Publications

OBJECTIVE: We examined the prevalence and patterns of complementary health approaches (CHA) use and interest in CHA research participation among COSMOS older adults.

METHODS: We conducted cross-sectional analyses of the COSMOS Study 2024 survey that asked participants about their use of and research interest in six CHA categories (manual therapies, mind-body therapies, herbal products, acupuncture, spiritual practices, and cannabis/psychedelics). We compared key baseline sociodemographic, lifestyle, and clinical characteristics between CHA users and non-users overall, and for each CHA category. We used multivariable logistic regression models to estimate the odds of CHA use in the past 12 months and ever in lifetime.

RESULTS: Of the 16,144 participants who responded (median age, 77.5 y), 58.8% and 76.4% indicated using CHA at least once in the past 12 months and ever in lifetime, respectively, and 50.4% reported interest in participating in CHA research. The highest prevalence of recent use was observed for spiritual practices (38.6%; 95% CI, 37.8- 39.3) and lifetime use for manual therapies (51.9%; 95% CI, 51.2-52.7). A history of falls or depression was linked to higher odds of recent and lifetime CHA use.

CONCLUSIONS: The high prevalence of selected CHA highlights the need to identify evidence gaps for safety, harm, and public health impact for new focused research studies. Limited generalizability to more diverse and medically underserved populations underscores the need for continued integrative health research.

BACKGROUND: Cardiovascular disease is a risk factor for severe COVID-19 (ie, hospitalization or death). Whether better cardiovascular health (CVH) is associated with lower risk of severe COVID-19 among adults without cardiovascular disease is unknown. We aimed to test if the American Heart Association's Life's Essential 8 (LE8) metric and its components were associated with severe COVID-19 in the C4R (Collaborative Cohort of Cohorts for COVID-19 Research) consortium.

METHODS: Participants with cardiovascular disease were excluded. Two waves of questionnaires, events surveillance, and a serosurvey identified COVID-19 infections. Associations of incident severe COVID-19 with continuous LE8, categorical LE8 (low [<50], moderate [50 to <80], and high [≥80] CVH), and individual LE8 components, were tested in adjusted cause-specific hazards models.

RESULTS: Among 29 740 participants in 9 cohorts (mean age, 66±14 years; 61% women; 35% White race; 22% Black race; 34% Hispanic ethnicity), there were 681 severe COVID-19 cases between March 1, 2020, and February 28, 2023. There was a 20% lower hazard of severe COVID-19 per each 1-SD higher LE8 (adjusted hazard ratio [aHR], 0.80 [95% CI, 0.73-0.88]). Relative to low CVH, high CVH was associated with lower risk of severe COVID-19 (aHR, 0.54 [95% CI, 0.37-0.78]); this was not seen for moderate CVH (aHR, 0.81 [95% CI, 0.64-1.04]). Of LE8 components, better physical activity, body mass index, blood pressure, and sleep were associated with a lower hazard of severe COVID-19.

CONCLUSIONS: Better CVH was associated with lower severe COVID-19 risk among cardiovascular disease-free adults. Whether CVH optimization could mitigate adverse risk from COVID-19 and other harmful viruses warrants further investigation.

OBJECTIVE: This study pilot tested a novel Decision Aid (DA) that clarifies the impact of multimorbidity on Lung Cancer Screening (LCS) risks and benefits. Outcomes of interest include LCS knowledge, disposition to complete LCS, decisional conflict and confidence.

METHODS: Evaluation scales were administered before and after DA exposure to 50 patients with smoking history; 70% of them having moderate or severe multimorbidity.

RESULTS: LCS Knowledge Measure scores improved (median 3 vs. 5 on scale 0-12, p < 0.0001). Scores of Decisional Conflict subscale related to feeling uninformed improved (median 3.5 vs. 3 on scale 0-15, p = 0.03). Overall Decisional Conflict (median 16 vs. 16 on scale 0-80), Stage of Decision Making (median 4 vs. 4 on scale 1-4), and share of participants disposed to complete LCS (86% vs. 84%) were similar.

CONCLUSION: Exposure to a DA tailored to individuals with multimorbidity was associated with improved knowledge of LCS. Further investigation is needed to evaluate the DA efficacy in patients with higher baseline decisional conflict and lower baseline confidence.

INNOVATION: A novel DA presenting information on the impact of comorbidities on LCS risks and benefits was found to hold potential for better supporting the decision-making of patients with multimorbidity.

BACKGROUND: While clinical trials (CTs) are crucial for advancing healthcare, public knowledge remains limited. Individuals with cancer may be more engaged with experimental treatments than those with other chronic conditions like cardiovascular disease (CVD). Whether CVD patients have comparable CT knowledge, and how this varies by sociodemographic factors, remains unclear.

OBJECTIVES: To examine CT knowledge variation between individuals with cancer and CVD and identify sociodemographic correlates of knowledge within CVD population.

METHODS: HINTS is a nationally representative survey of U.S. adults aged ≥18 years. Participants self-reported cancer history, CVD status, and CT knowledge. Logistic regression assessed associations between disease status and CT knowledge, adjusting for sociodemographic and health factors. Within CVD group, variables with P < 0.25 in univariable models were retained in multivariable model. Analyses applied sampling weights.

RESULTS: Among a weighted sample (n = 3772) representing ∼250 million (mean [SD] age, 57 [17.0] years; 50% women), 6% reported cancer and 8% CVD. CT knowledge was 61% in CVD and cancer groups; 35% of CVD group were low-income. In adjusted models, CT knowledge among cancer-only (OR 1.09, 95%CI 0.70-1.68) and CVD-only (OR 1.26, 95%CI 0.73-2.18) groups did not differ significantly from adults without CVD or cancer. Among CVD population, lower income participants (OR 0.24, 95%CI 0.06-0.98) had significantly lower odds of CT knowledge.

CONCLUSION: Most adults with CVD and cancer lacked CT knowledge, underscoring need for broader education. Reduced income was independently associated with diminished knowledge, suggesting targeted efforts may benefit underserved patients and expand access to innovative therapies.

In psychiatry and medicine, there is a long history of framing placebo effects primarily as nuisance factors and focusing on how they should be minimised in clinical trials. However, a new view on placebo effects has emerged with advances in understanding their complex neurobiology and observations of unexpectedly large placebo responses in recent psychiatric trials. In particular, novel therapeutic device trials for depression have shown placebo-group remission rates nearing 50%. Instead of considering these studies as a failure and moving on, questions should be raised on how such responses are possible and how these effects can be harnessed for the benefit of patients. There have also been important new insights into the mechanisms of nocebo effects and analogous questions on how best to mitigate the effect of negative expectations on symptoms and medication side-effects. In this Review, paper 1 of 2 on reconceptualising placebo and nocebo effects, we discuss the rationale, strategies, and ethical considerations related to harnessing placebo effects and mitigating nocebo effects in clinical practice, including discussion of target patient populations, traditional pure and impure placebos, authorised deception, honest open-label placebo, pharmacotherapy dose reduction via conditioned placebo, nocebo education, nocebo reframing, and other ways to apply principles underlying placebo and nocebo effects, such as shifting mindsets and enhancing the therapeutic context. Lastly, we highlight the centrality of this topic to psychiatry, but explore how better understanding the interactions of mind, brain, and body-epitomised by placebo and nocebo effects-has crucial relevance across medicine.

OBJECTIVE: This retrospective cohort study assessed the association between aneurysm diameter and 1 year sac behaviour.

METHODS: All endovascular aneurysm repairs (EVARs) with 1 year imaging follow up in the Vascular Quality Initiative (2003 - 2024) were included. Sac behaviour was defined as expansion (≥ 5 mm enlargement), regression (≥ 5 mm shrinkage), or stable (< 5 mm change). Aneurysm diameter was categorised by sex specific thresholds (female/male): < 45/< 50 mm, 45 - 50/50 - 55 mm, 50 - 55/55 - 60 mm, 55 - 60/60 - 65 mm, 60 - 65/65 - 70 mm, and > 65/> 70 mm. Sac behaviour was estimated using multinomial logistic regression, with sac stability and 50 - 55/55 - 60 mm as reference categories. Restricted cubic splines (RCS) were incorporated to explore the continuous relationship.

RESULTS: A total of 28 275 patients were included. At 1 year, 48.5% had sac regression, 45.4% stability, and 6.1% expansion. Using 50 - 55/55 - 60 mm as the diameter reference and sac stability as the outcome reference, adjusted odds ratios (95% confidence interval) for sac regression were 0.40 (0.37 - 0.43) for < 45/< 50 mm, 0.82 (0.77 - 0.86) for 45 - 50/50 - 55 mm, 1.25 (1.17 - 1.33) for 55 - 60/60 - 65 mm, 1.38 (1.29 - 1.48) for 60 - 65/65 - 70 mm, and 1.46 (1.37 - 1.57) for > 65/> 70 mm. Corresponding odds ratios for expansion were 1.92 (1.88 - 1.95), 1.03 (1.02 - 1.04), 1.20 (1.18 - 1.21), 1.43 (1.41 - 1.45), and 1.67 (1.64 - 1.69), respectively. RCS demonstrated that regression increased steeply with diameter up to ∼55 mm, while stability declined progressively. Expansion was most common in small aneurysms and least likely near 55 mm.

CONCLUSION: Pre-operative aneurysm diameter showed a non-linear association with 1 year sac behaviour. Sac regression increased up to ∼55 mm, where the predicted probability of expansion was lowest. Small aneurysms had nearly twofold higher odds of expansion relative to stability. In larger aneurysms, higher odds of expansion reflected lower stability rather than a meaningful rise in absolute expansion risk. Further investigation is needed to clarify the mechanisms underlying sac expansion in small aneurysms. These findings suggest that patients treated at small diameters may require closer surveillance.

BACKGROUND AND AIMS: Heart failure with preserved ejection fraction (HFpEF) is increasingly recognized as a syndrome of reserve dysfunction. However, integrated assessment of biventricular (LV/RV) volumetric reserve under physiological stress remains underexplored. We aimed to investigate whether exercise cardiac magnetic resonance (Ex-CMR) can reveal distinct volumetric reserve profiles across the HFpEF spectrum.

METHODS: In this retrospective analysis of a prospective observational, multicentre study, supine ergometer Ex-CMR was performed in HFpEF patients across early to advanced stages (stage B, exercise-induced, stage C), along with healthy controls and a non-cardiac dyspnoea (NCD) group. Percentage changes in LV/RV end-diastolic (ΔEDV%) and end-systolic volumes (ΔESV%) from rest to stress defined EDV reserve and ESV reserve, respectively. Ventricular efficiency index (EI) was defined as ΔEDV%-ΔESV%; biventricular EI as LVEI + RVEI. Group comparisons were performed using ANOVA and post hoc testing. Multivariable general linear model analyses adjusted for age, sex, BMI, and exercise response. A composite phenotyping assessment incorporating all four key reserve parameters was explored.

RESULTS: Among 140 participants (40 healthy, 27 NCD, and 73 HFpEF), all HFpEF subgroups showed impaired LVEDV reserve and reduced LVEI (P < .0001). LVESV reserve was impaired only in stage C (P < .0001). Exercise-induced RV dysfunction was a hallmark of HFpEF with pulmonary hypertension (P < .0001). Biventricular EI declined progressively with advancing HFpEF stage (P < .0001) and was significantly lower in NYHA > II (P = .0006). Six distinct reserve phenotypes emerged.

CONCLUSION: Ex-CMR-based assessment of LV/RV volumetric reserve reveals progressive biventricular dysfunction across HFpEF stages and supports biventricular volumetric reserve-based phenotyping for characterizing HFpEF pathophysiology.

KEY QUESTION: Can the integration of left and right ventricular end-diastolic and end-systolic volume reserve under physiological stress reveal distinct profiles across the HFpEF spectrum and enhance our understanding of its haemodynamic heterogeneity?

KEY FINDINGS: Non-invasive assessment of biventricular volumetric reserve, along with their intra- and interventricular interactions using exercise CMR, revealed a significant, stepwise deterioration across HFpEF subgroups, worsening with NYHA class > II. Exercise CMR enabled composite volumetric reserve-based phenotyping and identified six distinct reserve phenotypes.

TAKE HOME MESSAGE: Biventricular volumetric reserve assessment is feasible through exercise CMR and may support future precision therapy strategies.