Th2 and Th17-associated immunopathology following SARS-CoV-2 breakthrough infection in Spike-vaccinated ACE2-humanized mice.

Vaccines have demonstrated remarkable effectiveness in protecting against COVID-19; however, concerns regarding vaccine-associated enhanced respiratory diseases (VAERD) following breakthrough infections have emerged. Spike protein subunit vaccines for SARS-CoV-2 induce VAERD in hamsters, where aluminum adjuvants promote a Th2-biased immune response, leading to increased type 2 pulmonary inflammation in animals with breakthrough infections. To gain a deeper understanding of the potential risks and the underlying mechanisms of VAERD, we immunized ACE2-humanized mice with SARS-CoV-2 Spike protein adjuvanted with aluminum and CpG-ODN. Subsequently, we exposed them to increasing doses of SARS-CoV-2 to establish a breakthrough infection. The vaccine elicited robust neutralizing antibody responses, reduced viral titers, and enhanced host survival. However, following a breakthrough infection, vaccinated animals exhibited severe pulmonary immunopathology, characterized by a significant perivascular infiltration of eosinophils and CD4+ T cells, along with increased expression of Th2/Th17 cytokines. Intracellular flow cytometric analysis revealed a systemic Th17 inflammatory response, particularly pronounced in the lungs. Our data demonstrate that aluminum/CpG adjuvants induce strong antibody and Th1-associated immunity against COVID-19 but also prime a robust Th2/Th17 inflammatory response, which may contribute to the rapid onset of T cell-mediated pulmonary immunopathology following a breakthrough infection. These findings underscore the necessity for further research to unravel the complexities of VAERD in COVID-19 and to enhance vaccine formulations for broad protection and maximum safety.

Determining the optimal radiation-surgery interval (RSI) for oncologic proctectomy following radiotherapy for rectal adenocarcinoma.

Preoperative radiotherapy has improved outcomes in rectal cancer patients, however, the optimal interval between radiation and proctectomy is unknown. A review of contemporary literature suggests an 8-12 week interval between radiation and surgery likely improves tumor response rates for rectal cancer patients undergoing proctectomy, which may convey modest improvements in long-term oncologic outcomes. Prolonged radiation-surgery intervals may expose surgeons to pelvic fibrosis, however, which may impact later-term proctectomies and compromise perioperative and oncologic outcomes.

Mind The Gap, Aboriginal and Torres Strait Islander Cardiovascular Health: A Narrative Review.

Australia's First Nations Peoples, Aboriginal and Torres Strait Islanders, have reduced life expectancy compared to the wider community. Cardiovascular diseases, mainly driven by ischaemic heart disease, are the leading contributors to this disparity. Despite over a third of First Nations Peoples living in New South Wales, the bulk of the peer-reviewed literature is from Central Australia and Far North Queensland. Regardless of the site of publication, First Nations Peoples are significantly younger at disease onset and have higher rates of comorbidities, in turn driving adverse health events. On top of this, very few First Nations Peoples specific cardiovascular interventions or programs have been shown to improve outcomes. The traditional biomedical model of care is less efficacious and non-traditional models of communication such as clinical yarning may benefit both clinicians and patients. The key purpose of this review is to highlight the deficiencies of our knowledge of cardiovascular burden of disease for First Nations Peoples; and to serve as a catalyst for more dedicated research. We need to have relationships with communities and concentrate on community improvement and partnerships. By involving First Nations Peoples researchers in collaboration with local communities in all levels of health care design and intervention will improve outcomes.

Computed tomography Coronary angiography in rural referral hospitals: A single-Centre experience.

OBJECTIVE: To describe the first 9 months of a newly established computed tomography coronary angiogram (CTCA) over the period of the COVID-19 pandemic. METHODS: A retrospective analysis of the first 9 months of a CT-CA program. DESIGN: Data were collected for the period of June 2020 to March 2021. Information reviewed included demographics, risk factors, renal function, technical factors and outcomes including Calcium Score and Coronary Artery Disease Reporting and Data System (CAD-RADS). SETTING: A single Rural Referral Hospital in regional New South Wales. PARTICIPANTS: Ninety-six CTCAs were reviewed. Ages ranged from 29 to 81 years. 37 (39%) male, 59 (61%) female. 15 (15.6%) identified as Aboriginal and/or Torres Strait Islander. MAIN OBJECTIVE OUTCOMES: CTCA is a viable alternative to invasive coronary angiogram in appropriate populations for regional areas. RESULTS: Eighty-eight (91.6%) were considered technically satisfactory. Mean heart rate was 57 beats per minute with a range of 108. Cardiovascular risk factors included hypertension, dyslipidemia, smoking status, family history and diabetes mellitus. Of patients with CAD-RADS scores 3 or 4 who underwent subsequent invasive coronary angiogram (ICA), 80% were determined to have operator-defined significant stenosis. Significant cardiac and non-cardiac findings were extensive. CONCLUSIONS: CTCA is a safe and efficacious imaging modality for low- to moderate-risk chest pain patients. There was acceptable diagnostic accuracy and the investigation was safe.

Evolutionary conservation and positive selection of influenza A nucleoprotein CTL epitopes for universal vaccination.

Influenza (flu) infection is a leading cause of respiratory diseases and death worldwide. Although seasonal flu vaccines are effective at reducing morbidity and mortality, such effects rely on the odds of successful prediction of the upcoming viral strains. Additional threats from emerging flu viruses that we cannot predict and avian flu viruses that can be directly transmitted to humans urge the strategic development of universal vaccination that can protect against flu viruses of different subtypes and across species. Annual flu vaccines elicit mainly humoral responses. Under circumstances when antibodies induced by vaccination fail to recognize and neutralize the emerging virus adequately, virus-specific cytotoxic T lymphocytes (CTLs) are the major contributors to the control of viral replication and elimination of infected cells. Our studies exploited the evolutionary conservation of influenza A nucleoprotein (NP) and the fact that NP-specific CTL responses pose a constant selecting pressure on functional CTL epitopes to screen for NP epitopes that are highly conserved among heterosubtypes but are subjected to positive selection historically. We identified a region on NP that is evolutionarily conserved and historically positively selected (NP137-182 ) and validated that it contains an epitope that is functional in eliciting NP-specific CTL responses and immunity that can partially protect immunized mice against lethal dose infection of a heterosubtypic influenza A virus. Our proof-of-concept study supports the hypothesis that evolutionary conservation and positive selection of influenza NP can be exploited to identify functional CTL epitope to elicit cross-protection against different heterosubtypes, therefore, to help develop strategies to modify flu vaccine formula for a broader and more durable protective immunity.

Unbundling Bundles: Evaluating the Association of Individual Colorectal Surgical Site Infection Reduction Bundle Elements on Infection Rates in a Statewide Collaborative.

BACKGROUND: Surgical site infection reduction bundles are effective but can be complex and resource intensive. Understanding which bundle elements are associated with reduced surgical site infections may guide concise bundle implementation. OBJECTIVE: The purpose of this study was to evaluate the association of individual surgical site infection reduction bundle elements with infection rates. DESIGN: This was a post-hoc analysis of a prospective cohort study. SETTING: This study took place at Illinois Surgical Quality Improvement Collaborative hospitals. PATIENTS: Patients who had elective colorectal resections at participating hospitals from 2016 to 2017. INTERVENTIONS: The intervention was a 16-element colorectal surgical site infection reduction bundle. MAIN OUTCOME MEASURES: Surgical site infection rates were compared among patients by adherence with each bundle element using χ 2 tests and multivariable logistic regression. Principal component analysis identified composites of correlated bundle elements. Coincidence analysis identified combinations of bundle elements or principal component composites associated with the absence of surgical site infection. RESULTS: Among 2722 patients, 192 (7.1%) developed a surgical site infection. Infections were less likely when oral antibiotics (OR 0.63 [95% CI 0.41-0.97]), wound protectors (OR 0.55 [95% CI 0.37-0.81]), and occlusive dressings (OR 0.71 [95% CI 0.51-1.00]) were used. Bundle elements were reduced into 5 principal component composites. Adherence with the combination of oral antibiotics, wound protector, or redosing intravenous antibiotic prophylaxis plus chlorhexidine-alcohol intraoperative skin preparation was associated with the absence of infection (consistency = 0.94, coverage = 0.96). Four of the 5 principal component composites in various combinations were associated with the absence of surgical site infection, whereas the composite consisting of occlusive dressing placement, postoperative dressing removal, and daily postoperative chlorhexidine incisional cleansing had no association with the outcome. LIMITATIONS: The inclusion of hospitals engaged in quality improvement initiatives may limit the generalizability of these data. CONCLUSION: Bundle elements had varying association with infection reduction. Implementation of colorectal surgical site infection reduction bundles should focus on the specific elements associated with low surgical site infections. See Video Abstract at http://links.lww.com/DCR/B808 . DESEMPAQUETANDO PAQUETES EVALUACIN DE LA ASOCIACIN DE ELEMENTOS INDIVIDUALES DEL PAQUETE DE REDUCCIN DE INFECCIONES DEL SITIO QUIRRGICO COLORRECTAL CON LAS TASAS DE INFECCIN EN UNA COLABORACIN ESTATAL: ANTECEDENTES:Los paquetes de reducción de infecciones del sitio quirúrgico son efectivos pero pueden ser complejos y requieren muchos recursos. Comprender qué elementos del paquete están asociados con la reducción de las infecciones del sitio quirúrgico puede guiar la implementación concisa del paquete.OBJETIVO:Evaluar la asociación de los elementos individuales del paquete de reducción de infecciones del sitio quirúrgico con las tasas de infección.DISEÑO:Análisis post-hoc de un estudio de cohorte prospectivo.ESCENARIO:Hospitales colaborativos para la mejora de la calidad quirúrgica de Illinois.PACIENTES:Resecciones colorrectales electivas en los hospitales participantes entre 2016 y 2017.INTERVENCIONES:Paquete de reducción de infección del sitio quirúrgico colorrectal de 16 elementos.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las tasas de infección del sitio quirúrgico entre los pacientes según la adherencia con cada elemento del paquete mediante pruebas de Chi cuadrado y regresión logística multivariable. El análisis de componentes principales identificó compuestos de elementos de paquete correlacionados. El análisis de coincidencia identificó combinaciones de elementos del haz o compuestos de componentes principales asociados con la ausencia de infección del sitio quirúrgico.RESULTADOS:Entre 2722 pacientes, 192 (7,1%) desarrollaron una infección del sitio quirúrgico. Las infecciones fueron menos probables cuando se administraron antibióticos orales (OR 0,63 (IC 95% 0,41-0,97)), protectores de heridas (OR 0,55 (IC 95% 0,37-0,81)) y vendajes oclusivos (OR 0.71 (IC 95% 0,51-1,00]) fueron usados. Los elementos del paquete se redujeron a 5 grupos de componentes principales. La adherencia a la combinación de (1) antibióticos orales, (2) protector de heridas o (3) redosificación de profilaxis antibiótica intravenosa más preparación de la piel intraoperatoria con clorhexidina-alcohol se asoció con la ausencia de infección (consistencia = 0,94, cobertura = 0,96). Cuatro de los cinco grupos de componentes principales en varias combinaciones se asociaron con la ausencia de infección del sitio quirúrgico, mientras que el grupo que consiste en la colocación del apósito oclusivo, la remosión del apósito en posoperatorio y la limpieza incisional posoperatoria diaria con clorhexidina no tuvo asociación con el resultado.LIMITACIONES:La inclusión de hospitales que participan en iniciativas de mejora de la calidad puede limitar la generalización de estos datos.CONCLUSIONES:Los elementos del paquete tuvieron una asociación variable con la reducción de la infección. La implementación de paquetes de reducción de infecciones del sitio quirúrgico colorrectal debe centrarse en los elementos específicos asociados con pocas infecciones del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B808 . (Traducción-Juan Carlos Reyes ).

The Prevalence of Iron Deficiency in Atrial Fibrillation: Low Hanging Fruit?

Background and Objectives: Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. The relationship between AF and iron deficiency is poorly understood. Materials and Methods: We conducted an observational study investigating the prevalence of iron deficiency in those with AF. Iron deficiency was defined by the American College of Cardiology (ACC) criteria for iron deficiency in heart failure. Results: Of 134 eligible subjects, 81 (60.4%) met the ACC definition of iron deficiency in heart failure. Those who were iron deficient were more likely to be female (OR 1.876, p = 0.005), have a history of diabetes mellitus (OR 3.085, p = 0.001) a history of stroke (OR 3.147, p = 0.016), and have higher CHA2DS2-VASc (p ≤ 0.0001) and Charlson Comorbidity Index scores (CCI) (p = 0.007). Conclusions: The prevalence of iron deficiency in those with AF appears high and warrants evaluation in a prospective study.

TCR/ITK Signaling in Type 1 Regulatory T cells.

Type 1 regulatory T (Tr1) cells can modulate inflammation through multiple direct and indirect molecular and cellular mechanisms and have demonstrated potential for anti-inflammatory therapies. Tr1 cells do not express the master transcription factor of conventional regulatory T cells, Foxp3, but express high levels of the immunomodulatory cytokine, IL-10. IL-2-inducible T-cell kinase (ITK) is conserved between mouse and human and is highly expressed in T cells. ITK signaling downstream of the T-cell receptor (TCR) is critical for T-cell subset differentiation and function. Upon activation by TCR, ITK is critical for Ras activation, leading to downstream activation of MAPKs and upregulation of IRF4, which further enable Tr1 cell differentiation and suppressive function. We summarize here the structure, signaling pathway, and function of ITK in T-cell lineage designation, with an emphasis on Tr1 cell development and function.

Ischaemic Heart Disease Mortality Increased With Weekend Admission: Results From a Large, Comprehensive Admission Cohort in Australia.

BACKGROUND: The phenomenon of the "weekend effect", whereby patient outcomes are significantly worse for those admitted to hospital on the weekend as compared to weekdays, is well-documented in systematic reviews and meta-analyses in the literature. We sought to assess the effect of the time of a patient's admission on outcomes across an entire cardiology admissions cohort and explore other factors that have been previously identified or proposed to influence these outcomes, including admissions out-of-hours, and patient transfers from other facilities. METHODS: We conducted a retrospective cohort study involving cardiology admissions at a large tertiary referral centre across a 6-year period from 1 January 2012 to 31 December 2017. Outcomes were in-hospital, 30-day and 1-year mortality rates as well as length-of-stay, and readmission rate. 14,078 patients admitted under a cardiologist across the 6-year period were identified, with 3,029 elective patients excluded. Patients were stratified into weekday (n=8,951) or weekend (n=2,098) categories. RESULTS: In-hospital mortality for weekend admissions was noted to be significantly higher compared to weekday admissions (adj OR 1.78, 95% CI 1.40-2.28; p<0.001). Mortality for weekend admissions was also higher at 30-days (adj OR 1.74, 95% CI 1.39-2.17; p<0.001) and at 1-year (adj OR 1.33 95% CI 1.14-1.55; p<0.001). Adjusted for diagnosis, there was a significant increase in in-hospital, 30-day and 1-year mortality seen only for weekend admissions with the final diagnosis of acute myocardial infarction. CONCLUSION: We have identified an association between weekend admissions and higher in-hospital, 30-day and 1-year mortality for the final diagnosis of acute myocardial infarction in our cardiology admissions data over an extended period of time, although confounders cannot be completely discounted. Any steps to reduce the weekend effect need to move to a system where weekend practices are not substantially different to a usual business day. The question of whether changes in organisation practice and the increased costs incurred would reduce mortality in this high-risk group needs to be addressed by further directed research.

Tuning T helper cell differentiation by ITK.

CD4+ effector T cells effectuate T cell immune responses, producing cytokines to orchestrate the nature and type of immune responses. The non-receptor tyrosine kinase IL-2 inducible T cell kinase (ITK), a mediator of T cell Receptor signaling, plays a critical role in tuning the development of these effector cells. In this review we discussed the role that signals downstream of ITK, including the Ras/MAPK pathway, play in differentially controlling the differentiation of TH17, Foxp3+ T regulatory (Treg) cells, and Type 1 regulatory T (Tr1) cells, supporting a model of ITK signals controlling a decision point in the effector T cell differentiation process.

Leveraging a Comprehensive Program to Implement a Colorectal Surgical Site Infection Reduction Bundle in a Statewide Quality Improvement Collaborative.

OBJECTIVES: Our objective was to examine the implementation and associated clinical outcomes of a comprehensive surgical site infection (SSI) reduction bundle in a large statewide surgical quality improvement collaborative leveraging a multifaceted implementation strategy. SUMMARY BACKGROUND DATA: Bundled perioperative interventions reduce colorectal SSI rates when enacted at individual hospitals, but the ability to implement comprehensive SSI bundles and to examine the resultant clinical effectiveness within a larger, diverse population of hospitals is unknown. METHODS: A multifaceted SSI reduction bundle was developed and implemented in a large statewide surgical quality improvement collaborative through a novel implementation program consisting of guided implementation, data feedback, mentorship, process improvement training/coaching, and targeted-implementation toolkits. Bundle adherence and ACS NSQIP outcomes were examined preimplementation versus postimplementation. RESULTS: Among 32 hospitals, there was a 2.5-fold relative increase in the proportion of patients completing at least 75% of bundle elements (preimplementation = 19.5% vs. postimplementation = 49.8%, P = 0.001). Largest adherence gains were seen in wound closure re-gowning/re-gloving (24.0% vs. 62.0%, P < 0.001), use of clean closing instruments (32.1% vs. 66.2%, P = 0.003), and preoperative chlorhexidine bathing (46.1% vs. 77.6%, P < 0.001). Multivariable analyses showed a trend toward lower risk of superficial incisional SSI in the postimplementation period compared to baseline (OR 0.70, 95% CI 0.49-10.2, P = 0.06). As the adherence in the number of bundle elements increased, there was a significant decrease in superficial SSI rates (lowest adherence quintile, 4.6% vs. highest, 1.5%, P < 0.001). CONCLUSIONS: A comprehensive multifaceted SSI reduction bundle can be successfully implemented throughout a large quality improvement learning collaborative when coordinated quality improvement activities are leveraged, resulting in a 30% decline in SSI rates. Lower superficial SSI rates are associated with the number of adherent bundle elements a patient receives, rendering considerable benefits to institutions capable of implementing more components of the bundle.

Specificity of Myocardial Perfusion Imaging: Issues With Proposed MBS Item Review.

Myocardial perfusion scanning (MPS) is commonly used to assess patients with an intermediate to high risk of coronary artery disease. Concerns have been raised about the accuracy of this test. There is little recent data regarding the specificity of the MPS in the context of current medical therapy. The primary objective of this study is to determine the specificity of MPS in diagnosing obstructive coronary artery disease. A total of 184 patients fulfilled study criteria. The overall specificity of MPS for obstructive coronary artery disease was 54%.The only demographic variable that influenced specificity was gender: males with a specificity of 66% and females with a specificity of 29% (p-value=0.001). These results suggest that the real world specificity of MPS is lower than previously indicated, particularly in the female population. The limitations proposed by the Cardiac Services Committee Report are therefore unlikely to improve patient outcomes.

Groin Haemostasis With a Purse String Suture for Patients Following Catheter Ablation Procedures (GITAR Study).

BACKGROUND: The most frequent complications from percutaneous electrophysiology procedures relate to vascular access. We sought to perform the first randomised controlled trial for femoral venous haemostasis utilising a simple and novel purse string suture (PSS) technique. METHODS: We randomised 200 consecutive patients who were referred for electrophysiology procedures at two different hospitals to either 10minutes of manual pressure or a PSS over the femoral vein and determined the incidence of vascular access site complications. RESULTS: The mean age was 61.8±12.1years and 138 (69%) were male. Bleeding requiring addition pressure or a FemStop (Abbott Laboratories, Abbott Park, IL, USA) for complete haemostasis occurred in 17/99 (17%) patients in the PSS arm and 19/101 (19%) patients in the manual pressure arm (p=0.72). There were no cases of haematoma prolonging hospital stay, arterio-venous fistula, pseudoaneurysm or retroperitoneal bleeding. The mean duration to achieve haemostasis was 45seconds in the PSS arm and 10minutes 44seconds in the manual pressure arm (p<0.001). Pain/discomfort associated with haemostasis occurred in 15/99 (15%) patients in the PSS arm and in 29/101 (29%) patients receiving manual pressure (p=0.03). CONCLUSIONS: In this randomised trial we demonstrate that an easy to perform PSS is as effective at achieving haemostasis as 10minutes of manual pressure for catheter ablation procedures. The PSS is considerably faster to perform and is more comfortable for patients than manual pressure.

Evaluation of Noninvasive Thermometers in an Endoscopy Setting.

The measurement of body temperature is an important aspect of assessment prior to invasive procedures. The purpose of the study was to determine the level of agreement between temporal artery, noncontact infrared, and disposable oral electronic thermometers to a clinical reference device (nondisposable oral electronic thermometer) in outpatients prior to an endoscopic procedure. A descriptive, method-comparison study design was used to compare 3 noninvasive thermometers with a clinical reference device. Four noninvasive temperatures were measured with 3 test devices (temporal artery with ear tap; temporal artery without ear tap; disposable oral electronic; and noncontact infrared), followed by measurement with the clinical reference device (nondisposable, oral electronic). Differences (bias) and limits of agreement (±1.96 SD) were calculated for the test devices and graphed using Bland-Altman method. Clinically acceptable levels of agreement were set at a bias of 0.54 °F or less and precision of 0.90 °F or less. A total of 25 endoscopy patients (N = 14 female; N = 11 male) were studied, with temperatures ranging from 97.5 to 98.9, averaging 98.1 ± 0.3 °F. All thermometers, with the exception of the noncontact infrared (0.66 °F), had acceptable ranges for use in clinical practices. Findings from this study support the use of both temporal artery and disposable oral electronic thermometers in afebrile outpatients but not the noncontact infrared thermometer.

Heart Failure Hospitalisations in the Hunter New England Area Over 10 years. A Changing Trend.

BACKGROUND: Heart failure carries a major burden on our health system, mainly related to the high rate of hospital admission. An understanding of the recent trends in heart failure hospitalisation is essential to the future allocation of health resources. Our aim is to analyse the temporal trends in heart failure hospitalisation. METHODS: We extracted all separations in the Hunter New England Local Health District between 2005-2014 (n=40,119) with an ICD 10 code for heart failure (I-50) in the first four diagnoses on discharge. The numbers of hospitalisations were age-standardised to the 2001 Australian population and compared based on gender and remoteness. RESULTS: There was a decline in the age-standardised hospitalisation. However, there was a clear inflection point between 2009-2010, after which the decline levelled off. The absolute number of hospitalisations increased between 2010 and 2014. Heart failure hospitalisation was higher in males compared to females and rural compared to metropolitan inhabitants. CONCLUSION: The gains in heart failure treatment noted in recent years seem to have come to an end. Patients aged 75 years and older are contributing the majority of age-standardised hospitalisations.

Preoperative Considerations for the Ostomate.

Intestinal stomas significantly impact patients' quality of life. Stoma-related complications are common, but even without complications, patients are faced with new challenges in stoma management and daily activities. Preoperative patient education and stoma site marking, in conjunction with conscientious surgical stewardship, are key to patient satisfaction and successful operative outcomes.

The anthropometric definition of the rectum is highly variable.

PURPOSE: The precise definition of the rectum is essential for localizing colorectal pathology, yet current definitions are nebulous. The objective of this study is to determine the anthropometric definition of common pelvic landmarks in relation to patient characteristics. METHODS: Seventy-one patients underwent open proctectomy with intra-operative measurements from the anal verge to various pelvic landmarks, and patient characteristics were evaluated. Analyses were performed using Spearman correlation and Wilcoxon rank sum. RESULTS: The mean landmark distance was dentate line = 1.7 cm (range 0.8-4.0 cm), puborectalis muscle = 4.2 cm (range 2.0-8.0 cm), anterior peritoneal reflection = 13.2 cm (range 8.5-21.0 cm), sacral promontory = 17.9 cm (range 13.0-26.0 cm), and confluence of the taenia = 25.5 cm (range 16.0-44.0 cm). Men had longer mean distances to the dentate line (p = 0.0003), puborectalis muscle (p = 0.03), and anterior peritoneal reflection (p = 0.02). Patient weight significantly correlated with distance to all landmarks except for the confluence of the taenia, which did not correlate with any patient factor. CONCLUSIONS: The location of common pelvic landmarks is highly variable. The use of predefined absolute measurements from the anal verge to localize rectal pathology is inaccurate and fails to account for patient variability.

Authenticity and healing.

Caring and compassion cannot be faked. These are not actions we perform mechanically but states of being that flow from within to make healing connection with others in need. To be authentically healing requires that we live authentic lives. This paper describes what it means to be authentic from a psychospiritual perspective, discusses the components of authentic caring and ends with an exploration of ways to cultivate the authenticity of our lives in general and in our efforts to heal others.