This study compared rates of multiple forms of COVID-19 racism-related discrimination experiences, fear/worries, and their associations with mental health indices among Chinese American parents and youth between 2020 and 2021. Chinese American parents of 4- to 18-year-old children and a subsample of their 10- to 18-year-old adolescents completed surveys in 2020 and 2021. A high percentage of Chinese American parents and their children continued to experience or witness anti-Chinese/Asian racism both online and in person in 2021. Parents and youth experienced less vicarious discrimination in person but more direct discrimination (both online and in person) and reported poorer mental health in 2021 than in 2020. Associations with mental health were stronger in 2021 than in 2020 for parents’ and/or youth’s vicarious discrimination experiences, perceptions of Sinophobia, and government-related worries, but weaker only for parents’ direct discrimination experiences. The spillover effect from parents’ vicarious discrimination experiences and Sinophobia perceptions to all youth mental health indices were stronger in 2021 than in 2020. Chinese American families experienced high rates of racial discrimination across multiple dimensions, and the detrimental impacts on their mental health were still salient in the second year of the pandemic. Vicarious and collective racism may have even stronger negative impacts on mental health and well-being later in the pandemic. Decreasing health disparities for Chinese Americans and other communities of color requires extensive, long-term national efforts to eliminate structural aspects of racism. Anti-Asian racism and xenophobia have surged in the United States since the outbreak of the COVID-19 pandemic in December 2019 and continued to rise in 2021. Between March 2020 and 2022, the Stop AAPI (Asian American and Pacific Islanders) Hate Reporting Center received 11,467 reports of racism and discrimination against Asian Americans in the United States, with Chinese Americans comprising the majority (43%) of the adult respondents and 9% of the youth respondents (below 18 years old) [The harmful effects of COVID-19-related racial discrimination on Asian Americans’ mental health have been documented in several studies conducted shortly after the pandemic outbreak. These findings consistently show that Asian Americans experienced racial discrimination during the pandemic ,4,5,6,7,COVID-19-related experiences of discrimination, Sinophobia, and racism-related fear/worries can affect children’s mental health both directly and indirectly through their parents’ experiences . For botdirect targets of racial discrimination, but also vicariously witness, read, or hear about an incident of discrimination directed at same-race others [online, in addition to in-person, experiences with discrimination [direct and indirect (vicarious) racial discrimination, both in person and online.Racism occurs across various interpersonal, institutional, and cultural contexts, and discrimination based on race is manifested in various forms and levels . We capte others . Increasmination . TherefoTo capture cultural-symbolic and sociopolitical manifestations of racism, we also assessed racism at the collective/group level. Specifically, we assessed two forms of Sinophobia: health-related Sinophobia, in which Americans consider the Chinese to be a health threat to American society, and media Sinophobia, which refers to the U.S. media’s perpetuation of Sinophobia during the pandemic . Use of To summarize, we compared the rates of the following COVID-19 racism-related discrimination experiences, fear/worries, and mental health indices of Chinese American parents and youth in the Spring of 2020 and 2021: (1) online direct, (2) online vicarious, (3) in-person direct, and (4) in-person vicarious. We also assessed their perceptions of: (5) health-related Sinophobia, (6) Sinophobia in the media, and their (7) fear/worries about government-caused racism. In addition, we assessed parents’ and youth’s (8) psychological well-being and (9) generalized anxiety symptoms, and parents’ (10) depressive symptoms and youth’s (11) internalizing and externalizing problems. Finally, we assessed the associations between each of these racism-related experiences and mental health indices and compared the strength of these associations between 2020 and 2021.Parents who self-identified as ethnically Chinese residing in the United States with at least one 4- to 18-year-old child were eligible to participate. The 2020 data were collected between March to May 2020 and included 529 Chinese American parents . From thQualtrics online platform. Rigorous data legitimacy checks  were conducted to ensure the validity and accuracy of the data [Participants were recruited through phone calls and distribution of flyers via e-mails to different Chinese American organizations, and Facebook and WeChat groups. This recruitment strategy was necessary because we targeted a specific minority group within a short period, and social distancing regulations did not allow for community-based data collection. Parents provided consent for themselves and their children. Youth’s online assent was obtained separately. The surveys were hosted on the the data . Measurethe data . ParentsParents reported on their family’s demographic characteristics. Parents and youth separately reported on their experiences with four types of COVID-19-related racial discrimination, perceptions of health-related and media Sinophobia, government-related fear/worries, and their mental health. Details on the measures of different types of discrimination, Sinophobia, and government-related worries can be found in Online direct racial discrimination was assessed using four items  [Online vicarious racial discrimination was assessed using three items . Respondents rated how often they experienced each incident on a 5-point scale ranging from 1 (never) to 5 (every day).In-person direct racial discrimination was assessed using five items for the parent survey and four items were used for the youth survey  [in 2021) . RespondIn-person vicarious racial discrimination was measured using four items  [in 2021) . RespondHealth-related Sinophobia was assessed using three items  [Sinophobia in the media was assessed using five items  [Government-related fear/worries was measured using three items that were created for the purpose of this study to capture Chinese American parents’ and youth’s fear, worries, and concerns for their safety and well-being as racial minorities due to the U.S. government’s handling and responses to the COVID-19 pandemic . Items were rated on a 4-point scale ranging from 1 (strongly disagree) to 4 (strongly agree).Psychological well-being was measured using Ryff’s 18-item Psychological Well-Being Scale [ng Scale . RespondGeneralized anxiety symptoms were assessed using the 7-item Generalized Anxiety Disorder Screener [Screener . RespondDepressive symptoms in parents were measured using the 21-item Beck Depression Inventory-II [ntory-II . Only paInternalizing and externalizing problems in youth were assessed using the Strengths and Difficulties Questionnaire (SDQ) [re (SDQ) . Only yoIn 2020, 3% and 2% of the data were missing in the parent and the dyad sample, respectively. In 2021, 0.5% and 2% of the data were missing in the parent and the dyad sample, respectively. Missing patterns in all samples were completely at random and were handled using the maximum likelihood approach. The data were transformed to a long format to include a Year of Data Collection variable  and a Participation Status variable  for the analyses.First, a set of ANCOVA analyses were conducted to compare parents’ and youth’s experiences of the four types of COVID-19-related racial discrimination, perceived health-related Sinophobia and media Sinophobia, government-related fear/worries, and mental health indices between 2020 and 2021. The year of data collection was the independent variable and the variables listed above were the outcomes in each of the ANCOVA models. Participation status was entered as a covariate in each model. When comparing parent variables, parent age, gender, nativity, education, household SES, and region of residence were also controlled as covariates. When comparing youth variables, youth age, gender, nativity, household SES, and region of residence were controlled as covariates. SES was coded using the Hollingshead Four-Factor Index of Social Status-Revised .Next, three sets of moderated multiple regression models were conducted to compare the following associations across 2020 and 2021: (1) parents’ racial discrimination experiences and their own mental health; (2) parents’ racial discrimination experiences and their children’s mental health; and (3) youth’s racial discrimination experiences and their own mental health. In each model, one type of racial discrimination, Sinophobia perception, or government-related fear/worries, the data collection year, and the interaction between the discrimination variable and the data collection year were examined as predictors, and each mental health outcome was examined as the outcome variable. Covariates included parents’ and youth’s participation status, age, gender, nativity, household SES, and region of residence. Simple slope analyses were conducted to probe significant interactions between discrimination and Year variables in predicting mental health outcomes. Confidence intervals were obtained using the bootstrapping method of 2000 resampling replications.mean = −0.28, p < 0.001, ŋp2 = 0.03), (2) in-person direct discrimination , and (3) perceived media Sinophobia , and lower levels of: (1) in-person vicarious discrimination , and (2) psychological well-being . Similarly, youth in 2021 reported higher levels of: (1) online direct discrimination , (2) in-person direct discrimination , but also (3) generalized anxiety , and significantly lower levels of: (1) in-person vicarious discrimination , (2) perceived health Sinophobia , and (3) psychological well-being  than in 2020  and more strongly positively associated with parent anxiety symptoms  in 2021 than in 2020.b = 1.03, p < 0.001), and parent government-related worries were more strongly negatively associated with parent psychological well-being  in 2021 than in 2020. In contrast, parent online direct discrimination experiences were less strongly positively associated with parent depressive symptoms  and parent in-person direct discrimination was less strongly positively associated with parent depressive symptoms  and less strongly negatively associated with parent psychological well-being  in 2021 than in 2020.In addition, parent online vicarious discrimination was more strongly and positively associated with parent depressive symptoms  and internalizing problems  in 2021 than in 2020. In contrast, the magnitude of the associations between youth online direct discrimination, in-person direct discrimination, and government worries and the four youth mental health outcomes did not differ  between the two years, although all remained significant.Parent-youth associations. Further, the associations between parent discrimination variables and youth mental health outcomes were also stronger in 2021 compared to 2020. Specifically, parent online vicarious discrimination, in-person vicarious discrimination, and health-related and media Sinophobia perceptions were more strongly negatively associated with youth psychological well-being , more strongly positively associated with youth anxiety symptoms , and more strongly positively associated with youth internalizing and externalizing problems , except for the non-significant interaction terms for the associations between parent health-related and media Sinophobia and youth externalizing problems, in 2021 than in 2020. In addition, parent government-related worries were more strongly negatively associated with youth psychological well-being  in 2021 than in 2020. In contrast, no significant differences were observed for the associations between parent online and in-person direct discrimination and the four youth mental health outcomes  in 2021 compared to 2020, although all remained significant.Our findings revealed that a high percentage of both Chinese American parents and their children personally experienced or witnessed anti-Chinese/Asian racial discrimination both online and in-person due to the COVID-19 pandemic in 2021. The rates of vicarious discrimination decreased for in-person experiences and did not change significantly for online experiences between 2020 and 2021. However, these numbers were already high in 2020 and remained so in 2021, with 14–18% of parents and youth reporting vicarious racial discrimination almost every day and about 80% of parents and youth reporting experiencing or witnessing racial discrimination targeting Asian individuals due to COVID-19 at least once in 2021.direct victimization both online and in person were significantly higher in 2021 compared to 2020. The increase in experiences of direct discrimination at least once is alarming (51% for parents and 50% for youth in 2020 to 55% for parents and 58% for youth in 2021) and may reflect more people returning to in-person settings for work, school, and public spaces in 2021, which increases the risk of racism-related exposure [Importantly, the experiences of exposure . These nexposure . Anotherexposure .In examining perceptions of collective racism towards their racial-ethnic group (Sinophobia), both parents’ and youth’s Sinophobia perceptions did not vary significantly across two years. However, parents were more likely to perceive that Sinophobia against Chinese Americans was presented and promoted by the media in 2021 than in 2020, indicating continued and manifested negative Sinophobic messaging over time. Despite the change in administration, in 2021, Chinese American parents’ and youth’s heightened worries, fear, and concerns for their safety and well-being as racial minorities due to the Trump administration’s handling and responses to the COVID-19 pandemic did not decrease significantly from 2020. These findings support Tong et al.’s  nationalRegarding mental health indices, both parents and youth reported poorer mental health in 2021 than in 2020. These data indicated that more parents reported slightly elevated risks for developing depressive symptoms (24% versus 15%) and more youth reported slightly elevated risks for developing anxiety symptoms (18% versus 8%) in 2021 compared to 2020. These elevated mental health risk percentage numbers in 2021 were also higher than population norms  ,39, suggIn 2021, all types of COVID-19-related racial discrimination and racism were associated with poorer mental health among Chinese American parents and youth, consistent with previous studies on non-COVID-19-related discrimination . FurtherIn contrast, vicarious discrimination experiences either online or in-person were generally associated more strongly with negative mental health indices in 2021 compared to 2020 for both parents and youth. These findings highlight the detrimental long-term impact of vicarious discrimination, where injustices committed against other members of the same social group are collectively shared and can be personally stressful for Chinese American families ,42. ThisRegarding collective racism, both health-related and media Sinophobia were more strongly associated with poor mental health in 2021 than in 2020. Moreover, Chinese American parents’ fears and worries about being targeted and having more difficult lives due to the Trump administration’s racist responses to the COVID-19 pandemic were more strongly associated with their poorer psychological well-being in 2021 compared to 2020, although the mean levels were not significantly different across the years. Together, these findings imply that vicarious experiences with discrimination, collective racism, and institutional racism may have a stronger negative toll on these families’ mental health further along in the pandemic, perhaps because they are perceived to be more systemic and widespread, and thus, less controllable or changeable .all indices of poorer mental health in youth. Chinese American parents’ government-related worries and concerns were further associated with their youth’s poorer psychological well-being. Parents’ own racial victimization experiences and feelings of being unsafe might impact their children’s mental health either directly or indirectly through a more stressful or hostile family environment, and/or maladaptive parenting [When we examined Chinese American parents’ experiences of racism in relation to their children’s self-reported mental health, a similar pattern was found where parents’ vicarious (but not direct) experiences of racial discrimination both online and in-person and parents’ Sinophobia perceptions were more strongly associated with arenting . Given tarenting ,47. In aarenting .Although the course of the pandemic is waning, pediatricians and other healthcare professionals should continue to be sensitive to the mental health needs of Chinese American youth and their parents related to various forms of racism at different levels. The cumulative negative effects of racism, particularly vicarious discrimination and collective forms of racism may continue to have adverse health effects on Chinese Americans. We recommend that healthcare providers continue to identify youth with mental health concerns and to facilitate referrals to mental health services using culturally competent approaches that validate and normalize mental health help-seeking behavior among Asian Americans.Although our sample comprised families from 30 states, it was not nationally representative of Chinese Americans due to the urgent need for rapid data collection. Thus, we were unable to examine regional differences in discrimination experiences and their correlates . In addiFurther, no causal interpretations can be made as our data were cross-sectional, although longitudinal studies have found that discrimination predicts mental health and not the other way ,49. In aGovernments and health authorities should denounce inflammatory political rhetoric that contributes to the scapegoating of Asian Americans for the public health crisis  ,51. The During the COVID-19 pandemic, the salience of anti-Asian sentiments and violence targeting Asian Americans increased and led to several key medical commentaries ,53 and sFuture research identifying protective factors to decrease and ameliorate the negative effects of these experiences is imperative ,10,14. O


Accurate biomarkers are a crucial and necessary precondition for precision medicine, yet existing ones are often unspecific and new ones have been very slow to enter the clinic. Mass spectrometry (MS)-based proteomics excels by its untargeted nature, specificity of identification, and quantification, making it an ideal technology for biomarker discovery and routine measurement. It has unique attributes compared to affinity binder technologies, such as OLINK Proximity Extension Assay and SOMAscan. In in a previous review in 2017, we described technological and conceptual limitations that had held back success. We proposed a ‘rectangular strategy’ to better separate true biomarkers by minimizing cohort-specific effects. Today, this has converged with advances in MS-based proteomics technology, such as increased sample throughput, depth of identification, and quantification. As a result, biomarker discovery studies have become more successful, producing biomarker candidates that withstand independent verification and, in some cases, already outperform state-of-the-art clinical assays. We summarize developments over the last years, including the benefits of large and independent cohorts, which are necessary for clinical acceptance. Shorter gradients, new scan modes, and multiplexing are about to drastically increase throughput, cross-study integration, and quantification, including proxies for absolute levels. We have found that multiprotein panels are inherently more robust than current single analyte tests and better capture the complexity of human phenotypes. Routine MS measurement in the clinic is fast becoming a viable option. The full set of proteins in a body fluid  is the most important reference and the best process control. Additionally, it increasingly has all the information that could be obtained from targeted analysis although the latter may be the most straightforward way to enter regular use. Many challenges remain, not least of a regulatory and ethical nature, but the outlook for MS-based clinical applications has never been brighter.  •Technological developments in MS-based biomarker discovery.•Successful use cases for MS-based proteomics in body fluids in biomarker discovery.•High-throughput capabilities now enable the analysis of large and independent cohorts.•Multi-protein biomarker panels as the future of diagnostics.•Emerging focus on downstream aspects such as data protection and ethics. Mass spectrometry is by its nature well suited for identification of body fluid biomarkers and their routine measurement but has been held back by technological and conceptual constraints. Here, we show that improvements in throughput, streamlining, robustness, and study design are progressively overcoming these constraints and have recently enabled promising success stories. Cutting-edge scan modes, multiplexing, and sample preparation promise to further enhance the technology, which we envision will finally bring MS-based proteomics to the clinic. A biomarker is a “defined characteristic that is measured as an indicator of normal biological processes, pathogenic ones, or a response to an exposure or intervention” , 2. It ihttps://edrn.nci.nih.gov/data-and-resources/biomarkers/).Proteins are major components of body fluids and are used widely for contemporary diagnostic testing, for instance, they constitute more than 40% of blood analyses . InspireIn 2017, we reviewed the state of biomarker discovery by plasma proteomics, highlighting pitfalls, and how they might be alleviated , 12, 13.via modern strategies have already provided proof of concept that such utility can be achieved given the right study design, for example, by outperforming state-of-the-art clinical assays . In fact, body fluid applications have driven the quest for these qualities in MS-based proteomics in general, highlighted by an ISO standardized plasma proteomics workflow  , the Seehttps://www.thermofisher.com/document-connect/document-connect.html?url=https://assets.thermofisher.com/TFS-Assets%2FCMD%2FTechnical-Notes%2Ftn-000635-ccs-upac-column-robustness-proteomics-tn0006358-en.pdf)  separation of peptides before the MS analysis was the most variable part of the entire pipeline. High-performance but difficult-to-produce “in house” columns were typically used in proteomics laboratories. There is a clear trend toward commercial ones, as they are more robust and much less variable between laboratories. Micropillar-structured columns  may become an attractive alternative to packed columns because of their high resolution and the absence of bead material that may change over time (-en.pdf) .In our own group, until a few years ago, we used long columns (40–50 cm) and gradients (45–100 min) with extensive overhead times (up to 20 min) corresponding to 12 to 24 samples per day , 18, 39.https://sciex.com/content/dam/SCIEX/tech-notes/life-science-research/proteomics/ruo-mkt-02-3637-a/Microflow-SWATH_6600_RUO-MKT-02-3637-A.pdf) but are now well-established across a variety of platforms  MS in recent years has marked a significant milestone. This progress has been primarily driven by the development of novel algorithms and high-performance mass spectrometers , 44. DIAhttps://sciex.com/products/mass-spectrometers/qtof-systems/zenotof-7600-system.html). Importantly, the direct correlation of precursors and fragments mentioned above will open up for the discovery of modified and otherwise unexpected peptides, including their use as potential biomarkers. Overall, we expect significant improvements in MS technologies and accompanying algorithms in the near future, creating a very deep and solid basis for urinary and CSF proteomes, and going a long way towards deep investigation of the plasma proteome.For these and other acquisition methods, algorithmic methods urgently need to be developed or improved to take full advantage of them. We expect such software developments to catch up with these new scan modes soon. Once this has happened, these scan modes can be used universally, directly benefitting the depth and quantitative accuracy of body fluid proteomics. MS instrumentation is likewise constantly being improved, for instance with the development of the “Zeno trap,” leading to much-improved fragment detection and quantification and alternative fragmentation modes becoming more readily available (Sample multiplexing by isotopic labeling is an established approach to increase throughput in proteomics measurements. Tandem Mass Tag (TMT) is currently the most popular variant, wherein each condition is assigned a distinct isobaric label. These labels produce the same mass shifts of precursors but their fragmentation yields channel-specific reporter ions at the same mass for all precursors , 58, 59.Non-isobaric multiplexed DIA (mDIA or plexDIA) , 68, 69 B). Importantly, mDIA opens up for the reference channel concept, which could be particularly beneficial for body fluid proteomics. This reference channel consists of a standardized reference sample that is admixed to all samples in a cohort . This standard does not need to be confined to one study or one laboratory but could be shared within the entire community. Although very attractive conceptually, much thought will have to be invested in the design of such standards, to which degree they should be universal or disease-specific and how to share them in the community.The reference channel can also be used as a built-in quality control of the analytical setup throughout the measurements, thereby replacing injections of standard samples interspersed between the actual samples. If desired, the reference channel can be absolutely quantified for particular biomarkers of interest. This requires a (separate) combined measurement of the reference together with one or more labeled standards, which can even be done retrospectively B. This shttps://olink.com/resources-support/publications/, https://somalogic.com/publications/). Many of the MS studies were small and specialized, whereas the affinity binder studies are quite costly but have nevertheless been employed on large cohorts.Over the last years, affinity binder technologies have been used extensively to measure large clinical plasma or serum cohorts—mainly by Olink’s antibody-based proximity extension assay (PEA) or SomaLogic’s DNA aptamer-based SOMAscan assay, reviewed elsewhere , 75, 76.https://somalogic.com/somascan-platform/, https://olink.com/products-services/explore/). Similarly, affinity binder proteomics studies were limited to hundreds of samples a couple of years ago, whereas—given sufficient funds—even population studies of tens of thousands of individuals are now feasible . Moreover, it is suited to study additional proteome aspects less accessible to binder technologies. These include protein isoforms, the peptidome, and the post-translational modification landscape (B). As a specific example, glycosylation of secreted proteins is an abundant modification of plasma proteins, and glycation of blood hemoglobin is the gold standard for monitoring blood sugar levels in diabetes, which is readily detected by MS-based proteomics but not currently by the binder assays . Optimal selection of biomarker candidates for further validation is especially important, given the exponentially increasing costs when turning these candidates into actual clinical tests. Previously, sample throughput often limited study size, however, as noted, these constraints are rapidly disappearing. Our own studies were initially around dozens of samples but have moved on to hundreds of or even thousands of samples due to technological improvements (B). Similarly, identification of genetic effects on protein levels in body fluids termed protein quantitative trait loci (pQTL) typically requires large study collectives . Additionally, complex scenarios may only be resolvable by a population-based understanding that is enabled by large study collectives. On the analysis side, researchers should not try to slice phenotypic continuums into ever smaller categories with specific biomarker signatures and cutoffs. Rather, biomarker panels should report a position on a continuum. Again, validation of the clinical utility of such findings hinges on the quality of clinical data. Apart from these issues, intended applications of biomarkers influence the study's collective composition. For instance, in screening applications, the specificity of a biomarker needs to reflect the underlying frequency of a condition in the population. To wit, if the general population is screened for a relatively infrequent condition, the specificity needs to be almost perfect while maintaining an overall high sensitivity to prevent the large majority of positive cases are actually false positives—a well-known issue for any population screen . The unbiased nature of MS proteomics makes it well-suited for discovery without previous hypotheses. This approach also avoids the time-consuming establishment and validation of candidate approaches and does not require a priori knowledge of or insights into disease mechanisms. As technology improves, untargeted approaches such as DIA-based strategies with increasingly powerful mass spectrometers, will increasingly subsume the analytical capabilities of targeted MS assays (B). As mentioned earlier, MS-based proteomics competes with binder assays and should further develop throughput and proteomics depth to bring its inherent advantages to bear.In the clinic, the two roles of MS-based proteomics comprise the measurement of cohorts with the intent to find biomarkers and the much more common task of clinical routine measurement for diagnostic purposes A. The unS assays B. As mene.g. 5–20) (A and B). This multiplexing and the high specificity and quantitative accuracy are key conceptual advantages of MS compared to classical ELISA or affinity binder technologies  , A and Bnologies . In our C). For instance, urinary biomarkers/analytes are routinely normalized to urinary creatinine to ensure interpretability by accounting for water reabsorption in the kidney  need toM. M is an indirect investor in Evosep Biosciences.


Adequate peri-operative care is essential to ensuring a satisfactory outcome in cardiac surgery. In this study, we look at the impact of evidence-based protocols implemented at Stanford Hospital.This study is a single-center, retrospective analysis. Enhanced recovery after surgery (ERAS) protocols were implemented for CABG/Valve and open Aortic operations on 11/1/2017 and 6/1/2018, respectively. Propensity-score matched analysis was used to compare 30-day mortality and morbidity of patients from the pre- and post-implementation cohorts. Secondary endpoints included the following: total hospital length of stay (LOS), ICU LOS, time until extubation, and time until urinary catheter removal.After the implementation of the ERAS protocols for CABG/Valve operations, the median post-op LOS decreased from 7.0 days to 6.1 days (p<0.001), and median ICU LOS decreased from 69.9 hours to 54.0 (p = 0.098). There was no significant decrease in 30-day mortality . However, the incidence of post-op ventilator associated pneumonia (VAP) decreased from 5.0% to 2.1% (p = 0.003) and post-op urinary tract infections (UTIs) from 8.3% to 3.6% (p<0.001). Patients who underwent open aortic procedures experienced an improvement in 30-day mortality , decrease in median ICU LOS , and a decrease in duration of mechanical ventilation . There was a decrease in post-op LOS, post-op VAP, and post-op UTI, although statistical significance was not attained.At Stanford Hospital, ERAS pathways have led to decreased morbidity and LOS while simultaneously improving mortality amongst our critically ill patient population. Comprehensive perioperative care is essential to ensuring excellent surgical outcomes. Such care promotes recovery and has the potential to improve postoperative morbidity after cardiac surgery . SuccessA small pilot study by Fleming and colleagues in 2016 demonstrated promising outcomes for ERAS implementation in cardiac surgery. The study showed that ERAS protocols were feasible and had the potential to result in improved postoperative morbidity . DespiteIn previous literature, postoperative ERAS strategies have focused on early extubation, promotion of patient mobility, pain control, nutrition, gastrointestinal function, and fluid management .At our institution, we have established comprehensive evidenced-based ERAS post-operative care pathways for CABG/Valve and Aortic surgeries. In this study, we looked at the impact of these evidence-based pathways. We compare quality metrics measured in the post pathway implementation cohort with a similar patient population that preceded the implementation of the ERAS pathways.This study was a single-center retrospective analysis of consecutive patients undergoing Open Aortic, CABG, and Valve surgery at Stanford Hospital. The data was collected via the electronic medical record (EMR). The EMR utilized at Stanford Hospital during this time period was Epic Systems Corporations . The study was approved by the Stanford IRB (#60785) and adhered to the institution’s protocols. The Stanford IRB waived the requirement for informed consent for this study and HIPAA guidelines was adhered to during the collection of data and reporting of our results.The start dates for the CABG & Valve pathway and the Aortic Procedure pathway were 11/01/2017 and 06/01/2018, respectively. Order sets were created within Epic to implement the post-operative care pathways and standardize care. Orders are placed by the surgical team immediately after the completion of the procedure prior to leaving the operating room. The orders are subsequently released by the ICU team on the arrival of the patient to the unit.In our analysis of the impact of the CABG & Valve pathway, we included patients who underwent isolated CABG cases, isolated Valve repair and replacement operations, and CABG/Valve combination procedures via robot-assisted, full sternotomy, partial sternotomy, and thoracotomy approaches. Patients who underwent transcatheter valve repair or replacement were excluded from the study as they were not managed postoperatively using the CABG & Valve order set. We use propensity scores to match patients into the pre-implementation and post-implementation groups with a cohort that underwent similar operations prior to the implementation of the pathway from 08/05/2009–11/02/2017. Patients were stratified into these two groups, and a logistic regression model was used to calculate propensity scores based on history of COPD, dialysis, diabetes, and NYHA score. We applied a greedy nearest neighbor matching algorithm without replacement with a caliper of 0.01 to calculate propensity scores. Balance of the match was assessed using standardized differences.The analysis of the Aortic Procedure pathway included patients who underwent open aortic surgery after its implementation in June 2018. Open aortic surgery at our institution addresses a wide spectrum of aortic disease including aneurysms, dissections, and rupture; operations span the entirety of the thoracic aorta, from valve sparing root replacements to thoracoabdominal aneurysm repairs. Patients who had surgeries that utilized an endovascular approach  were excluded from our study. Patients on ECMO or those who had an intra-aortic balloon pump (IABP) were also excluded from our study. These patients were also propensity matched with patients who had similar procedures prior to the pathway implementation from 09/15/2012–06/01/2018. A logistic regression model was similarly used to calculate propensity scores among the pre-implementation group versus the post-implementation group based on history of COPD, diabetes, and NYHA score. Mean pain scores were obtained from post-operative day three. They were obtained from the patient directly, if extubated. The scale used ranged from 0 to 10. 0 was considered no pain at all and 10 was considered to be the worst pain imagined.The comprehensive evidence-based post-operative care pathways at our institution adopt a multimodal approach and are broken down into organ systems: neurological, cardiac, pulmonary, endocrine, renal, gastrointestinal, labs, anticoagulation, prophylaxis, wound, activity, patient education, and discharge planning. Figs In the CABG/Valve group, 1131 patients were included in the pre-implementation cohort and 756 in the post-implementation cohort . In the A total of n = 747 patients from the CABG/Valve pre-implementation group and CABG/Valve post-implementation groups were propensity matched, as seen in 586 patients were matched in the Aortic pre- and post- implementation cohorts . CompareThe ERAS concept was first introduced by academic surgeons aiming to improve perioperative care for patients receiving colorectal care ; it is nSuccessful cardiac surgery requires cohesive integration of a sizeable team’s workflows in all phases of care. Post-operatively, it is imperative that the surgical team works in concert with the clinical staff in the ICU and in step-down units to enhance patient care. Standardized, evidence-based protocols that address, glycemic control, opioid-sparing pain management, post-operative nausea and vomiting (PONV), timely lines and catheter removal, extubation strategies, and early enteral feeding reduce surgical morbidity and have been shown to result in a reduced total hospital LOS, ICU LOS , 4.At our institution, we have created separate evidenced-based care pathways for post-op CABG/Valve patients and patients who have undergone open aortic surgery. We excluded all patients who underwent endovascular procedures , or required ECMO or an Intra-Aortic Balloon Pump. The post-op care pathways are broken down into 13 components: Neurological, Cardiac, Pulmonary, Endocrine, Renal, Gastrointestinal, Labs, Anticoagulation, Prophylaxis, Wound, Activity, Patient Education, and Discharge planning. The care pathways focus on earlier extubation when appropriate, pain control, delirium management, expedient attempts at ambulation, early swallow screen after extubation, enteral nutrition, aggressive bowel regimen, and DVT prophylaxis. Prior to the ERAS order set, although there was a focus to reduce opioid utilization there was no standardization in the multi-modal pain control regimen, stool softener regimen, ambulation or extubation protocol.Our study showed significant improvement in both postoperative LOS and total ICU LOS in patients undergoing CABG/Valve and open Aortic procedures post protocol implementation. Significant improvements were also made in duration of mechanical ventilation, time to foley catheter removal, time to first ambulation, and time to first bowel movement for both groups as well. These findings are in line with previous studies , 14.Past literature has shown an association of early extubation with decreased pulmonary complications and decreased LOS , 5. Our Prolonged indwelling urinary catheters are associated with increased risk of UTIs and surgical morbidity , 16. OurEarly ambulation decreases the incidence of atelectasis and improves patient recovery . Once exAn aggressive bowel regimen and timely resumption of enteral nutrition has been shown to be associated with a faster return of bowel function and healing , 19. OncIt is important to recognize the synergistic impact one aspect of the care pathway may have on another. An early extubation protocol allows for a probable reduction in the total dose of opioids and is associated with a decreased incidence of ventilator associated pneumonia. Early extubation has a direct impact on the timing of patient ambulation and allows for consideration of timely urinary catheter removal. Furthermore, return of bowel function has been linked to ambulation and decreased usage of opioids. Fortunately, the COVID pandemic did not result in any staffing constraints within our department. We have not had to change any of our intra-op or ICU post op protocols as a result of the pandemic. Pre-operatively we have added COVID testing to be in compliance with California state mandates.The implementation of the ERAS protocol at Stanford Hospital is associated with improvements in patient outcome and ensures patients will receive multi-modal care. Significant improvements in morbidity quality metrics can be expected to improve bed utilization and cost-revenue ratios.Further investigation is warranted regarding the cost analysis of these post-op care pathways.


Organic solvent tolerant oxidoreductases are significant for both scientific research and biomanufacturing. However, it is really challenging to obtain oxidoreductases due to the shortages of natural resources and the difficulty to obtained it via protein modification. This review summarizes the recent advances in gene mining and structure-functional study of oxidoreductases from extremophiles for non-aqueous reaction systems. First, new strategies combining genome mining with bioinformatics provide new insights to the discovery and identification of novel extreme oxidoreductases. Second, analysis from the perspectives of amino acid interaction networks explain the organic solvent tolerant mechanism, which regulate the discrete structure-functional properties of extreme oxidoreductases. Third, further study by conservation and co-evolution analysis of extreme oxidoreductases provides new perspectives and strategies for designing robust enzymes for an organic media reaction system. Furthermore, the challenges and opportunities in designing biocatalysis non-aqueous systems are highlighted. What makes oxidoreductases particularly interesting from a standpoint of industrial application is their functional complementarity for the biosynthesis of chiral fine chemicals and application in biosensors . Non-aquExtremophiles are found in the most severe environments, such as hydrothermal vents, hypersaline lakes, alkaline soda pools, and volcanic areas . To survSeveral in-depth reviews have been published recently about extremozymes . Wang etBiocatalysis in high-concentration organic solvents offers many advantages, which include effective solvation of reactants, minimization of substrate or product inhibition, and easy separation. However, realizing this process remains a huge challenge. The development of biocatalysts for non-aqueous systems involves the adaption of the entire protein structures, which may decrease the catalytic efficiencies. In this paper, we focus on reviewing organic solvent tolerant oxidoreductases from the viewpoints of gene mining, structure-function characterization, and then the design principle of enzymes for non-aqueous system . First, Haloquadratum walsbyi (HwADH), which was active in the presence of 10% (v/v) organic solvents . The enzyme displayed NAD+/NADP+ dual cofactor specificity and a broad substrate scope, including benzyl alcohol and 2-phenyl-1-propanol, acetophenone, and phenylacetone. Alsafadi et al. . M. MNatranExpanding the synthetic capabilities to apply enzymes in a non-aqueous system is a dream for protein engineers and organic chemists. However, the general and transferable design principles to improve the organic solvents resistance of enzymes are poorly understood. The study indicated that organic solvent tolerance is greatly dependent on the whole structure of the halophilic enzyme, which resulted from million years of evolution. Therefore, it may be one of the reasons as to why improving organic solvent tolerance by protein engineering strategies such as directed evolution and site-mutations is difficult . AcATAM2) AcATAM2F56D, and AcATAM2F56V, not only displayed improved enzyme activity but also showed enhanced DMSO resistance. The half-life value increased from 25.71 to 42.49 h under 60% DMSO. MDS revealed that the increase in DMSO resistance was mainly caused by the decrease in the number of DMSO molecules in the substrate-binding pocket [The development of new efficient computational protocols to design an active enzyme for a given reaction would reduce the experimental costs . Organicg pocket . T. pseudoethanolicus and T. brockii by using site-directed mutagenesis and directed evolution for chiral alcohols and amines in organic solvents. Munawar et al. [Halobacterium salinarum, which was converted into a dehydrogenase accepting L-methionine, L-norleucine, and L-norvaline as substrates by site-directed mutation and showed enhanced thermostability and organic solvent tolerance even at 70 °C. Javier et al. [v/v) up to 23-fold over parental type, which was also stable in acetone, methanol, and dimethyl sulfoxide mixtures. Li et al. [+, which showed that the enzyme activity of mutant P45A was 1829 U/mg, with an improvement of 28-fold compared to wild-type GDH. P45A also showed better catalytic ability in 10% isopropanol, which was 19-fold that of the wild-type GDH. Rosli at al. [A. geothermalis ALDH can maintain an activity level of more than 50% in the 25% of DMSO, methanol, xylene, n-hexane, octanol, 2-propanol, n-heptane, and n-tetradecane.Musa et al.  studied r et al.  studied r et al.  construci et al.  studied i at al.  reportedCurrent strategies to identify enzyme activity rely on laborious tests carried out by incubation in different organic solvents and determination of residual activity. Computational techniques can be used to engineer enzymatic reactivity, substrate specificity and ligand binding, access pathways and ligand transport, and global properties such as protein stability, solubility, and flexibility . To desiIdentifying the specific mechanisms that need to be improved when tailoring the enzyme structure considerably improves the chances to succeed in generating highly efficient and robust oxidoreductases in the future. Improving enzyme activity and stability for non-aqueous catalysis is crucial for biocatalysis. Extreme enzymes play key roles in catalyzing valuable chemicals effectively and making them environmentally friendly. In this study, we focused on the mining and modification of robust oxidoreductases from extremophiles to meet the increasing demand of biocatalysis in non-aqueous systems . We inteA current challenge is how metagenomic mining can improve the discovery of polyextremophilic enzymes from multiple sources. Biotechnological exploitation of oxidoreductases from sequence derived statistics to the detailed atomic-level modeling of enzymes can provide cutting-edge technology in sequence annotation pipelines and bioinformatics resources;Using machine learning to effectively analyze big data on a higher-dimensional levels to establish an exemplary discipline assist experiment and reveal the interrelationships between the gene data, structure, and function ;Key research challenges focus on high throughput screening and for the expression of extreme enzymes through dedicated hosts and purification systems and upscaling;Using extreme enzymes for electrochemical reaction offers enhanced stability and applications in extreme environments where common oxidoreductase would not survive . The devNovel immobilization strategy for oxidoreductases by tailoring the enzyme microenvironment for the further enhancement of organic solvent tolerance, such as MOF and polymeric microcapsules as the immobilization carrier ,67.The challenges and future prospects for extreme enzymes in non-aqueous systems are discussed below:Other innovative research in the field and future outlooks on the highly efficient oxidoreductases in a non-aqueous reaction system have received considerable attention for their potential application in biosynthesis and for bridging the gap between laboratorial and industrial production .


While interoceptive self-report scales provide a foundation for measuring the mind-body connection, they variably consider other important factors that could influence interpretations of internal bodily sensations and perceptions related to mind-body integration. The proposed Body-Mind Connection Questionnaire (BMCQ) aimed to operationalise the notion that this construct involves three major components: (a) Interoceptive Attention, (b) Sensation-Emotion Articulation, and (c) Body-Mind Values.MAge=30.78), alongside established self-report measures of interoceptive sensibility, body awareness, sensory processing sensitivity, and alexithymia. We examined the BMCQ factor structure through exploratory factor analysis and analysed convergent and discriminant validity.Following panel review and piloting with the target population, the developed BMCQ was evaluated in 316 participants  aged 18-50 (rs=0.38 to 0.59). BMCQ scales were supported by convergent (r=0.33 to 0.67) and discriminant evidence .Exploratory factor analysis supported three scales of the BMCQ, which explained 54.03% of variance. Factor loadings (>0.44) and reliability indices (0.74 to 0.85) were acceptable. Inter-scale correlations suggested that the scales are distinct but related (Preliminary psychometric properties indicate that the BMCQ is multidimensional and consists of three constructs that differentially relate to theoretically associated measures. Interoceptive Attention, Sensation-Emotion Articulation, and Body-Mind Values may serve as a basis for efficiently assessing the mind-body connection more holistically, which could be useful for developing interventions aimed at enhancing mind-body integration.The online version contains supplementary material available at 10.1186/s40359-023-01302-3. A popular view of the mind and body is that they exist as distinct and separable entities. While some may experience their mind as qualitatively different to their body, mind-body dualism is not biologically plausible. Major advancements in neuroscience indicate that cognition is embodied , where cSeveral processes emerge as exemplifying the mind-body connection, namely interoception and emotion. Interoception refers to the processes by which the nervous system anticipates, senses, interprets, integrates, and regulates signals originating from the body across unconscious and conscious levels , 77. By Despite a growing appreciation of these functions underlying the mind-body connection, existing self-report measures in this area vary in the degree to which emotional processes are captured. What appears omitted amongst them is the consideration of broader values regarding the mind-body connection, which may provide additional insights into the role of holistic health and wellbeing perspectives in physical and psychological outcomes. Considering these factors, a new self-report measure of the mind-body connection incorporating these notions was developed.Maintaining desirable physiological states is critical for assuring survival and serves as the foundation of physical wellbeing , 30, whiInteroceptive signals continuously interact with cognitive models comprising past experiences and internal and external environmental regularities e.g., , 83), wh, wh83]),A longstanding theoretical tradition describes emotions as inexorably linked to changes arising from within the body through interoception e.g., , 53, 80), 8053, 8It is now accepted that conscious interoception, which forms the foundation of emotional processes, is multidimensional . VariousOn the other hand, IS is a purely subjective dimension, encompassed by the dispositional inclination to possess an internal focus and be interoceptively cognisant . TypicalWhile acuity in accuracy and awareness is crucial for maintaining optimal functioning and facilitates adaptive behaviour , the subIn interoceptive research, the dimensions of interest are primarily those utilising behavioural performance measures . AssessBy contrast, subjective beliefs regarding the degree to which individuals are interoceptively cognisant appears to influence clinical indicators, including depression severity  suicidalRelative to IAcc and IAw, interoceptive self-report scales capture appraisals across multiple channels by nature of definition and design. There are many existing tools, which assess a range of beliefs available to conscious access. Trevisan and colleagues  . Furthermore, an embodied sense of self reflects a high-order function that can encompass facets of regulatory behaviours guided by bodily cues and trust in body sensations , which mIn sum, prevalent interoceptive self-report scales vary in the concurrent measurement of emotional abilities that could relate to how individuals believe they detect and attend to specific sensations. In addition, there appears variable consideration of broader values pertaining to the mind-body connection and the importance of wellbeing. It is proposed that omission of these factors impinge upon the measurement of an individual’s perceived connection to their body and mind. For these reasons, the Body-Mind Connection Questionnaire (BMCQ) was developed to attempt to address limitations identified with existing self-report measures so as to enable clearer identification of whether individuals exhibit a connection with mind and body.In accordance with suggested guidelines for scale development , key doFollowing review, three key domains were identified, and proposed to be qualities informing one’s holistic connection to their body and mind. These were conceptualised as ‘Interoceptive Attention’, ‘Sensation-Emotion Articulation’, and ‘Body-Mind Values’. A total of 59 items were generated for these domains. Specifically, Interoceptive Attention items followed a theoretical grounding in foundational capacities, whereby these reflected non-biased, selective attentional capacities, as other functions  are captured in the MAIA. Eighteen items were generated for this domain. While ‘Emotional Awareness’ is captured in the MAIA, BMCQ items generated for the Sensation-Emotion Articulation domain drew upon alexithymic characteristics and constituents, following recent evidence showing the presence of a latent interoceptive factor in alexithymic assessment tools  coupled All items were screened for redundancy. If an item replicated items from existing questionnaires, it was removed. Next, remaining items were assessed for several factors, including grammatical complexity and technical jargon, and were rephrased to increase understanding or readability where necessary. Following these processes, the BMCQ was reduced to a 22-item pool. With respect to response scale ratings, it was agreed that clearly defined 7-point scales would enable respondents a greater degree of distinction in endorsement of BMCQ items. This was determined, as reliability and validity are better retained, and biases influencing responses  are mitigated .Four researchers with expertise in biological psychology and familiarity with interoception independently provided feedback on face validity, theoretical coherence, wording, and item clarity. Where there were differences in opinion, open discussions were held to explain perspectives which facilitated consensus being reached. Following discussions, several items were refined for clarity; the item pool was collectively deemed to be relevant to the hypothesised constructs. This process resulted in a retained 22 item pool to assess three constructs: Interoceptive Attention , Sensation-Emotion Articulation , and Body-Mind Values (10 items reflecting beliefs in mind-body integration and perceived importance of wellbeing).The BMCQ was then administered to 25 individuals known to the researchers to assess face validity from the perspective of respondents. This is recommended to determine whether target respondents interpret the items as intended . Due to The research team synthesised and reviewed these results. This included assessment of feedback for each item, and whether they yield skewed responses through review of means and standard deviations. No problematic items were identified. The 22-item BMCQ was retained and administered for field testing. Figure a priori sample size of 220 participants for the field test was determined to be the absolute minimum for this study, as this would provide a ratio of 10:1 respondents per item [Aged 18-50, to limit the effects of aging on physical health, including beliefs and practices Fluent in the English languageReside in Australia, Canada, New Zealand, the United Kingdom, or the United StatesFree of a current chronic pain condition , to limit the effects of chronic pain on subjective processing of homeostatic factors .An per item . Scale dper item . AccordiMAge=30.78, SDAge=8.34) were included in the study. Table Except for a current diagnosis of a chronic pain condition, there were no specific criteria to exclude individuals with a current diagnosis of other physical or mental health conditions. Participants were requested to disclose whether they were currently diagnosed with a physical and/or psychiatric condition, as previous literature indicates an association with altered interoceptive and emotional functioning . A totaOther indicators of health and wellbeing were also requested, including body mass index (BMI), smoking status, alcohol consumption, engagement in sport and exercise, yoga, and mindfulness and meditation practice. Table To test for convergent and discriminant validity, a questionnaire battery of several published measures sharing theoretical relatedness to the mind-body connection construct was assembled. This included the BPQ, BAQ, MAIA, Perth Alexithymia Questionnaire (PAQ), and the Highly Sensitive Person Scale (HSPS). Table not at all true of me (1) to very true of me (7). Items were scored such that higher scores represented greater capacities in connecting mind with body. The 22-item version is provided in the Supplemental Material. Additional details regarding scale refinement, reliability, and construct validity are outlined in later sections.The BMCQ administered for field testing consisted of 22 items pertaining to Interoceptive Attention, Sensation-Emotion Articulation, and Body-Mind Values. Participants rated how applicable each statement is to them generally on a scale ranging from never (0) to always (5), based on how often each statement applies to them generally in daily life. Scores are totalled and averaged for each subscale. Higher average scores reflect greater bodily awareness. MAIA scales demonstrate questionable to good internal consistency, where ɑ >0.65 for all subscales [The MAIA-2 is a 37-item self-report measure of interoceptive body awareness on 8 dimensions: 1) Noticing (MAIA-Not.); 2) Not-Distracting (MAIA-ND), 3) Not-Worrying (MAIA-NW), 4) Attention Regulation (MAIA-AR), 5) Emotional Awareness (MAIA-EA), 6) Self-Regulation (MAIA-SR), 7) Body Listening (MAIA-BL), 8) Trusting (MAIA-Trust). See Table ubscales . Incremenot at all true about me (1) to very true about me (7). Scores are summed, where higher values indicate higher body awareness. The BAQ shows good test-retest reliability (r = 0.72) and internal consistency reliability . BAr =0.56, ).Never (1) to Always (5). A summary score is calculated, where higher values reflect hypersensitivity [Body Awareness subscale of the BPQ demonstrates excellent internal consistency (ω=0.92) and test-retest reliability  and stress reactivity  and attentiveness to bodily sensations, as measured by BAQ items . Converrs=0.57, ), but ap.Strongly Disagree (1) to Strongly Agree (7). The PAQ assesses both positive and negative emotion identification and description, as well as EOT. Separate subscales exist for positive and negative DIF and DDF. A total score is also calculated to indicate global alexithymia. As BMCQ Emotion-Sensation Articulation items reflect identification and description of positive and negative emotions, composite scores were computed to provide general DIF and DDF [r = 0.76 [The PAQ is a 24-item measure assessing alexithymia. This includes difficulty identifying feelings (PAQ-DIF), difficulty describing feelings (PAQ-DDF), and externally oriented thinking (PAQ-EOT). Participants rate items according to how much they agree or disagree that the statement is true of them from  and DDF . Higher r = 0.76 ). PAQ scr = 0.76 .not at all (1) to extremely (7). Whilst SPS was initially conceptualised as unidimensional [r = 0.48 and 0.45, respectively, [The HSPS is a 27-item self-report measure of sensory processing sensitivity (SPS), a personality trait involving dispositional heightened processing of external  and internal  stimuli. Participants rate items on a 7-point Likert-scale, ranging from ensional , subsequensional . As the ensional . The HSPctively, ), SPS apctively, .Ethics approval was granted by the Victoria University Human Research Ethics Committee (VUHREC). Participants were recruited using the Prolific service, including screening for inclusion/exclusion criteria. Study details were published via Prolific, including the link for the study that was hosted on Qualtrics . Partic222= 48.27, ɑ = .001). To assess the absence of multicollinearity and singularity, squared multiple correlations were assessed. If any of these were 1.00 or close to, the corresponding item would be deleted [r=>0.32 was required. Bartlett’s Test of Sphericity was also reviewed, with p <.05 as the desired parameter. In addition, Kaiser-Meyer-Olin Measure of Sampling Adequacy (KMO) was assessed, with a cut-off of KMO=>0.60 [All analyses were conducted with IBM® SPSS® Statistics (Version 28) . As this deleted . FactoraMO=>0.60 . DiagonaMO=>0.60 .To examine the structure of the BMCQ, a combination of techniques was employed, per suggestions from Tabachnick and Fidell . First, All relevant assumptions for EFA were assessed. Normality amongst single variables was acceptable. Scatterplot inspection indicated that univariate linearity was acceptable. Whilst no major univariate outliers were detected, 12 multivariate outliers were identified. These cases were omitted from analysis. The remaining sample of 304 participants was deemed sufficient for EFA, as this provided an adequate ratio of approximately 14 respondents per item. No squared multiple correlations were close to 1.00.r=0.32 with at least one other item, indicating adequate factorability. Bartlett’s test of sphericity was significant, χ2231= 2430.63, p <.001, and KMO measure of sampling adequacy was 0.85. Diagonals of the anti-image correlation matrix were above 0.50. Communalities following extraction indicated that all items were suitable for inclusion, as they exceeded the minimum criterion of 0.32. Scree-plot inspection and Eigenvalues indicated that five to six factors would likely be extracted in the principal factors extraction analysis with all 22 items. Considering these overall indicators, principal factors extraction with oblique rotation was deemed to be suitable with all 22 items.All 22 BMCQ items were submitted to a preliminary PCA. The initial factorability of the 22 BMCQ items was examined. It was observed that 18 of the 22 items correlated at least I consider myself in touch with my body and mind’). Due to this item explicitly concerning mind-body valuation, it was retained for future investigations. Reliability analysis substantiated inclusion, based on consideration of acceptable squared multiple correlation (0.41) and reduced scale reliability, should the item be deleted  with poor internal consistency (ɑ=0.66) and low item-full scale correlations (<0.30). These were subsequently removed and analysis re-run. It was identified that one item cross-loaded (‘lation 0. and reduN=316). These are presented in Table In sum, the three factors of the BMCQ were Body-Mind Values, Sensation-Emotion Articulation, and Interoceptive Attention, reflecting that the body-mind construct involves cognitive and emotional processing of interoceptive signals, and holistic mind-body beliefs. As the scales ranged from three to six items, mean scores for each BMCQ factor were computed for the full sample of 316. As the data were normally distributed, internal consistency reliability and descriptive statistics were evaluated for the full sample with no psychiatric diagnosis  to a high of 5.17 (Interoceptive Attention), indicating that the sample endorsed characteristics underlying a strong connection with mind and body. To further understand the degree to which the BMCQ factors were related, correlations between the scales were conducted and are presented in Table Plausible directions were observed amongst the subscales, where stronger correlations were observed between theoretically related constructs , although the magnitude of some relationships indicated distinctness .Analyses were also undertaken to compare BMCQ scores in demographic variables . All means, standard deviations, and statistics are provided in the Supplemental Material. Results indicated that several demographic factors elicited significant differences for several BMCQ scales. These included gender, BMI, sport and exercise engagement, yoga practice, and mindfulness and meditation practice. See Tables SFor newly developed measures such as the BMCQ, evaluating correlations with other measures sharing theoretical relatedness enables a preliminary understanding of the meaning of the developed scale.a priori hypotheses, and (2) examining correlations of each BMCQ scale across all validity measures and interpreting the meaning of these relationships . In presenting the results for convergent and discriminant validity, characteristics across all BMCQ scales in conjunction with validity measures and subscales were interpreted to engender greater clarity regarding the body-mind connection.To test for convergent and discriminant validity, a similar approach to Mehling et al.  was adopA priori hypotheses were formulated in terms of strength and directionality. Based on the approach of Mehling et al. [r=≥0.50), mid-rank (r=0.30 to 0.49), and low rank (r=0.00 to 0.29). Significant correlations were interpreted where p<.05 (two-tailed).g et al. , the cong et al.  conventiThe Interoceptive Attention scale assesses spontaneous and purposeful direction of attention toward internal bodily sensations. This was expected to correlate with other measures of mindful, non-biased attentional capacities and tendencies in the context of interoception and bodily awareness , but not with scales assessing heightened sensory processing sensitivity (HSPS). Sensation-Emotion Articulation scale items were generated to represent the inverse of alexithymic characteristics, and therefore expected to negatively relate to alexithymia scales, but positively relate to emotional awareness. This was not expected to relate to scores from questionnaires that do not assess the interface of emotion and interoception . The Body-Mind Values scale was expected to relate to other scales assessing regulatory and behavioural tendencies involving higher order interoceptive processing and body awareness more strongly . It was expected that this would be distinct from scales involving negative emotional interpretations and behaviours related to pain and discomfort. Table a priori hypotheses, are also reported. Table To assess convergent and discriminant validity, correlational analyses were conducted between BMCQ subscales, the MAIA, BPQ, BAQ, HSPS, and PAQ. Results are discussed with respect to each BMCQ scale and hypothesised correlations. Correlations demonstrating a moderate relationship, irrespective of Stronger beliefs in mind-body integration and the importance of wellbeing was strongly positively correlated with MAIA-Trust., MAIA-BL, and MAIA-SR scales. Body-Mind Values was moderately positively related to MAIA-AR, and the BAQ. By contrast, Body-Mind Values was marginally positively related to MAIA-ND and did not correlate with MAIA-NW. Additionally, correlational patterns indicated that Body-Mind Values moderately positively correlated with MAIA-Not., MAIA-EA, and HSPS-AES. Additionally, this scale moderately negatively correlated with PAQ-Total and PAQ-EOT.A stronger capacity to identify and describe internal body changes in emotional contexts and be internally focused, as measured by the BMCQ Sensation-Emotion Articulation scale, was moderately negatively correlated with PAQ-Total. Further review of the relationship between Sensation-Emotion Articulation, as measured by the BMCQ, and PAQ alexithymia subscales revealed a strong negative correlation with PAQ-EOT and moderate negative correlations with PAQ-DIF and PAQ-DDF. A moderate positive correlation with MAIA-EA was also observed. There were small but significant positive correlations between Sensation-Emotion Articulation and the BAQ and BPQ, respectively. Correlational patterns indicated that Sensation-Emotion Articulation was also moderately positively correlated with MAIA-Not. and MAIA-BL.r ≥0.30), Interoceptive Attention strongly positively correlated with MAIA-Trust., moderately positively correlated with MAIA-BL and MAIA-SR, and moderately negatively correlated with PAQ-Total, PAQ-DIF, PAQ-DDF, and PAQ-EOT. See Table The BMCQ Interoceptive Attention scale, which captures the self-reported ability to direct attentional resources toward internal bodily sensations showed moderate positive correlations with MAIA-AR, MAIA-Not., and the BAQ. A low positive correlation with HSPS-Total was observed; Interoceptive Attention was not significantly correlated with HSPS-EOE or HSPS-LST. However, there was a moderate positive correlation with HSPS-AES. In examining patterns of correlations , active listening to the body for insight (MAIA-BL) and regulating distress by attention to body sensations (MAIA-SR). These three scales arguably represent the zenith of healthy mind-body integration . ExperieDiscriminant evidence further suggested that the Body-Mind Values scale is distinct from the tendency to not ignore or distract oneself from sensations of pain or discomfort (MAIA-ND) or experience minimal emotional distress or worry (MAIA-NW). This is in line with previous findings which demonstrated these MAIA scales are related to pain catastrophising and maladaptive bodily awareness. However, it is noted that the present study excluded participants with chronic pain conditions that might underlie altered attentional focus and catastrophising .The Sensation-Emotion Articulation scale was created to assess the capacity to articulate the emotional meaning of internal bodily sensations, in conjunction with internally oriented thinking. As anticipated, moderate to strong correlations were observed with difficulties identifying feelings (PAQ-DIF), difficulties describing feelings (PAQ-DDF), externally oriented thinking (PAQ-EOT), and global alexithymia , as was a moderate positive correlation with MAIA-EA. Such capacities could underpin capabilities for cultivating emotions with precision and specificity across multiple contexts , 96. TheThis view is particularly emphasised upon review of discriminant evidence for the Sensation-Emotion Articulation scale. Although they were significant, correlations with the BAQ and BPQ were observed to be small in magnitude. Accordingly, this scale is distinct from attentiveness to normal non-emotive body processes (BAQ) and maladaptive hypersensitivity toward bodily sensations (BPQ), given that each of these measures do not examine the interface of interoception and emotion . MoreoveThe Interoceptive Attention scale was designed to operationalise the notion that attention can be purposefully and spontaneously directed toward internal bodily sensations. As expected, Interoceptive Attention scores showed moderate positive correlations with MAIA-AR, MAIA-Not., and the BAQ. Each of these scales assess elements of self-reported attentional processes, ranging in complexity. MAIA-Not. forms a foundational facet of attention, by which baseline awareness of sensations is measured. By contrast, MAIA-AR qualitatively involves more sophisticated body-centric attentional processes , whereas BAQ items involve a capacity to integrate external information relative to the physiological condition of the body . In lineDiscriminant validity was also demonstrated, as the Interoceptive Attention scale was mostly unrelated to sensory processing sensitivity—a trait typified by deep cognitive processing of external and internal stimuli that is augmented by greater negative emotional reactivity . SpecifiWhile the findings are valuable, several limitations should be considered. The convenience sampling, cross-sectional design, and reliance on self-report data for the measurement of these constructs indicate that there should be some caution exerted in interpreting results. This is pertinent, given the proportion of the sample that provided demographical information that has been related to poorer health and wellbeing outcomes . Furthermore, it is acknowledged that one item was retained as part of the Interoceptive Attention scale, despite cross-loading on the scale it was generated for—Body-Mind Values. Accordingly, cross-validation studies are strongly suggested to further confirm the structure and validity of the BMCQ. Furthermore, the present study recruited 101 individuals that self-reported a range of psychiatric diagnosis that can differentially affect mind-body connection perceptions . SampleDespite these factors, the current findings are of clinical relevance, considering arguments for the importance of coaching individuals with alexithymia to utilise awareness-of-sensation practices, so as to enable more granular differentiation between bodily perceptions and psychological interpretation , the effThe BMCQ therefore presents a promising tool for clinicians that could also enable the development of more targeted psychological interventions. For instance, clinical populations such as those typified by comorbid interoceptive and emotional dysfunction  couIn conclusion, the results from this study indicate that the BMCQ is a parsimonious measure of the mind-body connection. The self-report may be a valuable tool for assessing perceptions related to one’s concept of mind-body constituents. To our knowledge, the BMCQ is the first self-report measure that incorporates interoceptive attentional control, the ability to articulate the link between sensations and emotions, and broader mind-body values. Furthermore, the BMCQ is a brief, convenient 13-item self-report measure that extends upon elements of the mind-body connection disparately captured by other self-report scales. The BMCQ provides researchers and clinicians with an alternative Interoceptive Attention scale that differs from pre-existing tools that capture the proclivity to notice sensations, because it considers the direction and allocation of resources to bodily sensations in spontaneous and purposeful manners. Furthermore, the Sensation-Emotion Articulation scale builds upon how emotion is currently captured in similar scales, where awareness of the connection between sensations and discrete emotions is emphasised. With this new scale, identifying and describing this connection is assessed, alongside preference for an internally oriented focus, which is inversely related to alexithymia. Lastly, the BMCQ provides an alternative scale of mind-body beliefs than is currently captured in existing tools; broader, albeit explicit, measurement of whether mind and body are viewed as integrated entities is now captured by the BMCQ. Though the Body-Mind Values scale strongly related to body listening and trusting, endorsement of such concepts may underlie the value one places on their holistic wellbeing.The present findings indicate that the BMCQ serves as a basis for considering Sensation-Emotion Articulation and Body-Mind Beliefs as forming part of one’s mind-body connection in addition to Interoceptive Attention. Based on the preliminary assessment of construct validity, the BMCQ should be considered a multidimensional self-report measure of the mind-body connection—not subjective interoception. Accordingly, the scales and constructs comprising the BMCQ could better serve research pursuits pertaining to the mind-body connection and importantly enable the development of targeted psychological interventions aimed at fostering and fortifying adaptive mind-body connections.Additional file 1: Table S1. Self-Disclosed Diagnoses of Physical and Psychiatric Conditions. Table S2. Means and Standard Deviations for BMCQ Scales According to Age, Education Level, BMI (Self-Reported), Smoking Status, Alcohol Consumption, Psychiatric Diagnosis, Sport and Exercise Engagement, Yoga Practice, and Mindfulness and Meditation Practice (N=316). Table S3. Results of Group Difference Analyses for BMCQ Scales According to Age, Education Level, BMI (Self-Reported), Smoking Status, Alcohol Consumption, Psychiatric Diagnosis, Sport and Exercise Engagement, Yoga Practice, and Mindfulness and Meditation Practice (N=316).


Shared decision-making, a communicative process to reach decisions based on informed preferences, evidence, and co-created goals, improves care satisfaction and patients’ quality of life. However, shared decision-making has not been widely implemented in long-term care facilities, and few studies have examined how to promote the shared decision-making practice. This study aimed to identify the influencing factors of shared decision-making based on the Person-centered Practice Framework in long-term care facilities.A total of 300 staff  in 13 Korean long-term care facilities participated in this study. Data from 280 respondents were finally analyzed, excluding respondents with missing values. Data were collected using structured questionnaires that included items on shared decision-making, personal factors , and care environment factors . Multilevel linear regression analyses were performed using Mplus Version 8.8.p = 0.034), a higher person-centered attitude score , and a higher communication behavior score  were more likely to report a higher shared decision-making score. In addition, staff who viewed their care environment as more person-centered were more likely to report a higher shared decision-making score .The mean shared decision-making score was 35.78 (range 8–45). Staff with experience of person-centered care education  and care environment  factors could influence shared decision-making for long-term care residents. These findings could be foundational evidence for facilitating shared decision-making practice in long-term care settings.The online version contains supplementary material available at 10.1186/s12877-023-04301-6. Shared decision-making (SDM) is an increasingly prominent approach in healthcare, focusing on the effective two-way exchange of information and perspectives between healthcare professionals and patients regarding various care options . SDM is There has been increasing discussion around the need to apply SDM in long-term care settings . BecauseWhile SDM enables long-term care staff to focus on each resident`s unique needs and values, it is yet to be actively applied in long-term care facilities for older adults. One reason is the lack of knowledge and education among healthcare providers regarding SDM, thereby hindering its implementation . AdditioWith the rapid increase in Korea’s older population, the long-term care insurance system was established in 2008 as a social insurance to provide care for the older adults experiencing challenges in their daily lives and to relieve the care burden on their family caregivers. In Korea, the number of long-term care facilities more than tripled from approximately 1,700 at the end of 2008 to 6,334 at the end of 2021; there were 230,170 facility benefit recipients at the end of 2021 . While tprerequisites focused on the staff` attributes which enable effective person-centered care, practice environment focused on the context in which healthcare is provided, person-centered processes with person-centered care delivered through various activities, and effective person-centered outcomes [Adopting a person-centered care approach focused on residents’ individual characteristics and ensuring their autonomy and self-determination is essential to ensure effective SDM , 18. Theoutcomes . Person-outcomes , 22. Simoutcomes , and theoutcomes .The well-being of residents in long-term care facilities is greatly dependent on the care provided by the staff, considering their cognitive and physical dependencies. Despite their reduced ability to express their needs and preferences, it is important to acknowledge that these residents still possess individual needs and preferences. Therefore, individualized care provided through SDM becomes essential. This study aims to determine the current status and influencing factors of SDM among long-term care staff including nursing staff, social workers, and personal care workers.This study utilized a descriptive survey design to examine the current status of SDM among staff members at long-term care facilities. It also aimed to identify the personal characteristics of care providers and care environment characteristics that influence SDM, based on a PCPF.The participants in this study included nursing staff , social workers, and personal care workers from 13 long-term care facilities in the Republic of Korea, selected through convenience sampling. The sample size was determined using the G-power program version 3.1.9.4 , with a minimum sample size of 172 participants required for a multiple linear regression analysis considering 10 explanatory variables, an effect size of 0.15, an α error probability of 0.05, and a power of 0.95. Considering the possibility of missing data, a total of 300 participants were enrolled in this study. With the exclusion of 20 participants with missing data on the dependent variable (SDM), the data of 280 participants were analyzed.The study employed the PCPF which outlines the factors influencing person-centered processes and outcomes . AccordiDaesangja (care receiver in Korean) or family,” respectively. The revised instrument was reviewed for its suitability for long-term care facilities by a nursing professor with expertise in person-centered care and a director of a long-term care facility. The instrument consists of nine items, each rated on a six-point Likert scale (from 0 “Completely disagree” to 5 “Completely agree”). The total score is obtained as the sum of all item scores, with higher total scores indicating higher levels of SDM. To assess the construct validity of the revised instrument, its correlation with the average score for person-centered care, as measured by the Person-centered Care Assessment Tool (P-CAT) [p < 0.001). Furthermore, the instrument demonstrated high reliability in measuring SDM, with a Cronbach’s α coefficient of 0.950 in this study.To measure SDM, the Shared Decision Making Questionnaire - Physician version (SDM-Q-Doc), a tool developed by Scholl et al.  and subs (P-CAT) , was anaTo measure the knowledge about dementia, this study employed a tool developed by Hwang & Jang , specifiTo measure person-centered climate, the Person-centered Climate Questionnaire-Staff (PCQ-S) developed by Edvardsson et al.  and subsThe general characteristics of participating facilities included location , accreditation grade, operating periods, number of beds, and number of study participants. In terms of accreditation grade, the Korean National Health Insurance Service’s publicly recognized quality ratings in 2021 were used. The accrediting grade comprises five levels: A (superior), B (excellent), C (good), D (fair), and E (poor). Participants’ general characteristics included age, gender, educational attainment, marital status, religion, occupation type, and monthly salary.This study was approved by the Institutional Review Board at the author’s affiliated center (IRB No. 2022 − 0164). The study purpose and procedures were communicated to the directors or managers of the long-term care facilities. For the facilities that permitted the recruitment of study participants, the study purpose and procedures were then explained in detail to the nurses, nurse aides, personal care workers, and social workers working at those facilities. Participation in the study was entirely voluntary and only those who agreed to participate by providing their written consent were included. In addition, participants were informed that they could withdraw from the study if they so desired.2 tests or t-tests. Only variables with significant results in these difference tests were included in the regression analyses to determine the factors that influence SDM. Considering that statistical independence could be reduced due to workers within the same facility providing responses, the intra-cluster correlation coefficient (ICC) was calculated. As the ICC for SDM was determined to be 0.162, multilevel linear regression analyses were performed using Mplus Version 8.8. Given that SDM is an ordinal variable, a statistical adjustment was made using weighted least square mean and variance (WLSMV) estimation with robust standard errors.Descriptive statistics were utilized to calculate the mean, standard deviation, percentage, and range of the data. Based on the median value of SDM, the participants were divided into two groups. Between-group differences were compared using χOf the 13 long-term care facilities included in the sample, eight were located in urban areas and five were located in rural areas , communication behavior , and job tenure . Regarding care environment characteristics, the high-level SDM group exhibited higher levels of person-centered climate , effective staff relationships , supportive supervisors , and power-sharing  in long-term care facilities compared to the low-level SDM group.The total study participants were classified into two groups (high-level and low-level) according to the median value of the SDM score . In terms of personal characteristics, the high-level SDM group had a significantly higher percentage of individuals with experience in person-centered care education , a more person-centered attitude  and more appropriate communication behavior  were more likely to report a higher SDM score. Additionally, among the care environment factors, working at a facility with a more person-centered climate  was associated with a higher SDM score.Table This study examined the current status of SDM and identified the personal characteristics of care providers and the care environment characteristics that influence SDM among long-term care facility staff. The study employed a PCPF and identified the experience of person-centered care education, person-centered attitude, communication behavior, and person-centered climate as key factors influencing SDM.The mean score of SDM in this study was 35.78, which was slightly higher than the mean score observed among physicians in primary care clinics in Japan (31.65) using the same measurement tool . This diRegarding the personal characteristics analyzed in this study, the experience of person-centered care education was found to have a significant impact on SDM. SDM is a communication approach based on the philosophy of person-centered care, which emphasizes incorporating the preferences of the care receiver, addressing their physical, psychological, and social needs, and promoting their engagement , 36. TheIn addition, a person-centered attitude was found to significantly influence SDM. Person-centered attitude encompasses the care receiver’s sense of agency, belief in their competency for psychosocial engagement, and respect for personhood . Of thesFurthermore, effective communication behavior in care providers involves considering and accommodating the care receiver’s communication impairments and needs . By engaEspecially, as most residents in long-term care facilities may experience cognitive decline and have difficulty expressing their opinions, it is necessary to develop tools or strategies to assist in their communication. These tools can bridge the communication gap between care receivers and care providers and encourage family participation. Cranley et al. have recently developed a communication tool specifically designed for interacting with individuals with dementia, suggesting that it can be utilized in a structured format known as SBARR  during communication . EmployiIn terms of the care environment characteristics, the results of this study confirmed that staff working at care facilities with a higher level of person-centered climate reported a higher level of SDM. The score for person-centered climate in this study was slightly higher than the mean score  of the staff at long-term care facilities obtained during the development of the Korean version of the PCQ-S . The comAlthough the present study reveals important findings, it has several limitations. First, as the study participants were recruited from only 13 long-term care facilities, it might be limited to generalize these results. In the future, large-scale studies should be conducted using a more representative sample of staff from various long-term care facilities. Second, as a cross-sectional study, the cause-and-effect relationship between SDM and the explanatory variables of this study could not be verified. Thus, a prospective longitudinal study should be conducted as a follow-up to examine the causal relationship between these variables.SDM involves long-term interactions between care receivers or their families and care providers, encompassing information exchange, discussions, and reaching mutual agreements aimed at providing individualized care that reflects the values, preferences, and functional levels of the care receiver. The results of this study have identified several key factors that influence SDM in long-term care facilities, including the experience of person-centered care education, person-centered attitude, communication behavior, and person-centered climate. These findings are anticipated to provide practical insights to promote SDM within long-term care facilities, ultimately contributing to enhanced quality of care and the improved quality of life for residents.Below is the link to the electronic supplementary material.Supplementary Material 1