Insight into the Functional Dynamics and Challenges of Exosomes in Pharmaceutical Innovation and Precision Medicine.

Of all the numerous nanosized extracellular vesicles released by a cell, the endosomal-originated exosomes are increasingly recognized as potential therapeutics, owing to their inherent stability, low immunogenicity, and targeted delivery capabilities. This review critically evaluates the transformative potential of exosome-based modalities across pharmaceutical and precision medicine landscapes. Because of their precise targeted biomolecular cargo delivery, exosomes are posited as ideal candidates in drug delivery, enhancing regenerative medicine strategies, and advancing diagnostic technologies. Despite the significant market growth projections of exosome therapy, its utilization is encumbered by substantial scientific and regulatory challenges. These include the lack of universally accepted protocols for exosome isolation and the complexities associated with navigating the regulatory environment, particularly the guidelines set forth by the U.S. Food and Drug Administration (FDA). This review presents a comprehensive overview of current research trajectories aimed at addressing these impediments and discusses prospective advancements that could substantiate the clinical translation of exosomal therapies. By providing a comprehensive analysis of both the capabilities and hurdles inherent to exosome therapeutic applications, this article aims to inform and direct future research paradigms, thereby fostering the integration of exosomal systems into mainstream clinical practice.

Hearing loss and psychosocial outcomes: Influences of social emotional aspects and personality.

The aim of this study was to examine the effects of social isolation, loneliness, anxiety, depression, higher stress, and memory complaints interacting with personality traits as a function of hearing loss. Personality traits have previously been shown to correlate with anxiety and depression, as well as hearing loss, suggesting an effect of personality on the relationship between social emotional outcomes and hearing loss. A cross-sectional survey including validated screening measures was anonymously administered. Measures included personality (Big Five Index-2 Extra-Short Form), stress (Perceived Stress Scale), anxiety and depression (Patient Health Questionnaire for Depression and Anxiety), loneliness (Three-Item Loneliness Scale), social engagement (Lubben Social Network Scale-6), and self-perceived memory complaints (Subjective Cognitive Function). Eight hundred and ninety-one responses were obtained from adults between the ages of 18 and 90 years old (M = 50 years old). Hearing loss was positively correlated with subjective memory complaints only when not accounting for demographic variables, personality traits, psychosocial outcomes, and social emotional outcomes. There were additive effects of hearing loss and negative emotionality on increases in memory complaints in those who self-identified as maybe having hearing loss. Higher degrees of hearing loss also increased loneliness, with greater hearing loss negating the positive correlation between extraversion and social engagement. Overall, our results suggest that hearing loss significantly interacts with personality traits and other social emotional measures. Our results suggest that the impact of hearing loss on memory complaints, social isolation, and loneliness may differ across patients with hearing loss in comparison with those who think they maybe have hearing loss. Information from this study may provide insights for hearing healthcare and mental healthcare professionals to better serve persons with hearing loss who may require additional support or interventions.

Digits-in-Noise Test as an Assessment Tool for Hearing Loss and Hearing Aids.

The aim of this study was to examine the relationship between an American English Digits in Noise (DIN) test and commonly used audiological measures to evaluate the DIN test's ability to detect hearing loss and validate hearing aid fitting. QuickSIN and DIN tests were completed by participants with untreated hearing loss (n = 46), prescription hearing aids (n = 15), and over-the-counter (OTC) hearing aids (n = 12). Performance on the QuickSIN showed moderate positive correlations with DIN for untreated hearing loss participants and prescription hearing aid users, but not for OTC hearing aid users. For untreated hearing loss participants, both QuickSIN and DIN tests showed positive moderate to strong correlations with high frequency puretone averages. In OTC users, DIN scores did not significantly change over a 6-month time period and were better when conducted remotely compared to in-person testing. Our results suggest that the DIN test may be a feasible monitoring option for individuals with hearing loss and those fitted with hearing aids. However, due to small sample size in this pilot study, future research is needed to examine DIN test's utility for fitting and validating OTC hearing aids.

Risk Factors for Fragility Fractures in Chronic Lymphocytic Leukemia.

Abnormal bone health and fragility fractures (FF) are more common in patients with chronic lymphocytic leukemia (CLL). We hypothesize that there may be risk factors in CLL patients with osteoporosis that increase the risk of FFs. We conducted a cohort study encompassing all patients diagnosed with CLL from January 1, 2000, to July 31, 2020, utilizing International Classification of Diseases (ICD) codes related to abnormal bone health (osteopenia, osteoporosis, and/or presence of FF) within a single tertiary care institution. Of the 89 patients included, 55 (62%) were female with a mean age of 68 ± 11 years at cohort entry. Fifty-nine (66%) had at least one FF present (pFF) and 30 (34%) did not have an FF (nFF). There were no differences in IGHV (Immunoglobulin heavy chain variable region gene) mutation status, chromosomal abnormalities, or the presence of a complex karyotype. The spine accounted for 81% of identified FF. T-score <-2.5 was more common in those without FF (pFF 38% vs. nFF 71%, P = 0.02). DXA evaluation was not conducted for 36 (40%) individuals within the cohort. Risk factors for fragility fractures included male sex (relative risk [RR] 8.1, 95% confidence interval [CI] 2.1-31.7), diabetes mellitus (RR 1.4, 95% CI 1.04-1.8), smoking (RR 1.3, 95% CI 1.02-1.8), Rai stage >0 (RR 1.4, 95% CI 1.04-1.9), and T-score >-2.5 (RR 1.8, 95% CI 1.1-3.1). There is a high frequency of vertebral FFs in people with CLL despite T-scores not being in the osteoporotic range. Increased awareness to screen and treat vertebral FFs in people with CLL is needed.

Laryngological Symptomatology in Patients with Ehlers-Danlos Syndrome.

Laryngological manifestations of connective tissue diease with hypermobility such as ehlers-danlos syndrome (EDS) are not well defined in the literature. EDS is an inherited, hetrogeneous, connective tissue disorder characterized by joint hypermobility, skin extensibility, and joint dislocations. A case series of 9 patients is presented with varying laryngological complaints. Common comorbities include postural orthostatic tachycardia syndrome (POTS), fibromyalgia, irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD)/laryngopharyngeal reflux disease (LPRD). Six patients were singers. Videostroboscopic parameters and treatment courses are described. It may be beneficial to view patients with EDS and laryngological complaints through a holistic lens as many may need interdisciplinary assessment and management. Laryngoscope, 134:894-896, 2024.

Auditory Cortex Maturation and Language Development in Children with Hearing Loss and Additional Disabilities.

A significant portion of hearing-impaired children have additional disabilities, but data about the maturation of their auditory cortex are scarce. In these children, behavioral tests are often unreliable, and objective tests are needed for diagnostics and follow-up. This study aimed to explore auditory cortical maturation and language development, and the usability of an objective electroencephalogram-based biomarker in children with multiple disabilities. In 65 hearing aid and cochlear implant users (36 females; 36 with multiple disabilities; 44.3 ± 18.5 months of age, mean ± SD), auditory processing was examined using the P1 cortical auditory evoked response biomarker, and language development with the Preschool Language Scales 5th edition (PLS-5). During the study, all of the children received intensive extra language therapy for six months. No significant differences were found between the groups in P1 latency development, the proportion of abnormal P1 latencies, or the number of children whose P1 latencies changed from abnormal to normal during the study. The PLS-5 total language scores, auditory comprehension scores, or expressive communication scores did not differ between groups either. The P1 latencies showed meaningful negative correlations with the language scores. The results suggest that auditory cortex development is similar in hearing-impaired children with/without additional disabilities, and the P1 biomarker is a feasible tool to evaluate central auditory maturation in children with multiple disabilities.

Comparative Evaluation of the Rigidity and Accuracy of Different Elastomeric Impression Materials with Open Tray Implant Level Impression Technique-An In vitro Study.

Introduction: An implant-supported prosthesis requires a precise imprint to provide a good fit. It has been suggested that for implant/abutment level impressions, both the indirect (closed tray) and direct (open tray) methods are effective in achieving a passively fitting prosthesis. Aim: With an open plate embed level impression technique, this in vitro investigation set out to evaluate three different elastomeric imprint materials for their relative rigidity and precision. Materials and Methods: Sixty bespoke trays were created. Part I (rotational opposition assessment) of the investigation included selecting 30 uniquely shaped plates at random and using them to create embed-level open plate engraves. The second part of this investigation (evaluation of rotational discrepancy and vertical inconsistency) used open plate embed level impressions generated with the remaining thirty individualized plates to evaluate how well these materials recreated the patient's impressions. Result: Within the bounds of the current investigation, vinylpolysiloxane had the highest degree of stiffness among the impression materials examined in comparison to polyether and vinylsiloxanether, as seen by its much greater rotational resistance to torquing. A rotational discrepancy was shown to be much lower in polyether open tray implant level impressions compared to vinylpolysiloxane and comparable to vinylsiloxane. Conclusion: In this investigation, the firmest impression medium was vinylpolysiloxane, followed by polyether and vinylsiloxanether for taking imprints of implants. Polyether material, however, was more precise than vinylpolysiloxane and vinylsiloxanether.

Development of DNA markers using next-generation sequencing approach for molecular authentication of Boerhavia diffusa L. and Tinospora cordifolia (Willd.) Miers.

The adulteration of plants and their materials used in herbal formulations poses a severe health concern. Hence, there is a need to establish a reliable, cost-effective, and robust molecular biomarker to distinguish among species and identify herbal plants and raw drugs from adulterants. The present study used suppressive subtractive hybridization and next-generation sequencing technology to identify novel DNA markers for Boerhavia diffusa L. and Tinospora cordifolia (Willd.) Miers. We identified two primer sets for B. diffusa and one for T. cordifolia. The DNA markers were validated in different accessions of B. diffusa and T. cordifolia and their common adulterants to determine the sensitivity and specificity of developed DNA markers. The designed DNA markers showed 100% sensitivity and specificity in detecting B. diffusa and T. cordifolia from their adulterants. The strategy described here can be extrapolated for developing DNA markers to authenticate other plant species. Supplementary Information: The online version contains supplementary material available at 10.1007/s13205-023-03732-7.

CDMS Analysis of Intact 19S, 20S, 26S, and 30S Proteasomes: Evidence for Higher-Order 20S Assemblies at a Low pH†.

Charge detection mass spectrometry (CDMS) was examined as a means of studying proteasomes. To this end, the following masses of the 20S, 19S, 26S, and 30S proteasomes from Saccharomyces cerevisiae (budding yeast) were measured: m(20S) = 738.8 ± 2.9 kDa, m(19S) = 926.2 ± 4.8 kDa, m(26S) = 1,637.0 ± 7.6 kDa, and m(30S) = 2,534.2 ± 10.8 kDa. Under some conditions, larger (20S)x (where x = 1 to ∼13) assemblies are observed; the 19S regulatory particle also oligomerizes, but to a lesser extent, forming (19S)x complexes (where x = 1 to 4, favoring the x = 3 trimer). The (20S)x oligomers are favored in vitro, as the pH of the solution is lowered (from 7.0 to 5.4, in a 20 mM ammonium acetate solution) and may be related to in vivo proteasome storage granules that are observed under carbon starvation. From measurements of m(20S)x (x = 1 to ∼13) species, it appears that each multimer retains all 28 proteins of the 20S complex subunit. Several types of structures that might explain the formation of (20S)x assemblies are considered. We stress that each structural type [hypothetical planar, raft-like geometries (where individual proteasomes associate through side-by-side interactions); elongated, rodlike geometries (where subunits are bound end-to-end); and geometries that are roughly spherical (arising from aggregation through nonspecific subunit interactions)] is highly speculative but still interesting to consider, and a short discussion is provided. The utility of CDMS for characterizing proteasomes and related oligomers is discussed.

Core microbiota of wheat rhizosphere under Upper Indo-Gangetic plains and their response to soil physicochemical properties.

Wheat is widely cultivated in the Indo-Gangetic plains of India and forms the major staple food in the region. Understanding microbial community structure in wheat rhizosphere along the Indo-Gangetic plain and their association with soil properties can be an important base for developing strategies for microbial formulations. In the present study, an attempt was made to identify the core microbiota of wheat rhizosphere through a culture-independent approach. Rhizospheric soil samples were collected from 20 different sites along the upper Indo-Gangetic plains and their bacterial community composition was analyzed based on sequencing of the V3-V4 region of the 16S rRNA gene. Diversity analysis has shown significant variation in bacterial diversity among the sites. The taxonomic profile identified Proteobacteria, Chloroflexi, Actinobacteria, Bacteroidetes, Acidobacteria, Gemmatimonadetes, Planctomycetes, Verrucomicrobia, Firmicutes, and Cyanobacteria as the most dominant phyla in the wheat rhizosphere in the region. Core microbiota analysis revealed 188 taxa as core microbiota of wheat rhizosphere with eight genera recording more than 0.5% relative abundance. The order of most abundant genera in the core microbiota is Roseiflexus> Flavobacterium> Gemmatimonas> Haliangium> Iamia> Flavisolibacter> Ohtaekwangia> Herpetosiphon. Flavobacterium, Thermomonas, Massilia, Unclassified Rhizobiaceae, and Unclassified Crenarchaeota were identified as keystone taxa of the wheat rhizosphere. Correlation studies revealed, pH, organic carbon content, and contents of available nitrogen, phosphorus, and iron as the major factors driving bacterial diversity in the wheat rhizosphere. Redundancy analysis has shown the impact of different soil properties on the relative abundance of different genera of the core microbiota. The results of the present study can be used as a prelude to be developing microbial formulations based on core microbiota.

Associations Between Vascular Risk Factor Levels and Cognitive Decline Among Stroke Survivors.

Importance: Incident stroke is associated with accelerated cognitive decline. Whether poststroke vascular risk factor levels are associated with faster cognitive decline is uncertain. Objective: To evaluate associations of poststroke systolic blood pressure (SBP), glucose, and low-density lipoprotein (LDL) cholesterol levels with cognitive decline. Design, Setting, and Participants: Individual participant data meta-analysis of 4 US cohort studies (conducted 1971-2019). Linear mixed-effects models estimated changes in cognition after incident stroke. Median (IQR) follow-up was 4.7 (2.6-7.9) years. Analysis began August 2021 and was completed March 2023. Exposures: Time-dependent cumulative mean poststroke SBP, glucose, and LDL cholesterol levels. Main Outcomes and Measures: The primary outcome was change in global cognition. Secondary outcomes were change in executive function and memory. Outcomes were standardized as t scores (mean [SD], 50 [10]); a 1-point difference represents a 0.1-SD difference in cognition. Results: A total of 1120 eligible dementia-free individuals with incident stroke were identified; 982 (87.7%) had available covariate data and 138 (12.3%) were excluded for missing covariate data. Of the 982, 480 (48.9%) were female individuals, and 289 (29.4%) were Black individuals. The median age at incident stroke was 74.6 (IQR, 69.1-79.8; range, 44.1-96.4) years. Cumulative mean poststroke SBP and LDL cholesterol levels were not associated with any cognitive outcome. However, after accounting for cumulative mean poststroke SBP and LDL cholesterol levels, higher cumulative mean poststroke glucose level was associated with faster decline in global cognition (-0.04 points/y faster per each 10-mg/dL increase [95% CI, -0.08 to -0.001 points/y]; P = .046) but not executive function or memory. After restricting to 798 participants with apolipoprotein E4 (APOE4) data and controlling for APOE4 and APOE4 × time, higher cumulative mean poststroke glucose level was associated with a faster decline in global cognition in models without and with adjustment for cumulative mean poststroke SBP and LDL cholesterol levels (-0.05 points/y faster per 10-mg/dL increase [95% CI, -0.09 to -0.01 points/y]; P = .01; -0.07 points/y faster per 10-mg/dL increase [95% CI, -0.11 to -0.03 points/y]; P = .002) but not executive function or memory declines. Conclusions and Relevance: In this cohort study, higher poststroke glucose levels were associated with faster global cognitive decline. We found no evidence that poststroke LDL cholesterol and SBP levels were associated with cognitive decline.

Prioritizing research on over-the-counter (OTC) hearing aids for age-related hearing loss.

Hearing aids are the most commonly used treatment for people with age-related hearing loss, however, hearing aid uptake is low, primarily due to high cost of the device, stigma, and a lack of perceived need. To address accessibility and affordability issues, the U.S. Food and Drug Administration created a new over-the-counter (OTC) hearing aid category. Various types of hearing devices are available for both individuals with hearing loss and for those with normal hearing, as hearing enhancement devices. Hearing aids (i.e., prescription hearing aids, self-fitting OTC hearing aids, and pre-set OTC hearing aids) are regulated by the FDA. The purpose of this article is to (a) provide a summary of existing research on direct-to-consumer (DTC) hearing devices such as Personal Sound Amplification Products (PSAPs) that informs OTC service delivery models; (b) provide an update on existing and ongoing randomized controlled trials on currently marketed OTC hearing aids; and (c) highlight the need for immediate research on OTC hearing aids and service delivery models to inform policy and clinical care. It remains to be seen what effect OTC hearing aids have on improving the uptake of hearing aids by individuals with mild-to-moderate hearing loss. However, there is scant research on all aspects of OTC hearing aids that are currently on the market. We conclude that high quality independent research must be prioritized to supplement evidence provided by the OTC hearing aid manufacturers for regulatory approval purposes.

Bacterial Pyocyanin Inducible Keratin 6A Accelerates Closure of Epithelial Defect under Conditions of Mitochondrial Dysfunction.

Repair of epithelial defect is complicated by infection and related metabolites. Pyocyanin (PYO) is one such metabolite that is secreted during Pseudomonas aeruginosa infection. Keratinocyte (KC) migration is required for the closure of skin epithelial defects. This work sought to understand PYO-KC interaction and its significance in tissue repair. Stable Isotope Labeling by Amino acids in Cell culture proteomics identified mitochondrial dysfunction as the top pathway responsive to PYO exposure in human KCs. Consistently, functional studies showed mitochondrial stress, depletion of reducing equivalents, and adenosine triphosphate. Strikingly, despite all stated earlier, PYO markedly accelerated KC migration. Investigation of underlying mechanisms revealed, to our knowledge, a previously unreported function of keratin 6A in KCs. Keratin 6A was PYO inducible and accelerated closure of epithelial defect. Acceleration of closure was associated with poor quality healing, including compromised expression of apical junction proteins. This work recognizes keratin 6A for its role in enhancing KC migration under conditions of threat posed by PYO. Qualitatively deficient junctional proteins under conditions of defensive acceleration of KC migration explain why an infected wound close with deficient skin barrier function as previously reported.

Long-term effect of panretinal photocoagulation on optic nerve head parameters in diabetic retinopathy using Heidelberg retinal tomography III.

PURPOSE: The aim of this study was to evaluate the effect of panretinal photocoagulation (PRP) in diabetic retinopathy patients using Heidelberg retinal tomography III (HRT). SUBJECTS AND METHODS: A total of 90 eyes of 90 consecutive newly diagnosed patients with diabetic retinopathy (nonproliferative diabetic retinopathy, NPDR, Group I and proliferative, PDR, Group II) were recruited for the study. The eyes with PDR were subjected to PRP. The effect of PRP was measured on optic nerve head (ONH) parameters using HRT. RESULTS: Follow-up up to 4 years in both groups indicated that in Group II proliferative diabetic retinopathy (PDR) participants undergoing PRP, the ONH parameters showed a significant difference in cup area (P = 0.023), cup volume (P = 0.001), mean cup depth (P = 0.015), maximum cup depth (P < 0.001), mean retinal nerve fiber layer (RNFL) thickness (P < 0.001) at 1 year of follow-up, and remained significant in all at 4 years of follow-up, whereas there was no significant difference in any of the optic disc parameters in the participants of Group I belonging to NPDR group as compared to PDR group after 4 years. CONCLUSION: PRP affected the ONH morphology in the PDR group and the effect of this change should be interpreted with caution. This may require setting a new baseline for RNFL measurements using the HRT when documenting RNFL loss or glaucoma progression in patients who have undergone PRP.

Cost effective and reliable cell based ELISA as an alternative method of flow cytometry for assessment of binding activity of Vedolizumab.

Vedolizumab is a humanized monoclonal antibody used for inflammatory bowel disease treatment. Vedolizumab binds to the α4ß7 integrin complex and inhibits its binding to mucosal addressin cell adhesion molecule-1 (MAdCAM-1). To evaluate the binding efficacy and quality control check of Vedolizumab, flow cytometry is performed by using HuT78 cells. As we know, flow cytometer is costly and require high equipment maintenance with a designated technical manpower to handle it. In this regard, the aim of study was to develop and validate an economical, simple and efficient cell based ELISA assay for potency estimation of Vedolizumab which has not been reported in any pharmacopoeia. The proposed bioassay method was optimized by investigating Vedolizumab binding to α4ß7 integrin which is expressed by HuT78 cells. The validation of this method was done at different parameters including specificity, linearity, range, repeatability, precision, and accuracy. The Vedolizumab binding by ELISA results were found specific for Vedolizumab with linearity (R2 = 0.99) and precision (%Geometric Coefficient of variance) observed for repeatability and intermediate precision were 3.38% and 2.6% respectively. The relative bias was calculated as 8.68% for repeated performances by different analysts and found in accordance with parameter of accuracy as per various pharmacopoeial guidelines. The developed method is established as robust, effective, and less expensive than high maintenance setup like flow cytometry based assay.

Crossmodal plasticity in hearing loss.

Crossmodal plasticity is a textbook example of the ability of the brain to reorganize based on use. We review evidence from the auditory system showing that such reorganization has significant limits, is dependent on pre-existing circuitry and top-down interactions, and that extensive reorganization is often absent. We argue that the evidence does not support the hypothesis that crossmodal reorganization is responsible for closing critical periods in deafness, and crossmodal plasticity instead represents a neuronal process that is dynamically adaptable. We evaluate the evidence for crossmodal changes in both developmental and adult-onset deafness, which start as early as mild-moderate hearing loss and show reversibility when hearing is restored. Finally, crossmodal plasticity does not appear to affect the neuronal preconditions for successful hearing restoration. Given its dynamic and versatile nature, we describe how this plasticity can be exploited for improving clinical outcomes after neurosensory restoration.

Hearing Healthcare Professionals' Views about Over-The-Counter (OTC) Hearing Aids: Analysis of Retrospective Survey Data.

Over-the-counter hearing aids have been available to consumers in the US since 17 October 2022 following a ruling by the Food and Drug Administration. However, their reception by hearing healthcare professionals (HHP) has been mixed, and concerns have been expressed by many HHPs. The aim of this study was to examine the concerns that HHPs have towards over-the-counter (OTC) hearing aids. The study used a retrospective survey design. The survey data of HHPs (n = 730) was obtained from Hearing Tracker. A 22-item structured questionnaire was administered using a Question Scout platform. Descriptive analyses examined reported areas of concern and a Fisher's exact test examined the relationship between demographics and responses. A cluster analysis with partitioning around medoids (PAM) was used to identify a sub-group of participants based on responses. Nearly half of HHPs who participated reported that they will support patients with OTC hearing aids purchased elsewhere, whereas a quarter reported that they will sell OTC hearing aids in their clinic or website. HHPs expressed over 70% agreement in 'concern' statements in 14 of the 17 items. Issues about safety, counseling, and audiological care were the key concerns expressed by HHPs about OTC hearing aids. Some demographics (i.e., profession, primary position) were associated with responses to some statements. Two groups were identified based on the responses to concern statements. The HHPs in the first cluster 'OTC averse' (51%) agreed on all the 17 concern statements, whereas the second cluster 'OTC apprehensive' (49%) had some items rated as disagree (i.e., consumers will give up on amplification) and neither agree nor disagree (i.e., do not provide good value, warranties and return periods will be worse), and remaining items were rated as agree. OTC hearing aids were initiated to improve affordability, accessibility, and hearing aid uptake and are currently a rapidly emerging category of hearing devices. Overall, the results of the current study indicate that HHPs have serious concerns about OTC hearing aids. HHP concerns cited in this study provide useful feedback to stakeholders (e.g., HHP professional agencies, FDA, industry, and insurance payers) involved in improving OTC hearing aid implementation.

Deciding Whether to Take Sacubitril/Valsartan: How Cardiologists and Patients Discuss Out-of-Pocket Costs.

Background Out-of-pocket costs have significant implications for patients with heart failure and should ideally be incorporated into shared decision-making for clinical care. High out-of-pocket cost is one potential reason for the slow uptake of newer guideline-directed medical therapies for heart failure with reduced ejection fraction. This study aims to characterize patient-cardiologist discussions involving out-of-pocket costs associated with sacubitril/valsartan during the early postapproval period. Methods and Results We conducted content analysis on 222 deidentified transcripts of audio-recorded outpatient encounters taking place between 2015 and 2018 in which cardiologists (n=16) and their patients discussed whether to initiate, continue, or discontinue sacubitril/valsartan. In the 222 included encounters, 100 (45%) contained discussions about cost. Cost was discussed in a variety of contexts: when sacubitril/valsartan was initiated, not initiated, continued, and discontinued. Of the 97 cost conversations analyzed, the majority involved isolated discussions about insurance coverage (64/97 encounters; 66%) and few addressed specific out-of-pocket costs or affordability (28/97 encounters; 29%). Discussion of free samples of sacubitril/valsartan was common (52/97 encounters; 54%), often with no discussion of a longer-term plan for addressing cost. Conclusions Although cost conversations were somewhat common in patient-cardiologist encounters in which sacubitril/valsartan was discussed, these conversations were generally superficial, rarely addressing affordability or cost-value judgments. Cardiologists frequently provided patients with a course of free sacubitril/valsartan samples without a plan to address the cost after the samples ran out.