Linear Regression Analysis Research Articles

Background: It is currently unknown whether patient engagement in adult congenital heart disease (CHD) care is influenced by social determinants of health (SDOH) such as race/ethnicity, education, and income. Adapting from the chronic care model, patient engagement, defined as the knowledge, skills, ability, and willingness to manage one’s health, can minimize lapses in care and improve CHD care outcomes. Methods: This cross-sectional study analyzes data from patients aged 18 and older with a self-reported diagnosis of CHD enrolled in a digital health research study called Empower My Congenital Heart. Patient engagement was measured using the Gothenburg Empowerment Scale (GES). We compared mean GES scores across demographic categories (race/ethnicity, education, and income), using independent samples t-tests or one-way ANOVA as appropriate. Additionally, we conducted a multivariate linear regression analysis to evaluate the impact of race/ethnicity, education, and income on GES scores, adjusting for age, gender, marital status, parental status, and employment status. Results: Of 323 adult CHD patients, the mean age was 45.6 ±15 years, 32.5% were males, 89.9% were non-Hispanic White, 29.7% had less than a Bachelor's degree, and 43.5% had less than $100,000 annual household income. The mean GES score was 61.8 ± 8, with significantly higher scores observed for non-Hispanic White identifying individuals (p=0.006) and those with a Bachelor's or higher level of education (p=0.005), while no difference across income levels (p = 0.394) (Figure 1). Linear regression analysis demonstrated that race and ethnicity remained significantly associated with GES scores (Table 1). Conclusions: Race/ethnicity and education level (in the bivariate analysis only), but not income, are the SDOH variables significantly associated with how empowered a CHD patient is in managing their health care. Future interventions that target enhancing patient engagement and self-management skills should take into consideration the influence of these demographic and social factors.

Background: Hypertensive emergency (HE) is a life-threatening condition that poses a significant risk for increased morbidity and mortality. It is not known with certainty how a state of declining health, namely with frailty, affects in-hospital outcomes for patients admitted for HE. Herein, we aim to quantify the impact of frailty on in-hospital outcomes for adults admitted for HE and determine whether this association remains consistent across all adult age groups. Methods: Retrospective analysis was conducted using the National Inpatient Sample database from 2016 to 2022 with STATA18 statistical software. ICD-10 codes were used to identify patients with a primary diagnosis of HE and age at admission. Frailty was assessed using the Hospital Frailty Risk Score, with a score >5 indicating frailty. Multivariate logistic and linear regression analysis was performed to calculate adjusted odds ratios (aOR) while accounting for covariates. The impact of frailty was analyzed for all adults admitted with HE, with subgroup analyses performed for younger (<65 years) and older (≥65 years) patients. Results: Out of 337,335 patients admitted for HE, 48.6% were classified as frail and 51.4% classified as non-frail. The frail group had a higher average age (60.23 vs 57.93; p<.001) and were predominantly female (53% vs 47%; p<.001). Logistic regression showed frail patients had a significantly higher risk of in-hospital mortality (aOR 6.755, CI 4.577-9.967, p<.001), where similar trends can be seen for additional outcomes such as intracerebral hemorrhage, acute kidney injury, and GI hemorrhage demonstrated in Table 1. Moreover, linear regression showed frail patients experienced an increased adjusted mean length of stay by 1.812 nights (95% CI, 1.751-1.874; p<.001) and higher adjusted mean total charges by $17,649.41 (95% CI, 16,825.38-18,473.44; p<.001). Subgroup analysis stratified by age 65 demonstrated that frailty was still significantly associated with worse outcomes in both age groups (Table 2). Conclusion: Clinical outcomes are significantly worse with higher resource utilization in frail patients versus non-frail patients admitted for HE. This study demonstrates that the impact of frailty transcends chronological age and challenges the notion that frailty is limited to geriatric populations. Clinicians should be vigilant about assessing the role of frailty in HE to gain crucial clinical insight to enhance patient well-being and appropriate resource allocation.

Background: Atrial fibrillation (AF) is a common comorbidity in the U.S. and significantly contributes to the incidence of acute ischemic strokes. This study examines the impact of household income on management and outcomes of Acute ischemic stroke in patients with AF. Research: Question: How does socioeconomic status impact the management and outcomes of Acute ischemic stroke in patients with AF? Methods: We used data from the National Inpatient Sample database (2018-2020), analyzing adult hospitalizations with primary diagnosis of acute ischemic stroke and secondary diagnosis of AF. Patients were grouped into four income quartiles: Q1 ($1 - $51,999), Q2 ($52,000 - $65,999), Q3 ($66,000 - $87,999), and Q4 ($88,000+). Outcomes included in-hospital mortality, utilization of endovascular thrombectomy (EVT), length of stay (LOS), inflation-adjusted total charge (IATC), intracranial hemorrhage (ICH) and sepsis. Multivariable logistic and linear regression analyses were performed, for demographic, clinical, and hospital factors. Results: A total of 340,835 hospitalizations with Acute ischemic stroke and AF were identified. Mean age was 77 years (11), and 52% were female. When comparing highest income quartile to lowest, admissions in the highest income quartile had significantly lower in-hospital mortality rates (6.5% vs. 7.0%; p < 0.001), lower sepsis rates (2.7% vs. 3.3%; p = 0.032), shorter mean LOS (6.2 vs. 7.7 days; p < 0.001), and higher mean IATC ($116,076 vs. $107,568; p = 0.06). Hospitalizations in highest income quartile had higher rates of ICH (9.4% vs. 9.1%; p = 0.11) and EVT (6.8% vs. 6.1%; p = 0.7), but these differences were not statistically significant. After adjusting for confounders, higher income stayed markedly associated with lower in-hospital mortality (adjusted odds ratio [aOR]: 0.78, 95% CI: 0.70–0.86; p < 0.001), lower sepsis rates (aOR: 0.85, 95% CI: 0.74–0.99; p = 0.032), shorter LOS (aOR: -0.28, 95% CI: -0.43 to -0.14; p < 0.001), and higher IATC (aOR: 2,403, 95% CI: -4,911 to 105; p = 0.06). There were no significant differences observed in ICH (aOR: 0.95, 95% CI: 0.87–1.03; p = 0.02) and EVT (aOR: 1.06, 95% CI: 0.95–1.19; p = 0.3) between highest and lowest income quartiles. Conclusion: Higher socioeconomic status is associated with lower in-hospital mortality and sepsis rates, shorter LOS, and higher IATC. These disparities suggest the need for targeted interventions to address socioeconomic inequalities and improve stroke care.

Background: Myocardial fibrosis is a key determinant of diastolic dysfunction in non-dilated left ventricular cardiomyopathy (ND-LVCM). However, the extent to which fibrosis burden and histological distribution patterns influence diastolic function—particularly across specific etiologies such as amyloidosis—remains incompletely understood. Hypothesis: We hypothesized that the extent and pattern of myocardial fibrosis correlate with diastolic function indices, including global longitudinal strain (GLS) and deceleration time (DcT), and that in cardiac amyloidosis, the deposition pattern may be a more relevant determinant of diastolic impairment than overall fibrosis burden. Methods: We retrospectively analyzed 201 patients with ND-LVCM (left ventricular end-diastolic diameter <55 mm) who underwent endomyocardial biopsy, echocardiography, and cardiac MRI. Fibrosis burden was quantified via Masson trichrome staining and expressed as percentage of tissue area. In patients with cardiac amyloidosis (n=56), Congo red–positive deposits were semi-quantitatively classified as diffuse, scattered, or perivascular using image analysis software. Diastolic function was assessed by GLS and DcT. Subgroups included sarcoidosis (n=14), Fabry disease (n=12), hypertensive cardiomyopathy (n=49), hypertrophic cardiomyopathy (n=38), and unclassified ND-LVCM (n=32). Linear regression and subgroup analyses were performed. Results: Across the entire cohort, GLS showed a significant inverse correlation with myocardial fibrosis extent (GLS = −23.98 + 0.47 × fibrosis%, R 2 = 0.29, p < 0.0001). However, this correlation was attenuated in patients with cardiac amyloidosis. In the amyloidosis subgroup, GLS and DcT were more strongly influenced by the pattern of amyloid deposition: diffuse deposition was associated with markedly reduced GLS and shortened DcT, while perivascular or scattered patterns showed milder impairment. Fibrosis percentage alone was not a significant predictor of GLS in this subgroup. Across the full cohort, fibrosis extent also showed a weak but significant correlation with DcT (p < 0.05). Conclusions: In ND-LVCM, myocardial fibrosis burden correlates with diastolic dysfunction. However, in cardiac amyloidosis, the spatial pattern of amyloid deposition may more accurately reflect functional impairment than overall fibrosis extent. These findings highlight the clinical importance of detailed histological evaluation in understanding restrictive physiology.

Background: Staged palliation process for single ventricle (SV) patients alters preload, afterload, and ventricular mechanics, making accurate function assessment essential. Left ventricular echocardiography markers have been applied to SV patients such as ejection fraction (EF), though reliability is limited. Continuous wave Doppler (CWD)-derived dp/dt during isovolumetric contraction has surfaced as a potential non-geometric contractility index. Hypothesis: We predicted that CWD-derived dp/dt would correlate with cardiac magnetic resonance (CMR) -derived EF in adults with SV physiology. Methods: This was a single-center retrospective study of SV patients ≥18 at the Ahmanson/UCLA between 2010-2024. Inclusion required echo and CMR with volumetrics within one year. We measured dp/dt by obtaining the time interval that AV regurgitation velocity increased from 1 to 3 m/s. Correlation, linear regression, and ROC analysis were performed. Results: A total of 71 patients met inclusion criteria. Median age of 28.9 years (IQR: 23.6, 34.5), and 41 (57.8%) were female. 37 (52%) had a single left ventricle (LV), 30 (42.3%) had a single right ventricle, and 4 (5.6%) had mixed morphology. AV-valve regurgitation was classified as trace in 13 (25.3%), mild 37 (52.2%), moderate (25.4%), and severe 1 (1.6%). Median time between CMR and echo study was 13 days (IQR: -2, 64). Median CMR EF was 51%, with no significant difference by ventricular morphology (p=0.15). Median dp/dt was 803 mmHg/sec and did not significantly differ between right and left ventricle (p=0.09). Linear regression showed no association between dp/dt and CMR EF (p=0.1); however, with nEDV as a correction factor, correlation improved (β=0.025, p=0.007). The coefficient for the interaction term between dp/dt and nEDV was -0.0002 (p=0.025) which means that the association between dp/dt becomes stronger as nEDV decreases. ROC analysis revealed that qualitative echocardiogram assessment by experienced ACHD cardiologists (AUC 0.77) outperformed dp/dt (AUC 0.55-0.62) in identifying moderate-severe dysfunction. Conclusions: We demonstrate that echo CWD derived dp/dt has poor ability in distinguishing between mild and moderate/severe systolic SV dysfunction on CMR in ACHD patients. Even with adjustment for nEDV, dp/dt should not be used as an objective parameter to evaluate SV function. Our study shows that careful assessment by well-trained ACHD cardiologists is more sensitive in determining significant SV dysfunction.

Introduction: Social support is known to influence health-related quality of life and is associated with health outcomes, such as self-care, hospitalization rate, mortality. Sex and race differences in social support and clinical outcomes have been reported, but less is known about how social support varies among cardiac ICU survivors. Research Question and Hypothesis: This study aimed to examine whether the association between social support and the quality of life differed by sex and race, and whether higher levels of social support were associated with better quality of life among survivors of cardiac intensive care. Methods: This cross-sectional study was part of the Wellness and Needs of Men and Women after a Cardiac Intensive Care Unit Stay (WellNOW) study, an ongoing longitudinal cohort of CICU survivors. Data were collected from 130 participants diagnosed who were transferred to a step-down unit following discharge from the Cardiac Intensive Care Unit. The primary independent variable was social support, assessed using the ENRICHD Social Support Instrument. The outcome variable was health-related quality of life, measured using the 12-item Short Form Survey, comprising physical and mental component scores. Sex and race were self-reported and examined as potential effect modifiers. Multiple linear regression analyses were conducted, with interaction terms for sex and race tested in separate models, controlling for age, educational level, length of intensive care unit stay, and comorbidity. Results: Participants were an average age of 61.8 ± 13.4 years. The sample was mostly female (55.4%, n=72). Nearly one third of participants were Black (30.8%, n=40); most participants were White (62.3%, n=81). Higher social support was positively associated with better mental health-related quality of life (β = 0.62, p=0.001), while no association was found for the physical component of health-related quality of life (β=0.03, p=0.859), in adjusted regression models. The relationship between social support and mental health-related quality of life was not moderated by sex nor race. Conclusion: Better health-related quality of life, notably in the mental health domain, was associated with higher levels of social support among cardiac intensive care unit survivors. However, sex and racial differences did not affect this correlation. Future interventions may aim to enhance psychological wellness by increasing perceived social support in this population.

Background: Menopause is associated with adverse changes in vascular function that significantly increase vessel stiffness and cardiovascular disease (CVD) risk. Given the rising CVD risk in both younger and older adult females, it is important to identify predictors of vascular health, including body composition and physical activity levels, in both pre- and postmenopausal women. Research Questions: What are the optimal body composition and physical activity predictors of vascular health in Asian women, and do these predictors differ by menopausal status? Methods: A total of 236 Asian women (125 premenopausal, 111 postmenopausal) were evaluated for vascular health using carotid-femoral pulse wave velocity, central augmentation index, and mean arterial pressure assessed by SphygmoCor XCEL. Body composition measures included body fat percentage, skeletal muscle mass, and visceral adipose tissue, while anthropometric measures included body mass index and waist circumference. Physical activity was self-reported using the International Physical Activity Questionnaire. Multiple linear regression analyses were used to identify optimal predictors within and across menopausal groups. Results: For both pre- and postmenopausal samples, multiple linear regression showed that visceral adipose tissue positively predicted carotid-femoral pulse wave velocity (p<0.001). Skeletal muscle mass positively predicted central augmentation index (p=0.029), while body fat percentage (p=0.020) was inversely related to central augmentation index (p=0.020). There were no predictors of mean arterial pressure. In premenopausal women, visceral adipose tissue positively predicted carotid-femoral pulse wave velocity (p=0.013). Furthermore, waist circumference positively predicted central augmentation index (p=0.010), while skeletal muscle mass was inversely related to central augmentation index (p=0.033). In postmenopausal women, visceral adipose tissue was a significant predictor of both carotid-femoral pulse wave velocity (p=0.001) and mean arterial pressure (p=0.022). Physical activity was not predictive in any model. Conclusions: Visceral adipose tissue is considered the strongest predictor of vascular health in both pre- and postmenopausal Asian women. In premenopausal women only, higher waist circumference and lower skeletal muscle mass contributed to vessel stiffness and poor vascular health, highlighting the importance of early identification and preventive strategies before menopause.

Background: Fontan circulation is characterized by the absence of a subpulmonary ventricle with resultant systemic venous hypertension. Despite exercise intolerance being nearly universal in this population, the determinants of exercise capacity in this population are still poorly understood. Research Question: We investigated the prevalence of peripheral impairment and assessed the contribution of peripheral O 2 extraction versus central hemodynamics to peak O 2 consumption (pVO 2 ) post-Fontan palliation. Methods: This single-center retrospective cross-sectional study compared 52 consecutive adults post-Fontan procedure who underwent exercise catheterization to patients with heart failure with preserved ejection fraction (HFpEF) and non-cardiac dyspnea (NCD) at 1:1 ratio. Several previously reported measures for peripheral O 2 extraction were evaluated in the absence of a golden standard. Correlates of pVO 2 were identified by multivariate linear regression analyses using the backward selection method. Results: Patients with Fontan circulation were younger [age 32 (24;36) years] and tended to have a lower body mass index [26 (23; 29) kg/m 2 ] compared to patients with HFpEF [70 (57; 75) years, p<0.001 and 33 (27; 39) kg/m 2 , p<0.001] and NCD [48 (38; 61) years, p<0.001 and 27 (24; 35) kg/m 2 , p=0.08]. Peak heart rate [108 (85;126) vs 108 (95;125) bpm] and indexed stroke volume [46 (39;54) vs 45 (40;53) ml/m 2 ] were similar in the Fontan and HFpEF groups but lower compared to NCD [126 (108;141) bpm, p<0.001 and 51 (45;59) ml/m 2 , p<0.001]. Peak mean pulmonary artery pressures were highest in HFpEF [45 (41;50) mmHg, p<0.001], followed by Fontan and NCD [26 (22;31) vs 23 (19;25) mmHg, p=0.03]. Median peak O 2 extraction post-Fontan was comparable to HFpEF [12 (10;14) vs 11 (10;13) ml/dl, p=0.17] but higher than in NCD [10 (9;12) ml/dl, p<0.001]. It was <14 ml/dl in 73% compared to 94% and 98% of patients with HFpEF and NCD [p<0.001]. O 2 extraction ratio was <70% in 62% compared to 60% in HFpEF and 96% in NCD [p<0.001]. Correlates of pVO 2 post-Fontan were peak O 2 extraction [β 0.5±0.1 per ml/dl; p<0.001], mean pulmonary artery pressures [β -0.2±0.05 per mmHg; p=0.002], heart rate [β 0.03±0.01 per bpm; p=0.01], and systolic arterial blood pressure [β 0.03±0.01 per mmHg; p=0.02]. Conclusion: Impaired O 2 extraction is prevalent amongst adults post-Fontan. Whether exercise can modulate this important determinant of exercise capacity post-Fontan merits further investigation.

Introduction: Metabolic dysregulation is posited to underlie observed links between chronic distress and higher cardiometabolic disease risk. We recently identified a plasma metabolite-based distress score (MDS) related to prevalent depression and associated with increased risk of incident diabetes and cardiovascular disease. This study leverages repeated metabolomics measures in an ongoing cohort of women to assess the longitudinal relationship between depression and MDS. Hypotheses: We hypothesized that (1) depression at baseline is associated with greater increase in MDS over follow-up and (2) more severe distress is associated longitudinally with higher MDS. Methods: This is a secondary analysis with participants drawn from a harmonized data source of nested case-control studies within the Nurses’ Health Study (N=1152). White women with metabolomics data, depression measured by the Mental Health Inventory (MHI-5), and covariate data at baseline (1990) and follow-up (2000) were included. Women who developed major health conditions within two years of blood draws were excluded. To test if baseline depression status (MHI-5 ≤ 52) was associated with changes in the MDS, we performed multiple linear regression analyses (H1). To assess if depression severity (continuous MHI-5 score) was associated with MDS levels longitudinally, we fitted linear mixed models with random individual intercepts (H2). Both analyses adjusted for potential confounders incrementally in nested models: (1) baseline MDS and matching factors, (2) medical covariates, and (3) biobehavioral covariates. Results: At baseline, the average age was 56 (sd = 7), 53 women (4.6%) had severe depression, and mean MDS (scaled to sd = 1) was -0.064, increasing to -0.026 at follow-up. After adjusting for all relevant covariates, severe depression at baseline was associated with larger increases in MDS (β=0.29, 95% CI [0.05, 0.53]). A one-point increase in MHI-5 (i.e., less severe depressive symptoms) was linked to lower MDS levels (-0.004, [-0.007, -0.0004]). Conclusions: We establish novel longitudinal explorations revealing that depression severity is associated with increased MDS. Depression earlier in life could potentially lead to adverse longitudinal changes of metabolic profiles linked to cardiometabolic health over the course of ten years, which may have important implications for screening and managing cardiometabolic health in individuals with psychological distress.

Background: Acute myocardial infarction (AMI) is a leading cause of global morbidity and mortality, with prompt percutaneous coronary intervention (PCI) essential to improve outcomes. Resource constraints and reduced staffing on weekends may lead to delayed care and worse outcomes, termed the “weekend effect.” Limited data exist on this effect specifically in AMI patients undergoing PCI. Research Question: Does weekend admission impact in-hospital outcomes among AMI patients undergoing PCI compared to weekday admission? Methods: Using the 2018–2020 National Inpatient Sample, we identified adult AMI hospitalizations treated with PCI. Admissions were categorized as weekend (Saturday–Sunday) or weekday (Monday–Friday). Multivariable logistic and linear regression analyses assessed associations with outcomes, adjusting for demographics, comorbidities, socioeconomic factors, and hospital-level characteristics. Results: Among 931,555 AMI hospitalizations receiving PCI, 26.7% (n = 249,045) were admitted on weekends. The mean age was 65 years (SD ±13), and 68% were male. The crude in-hospital mortality rates were similar between weekend and weekday admissions (3.4% vs. 3.3%; p = 0.5). However, weekend admissions were associated with significantly longer median stays (3.00 vs. 2.00 days; p < 0.001), higher median charges ($92,098 vs. $89,989; p < 0.001), and a higher proportion of mechanical ventilation use (6.1% vs. 5.7%; p = 0.009). Favorable discharge rates were comparable (88% vs. 88%; p = 0.7). Multivariate analysis showed weekend admission was not significantly associated with increased mortality (OR 1.05; 95% CI 0.99–1.12; p = 0.082) but was linked to higher odds of mechanical ventilation (OR 1.08; 95% CI 1.03–1.13; p < 0.001) and lower odds of favorable discharge (aOR 0.96; 95% CI 0.92–0.99; p = 0.013). Linear regression further showed that weekend admissions were linked to longer stays (β = 0.21 days; 95% CI 0.16–0.25; p < 0.001) and higher charges (β = $2,159; 95% CI $1,002–$3,317; p < 0.001). Conclusion: Weekend admission was not linked to higher mortality but was associated with worse outcomes—more mechanical ventilation, lower favorable discharge, longer stays, and higher costs. These findings highlight the “weekend effect” and the need for consistent, high-quality care throughout the week.

Background: Cardiac fibrosis is a key pathological form of ventricular remodeling that occurs early in heart failure. Myocardial extracellular volume fraction (ECV), measured by cardiac computed tomography (CT), can assess this fibrosis. However, there are few specific biomarkers for cardiac fibrosis. SVEP1 (Sushi, von Willebrand factor type A, EGF, and pentraxin domain containing 1) has been implicated in cancer-associated fibroblast activity, but its role in cardiac fibrosis is unclear. Hypothesis: We hypothesized that circulating levels of SVEP1 are positively associated with myocardial ECV measured by cardiac CT, reflecting its potential role as a novel biomarker for cardiac fibrosis. Methods: We retrospectively enrolled 72 consecutive patients (age: 83.7±4.1 years; 45% women) with chronic heart failure due to severe aortic stenosis who underwent preprocedural CT for transcatheter aortic valve replacement planning. ECV was measured using iodine density images obtained by delayed enhancement dual-energy CT, and patients were stratified into high and low ECV groups based on the median ECV value. SVEP1 levels were measured and compared with brain natriuretic peptide (BNP), echocardiographic parameters, and ECV. Multivariable linear regression was used to assess the independent association of SVEP1 with ECV. We also conducted in vitro experiments using human cardiac fibroblasts to explore SVEP1 expression and function. Results: SVEP1 showed a significant positive correlation with ECV (R=0.41, p<0.01), which was stronger than that of BNP (R=0.26, p=0.03). Receiver operating characteristic (ROC) analysis demonstrated that SVEP1 had superior diagnostic performance compared to BNP (AUC: 0.71, 95% CI: 0.59–0.83 vs. AUC: 0.68, 95% CI: 0.42–0.69; p=0.06). In a multivariable linear regression analysis, SVEP1 levels were significantly associated with ECV after adjusting for age, sex, hypertension, atrial fibrillation, and chronic kidney disease. Higher SVEP1 was independently correlated with increased ECV (β=0.0079, p<0.001). In vitro experiments showed that SVEP1 expression was upregulated in activated human cardiac fibroblasts, and its inhibition suppressed fibroblast activation including cell proliferation. Conclusions: SVEP1 is significantly associated with cardiac fibrosis and may serve as a novel and specific biomarker. Its functional role in fibroblast activation highlights its potential not only as a biomarker but also as a therapeutic target in heart failure.

Background: Emerging evidence suggests that air pollution is a significant but under recognized contributor to cardiovascular disease (CVD) mortality, even in middle age adults. This study evaluates the association between long term statewise air quality, as measured by median Air Quality Index (AQI) and cardiovascular mortality rates among adults aged 35–44 years across the United States over a 25-year period. Methods: We linked annual statewise median AQI data from EPA AQS (2000–2024) with CDC WONDER mortality records for non-infectious CVD in the 35–44 age group. States were ranked by mean AQI to define “Highest 10” and “Lowest 10” AQI cohorts. Mean annual cardiovascular crude death rates were compared between these groups using t-tests, and trends were visualized year-by-year. Correlation and linear regression analyses assessed the association between AQI and mortality across all state years as well. Results: States with the highest long-term AQI (poor air quality) had significantly higher mean cardiovascular mortality rates (mean 46.99 per 100,000) than states with the lowest AQI (good air quality) (mean 30.35 per 100,000; p = 0.01). Yearwise analysis showed a persistent gap in mortality rates with the highest AQI states consistently exhibiting greater CVD mortality across the study period. Linear regression confirmed a significant positive association between AQI and mortality (slope = 0.62, p < 0.001), although AQI alone explained only a modest portion of the variation (R 2 = 0.095). Conclusions: Higher long term air pollution exposure, as measured by AQI, is associated with increased cardiovascular mortality among U.S. adults aged 35–44 years. This relationship is robust at the extremes of air quality and persists over time. This highlights the need for public health policies to improve air quality as a means to reduce early onset CVD mortality. Further studies should explore mechanisms and policy interventions to mitigate this risk.

Background: We investigated the prognostic value of two-dimensional speckle tracking echocardiography (2D-STE) detected left ventricular (LV) diastolic function (global peak early diastolic strain rate, LV-GSRe) in patients with pre-capillary pulmonary hypertension. Methods: Sixty-five pre-capillary PH patients were consecutively enrolled in our study, among which, 4 patients were lost to follow-up, and finally 61 patients were included. (22 males and 39 females, 36±13 years). Conventional echocardiography and 2D-STE were performed in all participants. Medical records were reviewed to obtain clinical data. Patients underwent follow-up assessments through structured clinic visits or standardized telephone interviews. The primary endpoint was all-cause mortality. Results: Linear regression analyses showed a significant but weak correlation between LV-GSRe and Peak oxygen consumption (r =0.509, P＜0.001), and N-terminal pro-brain natriuretic peptide (r=-0.526, P＜0.001). In addition, LV-GSRe significantly correlated with conventional echocardiographic RV parameters: peak early diastolic velocity of trans-tricuspid flow/early diastolic velocities (E/E’, r=-0.395, P=0.002 ), tricuspid annular plane systolic excursion (TAPSE, r=0.399, P=0.002), peak systolic velocities (S’, r=-0.44, P＜0.001) and fractional area change (FAC, r=-0.469, P＜0.001). During a median follow-up of 24.2 months [IQR 15.8-30.1], 6 deaths were recorded (9.83%). Receiver-operator characteristic curve showed LV-GSRe had the potential to predict all-cause mortality in pre-capillary PH patients (area under the curve=0.689, P=0.02). Optimal cut-offs found LV-GSRe＞1.06s -1 had a 80.8% sensibility and 62.3% specificity to predict all-cause mortality. Conclusions: 2D-STE detected LV-GSRe significantly correlated with clinical data and RV function, and had the potential to predict prognosis in pre-capillary PH patients.

To evaluate the post-traumatic change and chronic disease self-management in individuals with chronic illness who experienced the earthquake and determine the relationship between these dimensions. The earthquake, the disaster of the century, had a traumatic effect on all individuals, especially those with chronic diseases. This descriptive, correlational study included 463 individuals with a chronic disease diagnosed at least 1 year before the earthquake. Data were collected between March and July 2024, using a Personal Information Form, the Post-Trauma Change Scale (PTCS), and the Chronic Illness Self-Management Scale (CISMS). Mann-Whitney U test, Pearson correlation, and multivariate linear regression analyses were used in the analyses. The STROBE checklist was used. A negative correlation was determined between PTCS and the CISMS subscales of Self-Stigma and Treatment Adherence. A positive correlation was determined between PTCS and the CISMS subscales of Coping with Self-Stigma and Healthcare Efficacy. The CISMS subscale of Self-Stigma explained 9% of the PTCS Self-Confidence, Awareness, and Social Adaptability subscale total points. The CISMS subscale of Coping with Stigma explained 13% of the PTCS Self-Confidence and Awareness subscale total points. The Healthcare Efficacy subscale of the CISMS explained 13% of the PTCS Self-Confidence subscale total points. The CISMS Treatment Adherence subscale explained 4% of the PTCS Awareness subscale. The study results demonstrated that there was a neutral change in levels after the trauma, and chronic disease self-management was insufficient in the study participants. A negative correlation was determined between the PTCS and the CISMS subscales of Self-Stigma and Treatment Adherence. A positive correlation was determined between the PTCS and the CISMS subscales of Coping with Stigma and Healthcare Efficacy. According to our results, increasing self-confidence, awareness, and social adaptability will enable patients to achieve control of the traumatic event and chronic disease self-management in the long term. In traumatic events such as earthquakes, nurses should take an active role in the care, education, and guidance of individuals with chronic diseases who are in the vulnerable group. In addition, emergency health action plans should be determined in detail by health policy makers for individuals with chronic diseases, especially in risky regions.

Abstract Background Among patients diagnosed with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), several factors have been associated with hepatic fibrosis, including exposure to methotrexate (MTX) and metabolic syndrome. In this study, we compared the prevalence of hepatic fibrosis in RA and PsA patients who had been taking MTX, and explored factors associated with hepatic fibrosis in these patients. Methods Patients with RA or PsA who were treated with MTX and managed at the rheumatology clinic, Thammasat University Hospital, between November 2022 and December 2023 were included. Hepatic fibrosis was detected using transient elastography (TE). The prevalence of hepatic fibrosis was compared between the RA and PsA patients. Multivariable linear regression analysis was performed to determine the factors associated with hepatic fibrosis, with emphasis on metabolic syndrome and cumulative methotrexate dose. Results Among the 295 recruited patients, 185 (62.7%) were diagnosed with RA and 110 (37.2%) with PsA. Hepatic fibrosis detected by TE was found in 28.6% of RA patients and 45.5% of PsA patients, respectively. Higher prevalence of metabolic syndrome was observed in the PsA subgroup than that in RA subgroup. The linear regression analysis identified the association between hepatic fibrosis and metabolic syndrome (regression coefficient: 4.127; 95% confidence interval: 3.389 to 4.864; p < 0.001). Notably, cumulative MTX dose and MTX dose per body weight were not associated with hepatic fibrosis in the current analysis. Conclusions Patients with PsA have a higher prevalence of metabolic syndrome and hepatic fibrosis than those with RA. Metabolic syndrome is associated with hepatic fibrosis, even after adjusting for MTX exposure and types of inflammatory arthritis.

Which polycystic ovary syndrome (PCOS)-related and general patient characteristics are associated with higher levels of anxiety and depressive symptoms, as well as with reduced body appreciation in women with PCOS? Anxiety was more common among participants with alopecia, obesity, younger age, and a history of anxiety or depression; depression was more common in participants with alopecia, unemployment, and a history of depression; and body appreciation scores were lower in participants with hirsutism, acne, alopecia, obesity, younger age, and a history of anxiety or depression. Women diagnosed with PCOS face over 30% likelihood of clinically relevant anxiety symptoms, over a 15% likelihood of clinically relevant depressive symptoms, and also experience reduced body appreciation. Evidence suggests that in women with PCOS, various factors may contribute to increased levels of anxiety and depression and reduced body appreciation. However, findings across studies are inconsistent, and the nature of these associations, as well as the potential influence of patient characteristics that have been less studied, are still not well understood. A cross-sectional online survey study was carried out from May 2021 to July 2023. Recruitment occurred through fertility clinics in the Netherlands, employing posters, leaflets with QR codes, and online platforms run by patient organizations. The participants were women with self-reported PCOS. They completed the Hospital Anxiety and Depression Scale (HADS) and the Body Appreciation Scale-2 (BAS-2). We assessed the association with mental health outcomes (symptoms of anxiety and depression, as well as body appreciation) with PCOS-related patient characteristics (hirsutism, acne, alopecia, obesity, and oligomenorrhea) and general characteristics (age, employment status, medical history, and medication use). Multivariable logistic and linear regression analyses were used, and adjusted odds ratios (aORs) or adjusted mean differences (aMDs) with 95% CI were calculated. We included 982 women, with 37.0% showing clinically relevant symptoms of anxiety (score ≥11) and 17.4% showing clinically relevant depressive symptoms (score ≥11). Risk factors associated with anxiety symptoms were alopecia (aOR: 1.79, 95% CI 1.35-2.38), obesity (aOR: 1.40, 95% CI 1.03-1.90), younger age (aOR per year older: 0.93, 95% CI: 0.91-0.96), and medical history of anxiety or depression (aOR: 2.63, 95% CI 1.82-3.79 and aOR: 1.60, 95% CI 1.13-2.28). Risk factors associated with symptoms of depression were alopecia (aOR: 1.74, 95% CI 1.21-2.50), unemployment (aOR: 2.59, 95% CI 1.56-4.31), and a medical history of depression (aOR: 1.89, 95% CI 1.25-2.85). Risk factors associated with reduced body appreciation were hirsutism (aMD: -2.29, 95% CI -3.41 to -1.16), acne (aMD: -1.14, 95% CI -2.11 to -0.17), alopecia (aMD: -1.93, 95% CI -2.89 to -0.97), obesity (aMD: -6.31, 95% CI -7.36 to -5.27), oligomenorrhea (aMD: -1.81, 95% CI -2.78 to -0.83), and younger age (aMD per year older: 0.13, 95% CI 0.04-0.23). A medical history of anxiety or depression disorder was also associated with reduced body appreciation (aMD: -1.80, 95% CI -3.10 to -0.50; aMD: -2.81, 95% CI -4.05 to -1.57, respectively). Results are based on self-reported PCOS diagnoses and may have been affected by sampling bias. It is crucial for healthcare providers to understand which characteristics in women with PCOS may influence the development of anxiety, depression, or reduced body appreciation. Such awareness helps them to be more alert and better recognize the different types of mental health concerns, enabling referrals and more targeted mental health support. This study was not funded by a specific grant. No conflicts of interest were reported in relation to the current research. Not applicable.

Abstract Objective: This study aimed to assess medical students’ environmental sensitivity and climate change awareness and to identify the factors influencing these outcomes.
Materials and Methods: A cross-sectional study was conducted between March and April 2025 among 313 medical students at a university in the Western Black Sea region of Turkey. Data were collected via an online questionnaire including 16 socio-demographic items, the Environmental Sensitivity Scale, and the Climate Change Awareness Scale. Ethical and institutional approvals were obtained prior to data collection. Statistical analyses included descriptive statistics, Student’s t-test, one-way ANOVA, Kruskal–Wallis test, Pearson correlation, and multiple linear regression analysis. Significance was set at p < 0.05.
Results: Female students scored significantly higher than males in awareness sub-dimensions (t-test, p < 0.05). Students in later academic years showed higher concern and knowledge compared with first-year students (ANOVA, p < 0.05). Students whose income exceeded their expenses reported higher knowledge of climate change causes (ANOVA, p < 0.05). Those living in apartments had lower awareness scores compared with peers in other housing types (Kruskal–Wallis, p < 0.05). Participation in environmental activities and perceiving climate change as relevant to medical education were strong positive predictors of awareness (multiple linear regression, p < 0.001). Conversely, environmental sensitivity scores were negatively associated with several awareness sub-dimensions.
Conclusion: Medical students’ climate change awareness is shaped by socio-demographic and individual factors. Active participation in environmental activities and perceiving climate change as relevant to medicine enhanced awareness, while environmental sensitivity exerted significant predictive effects. These findings support the integration of applied climate and environmental health modules into medical curricula and the promotion of student-centered sustainability initiatives.

We examined whether trajectories of urine albumin-creatinine ratio (UACR) over 5- and 10-year periods were associated with subclinical and clinical heart failure (HF), heart failure subtypes, atrial fibrillation (AF), and coronary heart disease (CHD). We modelled 5-year UACR trajectories in 5,581 participants (mean age 61.7 years) from the Multi-Ethnic Study of Atherosclerosis using latent class mixed modelling across baseline, Exam 2, and Exam 3 (2000-2005). A separate sample of 4,343 participants with UACR measured at baseline, Exam 5, and at least one intermediate exam (2000-2012) was used for 10-year trajectory modelling. Cox proportional hazards models were used to assess associations between UACR trajectories and clinical endpoints. Linear regression analyses examined associations between UACR trajectories and N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hs-TnT), as well as myocardial fibrosis assessed by cardiac MRI T1 mapping. Three distinct trajectory groups were identified for each time window. In the 5-year model, the "sustained medium to high" group, and in the 10-year model, the "rapid rise" group (each ∼8%) had 1.5- to 3.7-fold higher risks of HF, HF subtypes, composite of HF/death, AF, and CHD. Most of these associations were independent of baseline UACR levels and remained significant even among individuals with normoalbuminuria at baseline. After censoring for interim AF or CHD, associations persisted for HF and HFpEF, but not HFrEF. These groups also exhibited elevated NT-proBNP, hs-TnT, native T1, and extracellular volume fraction. Progressive UACR increases identify individuals at elevated cardiovascular risk, particularly for HF.

This study involved 44 employees at MI Plus Fatahillah Ciledug, Tangerang City, and employed a quantitative approach using multiple linear regression analysis, the coefficient of determination test (R²), partial test (t), and simultaneous test (F) with SPSS version 25. The analysis resulted in the regression equation Y = 3.299 + 0.297X1 + 0.326X2 + 0.339X3. The Adjusted R² value of 0.714 indicates that 71.4% of employee performance is explained by leadership style, compensation, and work environment, while the remaining 28.6% is influenced by other factors. The t-test results show that all three variables have a significant partial effect on employee performance, with significance values below 0.05. Leadership style, compensation, and work environment each have a positive effect. The F-test shows an F count of 36.751 > F table of 2.84 with a significance of 0.000, indicating that the three variables simultaneously have a significant effect on employee performance.

Academic success in rigorous agricultural science courses like animal nutrition may be influenced by various student factors including demographics, preparedness behaviors, prior academic achievement, and proximity to agriculture. This study examined 1,097 students across four semesters of an animal nutrition course at a large land-grant university to identify predictors of academic performance. Using descriptive statistics and multiple linear regression analyses, our study found that prior academic success was the strongest predictor of student performance. Preparedness behaviors and certain demographic variables also demonstrated statistically significant relationships. However, agricultural proximity was the least predictive factor. Our findings highlight the importance of academic preparedness over background exposure and offer insights into improving student support strategies in agricultural education.