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\"Imagine waking up to the gentle noises of the city, and moving through your day with complete confidence that you will get where you need to go quickly and efficiently. Soft City is about ease and comfort, where density has a human dimension, adapting to our ever-changing needs, nurturing relationships, and accommodating the pleasures of everyday life. How do we move from the current reality in most cites-separated uses and lengthy commutes in single-occupancy vehicles that drain human, environmental, and community resources-to support a soft city approach? In Soft City David Sim, partner and creative director at Gehl, shows how this is possible, presenting ideas and graphic examples from around the globe. He draws from his vast design experience to make a case for a dense and diverse built environment at a human scale, which he presents through a series of observations of older and newer places, and a range of simple built phenomena, some traditional and some totally new inventions. Sim shows that increasing density is not enough. The soft city must consider the organization and layout of the built environment for more fluid movement and comfort, a diversity of building types, and thoughtful design to ensure a sustainable urban environment and society. Soft City begins with the big ideas of happiness and quality of life, and then shows how they are tied to the way we live. The heart of the book is highly visual and shows the building blocks for neighborhoods: building types and their organization and orientation; how we can get along as we get around a city; and living with the weather. As every citizen deals with the reality of a changing climate, Soft City explores how the built environment can adapt and respond. Soft City offers inspiration, ideas, and guidance for anyone interested in city building. Sim shows how to make any city more efficient, more livable, and better connected to the environment\"-- Publisher's website.

Aims Frailty increases healthcare utilization and costs for patients with heart failure but is challenging to assess in clinical settings. Hand grip strength (GS) is a single‐item measure of frailty yet lacks evidence as a potential screening tool to identify patients at risk of higher unplanned events and related healthcare costs. We examined the association of baseline and longitudinal GS measurements with healthcare utilization and costs among patients with advanced heart failure. Methods and results Between July 2017 and April 2019, we enrolled 251 patients with symptoms of advanced heart failure (New York Heart Association class III or IV) in a prospective cohort study in Singapore. We measured GS at baseline and every 4 months for 2 years and linked patients' survey data with their medical and billing records. We categorized patients as having weak GS if their GS measurement was below the 5th percentile of the age‐ and gender‐specific normative GS values in Singapore. We assessed the association between baseline GS and healthcare utilization (unplanned and planned events and healthcare costs, total costs, and length of inpatient stay) over the next 2 years using regression models. We investigated the association between longitudinal 4‐monthly GS assessments and the ensuing 4 months of healthcare utilization and costs using mixed‐effects logistic and two‐part regression models. At baseline, 22.5% of patients had weak GS. Baseline and longitudinal GS measurements were significantly associated with longer length of inpatient stay, greater likelihood of unplanned events, and higher related costs. Patients with weak GS had higher odds of an unplanned event occurring by 8 percentage points [95% confidence interval (CI) (0.01, 0.14), P = 0.026], incurred longer inpatient stays by 4 days [95% CI (1.97, 6.79), P = 0.003], and additional SG $ 4792 [US$  ~ 3594, 95% CI (1894, 7689), P = 0.014] in unplanned healthcare costs over the next 4 months. Conclusions GS is a simple tool to identify and monitor heart failure patients at risk of unplanned events, longer inpatient stays, and higher related healthcare costs. Findings support its routine use in clinical settings.

ObjectivesTo describe prescription patterns, dosing and persistence of guideline-directed medical therapy (GDMT) among patients with heart failure with reduced ejection fraction in Singapore, and to identify factors associated with the use of quadruple therapy (ACE inhibitor (ACEi)/angiotensin II receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI), β-blocker, mineralocorticoid receptor antagonist (MRA) and sodium-glucose cotransporter-2 (SGLT2) inhibitor).DesignRetrospective, observational cohort study.SettingSecondary and tertiary care settings across seven public hospitals in Singapore.Participants3999 adults hospitalised from 2020 to 2022 with a first heart failure-related admission and left ventricular ejection fraction ≤40%. Patients with absolute contraindications to specific GDMT classes were excluded from eligibility calculations.Primary and secondary outcome measuresPrimary outcomes were the proportions of eligible patients prescribed each GDMT class and quadruple therapy at discharge. Secondary outcomes were 6-month prescription patterns, dose attainment and predictors of quadruple therapy use.ResultsAmong eligible patients, 80%–99% met criteria for each GDMT drug class, yet only 29% received quadruple therapy at discharge in 2022. Prescription rates for ACEi/ARB/ARNI (67%), beta-blockers (89%), MRAs (40%), and SGLT2 inhibitors (46%) remained suboptimal despite high eligibility. At discharge, over 90% of patients on ACEi/ARB/ARNI and beta-blockers received ≤50% of target doses. By 6 months, prescription rates declined by 16% for ACEi/ARB/ARNI, 26% for beta-blockers and 7% for MRAs, while SGLT2 inhibitor use increased. Older age (OR 0.97, 95% CI 0.96 to 0.98) and chronic kidney disease stage 3a–4 (OR 0.65 to 0.04) were associated with lower odds of receiving quadruple therapy, while significant institutional variation was observed.ConclusionsDespite high eligibility, uptake and optimisation of GDMT remain poor in Singapore, with substantial treatment gaps driven by underprescription, inadequate dosing and discontinuation. Interventions targeting clinician awareness, postdischarge support and institutional practice variation may improve adherence to guideline-recommended therapy.

What you need to know Aural microsuction is commonly performed to remove impacted wax, discharge, or foreign bodies where other measures have failed The procedure can cause discomfort, pain, or dizziness, but less so than aural syringing Following water precautions and avoiding the use of cotton buds can prevent recurrence of wax impaction and the requirement for further microsuction A 48 year old man is referred to an ear, nose, and throat (ENT) clinic. Impaction of the ear with discharge, debris, wax, or a foreign body can often result in discomfort, pain, ringing in the ear, and hearing impairment, and is a common reason for presentation to primary care services. If the suctioning tip becomes blocked it might be taken out of the ear canal, unblocked, and then re-inserted During the procedure, the operator might need to re-position the head The patient might experience discomfort, pain, and dizziness during the procedure The patient can ask for a pause in the procedure at any time, for example if they find it uncomfortable It is difficult to estimate the likelihood of side effects, as the incidences of these have not been sufficiently reported in literature. Another questionnaire based observational study 4 reported the following average scores (out of 10, with 10 being the most severe) for common side effects across a cohort of 159 patients: 2.34 for pain 3.03 for noise discomfort 1.95 for dizziness. An observational study showed no statistically significant change in hearing levels, as measured by damage, or permanent...

Aims Cardiorenal syndrome (CRS) is a common problem of great morbidity and mortality. Hydralazine–isosorbide dinitrate (H‐ISDN) may be used in renal failure and may improve exercise capacity in heart failure (HF). Our proof‐of‐concept study aimed to evaluate early evidence of efficacy, safety, and feasibility of H‐ISDN compared with standard of care in CRS. Methods and results This multi‐centre, single‐blind, randomized trial in Singapore enrolled CRS patients, defined as chronic HF with concomitant renal failure [estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2]. The primary outcome was 6 min walk test (6MWT) distance measured at 6 months. Secondary outcomes included study feasibility; efficacy outcomes which included renal, cardiac, and endothelial functions, health‐related quality of life using Short Form‐36, clinical outcomes; and adverse events. Forty‐four patients [71 ± 10 years; 75% male; median (inter‐quartile range) N‐terminal prohormone brain natriuretic peptide 1346 (481–2272) pg/mL] with CRS (left ventricular ejection fraction 42 ± 12% and eGFR 46 ± 15 ml/min/1.73 m2) were randomized into two equal groups. Of these, 39 (89%) had hypertension, 27 (61%) had diabetes mellitus, and 17 (39%) had atrial fibrillation. Six (27%) discontinued H‐ISDN owing to intolerance and poor compliance. There was a trend towards improved 6MWT distance with H‐ISDN compared with standard of care at 6 months (mean difference 27 m; 95% CI, −12 to 66), with little differences in secondary efficacy outcomes. Giddiness and hypotension occurred more frequently with H‐ISDN, but HF hospitalizations and mortality were less. Conclusions Our pilot study does not support the addition of H‐ISDN on top of standard medical therapy to improve exercise capacity in patients with CRS.

The series Beihefte zur Zeitschrift für die neutestamentliche Wissenschaft (BZNW) is one of the oldest and most highly regarded international scholarly book series in the field of New Testament studies. Since 1923 it has been a forum for seminal works focusing on Early Christianity and related fields. The series is grounded in a historical-critical approach and also explores new methodological approaches that advance our understanding of the New Testament and its world.

In the mid-nineteenth century the Irish question-the governance of the island of Ireland-demanded attention on both sides of the Atlantic. InA Union Forever, David Sim examines how Irish nationalists and their American sympathizers attempted to convince legislators and statesmen to use the burgeoning global influence of the United States to achieve Irish independence. Simultaneously, he tracks how American politicians used the Irish question as means of furthering their own diplomatic and political ends. Combining an innovative transnational methodology with attention to the complexities of American statecraft, Sim rewrites the diplomatic history of this neglected topic. He considers the impact that nonstate actors had on formal affairs between the United States and Britain, finding that not only did Irish nationalists fail to involve the United States in their cause but actually fostered an Anglo-American rapprochement in the final third of the nineteenth century. Their failures led them to seek out new means of promoting Irish self-determination, including an altogether more radical, revolutionary strategy that would alter the course of Irish and British history over the next century.

Background Left atrial (LA) and ventricular (LV) functional impairment often co-exist in patients with heart failure (HF). However, some patients with HF have a disproportionate LA or LV dysfunction. We aimed to characterize patients with predominant LA and LV myopathy in a cohort of patients with chronic HF across the spectrum of LV ejection fraction (LVEF). Methods From a nationwide, prospective, multi-center, observational HF cohort, transthoracic echocardiographic examination was performed on each patient. LA reservoir strain and LV global longitudinal strain (LVGLS) were measured using dedicated software of the two-dimensional speckle tracking analysis to evaluate LA and LV function and to define the myopathy. Results A total of 374 patients with chronic HF (mean age 58.9±11.5 years, 20% female, mean LVEF 39±17%) were included. By calculating the residuals from the linear regression between LA reservoir and LVGLS, we identified 47 patients with predominant LA myopathy, 271 patients with balanced LA/LV and 56 patients with predominant LV myopathy. Patients with predominant LA myopathy were older, had a higher prevalence of atrial fibrillation (AF), diabetes, higher plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP), Growth differential factor 15(GDF15), high sensitivity Troponin T (hs-TNT) as well as more dilated left and right atria, and worse right atrial function compared to other groups (all p -values < 0.05). Using multivariable logistic regression adjusted for LVEF and LA size, independent predictors of predominant LA myopathy were the presence of AF, diabetes, and higher GDF15, whereas absence of diabetes independently predicted predominant LV myopathy. Patients with predominant LA myopathy group had a lower probability of survival than the other groups (Log rank p -value = 0.01). Conclusion While most patients with HF have balanced LA/LV myopathy, those with predominant LA myopathy are characterized by older age, more AF, more diabetes, higher circulating biomarkers of cardiac stress and injury, and worse outcomes.

Imagine waking up to the gentle noises of the city, and moving through your day with complete confidence that you will get where you need to go quickly and efficiently. Soft City is about ease and comfort, where density has a human dimension, adapting to our ever-changing needs, nurturing relationships, and accommodating the pleasures of everyday life. How do we move from the current reality in most cites—separated uses and lengthy commutes in single-occupancy vehicles that drain human, environmental, and community resources—to support a soft city approach? In Soft City David Sim, partner and creative director at Gehl, shows how this is possible, presenting ideas and graphic examples from around the globe. He draws from his vast design experience to make a case for a dense and diverse built environment at a human scale, which he presents through a series of observations of older and newer places, and a range of simple built phenomena, some traditional and some totally new inventions. Sim shows that increasing density is not enough. The soft city must consider the organization and layout of the built environment for more fluid movement and comfort, a diversity of building types, and thoughtful design to ensure a sustainable urban environment and society. Soft City begins with the big ideas of happiness and quality of life, and then shows how they are tied to the way we live. The heart of the book is highly visual and shows the building blocks for neighborhoods: building types and their organization and orientation; how we can get along as we get around a city; and living with the weather. As every citizen deals with the reality of a changing climate, Soft City explores how the built environment can adapt and respond. Soft City offers inspiration, ideas, and guidance for anyone interested in city building. Sim shows how to make any city more efficient, more livable, and better connected to the environment.

Aims The importance of iron deficiency (ID) in heart failure with preserved ejection fraction (HFpEF) is unknown. In HF with reduced ejection fraction (HFrEF), ID is reported as an independent predictor of mortality in HF although not all published studies agree. Different definitions of ID have been assessed, and the natural history of untreated ID not established, which may explain the conflicting results. This study aimed to assess the relationship between ID and mortality in HFpEF, clarify which definition of ID correlates best with outcomes in HFrEF, and determine the prognostic importance of change in ID status over time. Methods and results Analyses were conducted on data from 1563 patients participating in a prospective international cohort study comparing HFpEF with HFrEF. Plasma samples from baseline and 6 month visits were analysed for the presence of ID. Two ID definitions were evaluated: IDFerritin = ‘ferritin < 100 mcg/L or ferritin 100–300 mcg/L + transferrin saturation < 20%’ and IDTsat = ‘transferrin saturation < 20%’. The risk of all‐cause mortality and death/HF hospitalization associated with baseline ID (IDFerritin or IDTsat) and change in ID status at 6 months (persistent, resolving, developing, or never present) was estimated in multivariable Cox proportional hazards models. Of 1563 patients, 1115 (71%) had HFrEF and 448 (29%) HFpEF. Prevalence of ID was similar in HFpEF and HFrEF (58%). Patients with ID were more likely to be female, diabetic, and have a higher co‐morbid burden than patients without ID. ID by either definition did not confer independent risk for either all‐cause mortality or death/HF hospitalization for patients with HFpEF [IDFerritin hazard ratio (HR) 0.65 (95% confidence interval 0.40–1.05), P = 0.08; IDTsat HR 1.16 (0.72–1.87), P = 0.55]. In the overall study cohort (HFrEF + HFpEF) and HFrEF subgroup, IDFerritin was inferior to IDTsat in prediction of all‐cause mortality [overall cohort: HR 1.21 (0.95–1.53), P = 0.12 vs. HR 1.95 (1.52–2.51), P < 0.01; HFrEF: HR 1.12 (0.85–1.48), P = 0.43 vs. HR 1.57 (1.15–2.14), P < 0.01]. Persistence of IDTsat at 6 months was strongly associated with poor outcomes compared with never having IDTsat [HR 2.22 (1.42–3.46), P < 0.01] or having IDTsat at baseline self‐resolve by 6 months [HR 1.40 (1.06–1.86), P = 0.02]. Conclusions Iron deficiency is equally prevalent in HFpEF and HFrEF but is negatively prognostic only in HFrEF. The natural history of ID is important; persistent ID is strongly associated with mortality whereas resolution is not. IDTsat is the superior definition of ID and should inform future trials investigating the efficacy of intravenous iron replacement in patients with HFrEF.