do signals of understanding and misunderstanding affect the coordination of language use in conversation? Using a chat tool and a maze-based reference task, we test two experimental manipulations that selectively interfere with feedback in live conversation: (a) "Attenuation" that replaces positive signals of understanding such as "right" or "okay" with weaker, more provisional signals such as "errr" or "umm" and (2) "Amplification" that replaces relatively specific signals of misunderstanding from clarification requests such as "on the left?" with generic signals of trouble such as "huh?" or "eh?". The results show that Amplification promotes rapid convergence on more systematic, abstract ways of describing maze locations while Attenuation has no significant effect. We interpret this as evidence that "running repairs"-the processes of dealing with misunderstandings on the fly-are key drivers of semantic coordination in dialogue. This suggests a new direction for experimental work on conversation and a productive way to connect the empirical accounts of Conversation Analysis with the representational and processing concerns of Formal Semantics and Psycholinguistics.

Editors' Introduction: Miscommunication.

Miscommunication is a neglected issue in the cognitive sciences, where it has often been discounted as noise in the system. This special issue argues for the opposite view: Miscommunication is a highly structured and ubiquitous feature of human interaction that systematically underpins people's ability to create and maintain shared languages. Contributions from conversation analysis, computational linguistics, experimental psychology, and formal semantics provide evidence for these claims. They highlight the multi-modal, multi-person character of miscommunication. They demonstrate the incremental, contingent, and locally adaptive nature of the processes people use to detect and deal with miscommunication. They show how these processes can drive language change. In doing so, these contributions introduce an alternative perspective on what successful communication is, new methods for studying it, and application areas where these ideas have a particular impact. We conclude that miscommunication is not noise but essential to the productive flexibility of human communication, especially our ability to respond constructively to new people and new situations.

Impact of Volume and Type of Overnight Pages on Resident Sleep During Home Call.

BACKGROUND: Little research exists regarding factors that contribute to resident fatigue during home call. OBJECTIVE: We objectively tracked the number and type of pages received, as well as residents' sleep time, during home call. We then examined the relationship between paging volume, resident sleep, and resident fatigue. METHODS: A total of 4 of 4 urology residents (100%) at a single institution wore a FitBit Charge HR device from July 2015 to July 2016 to track sleep. Between January and July 2016, pages received by the on-call resident were counted as either floor (urology inpatient unit), clinic (after-hours answering service), or other. Postcall residents were defined as fatigued and excused at noon if they reported they were too tired to safely perform clinical duties. RESULTS: Residents slept an average of 408 minutes per night while not on call, versus 368 minutes while on call but not fatigued, and 181 minutes while on call and fatigued (P < .05). The most senior resident received fewer pages per night on average than the most junior resident. Each page was associated with 4.71 fewer minutes asleep on average for all residents. Pages in the other category were associated with 7.74 fewer minutes asleep per page for all residents, but only the most junior resident had significantly less sleep, 9.02 minutes, per floor page. CONCLUSIONS: Objective sleep data correlate with subjective assessment of resident fatigue and with volume and type of pages received. Senior residents spent less time awake per page and received fewer pages.

Tolerance of uncertainty: A systematic review of health and healthcare-related outcomes.

BACKGROUND: Uncertainty tolerance (UT) is thought to be a characteristic of individuals that influences various outcomes related to health, healthcare, and healthcare education. We undertook a systematic literature review to evaluate the state of the evidence on UT and its relationship to these outcomes. METHODS: We conducted electronic and bibliographic searches to identify relevant studies examining associations between UT and health, healthcare, or healthcare education outcomes. We used standardized tools to assess methodological quality and analyzed the major findings of existing studies, which we organized and classified by theme. RESULTS: Searches yielded 542 potentially relevant articles, of which 67 met inclusion criteria. Existing studies were heterogeneous in focus, setting, and measurement approach, were largely cross-sectional in design, and overall methodological quality was low. UT was associated with various trainee-centered, provider-centered, and patient-centered outcomes which were cognitive, emotional, and behavioral in nature. UT was most consistently associated with emotional well-being. CONCLUSIONS: Uncertainty tolerance is associated with several important trainee-, provider-, and patient-centered outcomes in healthcare and healthcare education. However, low methodological quality, study design limitations, and heterogeneity in the measurement of UT limit strong inferences about its effects, and addressing these problems is a critical need for future research.

Robot-assisted 3D-TRUS guided prostate brachytherapy: system integration and validation.

Current transperineal prostate brachytherapy uses transrectal ultrasound (TRUS) guidance and a template at a fixed position to guide needles along parallel trajectories. However, pubic arch interference (PAI) with the implant path obstructs part of the prostate from being targeted by the brachytherapy needles along parallel trajectories. To solve the PAI problem, some investigators have explored other insertion trajectories than parallel, i.e., oblique. However, parallel trajectory constraints in current brachytherapy procedure do not allow oblique insertion. In this paper, we describe a robot-assisted, three-dimensional (3D) TRUS guided approach to solve this problem. Our prototype consists of a commercial robot, and a 3D TRUS imaging system including an ultrasound machine, image acquisition apparatus and 3D TRUS image reconstruction, and display software. In our approach, we use the robot as a movable needle guide, i.e., the robot positions the needle before insertion, but the physician inserts the needle into the patient's prostate. In a later phase of our work, we will include robot insertion. By unifying the robot, ultrasound transducer, and the 3D TRUS image coordinate systems, the position of the template hole can be accurately related to 3D TRUS image coordinate system, allowing accurate and consistent insertion of the needle via the template hole into the targeted position in the prostate. The unification of the various coordinate systems includes two steps, i.e., 3D image calibration and robot calibration. Our testing of the system showed that the needle placement accuracy of the robot system at the "patient's" skin position was 0.15 mm+/-0.06 mm, and the mean needle angulation error was 0.07 degrees. The fiducial localization error (FLE) in localizing the intersections of the nylon strings for image calibration was 0.13 mm, and the FLE in localizing the divots for robot calibration was 0.37 mm. The fiducial registration error for image calibration was 0.12 mm and 0.52 mm for robot calibration. The target registration error for image calibration was 0.23 mm, and 0.68 mm for robot calibration. Evaluation of the complete system showed that needles can be used to target positions in agar phantoms with a mean error of 0.79 mm+/-0.32 mm.

Mass casualty incident response and aeromedical evacuation in antarctica.

Antarctica is one of the most remote regions on Earth. Mass casualty incident (MCI) responses in Antarctica are prone to complications from multiple environmental and operational challenges. This review of the current status of MCI risks and response strategies for Antarctica focuses on aeromedical evacuation, a critical component of many possible MCI scenarios. Extreme cold and weather, a lack of medical resources and a multitude of disparate international bases all exert unique demands on MCI response planning. Increasing cruise ship traffic is also escalating the risk of MCI occurrence. To be successful, MCI response must be well coordinated and undertaken by trained rescuers, especially in the setting of Antarctica. Helicopter rescue or aeromedical evacuation of victims to off-continent facilities may be necessary. Currently, military forces have the greatest capacity for mass air evacuation. Specific risks that are likely to occur include structure collapses, vehicle incapacitations, vehicle crashes and fires. All of these events pose concomitant risks of hypothermia among both victims and rescuers. Antarctica's unique environment requires flexible yet robust MCI response planning among the many entities in operation on the continent.