The goodness of fit of the mSOFA-g score was 5% higher than the SOFA score of the subgroup without diabetes. The SOFA score and human leukocyte antigen-D-related (HLA-DR) expression were comparable between the groups. The P3 group had lower HLA-DR expression on days 1 and 3 and a higher 90-day mortality. The three-group tool was useful for predicting 90-day mortality in patients with separate Kaplan-Meier survival curves and mortality HRs in the construction and validation cohorts. The peak glucose level, instead of diabetes status, can be used as an easy adjunctive tool for mortality risk stratification in critically ill septic patients.The effects of diabetes and glucose on the outcomes of patients with sepsis are somewhat conflicting. This retrospective study enrolled 1214 consecutive patients with sepsis, including a subpopulation of 148 patients with immune profiles. The septic patients were stratified according to their Diabetes mellitus (DM) status or peak glucose level  on day 1. Although the DM group had a lower hazard ratio (HR) for 90-day mortality compared to non-DM patients, the adjusted HRs were insignificant. The modified sequential organ failure assessment-glucose (mSOFA-g) score can predict 90-day survival in patients with and without diabetes (β = 1.098,  Sepsis is a life-threatening organ dysfunction resulting from a dysregulated host response to infection , and canDiabetes mellitus is a common comorbidity with an increasing incidence  in patieSepsis can induce stress hyperglycemia in both patients with and without DM . PatientThis retrospective study enrolled patients admitted to adult medical intensive care units  of Kaohsiung Chang Gung Memorial Hospital, a 2700-bed tertiary hospital in Southern Taiwan, between August 2013 and January 2017, as the construction cohort. Consecutive patients with sepsis admitted to the medical ICU between January and August 2020 were included in the validation cohort.This retrospective cohort study screened patients through a review of medical records. Consecutive septic patients who met the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria  and withThe peak glucose level on day 1 was defined as the highest glucose value measured during the first day of the ICU stay. The values included fingerstick or plasma glucose levels measured before or after meals. The P1 group was defined as having a peak glucose level of up to 140 mg/dL. The P2 group had a peak glucose level of 141–220 mg/dL. The P3 group was defined as having a peak glucose level greater than 220 mg/dL. The three ranges of peak glucose values  are based on the references in the literature ,24. We dDiabetes was defined as a diagnosis of DM, regardless of the treatment type before ICU admission. Patients without recognized diabetes were classified as having no previous DM or non-DM. The glycemic control method was at the discretion of the physician caring for the patient in the ICU. We did not routinely use a standardized protocol  for glucose control in the ICU. However, we usually targeted an upper blood glucose level ≤180 mg/dL, as suggested by the guidelines . IntensiMortality was defined as death in hospital or discharge under critical conditions. The comorbidities such as coronary artery disease, history of stroke, hypertension, chronic obstructive pulmonary disease (COPD), cancer, chronic kidney disease (CKD), liver cirrhosis, and diabetes mellitus were collected from medical records. The serial changes of severity scores were measured by systemic inflammatory response syndrome (SIRS), sequential organ failure assessment (SOFA), and quick sequential organ failure assessment (qSOFA) on day 1 and day 3. All the severity scores were documented in medical records.n = 148, all in the construction cohort) of the enrolled patients who had participated in our previous study of the immune dysfunction score [Clinical data, including data on diabetes status, peak glucose level on the first day, SOFA score ,30,31, son score  were alsHuman leukocyte antigen-D-related (HLA-DR) monocyte expression was measured according to the protocol described in the Patient demographics, clinical characteristics, and outcomes were summarized as frequencies and percentages for categorical variables. Median and interquartile ranges (IQRs), or 25th and 75th percentiles, were provided if appropriate. Because continuous variables were most likely not normally distributed, the Mann-Whitney U or Kruskal-Wallis tests were used when appropriate. Differences between the DM and non-DM groups were analyzed using Student’s t-test or the Mann-Whitney U-test, as appropriate, for continuous variables and the chi-squared test for categorical variables. Comparisons among the three groups were performed using Pearson’s chi-square tests and one-way analysis of variance (ANOVA), as appropriate. Pairwise comparisons were performed using ANOVA, with adjustments for multiple comparisons using Tukey’s range test for post-hoc comparisons. Kruskal-Wallis tests were used as a non-parametric alternative to ANOVA for non-normally distributed continuous variables. Dunn–Bonferroni pairwise tests were performed for post-hoc comparisons.To assess the survival outcomes between groups, Kaplan-Meier (K-M) survival curves were constructed, with log-rank tests used for comparisons between groups. Mortality hazard ratios between groups were also compared using Cox proportional-hazards regression analysis and crude hazard ratios and adjusted hazard ratios for 90-day mortality. Independent variables  included the peak glucose on day 1, DM status, and three-group tool , APACHE II, CCI, coronary artery disease, history of stroke, hypertension, chronic obstructive pulmonary disease (COPD), cancer, chronic kidney disease (CKD), and liver cirrhosis).p value < 0.05. All data were analyzed using IBM SPSS Statistics for Windows .Finally, we created a modified sequential organ failure assessment (mSOFA-g) score that included the peak glucose level score. The SOFA score is made up of six sub-scores, each representing an organ system . The sub-SOFA score ranged from 0–4 points for each item and the total SOFA score was 0–24 points. We propose the m-SOFA-g score, which consists of the SOFA score and an additional organ system . The maximal peak glucose level score is four points, which in this research, was assigned to P3 patients because of their highest 90-day mortality. The peak glucose level score included the P1 group (peak glucose level ≤ 140 mg/dL), which equaled one, P2 group (peak glucose level > 140 and ≤ 220 mg/dL) which equaled two, and P3 group (peak glucose level > 220 mg/dL), which equaled four. The mSOFA-g scores were equal to the sum of the SOFA scores and the peak glucose level scores. Logic regression was used to analyse the odds ratios of mortality related to the SOFA and mSOFA-g scores. The Nagelkerke R-squared was used to explain the model fit of the variables. Statistical significance was set at a two-sided Consecutive patients admitted to the medical ICU during the first and second study periods were screened. After excluding patients without sepsis or with incomplete data , 722 and 492 patients were analyzed in the construction and validation cohorts, respectively . DemograCompared to non-DM patients, patients with DM were older  and had a higher BMI. As shown in Assessment of the peak glucose levels on day 1  revealedAs shown in Cox regression analysis was performed for 90-day mortality. The crude and adjusted hazard ratios  are shown in p < 0.001); however, it did not increase the r-squared by more than 5% compared to the traditional SOFA score. Analysis of the validation cohort revealed similar results. The mSOFA-g score on day 1 still significantly predicted the 7-day, 28-day, and 90-day mortality; however, it did not increase the r-squared by more than 5% compared to the traditional SOFA scores.As shown in The Kaplan-Meier survival plot showed differences in the curves between the P2 and P3 groups B. ComparIn this study, we present four key findings. First, septic patients with DM were not associated with higher HRs for 90-day mortality. We observed comparable 90-day survival rates in critically ill septic patients with and without DM in the adjusted analyses. Second, our proposed tools according to the peak glucose level range on day 1 (three-group tool) can be helpful for risk stratification. Third, we created a modified sequential organ failure assessment-glucose score that increased the goodness of fit above 5% in the subgroup of patients without diabetes. Fourth, different underlying presentations of sepsis severity score and host immune status were noted among the groups. Although whether any difference in mortality could be explained by differences in immune response remains speculative, our findings shed light on the field.The 90-day survival curves showed that the patients with DM had better survival than patients without diabetes. However, after adjustment for age, sex, BMI, and comorbidities, the difference disappeared. This might be because the patients with diabetes had more comorbidities compared to patients without diabetes. In our previous study, we noted that the increase of HbA1c had a tendency to decrease the mortality in patients with sepsis and a poor nutrition status, and cancer was related with a significant independent increase in mortality risk . In thisFurthermore, we hypothesized that the peak glucose level on day 1 or within the first three days could reflect the progression or resolution of sepsis. We found that the tool when using peak glucose levels within the first three days also had promising results. However, it appeared that we needed to wait for three whole days to obtain the data on the peak blood glucose, to barely predict the prognosis of sepsis. Our study found that our three-group tool using the peak glucose levels on day 1 was useful. Sepsis-related metabolic abnormalities can cause a surge in glucose levels, which may be different from admission hyperglycemia. In a previous study, it was found that moderate glycemic control measures may benefit patients with severe hyperglycemia (>220 mg/dL) .p value was not significant. Our data showed that U-shaped curves were noted for outcomes in 28-day mortality according to the peak glucose levels, but such result was not observed in 90-day mortality. The peak glucose level in mg/dL did not significantly correlate with mortality after risk covariable adjustment. This is possibly because the p value reflects a comparison of multiple groups, and therefore, often obscures important relationships, for example, the U-shaped relationship between peak glucose levels and mortality.If we selected another three ranges of glucose peak values for analysis , the Kaplan-Meier survival curves were similar to our present three-group tool, but not better. We attempted to run the analysis with the peak glycemic status defined more simply, along more traditional cut-off thresholds such as those for euglycemia (<180 mg/dL) and hyperglycemia (≥180 mg/dL). The log-rank The mSOFA-g score can predict 90-day survival in patients with and without diabetes in the construction and validation cohort groups. In this study, the goodness of fit of the mSOFA-g score increased above 5% compared to the SOFA score in the subgroup without diabetes. This result implies that the mSOFA-g score can better predict 90-day survival in patients without diabetes. The validation data did not reveal any differences between the diabetes and non-diabetes groups, possibly because of the smaller number of cases in the validation group. A previous systemic review, which included nine studies, also pointed out that patients who suffered from hyperglycemia without diabetes had a 2.7-fold increase in hospital mortality compared to patients who suffered from hyperglycemic diabetes . This waThe metabolic milieu and host response to sepsis are complex and the optimal blood glucose ranges are difficult to define. Hyperglycemia and diabetes have deleterious effects on neutrophil and macrophage function ,40. TheyThe strength of our study includes its first introduction of peak glucose levels for risk stratification in consecutive critically ill patients with sepsis. We developed a new tool for risk stratification (three-group tool) and performed detailed comparisons of the mortality hazard ratios and serial sepsis clinical scores to explore their relationships. We used both the construction and validation cohorts to confirm our findings . The twoThere are some limitations to our study. First, the retrospective design and the limited number of cases with immune profiles preclude further analysis . AlthougIn conclusion, our results demonstrated the relationship between simple glucose metrics and mortality, stratified by the peak glucose levels on day one in critically ill patients with sepsis. The mSOFA-g score can be used to predict 90-day mortality in patients with sepsis and can more precisely predict the 90-day mortality in patients without diabetes. The DM status and maximum glucose level on the first day of ICU admission are easy to obtain for bedside clinicians. The peak glucose level range, instead of diabetes status, can be used for mortality-risk stratification of critically ill patients with sepsis.


In both studies, we also found that the relationship between narcissistic (vs. secure) national identity and unwillingness to vaccinate against COVID-19 was mediated by COVID-19 vaccine conspiracy beliefs. These effects were present even when we accounted for basic demographics (Studies 1 and 2) and identification with all humanity (Study 2), which had been found to be a significant predictor of health behaviors during COVID-19. In line with previous research, identification with all humanity was positively associated with the willingness to vaccinate against COVID-19. We discuss the implications for understanding the role of the way in which people identify with their national and supranational groups in antiscience attitudes and adaptive behaviors during COVID-19 pandemic.In the present research, we focus on COVID-19 vaccine hesitancy, and empirically examine how different forms of social identity  and conspiracy beliefs are associated with COVID-19 vaccine hesitancy. In two cross-sectional nationwide surveys (Study 1,  So far during the pandemic, various factors have impacted whether new COVID-19 cases globally increase or decline in countries. Among these factors are infection prevention policies, mutations of the coronavirus itself, and human responses to the COVID-19 pandemic, such as practicing physical distancing, handwashing, mask wearing, and especially attitudes toward the COVID-19 vaccines . AlthougShortly after the European Union had officially launched its program of mass vaccination against COVID-19 in December 2020, conspiracy theories and misconceptions about COVID-19 vaccines began to circulate online ,11,12,13This intergroup facet of conspiracy theories has inspired researchers to analyze conspiracy beliefs in relation to social and political identities. For example, many research projects ,18,19 emWe aimed to fill this gap and better understand the role of social identities  and COVID-19 vaccine conspiracy beliefs in predicting attitudes towards COVID-19 vaccines. Specifically, we sought to examine which forms of social identity may be linked to COVID-19 conspiracy beliefs and the unwillingness to vaccinate against COVID-19. We investigated whether those who score high (vs. low) on national narcissism would be more (vs. less) prone to endorse COVID-19 vaccine conspiracy theories and, in turn, express less (vs. more) willingness to vaccinate against COVID-19. We also controlled for a secure national identification  and identification with all humanity (Study 2) to check whether the effects of national narcissism on vaccine hesitancy would be present after accounting for these variables previously found to predict health behaviors in the context of COVID-19 ,24. In sAddressing people’s beliefs about their ingroups is becoming increasingly important in the general quest for understanding what is going on in the world today  and in tNational narcissism is characterized by a grandiose appraisal of one’s national group that is contingent on the external acknowledgement of its worth ,32,33. TWe would expect very different dynamics among secure identifiers whose national commitment stems from satisfied psychological needs . Ref. Ref42])We examined our predictions in two cross-sectional studies conducted in Poland, where uptake of COVID-19 vaccines among citizens is lower than the EU average . We assIn Study 1, we examined the relationships between different forms of national identity and attitudes toward COVID-19 vaccination. To this end, we analyzed data from a nationwide study that assessed national narcissism, national identification, COVID-19 vaccine conspiracy beliefs, willingness to vaccinate against COVID-19, and demographic factors, among other variables. We assumed that national narcissism  would be a negative predictor of the willingness to vaccinate against COVID-19, and that this relationship would be accounted for by COVID-19 vaccine conspiracy beliefs.M = 48.18; SD = 16.34). Data were collected via an Internet questionnaire (CAWI) by a Polish online survey research platform  that also conducts academic studies .The positive indirect effect of national identification on willingness to vaccinate via COVID-19 vaccine conspiracy beliefs was also significant, Study 1 showed that national narcissism was significantly associated with higher COVID-19 vaccine conspiracy beliefs and lower willingness to vaccinate against COVID-19. These effects were demonstrated over and above the effects of demographic variables. After controlling for the shared variance between both types of national identity, secure national identification predicted lower COVID-19 vaccine conspiracy beliefs and higher willingness to vaccinate against COVID-19, confirming Hypotheses 1 and 2. Most importantly, the relationship between national narcissism  and the willingness to vaccinate against COVID-19 was mediated by COVID-19 vaccine conspiracy beliefs. Thus, the study provided the first evidence that national narcissism and secure national identification may have opposite relationships with COVID-19 vaccine hesitancy.The purpose of Study 2 was twofold: we aimed to replicate the effects observed in Study 1 and to extend this model to include potential effects of identification with all humanity (IWAH). As previously mentioned, IWAH served as a significant predictor of health behaviors ,24. It wM = 45.68, SD = 15.49); it was representative of Polish adults in terms of gender, age, and size of place of residence.Data for Study 2 were obtained through an online survey (CAWI) conducted in Poland in early December 2020. Respondents were randomly selected from a nationally representative online panel. Data collection was performed online by a survey research company  also conducting academic investigations . The finNational narcissism was measured with the same 5-item version of the Collective Narcissism Scale [M = 2.90, SD = 1.13).sm Scale  as in StNational identification was measured with a shortened 3-item Social Identification Scale .n Scale . Higher mean scores indicated higher identification with all humanity.AH scale  in the PAH scale , with suCOVID-19 vaccine conspiracy beliefs were measured with the same 5-item scale as in Study 1 .Willingness to vaccinate against COVID-19 was measured using one item: “Do you plan to vaccinate against COVID-19 if there is a safe, tested vaccine available?”, with five answer options .Control variables. Following Study 1, analyses adjusted for gender , age, education , and size of place of residence .We first computed correlations between continuous variables see . NationaAs in Study 1, we examined the regression models with national narcissism and national identification as predictors of COVID-19 vaccine conspiracy beliefs (DV1) and willingness to vaccinate against COVID-19 (DV2), controlling for demographic variables and identification with all humanity.COVID-19 vaccine conspiracy beliefs (DV1). As predicted, when we simultaneously entered national narcissism and national identity into our regression equation, both emerged as significant predictors of COVID-19 vaccine conspiracy beliefs. As expected, their relationships with conspiracy beliefs were in opposite directions. These associations remained statistically significant after controlling for identification with all humanity and demographics (graphics .Willingness to vaccinate against COVID-19 (DV2). To test the hypothesis that national narcissism  would predict lower willingness to vaccinate against COVID-19, we conducted additional hierarchical regression analysis  was associated with greater endorsement of COVID-19 vaccine conspiracy beliefs and in turn greater unwillingness to vaccinate against COVID-19. As in Study 1, we found that secure identifiers rejected conspiracy beliefs and thus exhibited a greater intention to vaccinate against COVID-19. Study 2 additionally revealed that identification with all humanity did not significantly predict COVID-19 vaccine conspiracy beliefs. However, and more importantly, in line with previous research findings demonstrating its connection to health behaviors during pandemics , our anaSince the effectiveness of a vaccination campaign is largely dependent on wide vaccine uptake, this research program aimed to better understand psychological factors that could be associated with (un)willingness to get vaccinated against COVID-19. We conducted our investigations in Poland, a country that belongs to the group of Central and Eastern European nations with the lowest vaccination acceptability . In two In Studies 1 and 2, we established that national narcissism emerged as a robust predictor of COVID-19 vaccine conspiracy beliefs, which in turn significantly predicted lower willingness to get vaccinated. Results of both studies also showed that, when we controlled for the variance shared between national narcissism and national identification, the latter became a significant and positive predictor of willingness to vaccinate against COVID-19. In other words, secure identifiers rejected conspiracy theories, thus being more willing to get COVID vaccines. Thus, it seems that only defensive type of national identity, which is associated with sensitivity to intergroup threats  in a difImportantly, in Study 2, we additionally demonstrated that not only more specific , but also broad  social identities could be related to COVID-19 vaccine acceptance. Results revealed that those individuals who scored higher on identification with all humanity scale  were moAdditional investigations could also attempt to establish the causal links of observed relationships, for example, by experimentally manipulating the levels of national narcissism and COVID-19 vaccine conspiracy beliefs. It is reasonable to expect that boosting (vs. attenuating) national narcissism may result in higher (vs. lower) levels of conspiracy beliefs. On the other hand, we cannot exclude the possibility that boosting (vs. attenuating) COVID-19 conspiracy beliefs may change the levels of national narcissism . AnotherOverall, our research complements the broader literature on the role of social identities in adopting conspiracy theories and forming anti-science attitudes. It shows that, although some types of social identities  are positively linked to rejecting science, others  have the potential to strengthen acceptance of scientific claims, leading to positive health and prosocial behaviors. Thus, more empirical efforts should focus on finding an effective way to boost secure national identification and identification with all humanity, as both these factors seem to be promising for reducing COVID-19 and other vaccine hesitancy.


Using a large national database of people hospitalised with COVID-19, we investigated the contribution of cardio-metabolic conditions, multi-morbidity and ethnicity on the risk of in-hospital cardiovascular complications and death.A multicentre, prospective cohort study in 302 UK healthcare facilities of adults hospitalised with COVID-19 between 6 February 2020 and 16 March 2021. Logistic models were used to explore associations between baseline patient ethnicity, cardiometabolic conditions and multimorbidity , and in-hospital cardiovascular complications , renal injury and death.Of 65 624 patients hospitalised with COVID-19, 44 598 (68.0%) reported at least one cardiometabolic condition on admission. Cardiovascular/renal complications or death occurred in 24 609 (38.0%) patients. Baseline cardiometabolic conditions were independently associated with increased odds of in-hospital complications and this risk increased in the presence of cardiometabolic multimorbidity. For example, compared with having no cardiometabolic conditions, 1, 2 or ≥3 conditions was associated with 1.46 (95% CI 1.39 to 1.54), 2.04 (95% CI 1.93 to 2.15) and 3.10 (95% CI 2.92 to 3.29) times higher odds of any cardiovascular/renal complication, respectively. A similar pattern was observed for all-cause death. Compared with the white group, the South Asian  and black (OR 1.53 to 95% CI 1.37 to 1.72) ethnic groups had higher risk of any cardiovascular/renal complication.In hospitalised patients with COVID-19, cardiovascular complications or death impacts just under half of all patients, with the highest risk in those of South Asian or Black ethnicity and in patients with cardiometabolic multimorbidity. As of April 2021, SARS-CoV-2 has infected over 140 million people and claimed over 3 million lives worldwide. After infection, the course of the disease (COVID-19) varies, ranging from asymptomatic mild infection to severe complications and death. People who require hospital admission have the worse outcomes, with a mortality risk of 10%–26% in USA and the UK.Individuals from non-Caucasian ethnic groups or with multiple chronic conditions have been found to be susceptible to severe COVID-19 disease, in-hospital cardiovascular complications and death.Because people with COVID-19 often have a combination of different high-risk characteristics, it can be difficult to know which are the most important or whether some or all of the higher risk of COVID-19 complications in people who are non-Caucasian is explained by their cardiometabolic conditions. In order to unpick the relative importance of the various factors contributing to adverse COVID-19 prognosis, large, well-phenotyped samples are required, with good coverage of these contributing factors. Accordingly, this study investigated the contribution of multiple cardiometabolic conditions and patient ethnicity, to the risk of cardiovascular/renal complications and death, in a large nationally representative sample of people hospitalised with COVID-19.https://isaric4c.net). The ISARIC WHO CCP-UK study was registered at https://www.isrctn.com/ISRCTN66726260 and designated an Urgent Public Health Research Study by the National Institute for Health Research.We used data from the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK) for severe emerging infection. Developed by ISARIC and WHO in 2009, the protocol was reactivated on 17 January 2020 in response to the SARS-CoV-2 pandemic. The protocol and all study materials for this actively recruiting prospective cohort can be accessed online  were excluded. As of 16 March 2021, 140 975 patients were included in the CCP-UK Study of which 138 455 (98.2%) had a confirmed diagnosis of COVID-19. Of these, 65 624 (46.6%) had the relevant outcome and covariate data for analysis. Data on baseline cardiometabolic comorbidities including hypertension, obesity, diabetes, chronic cardiac conditions and chronic kidney disease were extracted from clinical records. Further information regarding how these variables were classified can be found in Ethnicity was coded into four groups, reflecting the most prevalent ethnic groups in the 2011 census in England and Wales,Sex was coded as female/male. Age was measured to the nearest year using the difference between date of birth and the admission date.The primary outcomes were (1) A dichotomous variable representing any in-hospital cardiovascular or renal complication; and (2) All-cause death. In-hospital cardiovascular complications were defined clinically in patient healthcare records and extracted by local investigators and included stroke, heart failure, arrhythmia, ischaemia, cardiac arrest and coagulation disorders . Due to the intrinsic nature of cardiovascular and renal dysfunction we also included ‘acute renal injury’ in the list of complications. These individual cardiovascular/renal complications were considered secondary outcomes. Further information regarding how these variables were defined can be found in Descriptive statistics are presented as number (%) and median (25th and 75th centiles) for categorical and continuous data, respectively, with differences between those with and without cardiovascular complications in these characteristics examined using standardised differences. To investigate the relationship between cardiometabolic comorbidities, ethnicity and outcomes, we constructed three models.any’ cardiometabolic comorbidity, (2) Cardiometabolic multimorbidity count and (3) Ethnic group, and the primary outcomes: (1) ‘any’ in-hospital cardiovascular/renal complication; (2) In-hospital death and the secondary outcomes: each individual cardiovascular/renal complication.Model 1: Unadjusted associations between the exposures: (1) ‘Model 2: Model 1 exposures (1–2), adjusted for age, sex and ethnicity and Model 1 exposures (3), adjusted for age, sex and baseline cardiometabolic comorbidities. Age was entered into the model as a restricted cubic spline, with four knots placed at the 20th, 40th, 60th and 80th centiles of the age distribution, with the reference value set to the mean age of the sample (70 years of age). This was repeated for the secondary outcomes.‘any’ in-hospital complications differed according to ethnicity status, we entered first-order interaction terms into Model 2, between ethnic group and ‘any’ cardiometabolic comorbidity and between ethnic group and the multimorbidity count variable. Interactions were formally assessed using the Wald test, with p<0.05 indicating a significant interaction term. Predicted probabilities for each interaction term and outcome were estimated and plotted using Stata’s postestimation ‘margins’ and ‘marginsplot’ commands.Model 3: To investigate whether the relationship between baseline cardiometabolic comorbidities and any’ cardio-metabolic comorbidity exposure variable with each individual baseline cardio-metabolic comorbidity. Furthermore, we repeated Models 1 to 3 using a composite outcome representing ‘any complication or all-cause death’ to account for the competing risk of death in assessing in-hospital complications.We repeated Models 1 and 2 replacing the dichotomous ‘A final set of models was constructed to investigate the separate and combined associations between baseline cardiometabolic comorbidities, in-hospital cardiovascular/renal complications and death. For this model, we created a single variable which categorised patients into four groups: patients with no baseline cardiometabolic morbidities or in-hospital cardiovascular/renal complications (reference group); patients with baseline cardiometabolic morbidities only; patients with in-hospital cardiovascular/renal complications only, and patients with both baseline cardiometabolic morbidities and in-hospital cardiovascular/renal complications. Logistic regression was then used to estimate the association between this categorical variable and death, with adjustment for sex, age and ethnicity.All analyses were conducted in Stata V.16 . Data are reported with 95% CI unless reported otherwise.This was an urgent public health research study in response to a public health emergency of international concern. Patients or the public were not involved in the design, conduct or reporting of this rapid response research.The sample comprised 34 891 men (53.2%), had a median age of 73 years (IQR: 58–84) and 55 588 (84.7%) of individuals were of ‘White’ ethnicity . Over twIn total, 24 921 (38.0%) of the sample experienced either a cardiovascular/renal complication or died.Unadjusted associations between baseline cardiometabolic comorbidity, multimorbidity, cardiovascular/renal complications and all-cause death are shown in Adjusted associations between baseline cardiometabolic comorbidities, multimorbidity and all-cause death are shown in Unadjusted associations between ethnic group and cardiovascular/renal complications are shown in After adjusting for sex, age and baseline cardiometabolic comorbidities, the South Asian  and black ethnic groups  were at significantly higher risk of all-cause death compared with the white group . The magThe association between baseline comorbidities and individual complications can been seen in The South Asian group was almost twice as likely to experience cardiac arrest  and almost 50% more likely to experience cardiac ischaemia  than the white group. The black group was more than twice as likely to experience cardiac arrest  and over 75% more likely to experience acute renal injury , compared with the white group .In adjusted models, chronic kidney disease exhibited the strongest association with the likelihood of experiencing any cardiovascular/renal complication , while obesity conferred the greatest odds of death  .We observed a consistent pattern of associations between cardiometabolic comorbidity, ethnicity and the composite outcome representing ‘cardiovascular/renal complication or all-cause death’ .Compared with patients with no baseline cardiometabolic conditions or in-hospital complications, patients with baseline cardiometabolic comorbidities only had 20% higher odds of death . Those with a baseline cardiometabolic condition and experiencing an in-hospital complication had over three times higher odds of death, compared with those with neither . However, those who had no baseline cardiometabolic conditions, but who subsequently experienced an in-hospital cardiovascular/renal complication, had almost four times higher odds of death, relative to patients with neither .In 65 624 hospitalised patients with COVID-19, 68% had at least one cardiometabolic comorbidity on admission and 38% experienced an in-hospital cardiovascular/renal complication or died. The presence of cardiometabolic conditions and multimorbidity on admission increased the risk of experiencing in-hospital cardiovascular/renal complications and death. Risk of in-hospital complications were also increased in people from South Asian and black ethnicity groups, independent of their cardiometabolic status on admission to hospital.Several studies have previously reported that the presence of chronic conditions is associated with a more severe course and progression of COVID-19, ultimately culminating in an increased risk of mortality.Our study extends the findings from previous studies,(interaction)=0.03, models not shown). Belonging to an ethnic minority group is associated with elevated risk for severe illness from COVID-19,While we did not observe strong evidence of a modifying effect of ethnicity on the relationship between cardiometabolic comorbidities and in-hospital complications (only), we did find some evidence that the association between cardiometabolic comorbidities and the composite outcome of cardiovascular/renal complications or death, was modified by ethnicity . This coThese data were collected prospectively across 302 hospitals and represent a large proportion (approximately 40%) of people hospitalised with COVID-19 in the UK, thus increasing the generalisability of our findings. Unlike our study, other smaller, or single-centre studies have typically focused either exclusively on patients who received critical care, or on one type of complication and lack systematic approaches to data collection.Our study highlights the importance of adequate risk factor control  in reducing the risk of hospital admission and complications if infected with COVID-19. This is especially important in individuals already at an increased risk of developing cardiometabolic conditions such as those with prediabetes, prehypertension or those who are overweight. Hospitalised patients with COVID-19 who survive after cardiovascular/renal complications are likely to experience long-term morbidity. As such, governments, policy makers, healthcare planners and front-line healthcare workers should anticipate an increased burden placed on health and social care resources, which will be critical to support those who survive COVID-19.Findings from several small and regional studies suggest that certain patient groups admitted to hospital with COVID-19 are more susceptible to in-hospital cardiovascular complications and death.In this cohort of 65 624 patients with COVID-19, in-hospital cardiovascular/renal complications or death occurred in 38%. A greater number of cardiometabolic comorbidities on admission and being of black or South Asian ethnicity increased odds of cardiovascular/renal complications. A similar pattern was observed for all-cause death.Our findings indicate the prognostic relevance of several risk factors on the risk of in-hospital complications if infected with COVID-19. This is especially important in individuals already at an increased risk of developing cardiometabolic conditions such as those with prediabetes, prehypertension or those who are overweight.


Idiopathic membranous nephropathy (IMN) has a varied clinical course that requires accurate prediction as a prerequisite for treatment administration. Currently, its prognosis relies on proteinuria, a clinical parameter whose onset lags behind kidney injury. Increased urinary excretion of matrix metalloproteinase-9 (MMP-9) and nephrin has been reported in a number of IMN-like glomerular diseases in which they reflected disease severity. However, little or nothing is known of the importance of these biomarkers in IMN, a major cause of adult nephrotic syndrome. To highlight their potential, we measured both biomarkers and assessed their relationships with key parameters of renal function in IMN.  We quantified urinary MMP-9 and nephrin in 107 biopsy-proven IMN patients and 70 healthy subjects by enzyme-linked immunosorbent assay (ELISA). We then compared biomarker levels between patients and healthy subjects and among patients with different clinical features. We also determined the relationship of each biomarker with proteinuria and the estimated glomerular filtration rate (eGFR). 2.  Urinary MMP-9 and nephrin were significantly higher in IMN compared to healthy controls. Unlike nephrin, MMP-9 correlated significantly with proteinuria and was significantly higher among patients with nephrotic range proteinuria. Both biomarkers were correlated with eGFR, but only MMP-9 was significantly higher in patients with eGFR less than 90 ml/min/1.73 m Our findings suggest that urinary MMP-9 holds a greater potential than urinary nephrin in monitoring the severity of IMN. IMN affects more men than women, and its prevalence among the primary glomerular diseases is on an increasing trend , 2. The (THSD7A) . Presents of IMN , 5.Presently, there is a scarcity of biomarkers capable of predicting the course of IMN, especially in its early stages. Proteinuria is the only prognostic parameter recommended by the 2012 kidney disease improving global outcomes (KDIGO) clinical practice guidelines. However, the use of proteinuria to predict the course of IMN is not without challenges. While proteinuria in the subnephrotic range (defined as urine protein < 350 mg/mmolCr) was found associated with a reduced risk of end-stage renal disease (ESRD) and could predict excellent long-term survival of kidneys , 7, it oMatrix metalloproteinase-9  and nephrin are some of the early markers of glomerular dysfunction. The urinary excretion and activity of these markers are already known to reflect the severity of nephrotic syndrome other glomerular diseases –13. DeriThe potential utility of these biomarkers has been documented in a number of glomerular diseases including diabetic nephropathy, Henoch-Schonleinpurpura, minimal change disease, and focal segmental glomerulosclerosis , 11–13. Despite these findings, the diagnostic and prognostic potential of these biomarkers has never been studied in human subjects. Only MMP-9 has had its diagnostic and prognostic potentials studied but in only childhood forms nephrotic syndrome , 9, 12. The study was approved by the research ethics committee of Shengjing Hospital of China Medical University.107 biopsy-proven IMN patients were recruited from the hospital's nephrology department from March 2018 to January 2020. At the time of recruitment, none of the patients had received IMN treatment. Participants were screened for all possible causes of secondary membranous nephropathy and other kidney diseases. Those found with neoplasms, cancers, diabetes, autoimmune diseases such as systemic lupus erythematosus, purpura nephritis, infections such as hepatitis B and hepatitis C viruses, and other comorbidities were excluded. Furthermore, patients were also excluded on the basis of history of exposure to drugs and chemicals such as rifampicin, captopril, probenecid, ibuprofen, birth control pills, diclofenac, formaldehyde, and volatile hydrocarbons. Renal biopsies were taken and subjected to an examination by light microscopy, electron microscopy, and fluorescence microscopy.Healthy controls were recruited from the health examination centre of Shengjing Hospital of China Medical University. Those found with urinary tract infections or any other abnormalities were excluded.Urine and blood samples were collected from participants before renal biopsies. Blood was collected into plain vacutainers and allowed to clot thoroughly before centrifuging to obtain serum while random urine samples were collected using clean plastic containers and centrifuged at 1000g for 20 minutes to obtain the supernatants. Both sera and urine supernatants were kept at -80°C pending analysis.K) a × (0.993) age × 1.018 .Demographic and clinical information about the recruited participants was collected from the hospital's Laboratory Information System (LIS) and Health Information System (HIS). The assay of biochemical parameters such as urine protein, serum creatinine, serum urea, serum cystatin C (Cys-C), blood glucose, total serum protein, serum albumin, and urine creatinine (UCr) was carried out using an ARCHITECT C 16000 biochemical analyzer . The estimated glomerular filtration rate (eGFR) was calculated using the chronic kidney disease epidemiology collaboration (CKD-EPI) formula: eGFR = 141 × -SEA937Hu.pdf). The concentrations of nephrin and MMP-9 were obtained, standardized with urine creatinine, and reported.The levels of urinary nephrin and MMP-9 were determined in accordance with instructions as laid down in the operator's manual kits -SEA553Hu.pdf and Urinary nephrin and MMP-9 were assessed for possible associations with urinary protein and eGFR as follows:To determine the association of urinary nephrin and MMP-9 with proteinuria, we first established the correlation of each biomarker with proteinuria in all patients. We then grouped patients into two groups, i.e., the subnephrotic range group (proteinuria < 350 mg/mmolCr) and the nephrotic range group (proteinuria > 350 mg/mmolCr), and compared their levels.2 and those with eGFR greater than 90 ml/min/1.73 m2) and compared the biomarker levels.To assess the associations of urinary nephrin and MMP-9 with renal function, we first determined the correlation of eGFR with each biomarker. We then stratified patients into two groups . Sex ratio was compared using the chi-square test while group means and medians were compared using independent samples Information regarding demographic and basic clinical characteristics of study participants is as summarized in There was no significant difference in age, sex ratio, fasting blood sugar, creatinine, and eGFR between patients and healthy subjects. However, there was significant difference in levels of serum albumin, serum total protein, serum cystatin C, serum urea, diastolic blood pressure, systolic blood pressure, and urine protein.Urinary nephrin and MMP-9 were significantly increased in IMN patients compared to the healthy subjects .Unlike MMP-9 that was detectable in both patients and healthy controls, nephrin was detectable only among patients.As shown in Urinary MMP-9 was significantly increased in patients with nephrotic range proteinuria compared to patients with subnephrotic range proteinuria. Unlike urinary MMP-9 however, the increase in urinary nephrin did not reach statistical significance.2 and those with eGFR greater than 90 ml/min/1.73 m2. As shown in 2. There was no significant difference in the levels of urinary nephrin between the two groups.To establish whether the urine excretion of nephrin and MMP-9 varies between patients with differences in renal function, we compared the biomarker levels between patients with eGFR less than 90 ml/min/1.73 mTo assess whether urinary levels of nephrin and MMP-9 are related with major parameters of renal function, we determined the correlation of each biomarker with eGFR and proteinuria. As shown in The management of IMN is still problematic due to lack of reliable biomarkers capable of predicting patient outcomes in the early stages. For so long, the prediction of patient outcomes has relied on proteinuria, a clinical parameter whose onset lags behind kidney damage. In this study, we examined the association of urinary nephrin and MMP-9 with key parameters of renal function with an aim of deducing their potential roles in the management of IMN.The levels of nephrin and MMP-9 were significantly increased among patients compared to the healthy controls Tables  and 4. UIn the current study, urinary MMP-9 in patients with nephrotic syndrome was not only higher but also correlated with proteinuria Tables  and 4, a2 , a cytokine that induces renal fibrosis [Regarding the suitability of urinary MMP-9 as a biomarker reflecting the decline in renal function, our results are in harmony with the previous studies which reported significant urinary levels that correlated well with eGFR , 21. In fibrosis , 24.2R. Depending on the magnitude of the insult, the injured podocytes can undergo apoptosis or a series of adaptational changes. The adaptational changes of podocytes include rearrangement of their actin cytoskeleton, a process that leads to foot process effacement and detachment of expressed proteins such as nephrin [IMN is a primary glomerular disease whose severity is dependent on the extent of glomerular damage. The glomerular podocytes are targeted for immune destruction by the anti-PLA nephrin . As the MMP-9 belongs to the gelatinase family. Gelatinases are a group of enzymes that cleave type IV collagen which is a major constituent of the GBM. Although the potential of MMP-9 to reflect the severity of IMN has not been studied, MMP-9 is a recognized player in the pathogenesis of several glomerular diseases . The expIdentification of MMP-9 as a potential marker for the severity of IMN is of utmost importance to its management. IMN has a variable clinical course with one-third of the patients progressing to ESRD. Such a progression can be prevented or reduced if its severity and prognosis are accurately determined and appropriate treatments administered in time.2R antibodies.The current study has for the first time demonstrated that a relationship exists between urinary MMP-9 and the renal parameters in IMN. Unlike nephrin, MMP-9 exhibited significant association with proteinuria, a parameter currently used to assess the severity of IMN. Accordingly, MMP-9 holds a greater potential in monitoring the severity of IMN. To further elucidate MMP-9's potential, more studies are needed especially in determining its relationship with the IMN-specific markers such as PLAThe limitations of this study include the design which did not permit assessment of biomarker levels over time and the lack of information regarding the other IMN-specific antibodies which hold pathogenic and prognostic roles. Future studies should investigate the urine excretion patterns of MMP-9 in a prospective manner for better appreciation of its prognostic potential for IMN.


The current study examines COVID-19 prevention behaviors and vaccine intentions among 83 youth at high risk for HIV. Most youth self-identified as Latinx (52%), cisgender men (84%), and homosexual (66%). Youth self-reported COVID-19 prevention behaviors and intentions to vaccinate. Participants reported wearing face masks, washing hands, and staying six feet apart, but fewer reported leaving home only for essential needs. About one-third reported that they would not get a vaccine, and lack of trust in their doctors and the government were significantly associated with non-intention. To improve efforts towards herd immunity, interventions to improve health messaging from trusted sources for at-risk youth may be necessary to achieve higher vaccine uptake. Youth at high risk for HIV may also be at increased risk for a SARS-CoV-2 infection, as at-risk youth identify with sexual, gender, and racial/ethnic minority status and are more likely to have lifetime histories of homelessness, incarceration, and high-risk sexual behaviors and substance use ,2. YouthMinimal research has explored the extent and determinants of COVID-19 vaccine intent among youth , despiteThe Institutional Review Board of University of California Los Angeles approved this study (IRB#16-001858-AM-00007).Youth aged 18–27 at-risk for HIV in Los Angeles enrolled in a pilot study examining the preferences and acceptability of Pre-Exposure Prophylaxis (PrEP) since February 2020 were recruited to participate in the current study about COVID-related behaviors from March to April 2020. Informed written consent was obtained electronically using Qualtrics and Zoom. The youth were also concurrently enrolled in the ATN149 CARES longitudinal trial investigating text-messaging, online peer support, and coaching strategies to optimize the HIV prevention continuum among seronegative youth in Los Angeles and New Orleans . At-riskAll participants self-reported demographic information including race/ethnicity, gender identity, sexual identity, health insurance, employment status see  and the Youth reported if they planned to get a COVID-19 vaccine when available (Yes/No) and their reasons (open-ended).Youth reported the frequency they engaged in the following behaviors: wearing a face mask in public spaces, washing hands, staying six feet apart from others, only leaving home for essential activities, and limiting contact to those in their households see .Youth reported their level of trust in their personal doctor and the government regarding vaccines, and in COVID-19 related information from the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and FDA see .χ2 tests to compare demographic and behavioral characteristics, COVID-19 prevention behaviors, and reported levels of trust in government and medical authorities by intentions to get a COVID-19 vaccine (No intention/ Intention). We also conducted logistic regression models assessing the likelihood of vaccination intention associated with levels of trust in government and medical authorities.We used Pearson SD = 2.3), and the majority self-identified as Latinx (52%), cisgender men (84%), and homosexual (66%). Most participants had health insurance (74%) and were employed part- or full-time (57%) (Youth were on average 23 years old (me (57%) . None ofIn the previous two months most (54% - 90%) youth engaged in COVID-19 prevention behaviors frequently . The most commonly reported prevention behaviors were wearing face masks (90%), washing hands (84%), and staying six feet apart from others (70%). Lower proportions reported leaving the home only for essential activities (57%) and limiting contacts to those inside one’s household (54%) . The assOne third (35%) of youth reported that they do not intend to get a COVID-19 vaccine when it is available. Reasons for not intending to get vaccinated included mistrust in vaccines, generally , desire to wait and see what happens to others who receive a COVID-19 vaccine, specifically , and concerns regarding safety and side effects .In the bivariate comparisons, a substantial proportion of participants reported that they do not frequently  trust the government (70%) or their personal doctor (42%) concerning vaccines, and they do not frequently trust the CDC (45%), WHO (42%), and FDA (58%) concerning COVID-19 related information. Infrequent trust in the government and in one’s personal doctor concerning vaccines were associated with non-intention to get a COVID-19 vaccine. Similarly, infrequent trust in the CDC, WHO, and FDA regarding COVID-19 related information was associated with non-intention to get a COVID-19 vaccine .OR = 3.51, 95%C.I. = 1.97, 6.25, p < .001), their doctor , the CDC , the WHO , and the FDA  were significantly more likely to intend to receive the vaccine.In the logistic regression analyses, youth who reported a higher levels of trust in the government (This cross-sectional study investigated the intention to receive a COVID-19 vaccine among youth at risk for HIV in Los Angeles County. In the current sample, 35% of youth reported that they do not intend to get a COVID-19 vaccine. Current resistance in receiving the vaccination among adults ,9,12 posLack of trust in health information from personal doctors, government, and public health agencies, were all significant determinants of non-intention to receive a COVID-19 vaccine among youth in our sample. Most respondents reported trust in their personal doctor but not in the government regarding vaccines. This is consistent with recent reports of trust in scientific research and likeliness to vaccinate in France  and ItalApproximately half of participants in our sample reported that they do not frequently limit their contact to those within their household or leave home only for essential activities. With fewer COVID-19 restrictions now in force than in 2020 when our study was conducted, it is likely that youth are now engaging in these preventive behaviors even less frequently  AlthoughOur findings are consistent with a recent CDC study, which identified healthcare providers as one of the most trusted sources for information on vaccinations . The stuOur findings also point toward important policy implications, particularly related to the role of trust in COVID-19 vaccination mandates targeting youth in schools and colleges, as well as new policies that could allow minors to be vaccinated without parental consent. California recently became the first state in the nation to require all youth attending school in-person to be fully vaccinated against COVID-19 . HoweverPolicies that allow youth to be vaccinated without parental involvement could also increase COVID-19 vaccine uptake among youth with parents who are hesitant to vaccinate their children. Currently, youth under the age of 18 are not legally able to get vaccinated without parental consent in most states ,44. For The current study was limited by a small sample size, the timing of data collection, potential self-reporting bias, issues with open-ended questions, and was restricted to only online procedures as it was conducted during the COVID-19 pandemic. This study recruited from a small pilot of youth at high risk for HIV with the aim to run during the first months of the pandemic before COVID-19 vaccines were available. As a result, we were not able to evaluate if vaccination intentions influenced actual COVID-19 vaccination behaviors, or whether preventive behaviors and trust in government and health agencies changed over time as the pandemic progressed. Finally, we could not assess the impact of parental vaccine hesitancy on youth vaccination intentions. Despite these limitations, our findings highlight important opportunities for intervention, such as strengthening relationships between youth and their personal doctors, who are more trusted among youth and likely to have a stronger influence on vaccination decisions than more distal government institutions.To address low COVID-19 vaccine uptake among at-risk youth, public information campaigns are needed to restore trust in messaging from health and government authorities and strengthen relationships between youth and their doctors. At risk adolescents must be a priority population for COVID-19 vaccination as a protective measure for themselves and for the population at large to achieve herd immunity .Youth at high risk for HIV are also disproportionately exposed to SARS-CoV-2 and should be prioritized for COVID-19 vaccination. Previous research has found that health care providers are the most trusted source for vaccination information among youth, and provider recommendations are a key determinant of vaccine uptake ,48. In t


The aim of this study was to assess age-related changes in cardiac autonomic modulation and heart rate variability (HRV) and their association with spontaneous and pharmacologically induced vulnerability to cardiac arrhythmias, to verify the translational relevance of mouse models for further in-depth evaluation of the link between autonomic changes and increased arrhythmic risk with advancing age.Heart rate (HR) and time- and frequency-domain indexes of HRV were calculated from Electrocardiogram (ECG) recordings in two groups of conscious mice of different ages (4 and 19 months old) (i) during daily undisturbed conditions, (ii) following peripheral β-adrenergic (atenolol), muscarinic (methylscopolamine), and β-adrenergic + muscarinic blockades, and (iii) following β-adrenergic  stimulation. Vulnerability to arrhythmias was evaluated during daily undisturbed conditions and following β-adrenergic stimulation.HRV analysis and HR responses to autonomic blockades revealed that 19-month-old mice had a lower vagal modulation of cardiac function compared with 4-month-old mice. This age-related autonomic effect was not reflected in changes in HR, since intrinsic HR was lower in 19-month-old compared with 4-month-old mice. Both time- and frequency-domain HRV indexes were reduced following muscarinic, but not β-adrenergic blockade in younger mice, and to a lesser extent in older mice, suggesting that HRV is largely modulated by vagal tone in mice. Finally, 19-month-old mice showed a larger vulnerability to both spontaneous and isoprenaline-induced arrhythmias.The present study combines HRV analysis and selective pharmacological autonomic blockades to document an age-related impairment in cardiac vagal modulation in mice which is consistent with the human condition. Given their short life span, mice could be further exploited as an aged model for studying the trajectory of vagal decline with advancing age using HRV measures, and the mechanisms underlying its association with proarrhythmic remodeling of the senescent heart. This study explores the translational relevance of mouse models for the investigation of the link between cardiac autonomic changes and increased arrhythmic risk with advancing age. In humans, the natural process of aging is associated with a progressive structural and functional remodeling of the heart that predisposes elderly people to higher vulnerability to both brady- and tachyarrhythmias, causing substantial morbidity and mortality . SusceptIndeed, low vagally mediated HRV has been proposed as a prognostic marker of increased mortality and propensity to lethal ventricular arrhythmias in post-myocardial infarction and chronic heart failure patients , and assFurther support to this view comes from the observation that increased vagally mediated HRV has been described in centenarians compared with old adults , suggestAnimal models could therefore be useful to shed light on the relation between aging of the cardiac ANS, decline in vagally mediated HRV, and proarrhythmic electrical remodeling of the heart. For example, a longitudinal study in rats reported a gradual increase in the occurrence of different types of spontaneous arrhythmias with aging, which was coupled with a decline in vagally mediated HRV and a progressive alteration of the specialized conducting system . More reOn the basis of these considerations, the purposes of this study are threefold. First, to investigate the relative contribution of sympathetic and vagal components on HR modulation in two groups of conscious mice of different age. To this end, we measured HR and HRV parameters from Electrocardiogram (ECG) recordings performed during daily undisturbed conditions, and following exposure to pharmacological autonomic challenges. We hypothesized that resting HR would be predominantly modulated by sympathetic influences in older mice and that this would be reflected by (i) reduced HRV, (ii) larger HR responses  to sympathetic block with atenolol (β-adrenergic receptor antagonist), and (iii) lower HR responses  to vagal block with methylscoplamine (muscarinic receptor antagonist) compared to younger mice. Second, to discuss the specificity of time- and frequency-domain HRV indexes to reliably reflect these autonomic changes. Anticipating that HRV would be largely modulated by vagal influences in mice, as in humans , we hypoad libitum.C57BL/6J mice (JAX from Charles River Europe) of two different ages (4-month-old and 19-month-old) were individually housed, kept in rooms with controlled temperature (22 ± 2°C) and humidity (60 ± 10%), and maintained in a 12/12 h light/dark cycle (light on from 7:00 to 19:00 h), with food and water Experiments were performed in accordance with the European Community Council Directive 2010/63/UE and approved by the Italian legislation on animal experimentation . All efforts were made to reduce sample size and minimize animal suffering.Mice were anesthetized using inhaled isoflurane . Anesthesia was induced by spontaneous breathing of 5% isoflurane in 100% oxygen at a flow rate of 1 L/min and then maintained at 1.5-3% isoflurane in 100% oxygen at a flow rate of 1 L/min; all animals received the analgesic Rymadil  and antibiotic Baytril  immediately prior to transmitter implantation. Mice were then implanted with radiotelemetric transmitters  for recordings of ECG (sampling frequency 2000 Hz), and locomotor activity  signals. The transmitter was placed in the abdominal cavity; one electrode was fixed to the dorsal surface of the xiphoid process and another electrode was placed in the anterior mediastinum close to the right atrium, according to a previously described procedure . This elAfter recovery from surgery, ECG and LOC signals were recorded for 120 s every 30 min for six consecutive days, with the animals left undisturbed in their home cages. ECG and LOC signals were picked up by platform receivers  and acquired via Dataquest A.R.T. (TM) Gold 4.3 acquisition system .Mice were injected intraperitoneally on different days, following a rotational design, with: (i) 1 ml/kg saline solution ; (ii) 0.1 mg/kg methylscopolamine ; (iii) 1 mg/kg atenolol ; (iv) methylscopolamine + atenolol . Each injection was separated by at least a 2-day washout period. Drug doses were selected on the basis of previous studies . ECG recMice were injected intraperitoneally with isoprenaline . ECG recordings were performed during the hour that preceded (baseline condition) and the hour that followed the injection. All injections were done between 14.00 and 15.00 h.2), (ii) the power (ms2) of the low frequency band  and  bands in absolute values (ms2) and normalized units (n.u.), and (iii) the low frequency/high frequency ratio (LF/HF).Initially, each raw ECG signal was visually inspected to ensure that all R-waves were correctly detected. Those parts of ECG recordings which exhibited recording artifacts were discarded without substitution and excluded from further analysis. Heart rate  and time- and frequency-domain parameters of HRV were quantified using ChartPro 5.0 software , following the guidelines suggested by Thireau and colleagues  for the post hoc analyses were conducted using Fisher’s LSD.Separate estimates of HR, HRV, and LOC were initially generated for each 2-min recording period and subsequently averaged as mean values of the 12 h-light and 12 h-dark phase of each recording day. These parameters were then further averaged to obtain light phase and dark phase means of the six recording days. Subsequently, to test for differences between the two groups of mice, a series of two-way ANOVAs for repeated measures were applied on HR and HRV data, with “group” as the between-subject factor (two levels: 4-month-old and 19-month-old mice) and “phase” as the within-subject factor (two levels: light and dark phases). Follow-up t-tests, with a Fisher’s correction for multiple comparisons.Each recording period was split in 2-min epochs . For each epoch, separate estimates of HR and HRV were generated. Initially, to test the effects of pharmacological autonomic manipulations on HR values within each group, ΔHR values were calculated as the differences between each 2-min post-injection period and the respective mean baseline value, and then averaged for the 60-min period corresponding to the second hour that followed each injection . For each group, ΔHR and ΔHRV values were analyzed by means of one-way ANOVAs for repeated measures, with “autonomic manipulation” as the within subject factor . Follow-up analyses were conducted using Student’s t-tests.Lastly, the occurrence of spontaneous and pharmacologically -induced cardiac arrhythmias was determined and quantified off-line as in p < 0.05.All data in figures and tables are presented as means ± SEM. All statistical analyses were performed using SPSS 24 software package  and OriginPro 2020 . Statistical significance was set at Basal HR and HRV indexes were evaluated in 4 and 19 month-old freely moving mice to identify possible aging associated changes.We initially tested for the presence of a circadian oscillation of HR and to this aim we collected 2 min-long ECG traces every 30 min for six consecutive days. Heart rate values measured during light and dark phases of equal duration of the daily cycle are shown for each mouse in In order to investigate the influences of the Autonomic Nervous System on HR and dissect the relative contribution of each autonomic arm in the two age conditions, we evaluated the HR responses to selective pharmacological blockades of the parasympathetic and sympathetic systems  by i.p. post hoc analysis revealed that in 4-month-old mice vagal blockade with methylscopolamine provoked a significant increase in HR compared with the control  condition (p < 0.05), whereas sympathetic blockade with atenolol provoked a significant decrease in HR compared with the control condition (p < 0.05). No significant changes in HR were observed in 4-month-old mice after double autonomic blockade (methylscopolamine + atenolol) compared with the control condition. In the 19-month-old group a significant decrease in HR was observed during sympathetic blockade (p < 0.05), while an increase, albeit not significant, was observed during parasympathetic deprivation. Quite interestingly, in the older group the double autonomic blockade caused a significant decrease of HR, thus revealing a substantial difference between the intrinsic and basal rate.Within-group statistics yielded a significant effect of “autonomic manipulation” both in 4-month-old and 19-month-old mice. Specifically, t-test, p < 0.05), while no difference was identified during sympathetic deprivation.We also further proceeded to verify whether the effect of autonomic blockade could reveal aging associated differences. To this aim we compared heart rate differences (ΔHR) during each specific pharmacological manipulation and confirmed that both vagal and double autonomic blockade were different between the two age groups (Student’s p < 0.05) SDNN, RMSSD, total power, HF, and LF values compared with the control  condition. No differences were observed in the LF/HF ratio. Interestingly, sympathetic blockade alone did not result in significant changes in any index.Basal heart rate results from the complex balance of at least three main elements: intrinsic heart rate, sympathetic and parasympathetic drive. Results obtained in previous figures clearly illustrate that 4 and 19 month-old mice have similar basal heart rates, but the underlying relative contribution of the above-mentioned elements is different. To shed light on this point and better characterize the differences, HRV analysis was carried out on the ECG traces collected during selective autonomic blockades , 4. In tp < 0.05) of all HRV parameters were observed under double autonomic blockade. In addition, differences LF/HF values were identified during sympathetic blockades, respectively.In 19-month-old mice , unexpecTaken together the result of A more rigid chronotropism  is a pro-arrhythmic marker in humans; therefore, based on our previous findings, and with the overall aim to test whether the mouse is a reasonable experimental model to study cardiac aging, we further proceeded to verify the propensity to arrhythmias in the two age groups.p < 0.05), without specific age-related differences in the incidence of the various arrhythmic subtypes.In p < 0.05 Student’s t-test) in 19-month-old  compared with 4-month-old mice .Since an increased adrenergic background drive is also a well-known pro-arrhythmic condition, we repeated the analysis of arrhythmic events in the presence of adrenergic stimuli with isprenaline, and a similar larger overall incidence of cardiac arrhythmias was found in 19-month-old mice , bottom.The present study combines HRV analysis and selective pharmacological autonomic challenges to demonstrate a relative lower contribution of the vagal component on HR modulation in 19-month-old mice compared with 4-month-old mice. This age-related cardiac autonomic effect is (i) observed both during the light and dark phases of the daily cycle in conscious and freely moving mice, (ii) independent from somatomotor activity levels, (iii) compensated by a reduction in intrinsic HR, leading to a stable basal resting HR with advancing age, and (iv) associated with a larger vulnerability to both spontaneous and pharmacologically induced arrhythmias. In the next sections, we discuss the age-related changes in cardiac ANS modulation, the utility of commonly used time- and frequency-domain indexes of HRV to capture these autonomic changes in mice, and their association with arrhythmia susceptibility.Specific patterns of cardiac ANS modulation may vary across species, with possible species-typical sympathovagal balance . For exaWe found an age-related reduction in time-  and frequency-domain  indexes of HRV during both phases of the daily cycle , which rIn interpreting our findings from a translational point of view, we must underline similarities and differences with the human condition. First, the fact that muscarinic receptor blockade with methylscopolamine was associated with a significant increase of the average HR in the younger group suggests that in young adult mice vagal modulation plays a significant role in the regulation of resting HR. It must be acknowledged, however, that the intrinsic HR in the young group was similar to the average resting HR, confirming that, contrary to young adult humans , restingHRV can be separated into various components, reflecting ANS influence on cardiac control, and its analysis has become a popular approach in several investigational domains, both in human and animal research . In humaIn the light of these considerations, we advocate the use of vagally mediated HRV indexes  for capturing the decline in cardiac vagal modulation in mouse models of aging. However, it must be noted that while HRV alterations are often ascribed solely to changes in ANS signaling, age-related changes in HRV in mice have also been associated with deterioration of autonomic neuronal receptor signaling and mechanisms intrinsic to heart pacemaker cells .Reduced vagally mediated HRV has been proposed as a prognostic marker of increased mortality and propensity to lethal ventricular arrhythmias in cardiac patients , and assIn this study 19-month-old mice exhibited, alongside reduced vagally mediated HRV, a larger vulnerability to both spontaneous and pharmacologically- induced cardiac arrhythmias compared to 4-month-old mice . ArrhythThe present study documents an age-related impairment in cardiac vagal modulation and HRV in mice, which is coupled with a larger vulnerability to cardiac arrhythmias. These results should be interpreted within the context of their limitations. Besides the use of only two age groups, we must acknowledge that HRV is influenced by several factors that were not considered here, including respiratory activity and blood pressure. For example, in rodents, the respiratory pattern consists of normal (eupnoea) or rapid (tachypnoea) breathing, intermingled with periods of sniffing of variable intensity and duration . While cFurthermore, an important component of short- and long-term blood pressure regulation is the arterial baroreflex, which plays a central role particularly in modulating sympathetic and vagal control of the heart and peripheral vasculature to respond to shifting metabolic demands and maintenance of a stable blood pressure . Given tLastly, since autonomic dysfunction can contribute to the physiological decline of cognitive functions linked to the aging process , it woulThe original contributions presented in the study are included in the article/All animal procedures performed in this study were carried out in accordance with the guidelines of the care and use of laboratory animals established by the Italian and UE laws , the experimental protocols were approved by the Animal Welfare Committee of the Universitá degli Studi di Milano and by the Italian Minister of Health (protocol number 141/2016).CP, LC, and MB: conceived and designed the research. CP and LC: acquired the data. CP, LC, DM, and MB: performed statistical analysis and drafted the manuscript. CP, LC, DM, ABu, DD, ABa, and MB: made critical revision of the manuscript for key intellectual content. DD and MB: handled funding and supervision. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


There are still insufficient data on the complexity and predictability of patient-related outcomes following trauma. The aim of this study was to assess longer-term outcomes in patients with significant injury and to develop a simple scoring method to identify patients at high risk of subsequent deficits 1–2 years after injury.We conducted a prospective cohort study of survivors of significant injury , with analysis of patients’ 1- to 2-year health-related quality of life (HRQoL) and their functional outcomes based on Short Form-36 (SF-36), Trauma Outcome Profile (TOP), and Quality Of Life after Brain Injury (QOLIBRI). Documented variables suspected or known from the literature to be possible factors associated with outcome were first analysed by univariate analysis, and significant variables were entered into a stepwise logistic regression analysis. Scores predicting longer-term impaired outcome were constructed from risk factors resulting from multivariate analysis.R = 0.4) and outcome at hospital discharge (R = 0.3). After logistic regression, the study variables explained a maximum variance of 23 per cent for somatic, 11 per cent for psychological, and 14 per cent for cognitive longer-term outcomes. The resulting Aarau trauma prognostic longer-term outcome scoring (ATPLOS) system, developed by checking eight risk factors, had a specificity of up to 80 per cent, and importantly may facilitate early detection of patients at risk of a poorer longer-term outcome.Depending on the patient-reported outcome measure (PROM) used, up to 30 per cent of 1052 study patients (mean NISS 18.6) indicated somatic, 27 per cent psychological, and 54 per cent cognitive deficits. The investigated sociodemographic, injury-related, treatment, and early hospital outcome variables demonstrated only low associations with longer-term outcome in univariate analysis that were highest for preinjury pain or function NCT 02165137 , to predict the longer-term outcome of patients using the patient-reported outcome measures (PROMs) Short Form-36 (SF-36) and Trauma Outcome Profile (TOP) with reasonable sensitivity, specificity, and likelihood ratio. Application of such predictive factors may therefore help attending clinicians to initiate well targeted therapeutic interventions earlier and more effectively. The teaching hospital serves a catchment population of about 750 000 inhabitants. From 1 January 2010 to 30 September 2018, all significantly injured patients  over 15 years of age and admitted to the emergency department within 24 hours of injury were recruited to this prospective quality control study and consecutively evaluated. Hospital procedural guidelines followed international standardsAll patients gave their informed consent to their inclusion in the study. The study was approved by the regional ethics committee and performed in accordance with the ethical standards laid down in the Declaration of Helsinki.versus high . Multiple injury was defined as an AIS greater than 1 in at least two AIS body regions. Exclusion criteria for this study were patients who died up to the time of follow-up or those presenting with a Glasgow Outcome Score (GOS)Specially trained and experienced study nurses who were not involved in the treatment of patients were responsible for data management and trauma scores. Injury severity was determined based on maximum information available at the end of hospital stay. Demographic characteristics included age at time of injury (years) and sex (men/women). Co-morbidity was measured with the age-unadjusted Charlson Comorbidity Index,Patient longer-term outcomes were assessed at 1 and/or 2 years following trauma by postal survey, complemented by phone interviews undertaken by specially trained study nurses for missing or non-plausible answers. Since follow-up examinations did not start until 2012, only 2-year follow-up data could be collected for patients who had sustained an injury in 2010. For all other patients, 1-year or, if missing, 2-year follow-up data were used. This was considered acceptable because earlier investigations had shown only minimal outcome differences between the first and second year after injuryet al.,The thresholds for impaired values for SF-36 were taken from the definitions of Pirente P < 0.050 was considered significant. For univariate statistics, missing cases were excluded variable-wise. For multivariate regression analysis, which used only dichotomized variables, missing values were replaced by the more frequent value of the whole cohort. Respondents were compared to non-respondents, with the paired t test for parametric data and with chi-square tests for binary values. R2 (explained variance) is shown to highlight the power of the results. Documented binary or dichotomized variables suspected or known from the literature to be possible factors associated with outcome were first analysed by univariate analysis using tetrachoric correlations, which can be interpreted analogously to Pearson correlations. Significant variables were entered into block and stepwise logistic regression analysis, with the entry criterion of P < 0.05 – first, including demographic and injury-related variables, and second, including treatment and hospital outcome-related variables as predictors of long-term somatically, psychologically, or cognitively impaired outcomes. Scores predicting longer-term impaired outcome were then constructed by giving 1 point for each significant variable as a risk factor in the multivariate analysis. The resultant ‘Aarau trauma prognostic longer-term outcome score’ (ATPLOS) is calculated by adding 1 point for each risk factor present (see results). The threshold values for the binary prediction score were defined according to the criterion that the number of risk factors had a higher percentage of impaired patients than the total sample. Sensitivity, specificity, likelihood ratios, and factors between low- and high-risk patients for longer-term impairment were calculated based on these binary prediction scores. Data were analysed using SPSS® for Windows 26.0 .Data are displayed as mean and s.d. for numeric variables; numbers and percentages are given for nominal variables. All statistical tests are two-tailed, and R2 = 0.02; Of 2453 eligible patients, a total of 1055 significantly injured individuals replied at longer-term follow-up . Long hospital stay and/or no direct home discharge correlated significantly with all outcome dimensions (maximum R = 0.30). In terms of somatic impairment, the variable ‘musculoskeletal injury’ (AIS 5) had the next best correlation (maximum R = 0.21), whereas psychological impairment could only be predicted very weakly by the injury . In the case of cognitive impairment, it was ‘head and neck injury’ had a positive correlation? . On the other hand, ‘head and neck injury’ (AIS 1) correlated slightly negatively with somatic impairment (R = 0.07).Univariate analysis of the influence of categorical patient, injury, and treatment characteristics on longer-term outcome (R2 = 0.02).Correlations calculated separately for patients with and without TBI only showed minor differences, compared to the total correlation matrix with  were constructed from a total of eight risk factors: five for each of somatic and psychological impairment, and four for cognitive impairment. The criteria for each score are summarized in This prospective study is the largest European trauma centre evaluation contemporaneously comparing general (SF-36) and trauma-specific  longer-term PROMs in non-selected patients following significant injury . Briefly summarized, about every second injured individual reported cognitive limitations. Even though a range of socioeconomic, trauma, and treatment variables were investigated, correlations with longer-term outcome in this evaluation were, at best, weak, given their low explained variance. The elaborated prognostic scoring tool (ATPLOS) had a reasonable sensitivity and specificity to serve as an additional diagnostic instrument to detect impaired patients more easily.,,,,,In addition to the well known high rate of somatic and psychological restrictions noted by patients 1–2 years following traumaR = 0.38). The fact that the majority of patients in the Brabant studyR = 0.13–0.21). This is equally valid for the low associations found in multivariate models, whereby the information available from all variables under investigation during hospital stay taken together explained a maximum of 23 per cent of the variance for somatic, and 11 to 14 per cent for psychological or cognitive (respectively) longer-term outcome. Comparison of the general and condition-specific PROMs used in this study found no important differences in the detection of patients’ longer-term deficits. This contrasts with the increasing consensus to use a combination of generic and condition-specific tools,,,Although a range of socioeconomic, trauma, and treatment variables were investigated, correlations with longer-term outcome in this evaluation are, at best, weak, given their low explained variance. In line with other studies, univariate analysis was performed and found the highest correlations for preinjury pain or functional impairment  who were all patients consecutively treated in a single Swiss trauma centre. It is not possible to comment on PROMs other than those investigated in this study. At first glance, a 43 per cent response rate 1 to 2 years after trauma may appear low. However, it is comparable with other reports on extended follow-up controls in the severely injured that included a bundle of standardized outcome instrumentsThis study of significantly injured patients showed a high rate of somatic and psychological impairments, but particularly cognitive deficits. Despite the finding that early sociodemographic, trauma, and treatment variables correlated only to a limited extent with the outcome 1 to 2 years after trauma, multivariate analysis allowed the development of a potential diagnostic instrument, the ATPLOS, to predict the longer-term outcome of patients by using the PROMs SF-36 and TOP with reasonable sensitivity, specificity, and likelihood ratio. The application of such predictive factors may help clinicians to initiate well targeted therapeutic interventions earlier and more effectively.zrab109_Supplementary_DataClick here for additional data file.