Pain is endemic for residents of long-term care homes, with many residents experiencing pain daily. Given that healthcare aides provide most daily care for residents, they are ideally situated to deliver timely assessment and non-drug interventions for managing resident pain. In this Cochrane-style systematic review, we searched 7 databases to identify intervention studies that included long-term care residents aged ≥60 years who received interventions to reduce chronic pain. Interventions were either delivered by healthcare aides at the resident level or were directed at healthcare aides to improve their pain management practices. We screened 400 titles/abstracts and 152 full-text articles. Nine studies met inclusion criteria and were included in a narrative review. Due to the limited number of studies and variety of study designs, data were insufficient to perform meta-analyses or thematic analysis. Three studies described pain interventions delivered by healthcare aides at the resident level reporting significant improvement of pain. Six studies described pain interventions delivered to healthcare aides. Results of these interventions were inconsistent; 2 reported significant improvements in pain-related outcomes , 3 reported insignificant changes, and 1 reported a positive correlation between measured pain and pain medication use. We concluded that despite the paucity of research in this area, this systematic review provides preliminary support for pain interventions by healthcare aides for long-term care residents. Future research exploring interventions for healthcare aides to take greater roles in pain management could unlock further improvements in resident care.


Although clinical parameters such as unexplained syncope or a family history of WPW may correlate with increased risk, most commonly the risk is estimated based on parameters observed during episodes of clinical tachycardia or variables measured during electrophysiology study (EPS).This case involves a 16-year-old female patient with WPW and episodes of supraventricular tachycardia since the neonatal period. Owing to increasingly frequent and prolonged episodes of supraventricular tachycardia with symptoms including severe chest pain and near-syncope, she was referred for EPS and catheter ablation. Her baseline ECG demonstrated ventricular pre-excitation with a pattern consistent with left anterolateral accessory pathway .Figure 1At diagnostic EPS, local ventricular pre-excitation with earliest activation was identified at the distal coronary sinus catheter. Ventricular pacing also demonstrated eccentric and nondecremental ventricular-atrial conduction at the anterolateral aspect of the coronary sinus. The antegrade accessory pathway effective refractory period was 270 ms with 600 ms cycle length drive train. There was persistent antegrade accessory pathway conduction with rapid atrial pacing at 260 ms. Induced orthodromic reciprocating tachycardia converted into atrial fibrillation with a single-interval SPERRI of 228 ms; however, the majority of R-R intervals were in the range of 350–400 ms . Atrial In patients with WPW, it is generally accepted that the risk of sudden death is related to the characteristics of the accessory pathway(s). The mechanism of sudden death is reported as atrial fibrillation with rapid antegrade accessory pathway conduction leading to ventricular fibrillation.For adult patients with WPW, high-risk is defined as the SPERRI during atrial fibrillation ≤250 ms, the presence of multiple accessory pathways, an accessory pathway refractory period ≤240 ms, or atrioventricular reentrant tachycardia precipitating pre-excited atrial fibrillation.Atrial flutter and atrial fibrillation are proposed to be related entities and may transform into one another, as demonstrated with our patient.Invasive risk stratification for pediatric patients with WPW is imperfect. The relationship of atrial fibrillation  and atrial flutter  may offer an explanation for sudden death or life-threatening events in children who have low-risk pathways by invasive electrophysiologic testing. Catheter ablation should be considered at the time of EPS if safe and feasible.


Physical therapists often treat pain and functional limitations associated with chronic musculoskeletal conditions common in aging adults. While patient report improvement after physical therapy, these results do not translate to sustained physical activity. This is a lost opportunity to support aging adults in adopting behaviors proven to improve quality of life and reduce comorbidity burden. We conducted semi-structured interviews with 30 physical therapists to understand how they support adoption of physical activity and identify what is needed to improve uptake. Physical therapists endorse physical activity as essential in the management of MSK conditions. Eliciting motivation, addressing psychosocial needs, and empowering patients to actively engage in solutions were identified as significant challenges in the effort to change physical activity. At the clinician level, physical therapists identified the need for improved skills in motivational interviewing and person-centered communication. Improved coordination with mental health providers and community resources were identified as environmental needs.


Amidst global shifts in the distribution and abundance of wildlife and livestock, we have only a rudimentary understanding of ungulate parasite communities and parasite-sharing patterns. We used qPCR and DNA metabarcoding of fecal samples to characterize gastrointestinal nematode (Strongylida) community composition and sharing among 17 sympatric species of wild and domestic large mammalian herbivore in central Kenya. We tested a suite of hypothesis-driven predictions about the role of host traits and phylogenetic relatedness in describing parasite infections. Host species identity explained 27–53% of individual variation in parasite prevalence, richness, community composition and phylogenetic diversity. Host and parasite phylogenies were congruent, host gut morphology predicted parasite community composition and prevalence, and hosts with low evolutionary distinctiveness were centrally positioned in the parasite-sharing network. We found no evidence that host body size, social-group size or feeding height were correlated with parasite composition. Our results highlight the interwoven evolutionary and ecological histories of large herbivores and their gastrointestinal nematodes and suggest that host identity, phylogeny and gut architecture—a phylogenetically conserved trait related to parasite habitat—are the overriding influences on parasite communities. These findings have implications for wildlife management and conservation as wild herbivores are increasingly replaced by livestock. They arHistorically, sampling limitations have impeded community-level multi-host/multi-parasite analyses. Gastrointestinal nematodes parasitize many different large mammalian herbivore species, yet accurate taxonomic identifications—necessary to quantify diversity and identify host-sharing networks—typically requires retrieving adult specimens from dead hosts or culturing larvae. Moreover, while several databases document host-species–parasite relationships ,13, dataFor diverse large-herbivore assemblages, such as those found in African savannahs, such approaches could address knowledge gaps about patterns and determinants of parasite prevalence, diversity and sharing in locations where wild and domestic hosts overlap . SeveralThree host-specific predictors are often proposed as correlates of parasite species richness across systems and species: body size , geographical range size , and population density (and thus intraspecific transmission opportunities) ,26. A reBecause sympatric herbivores share many of the same food and water resources that serve as transmission routes for gastrointestinal parasites , studiesWe used DNA metabarcoding of the ITS-2 region to analyse gastrointestinal nematode DNA (Strongylida) in fecal samples from a diverse community of wild and domestic large herbivores  in an East African rangeland. Strongylida are among the most common metazoan parasite groups in large herbivores and infect various parts of the digestive tract, including the stomach and intestines. While taxonomic reference data for nematodes remain limited, DNA metabarcoding enables comparative analysis of diversity and composition by clustering sequences by similarity even when taxonomic names are lacking, as has been validated for both parasitic and free-living nematodes ,35 ), richness and phylogenetic diversity? We hypothesized that, in addition to strong effects of host species identity on parasite assemblages , hosts t. 22 of semi-arid thorn-scrub savannah managed for wildlife conservation and livestock production ) (b)a,b; electronic supplementary material, figure S9), demonstrating the role of a few generalists in connecting the network. The high centrality of giraffe and camel—intriguing given that each is the only local member of its family and that both feed overwhelmingly in the overstorey—suggest that these species are infected by generalist parasites and may play an important role in cross-species transmission depending on their movement and density. One clear management implication is that regularly deworming camels, as done successfully for sheep and goats at our site, might help limit parasite transmission to wildlife . The same is true for donkeys, which had the highest centrality of the three equids and are likely to share parasites with the endangered Grevy's zebra and near-threatened plains zebra.Our finding that host–parasite links were highly aggregated aligns with previous studies showing that most parasites specialize on few hosts while only a few have broad host ranges ,81. Parafigure 3Our finding of phylogenetic influence on network centrality metrics is consistent with the likelihood that closely related hosts share ecological, anatomical and immunological traits that shape host–parasite coevolution. Indeed, models based on herbivore parasite records  suggest  (c)While the DNA barcode we sequenced can effectively distinguish parasitic nematode species across a wide range of hosts , it is lOur raw data contained low-abundance mOTUs that generated a highly interconnected host–host sharing network, but filtered data using mean RRA greater than or equal to 2% per species were more concordant with prior studies ,13. WhilWe could not identify 48% of parasite mOTUs to species due to gaps in genetic resources for many wildlife parasites . While t. 5We show that host phylogeny and digestive strategy explain a high degree of variance in parasite community composition and sharing across a diverse community of wild and domestic large herbivores. While additional work is needed to maximize the value of parasite metabarcoding data, this approach holds enormous promise to shed light beneath the tip of the biodiversity iceberg. Use of these methods in studies with spatially or temporally stratified sampling designs will allow researchers to capture multi-host parasite dynamics that have long remained elusive. Our finding of substantial parasite sharing at the livestock-wildlife interface suggests that regularly deworming camels and donkeys could be an effective local management intervention to reduce transmission between livestock and several globally threatened and near-threatened ungulates. More broadly, our results suggest that changes to domestic animal communities or their parasite loads  will impact parasitism in sympatric wild hosts.


The minimal dimension of critical isthmus regions may be less than 1 cm in more than 25% of circuits mapped.A 73-year-old man with history of dilated cardiomyopathy and left ventricular (LV) ejection fraction of 39%, complete heart block status post permanent pacemaker placement 15 years ago with upgrade to biventricular implantable cardioverter-defibrillator 2 years ago, presented with recurrent episodes of VT and appropriate implantable cardioverter-defibrillator therapies despite antiarrhythmic drug therapy with sotalol. Cardiac magnetic resonance imaging showed midmyocardial delayed enhancement with full-length midmyocardial scar from the basal anteroseptum to inferoseptum . He undeIn anticipation of mapping a septal VT, a linear multielectrode catheter  was placed in the septal right ventricular outflow tract (RVOT) and an ablation catheter  was positioned on the LV basal anterior septum via transseptal approach. A diagnostic 2F microcatheter  was placed into the distal coronary sinus to record within the AIV and SPV . During d, proving critical circuitry confined within the interventricular septum , a balloon technique was not implemented. However, VT remained reinducible at a faster rate and therefore additional ablation were performed at 50 W from the LV and RV septum. VT has not recurred for 9 months at the time of this report.A second VT with left bundle branch block morphology with VLMNA and TTN, are associated with VT recurrence rates that are among the highest in structural heart disease.LMNA variants in particular have been shown to have high rates of arrhythmia recurrence, progression of cardiomyopathy to end-stage heart failure, and high mortality.Catheter ablation for drug-refractory VT in patients with dilated cardiomyopathies, particularly in those with genetic mutations such as ,,Lamin cardiomyopathy classically involves the septum and periaortic region and seems to be predominantly related to reentry in and around regions of scar. Periaortic VTs have been increasingly described with regard to reentrant mechanism and circuit characteristics.,Prior studies have not demonstrated localized reentry completely confined within the intramural septum, which is the novelty of this report. These descriptions reiterated the propensity of LMNA to predominantly involve the septum,Strategies such as substrate modification via transcoronary venous ethanol may warrant further consideration, particularly when a full-length septal scar is present on magnetic resonance imaging, which portends a poor prognosis.Owing to high rates of recurrent VT associated with lamin cardiomyopathies, early collaboration and consultation with a heart failure team is warranted to discuss advanced management options, given modest outcomes from ablation and high risk of mortality from progression of heart failure. This case provides further mechanistic insights into the nature of septal VTs in this challenging patient population that may be entirely missed by traditional endocardial and epicardial mapping techniques.In midmyocardial septal scar substrates, SPV recordings may provide critical intramural information to elucidate the spatial dimensions and location of circuit-challenging VTs. Localized reentry recorded from a single bipole pair can be confined completely within the septum, which cannot be fully characterized from either endocardial surface.


Grandparent-headed families in South Korea have been growing prominent in the country’s cultural landscape. Approximately 153,000 Korean grandparent-headed households existed in 2015; this number is expected to double by 2035. This qualitative study explored Korean custodial grandparents’ experiences of raising grandchildren and the cultural significance of multigenerational caregiving in Korea. Using a phenomenological approach, semistructured interviews with 22 custodial grandparents were conducted. Significant functions of patrilineality and stigma surrounding divorce for Korean grandparent-headed families were found. Considering the complicated cultural factors, social/family service programs must pay attention to the unique needs of grandparent-headed families and consider the circumstances related to grandparents’ positions in the family . Korean government programs and policies could better help marginalized grandparent-headed families with an empowerment approach to help marginalized grandparent-headed families gain positive attitudes toward their caregiving situation.


Keratosis obturans is estimated to occur among 4 to 5 patients among 1000 new otological cases.A previously healthy 22 year-old Malay gentleman presented to our clinic with a two-month history of worsening left otalgia with bloody otorrhea. There was also left sided reduced hearing followed by asymmetry on the left side of face for the past 1 week. Patient claimed that there was no recent or any recurrent upper respiratory tract infection prior to this.Further history from patient revealed that he had similar complaints a year ago involving the right ear with no facial asymmetry. Patient was diagnosed with right aural polyp and polypectomy was done under local anaesthesia in another government hospital. However, patient defaulted his follow-up as the problem resolved completely.Upon examination, patient was comfortable, not septic looking and afebrile. Facial nerve examination revealed House–Brackmann Grade III lower motor neuron palsy as there was loss of left nasolabial fold and drooping of left angle of lip. Otoscopic examination revealed a polypoidal mass occluding the entire left ear canal covered with bloody, foul smelling otorrhea . Right eA high-resolution computer tomography (HRCT) scan of temporal was obtained, which revealed non-enhancing soft-tissue mass occupying left external auditory canal, left Prussak's space and middle ear with erosion of left scutum. The left inner ear was intact with normal right ear structures. There was no evidence of facial canal dehiscence or erosion; however signs of inflammation over the tympanic segment of facial canal were noted .Figure 2Patient underwent microscope-guided examination under anaesthesia which revealed polypoidal mass occupying entire lateral third of ear canal with whitish keratin-like debris noted medial to the mass. Polypectomy and aural toileting was commenced. As tympanic membrane appeared bulging, myringotomy and grommet insertion was performed. Histopathologic examination revealed cyst wall covered with stratified squamous epithelium containing lamellated keratin flakes suggestive of keratosis obturans  Post-opeKeratosis obturans can be of two types: Inflammatory type or silent type.Keratosis obturans usually affects younger age group, occurs bilaterally and manifests as severe otalgia, conductive hearing loss and widened ear canal.Computer tomography typically demonstrates soft tissue plug in bilateral external ear canal with evidence of ballooning of the osseous part. In our patient, his main complaint was severe otalgia and otorrhea which was followed by unilateral facial weakness and hearing loss. Although rare, few cases of keratosis obturans, presenting with facial weakness have been reported.Clinical differential diagnosis for mass in aural canal with facial nerve palsy includes external auditory canal cholesteatoma, neoplasms of external canal and malignant otitis externa. It is important to distinguish the diagnosis, as management of each of the differential diagnosis is notably different. Hence, thorough and detailed history, physical examination, radiological examination and most importantly histopathological examination is crucial prior to a diagnosis. Histopathological examination of the biopsied or excised mass is the main modality of diagnosis, more so when there is an atypical or rare presentation.As for management, keratosis obturans usually requires frequent aural toileting to remove the keratin plug and topical medication. This may be done under general anaesthesia especially among non-cooperative patients. Split skin graft and canalplasty method have also been reported for refractory keratosis obturans.Albeit commonly regarded benign, keratosis obturans may result in devastating complications including facial nerve palsy as in our patient. Hence, high clinical suspicion and prompt management among clinicians are of dire importance as absence of typical clinical features usually lands both the attending physician and patient in dilemma.The authors declare no conflicts of interest.


The COVID-19 pandemic caused severe disruptions in healthcare systems and societies and exacerbated existing inequalities for women and girls across every sphere. Our study explores health systems responses to gender equality goals during the COVID-19 pandemic and which role these goals play in pandemic recovery policies.We apply a qualitative comparative approach. Country case studies  were collected in March/April 2022. The sample comprised Australia, Brazil, Germany, United Kingdom and USA, reflecting conditions of high to upper-middle income countries with established public health systems, democratic political institutions and gender equality policies. Selected topics: maternity care/reproductive services, violence against women, and gender equality/female leadership.All countries tried to keep essential maternity and reproductive services open, but strong limitations applied especially for prevention and counselling services; at the same time, digitalisation/telemedicine supported service expansion. Violence against women and children strongly increased during the pandemic. Routine services were partly kept open and new helplines occasionally established, but no action was taken to scale-up mental health support and respond to new demand. A push-back of gender equality was observed across countries in all areas of health and social care, often coupled with strong increase in intersecting social inequalities; participation of women in decision-making bodies was generally weak and not monitored.Across countries, gender equality policies cracked under the pressure of the COVID-19 pandemic; this is true for countries with male and female political leaders, and for different areas of SDG5 and health. There is an urgent need for more effective intersectional gender equality policies and improved participation of women in global health and in health system recovery plans.• Health systems failed to take action to protect SDG5 goals; gender and intersecting inequalities strongly increased during the pandemic.• Building back better after COVID-19 will only be possible with an intersectional gender equality programme and feminist policy approaches.


Observational studies suggest psychosocial factors such as social support and loneliness are associated with vulnerability for frailty in older adults, but less is known about the generalizability of these putative psychosocial mechanisms in underrepresented groups. Thus, we evaluated whether better telecommunication social support and lower levels of loneliness were associated with decreased frailty and increased functional ability using a unique longitudinal cohort of rural South African older adults. We conducted generalized estimating equation and robust regression analyses using cross-sectional data from 347 participants in the HAALSI  Dementia Cohort. Social support via telecommunication and self-reported loneliness were measured using standard assessments and modeled as exposure variables. Outcomes were frailty (measured using Fried’s frailty phenotype) and functional status . Lower level of telecommunication social support was associated with higher impairment in ability to perform IADLs. This association persisted after additional adjustments for depression  and vascular risk factors . No associations were observed in relating telecommunication social support and loneliness with frailty. Among rural South African Black older adults, lower telecommunication-based social support was associated with greater risk of impairment in functional ability. Although further validation is required for possible reverse causality, our findings suggest that future intervention studies focused on promoting telecommunication-based social support to preserve independent functioning may be merited.


Poor physical function has been linked to greater depressive symptoms among older adults. On the other hand, older adults’ perceptions of positive and negative age-related changes provide personal strength and vulnerability to stressful events, respectively. We therefore expected that positive self-perceptions of aging (SPA) would be associated with fewer depressive symptoms, while negative SPA would be related to greater depressive symptoms, beyond the effect of physical function. We further tested the hypotheses that positive SPA would buffer the association between physical function and greater depressive symptoms, whereas negative SPA would exacerbate this association. This study used data from 108 older adults (mean age = 81.09) in independent-living or retirement communities. Results from a linear regression revealed that more positive SPA  and less negative SPA  were associated with fewer depressive symptoms, even after controlling for physical function, both types of SPA, and other covariates. In contrast, physical function was no longer significantly associated with depressive symptoms , after controlling for both types of SPA. There were no significant moderating effects of positive and negative SPA. Findings suggest that how positively and negatively older adults perceive their own aging may be important for their mental health while experiencing less physical function in late life.


Most children with developmental disabilities (DD) live in resource-limited countries (LMIC) or high-income country medical deserts (HICMD). A social contract between healthcare providers and families advocates for accurate diagnoses and effective interventions to treat diseases and toxic stressors. This bio-social model emphasizes reproductive health of women with trimester-specific maternal and pediatric healthcare interactions. Lifelong neuronal connectivity is more likely established across 80% of brain circuitries during the first 1000 days. Maladaptive gene-environment (G x E) interactions begin before conception later presenting as maternal-placental-fetal (MPF) triad, neonatal, or childhood neurologic disorders. Synergy between obstetrical and pediatric healthcare providers can reduce neurologic morbidities. Partnerships between healthcare providers and families should begin during the first 1000 days to address diseases more effectively to moderate maternal and childhood adverse effects. This bio-social model lowers the incidence and lessens the severity of sequalae such as DD. Access to genetic-metabolomic, neurophysiologic and neuroimaging evaluations enhances clinical decision-making for more effective interventions before full expression of neurologic dysfunction. Diagnostic accuracy facilitates developmental interventions for effective preschool planning. A description of a mother-child pair in a HIC emphasizes the time-sensitive importance for early interventions that influenced brain health throughout childhood. Partnership by her parents with healthcare providers and educators provided effective healthcare and lessened adverse effects. Effective educational interventions were later offered through her high school graduation. Healthcare disparities in LMIC and HICMD require that this bio-social model of care begin before the first 1000 days to effectively treat the most vulnerable women and children. Prioritizing family planning followed by prenatal, neonatal and child healthcare improves wellness and brain health. Familiarity with educational neuroscience for teachers applies neurologic diagnoses for effective individual educational plans. Integrating diversity and inclusion into medical and educational services cross socioeconomic, ethnic, racial, and cultural barriers with life-course benefits. Families require knowledge to recognize risks for their children and motivation to sustain relationships with providers and educators for optimal outcomes. The WHO sustainable development goals promote brain health before conception through the first 1000 days. Improved education, employment, and social engagement for all persons will have intergenerational and transgenerational benefits for communities and nations. Accurate clinical decisions require serial assessments across developmental time beginning before conception . A dual Accurate clinical decision-making is particularly crucial for children who have increased risks for neurologic sequelae such as those with developmental disabilities (DD). DD consist of a constellation of functional deficits that are expressed beginning early in life, adversely affecting a child’s physical, learning, or behavioral performance . ChildreA maternal-child pair medical case history is discussed to highlight the importance of time-sensitive diagnostic assessments from pre-conception through adolescence for successful interventions. Maternal and childhood adverse effects were addressed. Revised educational plans through her school years integrated maternal-pediatric healthcare histories into successful educational experiences. A dual diagnostic approach is discussed that teaches recognition of the maturational potential of any child according to principles of developmental neuroplasticity applied to clinical decision-making and therapeutic interventions. All healthcare providers and educators require knowledge and skills to implement the same diagnostic and educational approaches for the most vulnerable children in LMIC and HICMD.This child was previously included in a discussion of a diverse group of children who were diagnosed with genetic disorders . NeuroloThis maternal-child pair presented to healthcare providers and educators in a HIC. A serial diagnostic approach considered recognition of clinical phenotypes expressed by this woman, MPF triad, neonate, and child. Systems science application applied an understanding of etiopathogenesis pathways to the child’s neurologic sequelae. Time-dependent medical and scholastic resources were offered to preserve health while she completed high school education. Joint attention by her mother and healthcare providers addressed adverse childhood effects that potentially could reduce long-term benefits from interventions in response to early life expression of DD.Mother was a 28-year-old gravida 2 para 1–2 woman with asymptomatic Sjogren’s Disease and class 3 obesity  prior to conception. She followed a weight reduction plan which included bariatric surgery before pregnancy and achieved a lower body mass index. Her healthcare providers noted the inherited risks for this pregnancy consisting of an older child with autism spectrum disorder and parental anxiety disorders. Mother received behavioral interventions to manage her anxiety both before and during her pregnancy. A high-risk maternal fetal medicine service managed her autoimmune disease. No immunosuppressive medications were recommended given she remained asymptomatic for Sjogren’s disease after conception.An AV block on a fetal EKG was later documented during third trimester abdominal sonography at 28 weeks GA. Despite maternal treatment with digitalis, this dysrhythmia progressed to nonimmune hydrops fetalis at 32 weeks’ gestation secondary to cardiac failure. Labor induction and delivery was electively performed without complications after antenatal dexamethasone administration. No fetal distress occurred during delivery with a clinically stable female preterm newborn. She received 1- and 5-min Apgar scores of 6 and 7 without the need for advanced resuscitative interventions. Her anthropometric measurements were within appropriate gestational age ranges.The child subsequently required neonatal intensive care for multiple system-specific complications. Multiple cardioversions for cardiopulmonary arrest and severe hypotension/bradycardia were required to treat repetitive sudden heart block during her first week of life until effective digitalis dosing was established. Pulmonary disease, anemia and nutritional supplementation required medical interventions during the neonatal time. Neonatal cranial sonography did not document intraventricular hemorrhage or periventricular leukomalacia.Histological examination of the placenta at 10 days of life documented chronic villitis and maternal malperfusion lesions consisting of underdevelopment of the placental vasculature including decidual necrosis. These microscopic findings were supplemented by gross descriptions of a hyper coiled umbilical cord (2/cm) with a 1 cm marginal insertion.The child initially expressed hypotonia which later resolved with expression of age-specific developmental reflexes. Bulbar dysfunction initially required gavage feedings because of poor oropharyngeal function. Gradual transition to oral feeding was achieved during her early months of infancy.She required a permanent cardiac pacemaker at 11 months for persistent heart block for continued episodes of hypotension that remained unresponsive to medication adjustments. Cardiogenetic testing confirmed a long QT syndrome type II (G604S-KCNH-2), which was also confirmed for one parent.Developmental delay with borderline microcephaly (5%) was documented on serial assessments during her first 2 years of life. Vision and hearing evaluations were normal. No seizures occurred. Early intervention therapies were provided to supplement and support parental care. Primary care included social work support to address adverse childhood effects. Developmental testing documented cognitive, motor, social and language deficits. Sufficient skill acquisition was achieved during her preschool yea to matriculate into mainstream classes. She advanced through primary and middle school grades assisted by individual educational planning.She presented with status epilepticus associated with an acute hypertensive event at age 10 years. Brain lesions consistent with posterior reversible encephalopathy syndrome were noted on neuroimaging. Her pediatric intensive care successfully controlled seizures after stabilization of severe hypertension. With resolution of her encephalopathic state and renal dysfunction, she was discharged to home on antiepileptic medication. No neurologic regression occurred without further seizures. Antiepileptic medication was discontinued after a three-year interval.She experienced cognitive and behavioral challenges into adolescence. Cooperation between family and the school’s multidisciplinary team of teachers and therapists offered revised interventions at school and home to address all medical challenges based on information provided to healthcare providers. Mental health care addressed her generalized anxiety and socialization challenges with educational accommodations and counselling. Functional neurological disorders included psychogenic seizures during adolescence were addressed with resolution. Dysautonomic symptoms of postural orthostatic tachycardia syndrome were recognized and managed with preventive interventions.Individualized educational plans (IEP) accommodated this child’s expressive language delay, reading disability, hyperkinesis with short attention and lower limb spasticity, beginning during her preschool and primary school grades. Ambulation without ankle supports was achieved before her middle school years. She received psychotropic medications to manage anxiety without the use of stimulant medications. Serial neuropsychometric testing after age five years documented cognitive abilities within the normal range with subtest deficiencies in attention, reading and executive planning. She received educational accommodations through high school graduation. Behavioral interventions addressed her anxiety and socialization challenges which challenged her into adolescence. She successfully graduated high school with plans to pursue a nursing career.This next section reviews the systems science associated with the prenatal expression of diseases affecting this maternal-child pair. Applicability for effective horizontal and vertical approaches to diagnosis and treatment for a comparable woman in a LMIC and HICMD will be compared with the healthcare delivery received by this mother-child pair. Advocacy by healthcare providers regarding healthcare resources must consider diversity and inclusion to achieve optimal outcomes for healthcare and school readiness.Any child with a genetic disorder exemplifies G x E interactions that can begin before conception with time-dependent expression that are influenced by adverse maternal and childhood acquired conditions. Phenotypic presentations may first appear during pregnancy or after birth . For thiInteractions between familial genetic risks and acquired conditions affected this maternal-placental fetal (MPF) triad and neonate with adverse consequences into early childhood. Etiopathogenetic pathways across developmental ages during her first 1000 days altered phenotypic expressions of her brain disorders. Global developmental delay with borderline microcephaly were early phenotypes. A hypertensive disorder was a later childhood expression of this genetic disorder. Cognitive/behavioral and mental health disorders became more dominant phenotypes during her adolescent development.This child’s fetal presentation at 28 weeks GA with heart block occurred after activation of an inherited channelopathy by maternal autoantibodies despite mother’s asymptomatic Sjogren’s disease . AutoantWithout clinical symptoms and the risk for adverse effects of corticosteroid use, mother received no treatment after conception. She alternatively was followed by a high-risk obstetrical service that monitored her based on maternal levels of care relevant to the this HIC health system.Pregnancy management for a woman in a LMIC or HICMD with asymptomatic Sjogren’s disease might advocate for more proactive medical interventions to maximize chances for favorable outcomes despite less available prenatal and neonatal services. Earlier steroid treatment despite no maternal clinical signs may be the more practical therapeutic option. Treatment prior to conception or early first trimester for any woman identified with autoimmune disease might avoid or lessen the severity of fetal cardiac disease, hydrops fetalis and prematurity. Long QT syndrome may still present at older postnatal ages. However, with greater brain maturity, less severe neurologic sequalae may result because of increased resilience to brain injury. Benefit from immunomodulators other than steroids  in the fPreventive healthcare training for maternal care by physicians, nurse practitioners and midwives in a LMIC and HICMD must prioritize preventive care to offset less access to expensive high-risk maternal fetal medicine and neonatal intensive care services. WHO guidelines for maternal and neonatal levels of care , have emOther non-infectious inflammatory conditions accompanied this mother’s Sjogren’s disease. Her obesity and anxiety worsened similar inflammatory disease pathways subserved by this autoimmune disorder. Suboptimal placental implantation and development began 2–8 days after conception given this exaggerated pro-inflammatory state. The placenta’s shared genetic endowment between parents and fetus  more likUse of corticosteroids, weight reduction and treatment for anxiety before conception in LMIC and HICMD could help delay or avoid trimester-specific placental diseases for a percentage of MPF triad This preventive approach could avoid fetal cardiac failure, hydrops fetalis and prematurity.Prematurity is a complex adverse outcome. Trimester-specific G x E interactions to the MPF triad involve placental dysfunction resulting in prematurity . SuboptiCurrent fetal surveillance tests cannot fully document placental disease pathways affecting many MPF triads. Training of healthcare providers particularly in LMIC and HICMD must anticipate these adverse effects of placental-cord pathology without the availability of fetal surveillance testing to document abnormalities. Chronic or acute diseases are often undetectable using fetal sonographic assessments of fetal heart patterns, Doppler flow indices and biophysical scores to assess fetal well-being. Appropriate measures of fetal growth and function does not exclude risks from placental disease with adverse outcomes to the fetal nervous system.Training of placental-cord development and pathogenesis enhances the provider’s understanding of time-dependent etiopathogenesis that contributes to sequelae such as DD. Placental-cord disease pathways are associated with diseases expressed by the woman, MPF triad and neonate. This perspective improves clinical decision-making, effective interventions, and prognosis. Despite normal fetal surveillance testing, postnatal pathological examinations may document trimester-specific disease pathways. Future prenatal structural and functional placental imaging studies will offer more effective diagnosis and interventions to improve outcomes for affected MPF triads  before fThree placental disease mechanisms cumulatively contribute to an understanding of adverse effects to the fetal brain. Knowledge of these disease entities are essential for maternal-pediatric healthcare providers to advocate for improved medical delivery particularly in LMIC and HICMD.Maternal immune activation (MIA) was the initial pathologic process that presented shortly after conception for this MPF triad. MIA represents immune intolerance between the embryo and the mother . SuboptiMIA is associated with reduced energy substrate delivery, waste removal, and deprivation of essential growth factors as embryonic-fetal maturation advances into second and third trimesters . MIA conIschemic placental syndrome (IPS) was the second placental disease that developed later during this pregnancy given postnatal gross and histological placental-cord findings. Prenatal sonographic measurements described preserved fetal growth for this child without fetal growth restriction. However, abnormal placental angiogenesis from IPS can still reduce placental blood flow to the fetus without current fetal surveillance detection. Defective spiral artery remodeling after 12 weeks GA results from abnormal precursor trophoblastic cellular development that begins during early first trimester ,21 with Marginal cord insertion  with hypFetal inflammatory response (FIR) is a third pathologic mechanism that potentially affected placental structure and function in addition to MIA and IPS . Often uMaternal autoantibodies , the metabolic syndrome  and elevated endogenous steroid and norepinephrine production  cumulatively contributed to this mother’s non-infectious pro-inflammatory state into the third trimester.FIR type I is the more predominant etiopathogenetic mechanism closer to delivery. Two disease pathways have been identified with FIR Type I, contributing to fetal brain injuries. Asphyxia occurs from inflammatory mediator-induced vasoconstriction within the placenta/cord and fetal brain blood–brain barrier vasculature resulting from direct effects by pathogens and abnormal cytokines on blood vessel caliber size and contractile responsivity. A second cytokine-associated mechanism with FIR Type I contributes to this asphyxial neuronal damage. Mitochondrial dysfunction within the cytosol and altered genetic expression within nuclei result in injury from cytokines with cell death or dysfunction in surviving neurons .Fetal brain maldevelopment and/or injury therefore potentially result from the cumulative effects of MIA, IPS and FIR to a vulnerable MPF triad across three trimesters. Altered embryonic-fetal brain structures during the first trimester impair multiple neuronal cell precursors within transient region with abnormal proliferation, differentiation, and migration. Abnormal neuronal connectivities later alter the cortical mantle during the second and third trimesters  with abnBalanced development of excitatory and inhibitory neuronal precursor activities is required for normal fetal brain maturation and function. An altered excitatory/inhibitory ratio resulting from these placenta-cord diseases contribute to altered brain circuitries expressed as DD, mental health disorders and epilepsy .Present standards of maternal levels of care  for thisFour “great neonatal neurological syndromes” comprise most children who require neonatal neurocritical care . NeonataG x E vulnerabilities of this maternal-child pair exemplified how prenatal and postnatal diseases contributed to EP and later DD.Developmental and destructive brain processes define EP with trimester-specific disease pathways that later influenced postnatal disease factors . Risks fOver 80% of nearly 15 million preterm children are born in LMIC . IncreasThese efforts will lower the prevalence and severity of EP for vulnerable MPF triads such as those exposed to healthcare disparities in LMIC and HICMD.Postnatal complications of prematurity further increased risks for EP following fetal cardiac failure with hydrops fetalis. An elective premature delivery with later postnatal medical complications occurred. Multiple pointes de torsade required emergent cardioversions during her first week of life to treat her cardiac decompensation. These events represented cumulative postnatal risks for injury from cerebral hypoperfusion. Additional adverse conditions of prematurity included pulmonary disease, anemia and gastrointestinal immaturity which contributed to reduced oxygen and nutrient delivery.Current conventional postnatal cranial sonography and conventional brain MRI studies  documentSuch diagnostic and therapeutic advances will be first available to MPF triads and neonates in HIC where there is greater access to research protocols. Research protocols in LMIC and HICMD require strategies for best practices to deliver technologies to those who are most vulnerable with healthcare disparities. Maternal-pediatric hospitals in these countries and regions require research efforts that compare different preventive, clinical and wellness study protocols to best deliver healthcare to women and children  to reducDevelopmental delay during this child’s first 1000 days represented postnatal clinical expression of previously acquired fetal and neonatal brain disorders. Early interventions supported by parental commitment offered greater healthcare and educational opportunities. Preschool expression of DD was replaced during school years with neurocognitive and mental health challenges as she matured into adolescence.Primary pediatric care partnering with early intervention programs need to offer all children opportunities to address medical and developmental needs. Support for early diagnosis and rehabilitative interventions must begin during the first 1000 days. Challenges are greater with more limited access to preventive, clinical and wellness resources in LMIC and HICMD. Community-based primary care with the ability to provide early intervention programs must be accompanied by wellness programs to minimize adverse childhood effects.Communicable and non-communicable diseases during childhood further complicate healthcare with adverse effects educational achievement. An acute hypertensive crisis with a cerebrovascular complication for this child at 10 years of age presented a new medical challenge. Her neurologic presentation of posterior reversible encephalopathy syndrome  was assoSudden systemic hypertension potentially alters cerebral blood flow preferentially to posterior brain regions where cerebral vasculature is highly susceptible to the adverse effects of increased systemic blood pressure. Persons with hypertensive disorders throughout their lifespan can experience brain injuries from this disease. The etiopathogenesis responsible for the clinical presentation of encephalopathy and seizures impairs function within the neurovascular unit . Risks for stroke and/or hemorrhage are known complications. A percentage of affected persons, however, exhibit transient or reversible neuroimaging findings as the acute clinical symptoms resolve. This child fortunately did not experience permanent injuries expressed by more severe sequelae.Intensive care management for this child included emergent treatment for status epilepticus and acute hypertensive crisis. Seizures were successfully controlled with resolution of neuroimaging findings on follow-up brain MRI images. Medication discontinuation without seizure reoccurrence after a three-year course of antiepileptic drug treatment was achieved. No apparent regression of her neurologic abilities resulted from these medical events.Healthcare systems in LMIC and HICMD need to prioritize continuity of medical delivery when childhood diseases present that require hospitalizations. Management of childhood medical complications present greater challenges when there is less access to advanced hospital-based medical care. WHO guidelines offer suggestions for improved hospital services for children confronted with acute illnesses in LMIC and HICMD . HealthcBrain maturation during adolescence involves accelerated synaptogenesis that reflects adaptative or maladaptive neuroplasticity. More complex brain connectivities are needed for optimal adult neurologic function. Increased neural network complexity is required to achieve sophisticated cognitive reasoning and social intelligence  requiredMental health challenges accompany DD which may intensify during adolescence. This child’s anxiety, mood instability, and problems with social interactions were adolescent expressions of abnormally increased synaptogenesis which potentially could further limit her adult performance. She experienced functional neurologic disorders and mental health challenges at home and in school despite lessening of earlier life DD. Continuity of psychiatric interventions and social supports by her family helped her through graduation. Continued mental health care by family and healthcare providers will be needed as she prepares for a career, establishes social relationships, and confronts life challenges .Mental illness expressed during childhood more likely is associated with brain disorders during the first 1000 days. Children in a LMIC or HICMD may not experience the same degree of recovery as the child presented for this discussion. Neuron-specific cell processes may result in atypical brain development starting during fetal life with more severe expressions of childhood neurocognitive/behavioral disorders including mental health disorders into adulthood. Public health resources must recognize the importance of mental health care and social problems to address childhood adverse effects. These risks are greatest for those with DD who experience healthcare disparities .Two longitudinal/cross-sectional cohorts present results applicable to the importance of preclinical diagnosis of mental health disorders. Comparisons of neuroimaging and genetic data sets suggested more accurate prediction of mental health disorders prior to clinical expression. Region-specific growth of the cerebral cortex was documented using detailed neuroimaging protocols based on large pediatric cohorts. These studies preceded mental illness and general psychopathology as expressed throughout childhood . These MThese neurodiagnostic advances will benefit children with DD who may also present with mental disorders. Availability for such diagnostic testing is needed in LMIC or HICMD for children at highest risk for mental health disorders accompanying DD.Healthcare policy therefore must advocate for mental healthcare in these vulnerable populations. Unfortunately, cultural misperceptions of DD and mental illness impede these efforts. Criminalization and religious demonization of people with these disorders result in exclusion of children with DD from receiving adequate healthcare and education. Support for families must respect religious, ethnic, and racial perspectives to properly direct interventions. Appropriate services need to be prioritized by community-religious leaders, policy makers, healthcare providers, and educators.The maternal-child pair used for this discussion stresses the continuum of prenatal and postnatal risks that began with maternal autoimmune disease, obesity, and anxiety. Fetal cardiac disease and complications of prematurity were adverse outcomes associated with these conditions. MPF triad phenotypes more broadly reflect multiple maternal diseases  pandemic . SeventeLawmakers and health policy leaders in both HIC and LMIC must adopt bio-social models of care that advocate for optimal care for all persons across the lifespan. This social contract by healthcare providers ,85 benefThe mother-child pair chosen for this review represented a family living in a comparatively resource-rich community. Her parents’ access to the internet and community services provided information and guidance to receive maternal and pediatric healthcare, minimize adverse childhood effects and plan educational interventions as their daughter’s medical and school challenges were identified. Teachers and therapists effectively applied knowledge of educational neuroscience applicable to her specific scholastic needs. Healthcare and educational services remained available for this family throughout high school.Healthcare strategies must address cultural, financial, and political barriers to care  beginninPrinciples of ontogenetic adaptation help explain long term effects of positive and negative neuroplasticity . Time-deWith advances in medical care into adulthood, longer life expectancy for older survivors with DD requires a greater priority for inclusion regarding optimal educational attainment during childhood to achieve better employment and societal interactions as adults . There iAs estimates for life expectancy increase for people with DD, acute and convalescent medical services and quality home care delivery must be anticipated to assist aging families and their proxies. Adults with moderate intellectual disability and cerebral palsy may potentially live into their fifties, assuming stable health without accidents or chronic illnesses. Milder clinical expressions of disability now experience similar life expectancy estimates as healthy populations without DD ,92,93.Communicable and noncommunicable diseases disproportionately affect more women and children in LMIC and HICMD. Maternal health consequences after genitourinary infections, hypertensive disorders, and diabetes mellitus are examples of prevalent maternal conditions that adversely affect fetal brain health presenting as diseases of the MPF triad and neonate. The great neonatal neurologic syndromes of encephalopathy, seizures, stroke, and EP are postnatal expressions of trimester-specific diseases after birth. Childhood neurologic disorders such as DD are further influenced by ongoing diseases or adverse conditions.Diversity and inclusion for healthcare and education delivery are essential for optimal outcomes. Integrating developmental origins and life course theories into clinical and public health practices  will serThe WHO sustainable development goals advocate for all women and children. Transactional models to achieve these goals require healthcare policies that integrate the continuity of maternal and pediatric healthcare beginning before conception when first addressing a girl’s reproductive health. These goals are later integrated with advocacy for pregnancy planning and optimal maternal preventive care during and between pregnancies. Communities require resources provided by public health programs for effective nutrition, health care, housing, and sanitation to maximize life-course health during and between each pregnancy.Preventive healthcare education and resources require support by a nation’s public health infrastructure that can effectively provide medical and educational services to children and families that recognize and overcome geographic-cultural barriers. With public health efforts, effective educational plans can be initiated at the earliest ages to optimize the school performance of a child with DD, applying educational neuroscience by teachers recognizing ethnic, racial, and cultural context. These actions will benefit the most vulnerable with healthcare disparities in LMIC and HICMD.While these efforts potentially have significant global impact, wide gaps remain between preclinical diagnosis of DD and implementation of interventions for women of reproductive age between and during their pregnancies. The WHO sustainable development goals recently highlighted brain health across the lifespan to promote adaptive neuroplasticity starting during critical-sensitive periods. This emphasis on brain health must advocate for women, children, and adolescent health, with interventions that begin during the first 1000 days and continue into adulthood .Every Newborn Action Plan presented by the WHO further emphasizes strategies to reduce neonatal morbidity and mortality. Success of this plan also advocates for prenatal health of women and MPF triads to maximize the benefits for neonates who require resuscitation, transport, and neonatal intensive care .International cooperation among government and nongovernmental organizations must advocate for a woman’s right for optimal health care and educational services for her children within their community. Such advocacy must be maintained from childhood through adulthood for healthy children and those with DD. Future research protocols need to address maternal and pediatric health disparities by applying public health initiatives that educate women and families to advocate for resources to sustain health into adulthood. Effective partnerships will improve the woman’s health and quality of life throughout life beyond her reproductive years as well as for her children and successive generations.Future biomarkers can potentially apply genetic-metabolomic, neurophysiologic and neuroimaging technologies  for pre-


Peer support complements traditional models of chronic kidney disease (CKD) care through sharing of peer experiences, pragmatic advice, and resources to enhance chronic kidney disease self-management and decision-making. As peer support is variably offered and integrated into multi-disciplinary CKD care, we aimed to characterize healthcare providers’ experiences and views on peer support provision for people with non-dialysis-dependent CKD within Canada.In this concurrent mixed methods study, we used a self-administered online survey to collect information from multi-disciplinary CKD clinic providers  on peer support awareness, program characteristics and processes, perceived value, and barriers and facilitators to offering peer support in CKD clinics. Results were analyzed descriptively. We undertook semi-structured interviews with a sample of survey respondents to elaborate on perspectives about peer support in CKD care, which we analyzed using inductive, content analysis.We surveyed 113 providers from 49 clinics. Two thirds (66%) were aware of formal peer support programs, of whom 19% offered in-house peer support through their clinic. Peer support awareness differed by role and region, and most referrals were made by social workers. Likert scale responses suggested a high perceived need of peer support for people with CKD. Top cited barriers to offering peer support included lack of peer support access and workload demands, while facilitators included systematic clinic processes for peer support integration and alignment with external programs. Across 18 interviews, we identified themes related to peer support awareness, logistics, and accessibility and highlighted a need for integrated support pathways.Our findings suggest variability in awareness and availability of peer support among Canadian multi-disciplinary CKD clinics. An understanding of the factors influencing peer support delivery will inform strategies to optimize its uptake for people with advanced CKD.The online version contains supplementary material available at 10.1186/s12882-022-02776-w. Chronic kidney disease (CKD) is a complex condition that affects 13% of the population globally and, in its most advanced stage, can result in kidney failure requiring dialysis or transplantation as life-sustaining therapy , 3. PeerPeer support may augment traditional models of multi-disciplinary CKD care by enabling peer validation of patients’ experiences and exchange of pragmatic resources for living well with their disease –8. Peer Limited research on peer support for people with kidney disease suggests that variability in awareness and promotion within kidney care programs poses a barrier to peer support uptake . While aWe used a concurrent mixed methods approach to understand how peer support is perceived and delivered in multi-disciplinary CKD clinics across Canada . This inEligible participants included healthcare providers  from multi-disciplinary CKD clinics across Canada. We purposively sampled eligible providers through the CKD Clinic Network, a pan-Canadian organization of providers and managers from multi-disciplinary CKD clinics who care for persons with advanced, non-dialysis-dependent CKD , 26. A nA self-administered online survey was developed by the investigators based on findings from previous work and related peer support and self-management literature  experienced in qualitative research and with no prior relationships with participants completed all interviews, which were audio-recorded and lasted approximately 30-40 min. A question guide was used to prompt discussion about the promotion and integration of peer support programs in CKD clinic care and their perceived need to address identified care gaps   groups are in silos” limited their availability to a broader range of people with CKD. Despite the potential value of integrating peer support within CKD clinics as an “adjunct” to existing support services, providers considered it critical to clarify the scope of services through clear boundaries and expectations.Ranked barriers and facilitators from survey responses and those reported in interviews with supporting quotes are compared in Table Survey respondents emphasized inconsistent awareness of peer support among clinic providers as a main barrier to integrating peer support. Interviews identified additional challenges posed by recent increases in virtual technology use. The latter issue made it difficult to identify patients who might benefit from peer support during clinic encounters and to offer peer support virtually to patients with limited access to technology. Interview and survey participants also identified barriers of workload demands, competing priorities, and lack of adequate time and resources to discuss or offer peer support.Across surveys and interviews, participants underscored having systematic approaches to offering peer support in clinics as a facilitator. This included processes for routine staff education about available programs and clear role definitions among team members as to who discusses peer support with patients. The importance of close relationships with external organizations to foster collaboration in peer support delivery was highlighted more frequently in interviews than surveys. Although leadership and management support were ranked highly as facilitators in the survey, participants did not emphasize this during interviews.Integrated findings across quantitative and qualitative phases suggest that despite variable awareness of peer support availability, participants appreciated the value of peer support for people with CKD. A lack of systematic processes for introducing peer support within and across CKD clinics meant that many providers were unable to consistently offer it to their patients. Participants expected that attempts at integrating peer support within CKD clinics would be met with challenges, including high workload demands and competing priorities for CKD clinic staff. The importance of addressing accessibility challenges through tailored peer support options was also emphasized across participants. Despite anticipated difficulties, providers offered suggestions for integrating peer support into CKD clinic care with appropriate organizational supports and collaboration.Participants across roles recognized that provider awareness of peer support was necessary to effectively promote programs to their patients. However, awareness was lower than anticipated and varied by role and region, which may point to variability in how CKD clinics operate and in peer support availability across the country. Although our results differ from other studies reporting higher awareness of peer support among staff in kidney care programs, poor knowledge of peer support practicalities has been identified as a major barrier to uptake of peer support programs among people with varying stages of kidney disease , 14, 33.In our study, peer support referral and embeddedness with other clinic support offerings were inconsistent given both limited resources and lack of formalized practices. Participants also described a lack of role clarity related to offering and/or integrating peer support within their clinics. Whereas nephrologists and nurses commonly assumed that social workers were the most appropriate team member to discuss peer support, social workers indicated it should be a shared responsibility. In contrast, respondents from other studies suggested peer support referral fit within the nursing scope of practice , 33. TakParticipants emphasized the importance of tailoring peer support delivery to their local context as a way of addressing lower receptivity and access to peer support among CKD patients, yet faced challenges in doing so in the clinic setting. As Canadian CKD clinics operate under regional health authorities and comprise different models of care and resources , 27, 35,Wood et al. recently reported on experiences related to the adoption of a national peer support program for patients across various kidney disease contexts, including dialysis, in the United Kingdom (UK) . In thisFindings from our study offer practical considerations for the provision of peer support as part of routine CKD care. CKD clinics may provide an optimal setting for offering or embedding peer support due to their provision of longitudinal care using a multi-disciplinary, team-based approach –22. Our Our study was strengthened by its inclusion of healthcare providers and CKD clinics from across Canada and exploration of complementary aspects of an important care issue for patients with CKD . HoweverIn this study we noted variability in how healthcare providers from CKD clinics across Canada promoted and offered peer support opportunities to patients and their caregivers. Our findings suggest that factors such as streamlined referral processes, collaboration between programs, and program adaptation to fit local contexts could encourage peer support awareness and uptake. A clearer picture of how peer support is currently offered to patients with non-dialysis-dependent CKD and providers’ needs related to peer support delivery can inform strategies to optimize its integration into CKD care. Future work to establish and evaluate systematic approaches to peer support in comprehensive CKD care are needed.Additional file 1. Consolidated Criteria for Reporting Qualitative Research (COREQ): completed checklist reporting on qualitative results according to recommended guidelines.Additional file 2. Peer support in CKD survey: questions included in the online survey.Additional file 3. Interview guide: questions used in the semi-structured interviews with a subset of healthcare providers.Additional file 4. Characteristics of in-house peer support: description of integrated peer support programs from respondents indicating peer support delivery within their clinic.Additional file 5. Characteristics of peer support processes: description of clinic processes from respondents indicating peer support awareness.Additional file 6. Likert scale responses: responses to Likert scale questions about perceived need, interest, and impact of peer support.


Halophyte [Cynodon plectostachus (K. Schum.) Pilg.] and non-halophyte grasses (Lolium perenne L. and Panicum maximum Jacq.) clustered along increasing soil salinity. Halophytic grasses [Panicum antidotale Retz. and Dicanthum annulatum (Forssk.) Stapf] congregated with Medicago sativa L., a non-halophytic legume along a gradient of increasing photosynthesis. Halophytic grasses  had strong yield-salinity correlations. Medicago sativa L. and Leptochloa fusca L. Kunth were ubiquitous in their forage biomass production along a continuum of medium to high salinity. Forage crude protein was strongly correlated with increasing salinity in halophytic grasses and non-halophytic legumes. Halophytes were identified with mechanisms to neutralize the soil sodium accumulation and forage productivity along an increasing salinity. Overall, halophytes-non-halophytes, grass-forbs, annual-perennials, and plant-bacteria-fungi synergies were identified which can potentially form cropping systems that can ameliorate saline soils and sustain forage productivity in salt-affected arid regions.Soil salinity limits crop productivity in arid regions and it can be alleviated by crop synergies. A multivariate analysis of published data ( Forage crops and rangeland species have immense potential to rehabilitate and improve the natural ecosystem services besides providing forage supply to livestock and wildlife. They maintain soil health by regulating environments against the effect of climate change and pollution. In arid regions, these benefits from vegetation have been jeopardized by adverse environmental conditions, particularly endemically marginal precipitation . Traditi–1 and sodium accumulation greater than 15%  ions which replace potassium (K+) ions in plant biochemical functions  how consistent are mechanisms of tolerance to salinity among forage species in different habitats, (ii) do species converge in their salinity tolerance mechanisms, (iii) what are the possible synergies among species in their adaptation to saline soils, and (iv) how can mechanisms of species tolerance and synergies be used to design forage cropping systems adapted to saline soils. Hence this article reviews and reanalyzes published data to determine crop yield loss to soil salinity, species mechanisms of salinity tolerance and ecosystem services, and their potential synergies which can be used to design forage cropping systems for sustainable and resilient agroecosystems.–1). Subsequently, crop species were categorized according to their ecosystem services reported in saline soils in arid and semi-arid habitats across continents. These involved studies spanning 1–5 years conducted in field conditions, each with a non-saline soil control besides an increasing magnitude of treatment to strongly saline soils. The criteria of + ion accumulation in crop biomass and their role in reducing soil salinity (bioremediation). Lastly, supporting services were crop microbe interactions that support nutrient cycling in forage cropping systems. The identified synergies were used as indicators to illustrate the model cropping systems that can alleviate soil salinity and enhance forage crop productivity and nutritive value.This article provides a synthesis of correlations between salinity tolerance mechanisms and ecosystem services of forage crops. The first stage was to determine forage crop yield losses to soil salinity and discuss its tolerance. Thereafter, attempts were made to determine if forage crop species converge in their mechanisms of salinity tolerance and what this implies to forage productivity. In this regard, tolerance was considered the ability to maintain photosynthesis and dry matter yields with increasing salinity up to 200 mM NaCl concentrations in the propagation medium . Salinite (saturated paste extract), and crop duration and cited authors. Additional variables including accumulated soil organic carbon, forage dry biomass, forage crude protein, soil EC change, and Na+ ion uptake. Data were subjected to the multivariate analysis procedure to determine correlations between variables and accordingly relationships among forage crop species. In doing so, the FactoMiner package was deployed to conduct principal component analysis (PCA) which also involved standardizing data according to the deviation of individual variates from the sample mean divided by sample standard deviation  Thwaites and Panicum antidotales Retz. have been reported to retain similar shoot moisture with increasing salinity levels from 0 to 140 mM NaCl (+ ions in the media around roots (Imperata cylindrica (L.) P. Beauv., Eragrotis amabilis (L.) Wight and Arn., Cynodon dactylon (L.) Pers., and Digitaria ciliaris (Retz.) Koeler  Thwaites grown in saline environments up to 140 mM NaCl  Kunth which enhanced photosynthesis up to 400 mM NaCl (+ and Cl– ions as well as their role in generating reactive oxygen species. This is exemplified in enhanced exudation of Na+ and Cl– ions by Sporobolus spicatus (Vahl) Kunth at 400 mM NaCl  Koeler , Festuca mM NaCl , and Agr mM NaCl . Under itabolism . Potassitabolism . Potassiectively . In thise shoots . In the  mM NaCl . In addi mM NaCl . Maintai mM NaCl . Species mM NaCl . Festuca mM NaCl , which d2 and O2 . These mCynodon plectostachyus (K. Schum.) Pilg.), a halophytic grass, clustered together with non-halophytes including perennial ryegrass (Lolium perenne L.) and guinea grass (Panicum maximum Jacq.) and less proximately with Setaria sphacelata (Schum.) Stapf and Hubb. and Pennisetum hybridus, all of which had close associations with increasing soil salinity. Alfalfa which is a non-halophyte clustered with halophytes namely marvel grass (Dicanthum annulatum (Forssk.) Stapf) and blue panicum grass  along increasing photosynthesis. Saltgrass (Sporobolus spicatus (Vahl) Kunth) which is a halophyte, stood alone with strong and near equitable contribution to increasing relative yield, photosynthesis and salinity. Saltgrass is reported to restrict the Na+ uptake with increasing soil salinity and secrete excess salts at night (Lotus corniculatus L.), a non-halophytic legume, congregated with halophytic grasses including intermediate wheatgrass , and blue panicum grass  associated with reducing salinity, photosynthesis, and relative yield. Intermediate wheatgrass has C3 photosynthetic machinery  and wheat (Triticum aestivum L.) which are considered marginal halophytes. These annual grain crops are commonly diversified with annual legumes in time or space. Nevertheless, their proximal grouping with birdsfoot trefoil suggests a potential coexistence, for instance, in living mulch or in prolonged rotations. Living mulch refers to maintaining a perennial legume crop in an annual cropping system. Oat (Avena sativa L.), a halophytic annual grain, and Pennisetum purpureum Schumach., a non-halophytic grass, had near neutral contribution to salinity, photosynthesis, and relative yields hence potential candidates for long perennial annual rotations. Overall, the results of PC indicate a convergence of halophytes and non-halophytes in their physiology and yield response to salinity. This suggests possibilities for synchrony of diverse species functional groups in their adaptation to salinity stress which can support synergies that enhance overall forage productivity. In broad sense, such coexistence and facilitation can compensate for generally low forage productivity of halophytes as It is of primary significance that grass and forb species mechanisms of salinity tolerance translate to sustainable forage biomass production and resilience to further exposure to salt stress. at night . This inachinery  and is lSynergies refer to the simultaneous increase or decrease in the provisioning of ecosystem services . Forage –1  to 41 dS m–1  are analyzed in sections “Provisioning Ecosystem Services of Forage Production” to “Supporting Ecosystem Services for Soil and Animal Health.”Overboard, crop diversification to mimic the stability of primary production and resilience of natural vegetation to disturbances is increasingly appealing to the design of sustainable agroecosystems . For exa–1. Blue panicum grass and Rhodes grass followed a similar pattern.As shown in + over Na+ ions in grass  and lower crude protein than legumes. As depicted here, grasses are versatile in their range of crude protein concentration, some of which march that of legumes. A combination of grasses and forbs to generate forage of NDF ≤ 50% and crude protein ≥ 20% of dry matter is recommended to support animal and ruminal microbial energy needs which invigorate animal health and reproduction . The balvia improved soil structure and therefore enhanced infiltration of Na+ ions down the soil profile , a halophyte, can extract an estimated 1 ton of Na+ ions ha–1 year–1. This subsequently enhanced plant water and K+ ion retention together with shoot biomass in succeeding barley (Hordeum vulgare L.). Saltwort has similar potential, for instance, accumulating up to 125 g of Na+ ion kg–1 of dry matter within a span of 1 year , saltmeadow cordgrass (3 dS m–1), and blue panicum grass (2 dS m–1) are reported to have intermediate effects  on biological N fixation by sweet clover (∼100%) and alfalfa (90–70%) except at 20 dS m–1 . It is suggested that N fixing bacteria release indole acetic acid at levels that safeguard the symbiotic process and plant growth from severe levels of soil salinity  with annual grain-legume mixtures in a sequence that extends through fallow periods. The halophyte is designed not only to adapt in marginal weather conditions but also able to absorb Na+ ions and supply surface mulch for the next annual grain-legume crop mixture. The fourth system is an annual grain monocrop-legume monocrop in rotation. This system advances the benefits of optimum forage productivity and cover crops over at least 3 years of rotation. Overall, the cropping systems suggested here are designed to exploit the ecosystem services that enhance N and P supplies and optimize forage productivity and nutritive value. These systems are also developed to sequester carbon and alleviate salt buildup and toxicity in a gradual process that leads to sustainable forage production in areas prone to salinity.All of the above information showed that there is overwhelming evidence that soil microbes are ingredients of ecosystem sustainability by virtue of their roles in soil nutrient cycling. Soil microbial communities rely on energy from their plant hosts, and when established, they can revitalize crops against the effects of soil salinity and support forage productivity and nutritive value. This potential has not been fully exploited in orchestrated cropping systems to alleviate soil salinity and its effects on ecosystem health. This article explored species mechanisms and synergies that can be incorporated in cropping systems to alleviate the challenges of soil salinity and sustain forage productivity in arid regions. It is clear that halophytic and non-halophytic forage crop species have convergent mechanisms of salinity tolerance manifested in enhanced photosynthesis and productivity. There are indicators of ubiquity of ecosystem services of both halophyte and non-halophytic species along a continuum of increasing soil salinity. Potential grass-forb, annual-perennial, halophytes-non-halophytes, and plant-bacteria-fungi synergies against effects of soil salinity were identified. These synergies can be harnessed in designing sustainable forage cropping systems that ameliorate saline soils and improve nutrient cycling to sustain optimum forage productivity.The original contributions presented in the study are included in the article/DA and AN conceived and designed the study. AN supervised the work. DA, EA, AH, and AE collected and analyzed the data. DA drafted the manuscript. AH, LK, KD, and AN validated the data analysis and reviewed all the versions of the manuscript. 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Post-traumatic stress disorder (PTSD) and abnormal spirometry are highly prevalent mental and health conditions in World Trade Center (WTC) responders. We tested the hypothesis that PTSD symptomatology and abnormal spirometry are conjointly and synergistically associated with poorer cognitive performance. A total of 1,326 responders  from the WTC Health Program took part in the study. PTSD symptomatology was assessed using the PCL-IV, and we calculated the FEV1/FVC ratio to measure pulmonary function. Cogstate assessments measured cognitive performance. Linear regressions were employed to evaluate PTSD and pulmonary function on cognitive performance while adjusting for age, sex, education, smoking status, and comorbidity. Higher PTSD symptomatology and lower pulmonary function were independently and conjointly negatively associated with cognitive performance. Further, a significant synergistic effect was present in that higher severity of PTSD symptomatology in the presence of lower pulmonary function was associated with poorer cognitive performance . Results suggested that chronic stress and lung damage might share underlying biological mechanisms, including inflammatory and oxidative stress pathways, which may also be affecting the brain. Early intervention efforts to mitigate preventable cognitive decline in high-risk populations should be studied.


Background: Many patients suffering from schizophrenia spectrum disorders continue having distressing auditory hallucinations and paranoid ideations despite receiving current treatment. Virtual reality assisted treatment offers the potential of advancing current psychotherapies for psychotic symptoms by creating virtual environments that can elicit responses  mirroring real-world settings. In two large-scale randomised clinical trials, we are investigating whether targeted virtual reality assisted psychotherapy can reduce psychotic symptoms and increase daily life functioning and quality of life. The CHALLENGE trial examines whether nine sessions of virtual reality-assisted psychotherapy is superior to nine sessions of standard treatments in reducing the severity, frequency, and distress of auditory hallucinations in patients with psychosis. In the Face your Fears trial we are investigating whether virtual reality assisted cognitive behavioral therapy (CBT) is superior to standard CBT in reducing levels of paranoid ideation in patients with psychosis spectrum disorders. Methods: The CHALLENGE and Face your Fears trials are randomised, assessor-blinded parallel-groups superiority clinical trials, allocating a total of 266 and 256 patients, respectively to either the experimental intervention or a control condition. The trials are currently enrolling patients; thus, no quantitative data is available yet. The main objective of this presentation is to give a qualitative account of this new psychotherapeutic methods as it is applied in both trials. Results: Qualitative data comprising case descriptions and video material will be presented at the conference. Discussion: The preliminary findings indicate great potential for these innovative treatments albeit important concerns regarding implementation will be raised.No significant relationships.


Research has repeatedly demonstrated that greater affective reactivity to daily stressors is associated with detrimental health outcomes . However, most research has only considered linear effects, which precludes an examination of whether moderate levels of stress reactivity may be beneficial. Using daily diary data from the National Study of Daily Experiences  we fit multilevel SEMs to simultaneously model daily within-person associations between stress and negative affect , and individual differences in the linear and quadratic associations between stress reactivity and life satisfaction, psychological distress, and chronic conditions. Significant quadratic effects were found for each of the three outcomes , indicating a U-shaped pattern where both low and high levels of stress reactivity were associated with poorer health, whereas moderate levels of daily stress reactivity predicted better health outcomes. The results suggest that some affective response to daily stressors can be beneficial.


Medication nonadherence is associated with numerous negative health outcomes among older adults, including myocardial infarction, stroke, preventable hospitalizations, and increased risk of decline in self-reported health status. Maintaining continuous use and access to needed medications in later life has important implications for quality and length of life. A primary barrier shown to interfere with medication adherence in older adults is an inability to pay for medication. Relative to their younger counterparts, older adults have more financial protections that increase access to needed prescription medication through health insurance coverage. Despite these added protections, older adults are more likely to experience financial insecurity, with some evidence suggesting that COVID-19 accentuated existing vulnerabilities. Data are derived from the Health and Retirement Study (HRS), leveraging data drawn from the 2016, 2018, and 2020 study waves . Logistic models were used to evaluate the association between five COVID-19 related financial setbacks , and medication nonadherence among adults 60+. Results show that net of pre-COVID financial vulnerabilities and socioeconomic status, individuals who reported being unable to pay medical bills and those unable to pay rent/mortgage after the start of the pandemic reported higher odds  of not taking/filling their prescription medication due to cost. Results suggest that greater financial protections for housing and medical bills among financially vulnerable older adults will increase medication adherence.