Evan S. Connell

Evan S. Connell (b. 1924–d. 2013) was born in Kansas City, Missouri, and grew up there in a prosperous family with historical ties—reflected in his middle name, Shelby—to Confederate general Jo Shelby. Although his physician father expected his namesake son to join him in his medical practice, Connell, while at Dartmouth College, began to consider more creative options, including writing and making art. After a three-year stint in the U.S. Navy Air Corps during World War II—he never left the country—Connell began writing down his experiences and finished his undergraduate studies at the University of Kansas. On the Lawrence, Kansas, campus, he studied art and continued to write, under the tutelage of Ray B. West, who edited the Western Review. With aid from the G.I. Bill and encouragement from West, Connell successfully applied to Wallace Stegner’s first class of creative writing fellows at Stanford University. He spent another year in writing and art classes at Columbia University in New York. Ultimately, he saw more of a future in writing, though he kept up a practice of life drawing and painting for many years. Connell had an early run of published short stories, beginning in 1946. After a fallow period in California, Connell went to Paris in 1952, where he became acquainted with the founding editors of The Paris Review. The literary journal published three of Connell’s stories, including segments from Connell’s novel in progress, which eventually was titled Mrs. Bridge. By then, Connell had taken up residence in San Francisco. After rejection by several New York publishers, the Viking Press took on Connell, releasing a story collection in 1957 before cementing Connell’s reputation with Mrs. Bridge, a quietly evocative portrait of a prosperous, middle-American family, which became his most admired and lucrative work of fiction. Over the next five decades Connell veered into an extraordinary variety of works—fiction, nonfiction, history, and hybrid experiments that looked like epic poetry. This pattern of no pattern in the arc of Connell’s work, combined with his lack of interest in self-promotion, seemed to confuse the New York publishing world, and critics often cited his unpredictability as the cause of a kind of literary marginalization. His sprawling account of Custer at the Little Bighorn became hugely popular in the 1980s, raising his profile and reviving his reputation as a writer.

Climate Change Anxiety Focus Groups: Executive Summary

During the year 2020, we were considering the problem of climate change anxiety in the Lawrence, Kansas, and Kansas City metro areas. In September of 2020, we partnered to conduct focus groups with environmentally engaged participants to understand their experience of climate change anxiety. We conducted 14 semi-structured focus groups with 46 community members to understand their emotions, behaviors, and perceptions of community in light of the climate crisis. We asked participants, many of whom were local environmental activists, to engage in a group discussion via Zoom videoconference which lasted between 60 and 90 minutes. After the discussion, we sent participants a brief survey. This executive summary is a preliminary report of the findings of that investigation. We present charts detailing participants’ responses to the focus group questions, followed by select excerpts from the conversations and some statistical relationships of interest.

Quality of life and disease experience in patients with heart failure with reduced ejection fraction in Spain: a mixed-methods study

ObjectivesTo gather insights on the disease experience of patients with heart failure (HF) with reduced ejection fraction (HFrEF), and assess how patients’ experiences and narratives related to the disease complement data collected through standardised patient-reported outcome measures (PROMs). Also, to explore new ways of evaluating the burden experienced by patients and caregivers.DesignObservational, descriptive, multicentre, cross-sectional, mixed-methods study.SettingSecondary care, patient’s homes.ParticipantsTwenty patients with HFrEF (New York Heart Association (NYHA) classification I–III) aged 38–85 years.MeasuresPROMs EuroQoL 5D-5L (EQ-5D-5L) and Kansas City Cardiomyopathy Questionnaire and patient interview and observation.ResultsA total of 20 patients with HFrEF participated in the study. The patients’ mean (SD) age was 72.5 (11.4) years, 65% were male and were classified inNYHA functional classes I (n=4), II (n=7) and III (n=9). The study showed a strong impact of HF in the patients’ quality of life (QoL) and disease experience, as revealed by the standardised PROMs (EQ-5D-5L global index=0.64 (0.36); Kansas City Cardiomyopathy Questionnaire total symptom score=71.56 (20.55)) and the in-depth interviews. Patients and caregivers often disagreed describing and evaluating perceived QoL, as patients downplayed their limitations and caregivers overemphasised the poor QoL of the patients. Patients related current QoL to distant life experiences or to critical moments in their disease, such as hospitalisations. Anxiety over the disease progression is apparent in both patients and caregivers, suggesting that caregiver-specific tools should be developed.ConclusionsPROMs are an effective way of assessing symptoms over the most recent time period. However, especially in chronic diseases such as HFrEF, PROM scores could be complemented with additional tools to gain a better understanding of the patient’s status. New PROMs designed to evaluate and compare specific points in the life of the patient could be clinically more useful to assess changes in health status.

791 Virtual visits in HF outpatient management during COVID-19-related lockdown

Aims Following the COVID-19 pandemic-related lockdown period in Italy, people have experienced psycho-physical distress. Many hospitals were converted in COVID-19 healthcare places and many specialist outpatient’s services were drastically reduced. Virtual visits may represent a strategy to overcome the lack of HF outpatient’s services, during this period. Our own experience underlines the importance of virtual visits to face the clinical and health status deterioration, associated with COVID-19, in HF outpatients. Methods and results We conducted an observational study, enrolling consecutive HF outpatients, previously hospitalized at the Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences of Sapienza University of Rome, who were discharged within 31 March 2019, and 30 April 2019. Two follow-up periods were scheduled: (i) within 20–30 days after the beginning of lockdown (ii) at 3 months after lockdown’s end. Virtual visits were conducted through telephone, assessing changes in clinical and health status; the latter was assessed through the short version of the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). According to the presence of at least one sign of HF deterioration, patients were divided into two groups: Group 1: patients who experienced a modification in at least one clinical parameter suggestive of HF deterioration. Group 2: patients who do not experienced any modification of HF deterioration clinical parameter. KCCQ-12 mean scores were compared between the two groups, at both scheduled virtual visits, in order to evaluate any change in HF outpatients’ health status, during and after the COVID-19-related-lockdown. 160 HF outpatients have been included in the study: 63 in the group 1, 97 in the group 2. At the first virtual visit, group 1 reported significantly lower mean KCCQ-12 score, compared to group 2 [46.2 (±14.6) vs. 53.8 (±11); CI: 95% 11.6 to − 3.6; P = 0.0003]. At the second virtual visit, group 1 patients reported a slightly, but not statistically significant, lower mean KCCQ-12 score, compared to group 2 [52.2 (± 13.3) vs. 53.1(±14.4); 95% CI: −5.4 to 3.6; P = 0.69]. Comparing the KCCQ-12 mean scores of each group between the two scheduled virtual visits, group 1 reported a statistically significant increase at the second visit, compared to the first [52.2 (±13.3) vs. 46.2 (±14.6); CI: 95% 1.1–11; P = 0.017]. Group 2 showed no statistically significant variation of mean KCCQ-12 score between the two follow-up periods [53.1 (±14.4) vs. 53.8 (±11); CI: 95% −4.3 to 3; P = 0.704]. Conclusions we observed a significant worsening of health status in HF outpatients who have experienced clinical deterioration. Therefore, patients were either hospitalized or received the optimization of diuretic and anti-hypertensive therapies. A significant health status improvement was observed at three months after the end of the lockdown, suggesting the importance of virtual visit as an adequate method to follow-up HF outpatients, reporting particular benefits in those with worsening of HF clinical signs and health status.

Prevalence and characteristics of patients with heart failure needing palliative care

Background Few hospitals and heart failure (HF) clinics offer concurrent palliative care (PC) together with life-prolonging therapies. To know the prevalence of patients in HF clinics needing PC and useful tools to recognize them are the first steps to extending PC in those settings. However, it is still unknown whether tools commonly used to identify patients with HF needing PC can correctly distinguish them. Two systematic reviews found that the NECesidades PALiativas (NECPAL) tool was one of the two most commonly used tools to asses PC needs in HF patients. Therefore, we assessed 1) the prevalence of PC needs in HF clinics according to the NECPAL tool, and 2) the characteristics of the patients identified as having PC; mainly, their quality of life (QoL), symptom burden, and psychosocial problems. Methods This cross-sectional study was conducted at two HF clinics in Colombia. We assessed the prevalence of PC in the overall sample and in subgroups according to clinical and demographic variables. We assessed QoL, symptom burden, and psychosocial problems using the 12-Item Short-Form Health Survey (SF-12), the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Edmonton Symptom Assessment System (ESAS). We compared the results of these tools between patients identified as having PC needs (+NECPAL) and patients identified as not having PC needs (–NECPAL). Results Among the 178 patients, 78 (44%) had PC needs. The prevalence of PC needs was twice as nigh in patients NYHA III/IV as in patients NYHA I/II and almost twice as high in patients older than 70 years as in patients younger than 70 years. Compared to –NECPAL patients, +NECPAL patients had worse QoL, more severe shortness of breath, tiredness, drowsiness, and pain, and more psychosocial problems. Conclusion The prevalence of PC needs in outpatient HF clinics is high and is even higher in older patients and in patients at more advanced NYHA stages. Compared to patients identified as not having PC needs, patients identified as having PC needs have worse QoL, more severe symptoms, and greater psychosocial problems. Including a PC provider in the multidisciplinary team of HF clinics may help to assess and cover these needs.

Planning to maintain the status quo? A comparative study of digital equity plans of four large US cities

The term digital equity is at the forefront of municipal government planning to mitigate digital equity. Digital equity signifies a desired future to be achieved, yet its meaning is not well-established. As such, planning for digital equity offers an opportunity for new discursive construction. This study examines how municipal governments have constructed the concept of digital equity through textual evidence, the digital equity plans of Kansas City, MO, Portland, OR, San Francisco, CA, and Seattle, WA. Adopting an approach from critical discourse studies, comparative analysis of the texts demonstrates how digital equity plans conceive of digital equity, characterize current problematic circumstances, and prescribe actions to make change. The plans have strikingly little to say about why digital inequality has emerged, yet they prescribe actions that indicate a more complex understanding of the problem than they articulate. The dynamics of policy diffusion suggest that the work of early adopters will influence other municipalities to create similar plans. Thus, the current moment is ripe for scholars to influence municipal planning for digital equity and participate in its discursive construction in both academic research and policymaking circles.

Multiplex PCR pathogen detection in acute gastroenteritis among hospitalized US children compared to healthy controls during 2011-2016 in the post rotavirus vaccine era

Background Despite vaccine-induced decreases in US rotavirus (RV) disease, acute gastroenteritis (AGE) remains relatively common. We evaluated AGE pathogen distribution in hospitalized US children in the post-RV-vaccine era. Methods From December 2011 to June 2016, the New Vaccine Surveillance Network (NVSN) conducted prospective, active, population-based surveillance in hospitalized children with AGE. We tested stools from two NVSN sites (Kansas City; Houston) with Luminex x-TAG Gastrointestinal Pathogen Panels (Luminex GPP) and analyzed selected signs and symptoms. Results For 660 pediatric AGE inpatients and 624 age-matched healthy controls (HC), overall organism detection was 51.2% and 20.6% respectively, p <0.001. Among AGE subjects, GPP PCR detected >1 virus in 39% and >1 bacteria in 14% of specimens. Detection frequencies for AGE subjects vs. HC were: norovirus (NoV) 18.5% vs 6.6%, rotavirus (RV) 16.1% vs 9.8%, adenovirus 7.7% vs 1.4%, Shigella 4.8% vs 1.0%, Salmonella 3.1% vs 0.1%, Clostridioides difficile in ≥2-year olds 4.4% vs 2.4%. More co-detections occurred among AGE (37/660, 5.6%) than HC (14/624, 2.2%), p=0.0024. Per logistic regression analysis, ill contacts increased risk for NoV, RV and Shigella, p<0.001. More vomiting episodes occurred with NoV and RV, and more diarrheal episodes with Shigella and Salmonella. Modified Vesikari scores were highest for Shigella and lowest for C. difficile. Conclusion NoV detection was most frequent, however RV remained important in hospitalized AGE in the post-RV-vaccine era. Continued active surveillance is important to document ongoing vaccine effects, pathogen emergence and baseline disease burden for new vaccines.

Impact of Chronic Obstructive Pulmonary Disease in Patients With Heart Failure With Preserved Ejection Fraction: Insights From PARAGON‐HF

Background Little is known about the impact of chronic obstructive pulmonary disease (COPD) in patients with heart failure with preserved ejection fraction (HFpEF). Methods and Results We examined outcomes in patients with heart failure with preserved ejection fraction, according to COPD status, in the PARAGON‐HF (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Global Outcomes in Heart Failure With Preserved Ejection Fraction) trial. The primary outcome was a composite of first and recurrent hospitalizations for heart failure and cardiovascular death. Of 4791 patients, 670 (14%) had COPD. Patients with COPD were more likely to be men (58% versus 47%; P <0.001) and had worse New York Heart Association functional class (class III/IV 24% versus 19%), worse Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores (69 versus 76; P <0.001) and more frequent history of heart failure hospitalization (54% versus 47%; P <0.001). The decrement in Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores with COPD was greater than for other common comorbidities. Patients with COPD had echocardiographic right ventricular enlargement, higher serum creatinine (100 μmol/L versus 96 μmol/L) and neutrophil‐to‐lymphocyte ratio (2.7 versus 2.5), than those without COPD. After multivariable adjustment, COPD was associated with worse outcomes: adjusted rate ratio for the primary outcome 1.51 (95% CI, 1.25–1.83), total heart failure hospitalization 1.54 (95% CI, 1.24–1.90), cardiovascular death (adjusted hazard ratio [HR], 1.42; 95% CI, 1.10–1.82), and all‐cause death (adjusted HR, 1.52; 95% CI, 1.25–1.84). COPD was associated with worse outcomes than other comorbidities and Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores declined more in patients with COPD than in those without. Conclusions Approximately 1 in 7 patients with heart failure with preserved ejection fraction had concomitant COPD, which was associated with greater functional limitation and a higher risk of heart failure hospitalization and death. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01920711 .

Empagliflozin, Health Status, and Quality of Life in Patients with Heart Failure and Preserved Ejection Fraction: The EMPEROR-Preserved Trial

Background: Patients with heart failure and preserved ejection fraction (HFpEF) have significant impairment in health-related quality of life (HRQoL). In EMPEROR-Preserved, we evaluated the efficacy of empagliflozin on HRQoL in patients with HFpEF and whether the clinical benefit observed with empagliflozin varies according to baseline health status. Methods: HRQoL was measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline, 12, 32 and 52 weeks. Patients were divided by baseline KCCQ Clinical Summary Score (CSS) tertiles and the effect of empagliflozin on outcomes were examined. The effect of empagliflozin on KCCQ-CSS, Total Symptom Score (TSS) and Overall Summary Score (OSS) were evaluated. Responder analyses were performed to compare the odds of improvement and deterioration in KCCQ related to treatment with empagliflozin. Results: The effect of empagliflozin on reducing the risk of time to cardiovascular death or HF hospitalization was consistent across baseline KCCQ-CSS tertiles (HR 0.83 [0.69-1.00], HR 0.70 [0.55-0.88] and HR 0.82 [0.62-1.08] for scores <62.5, 62.5-83.3 and ≥83.3, respectively; P trend=0.77). Similar results were seen for total HF hospitalizations. Patients treated with empagliflozin had significant improvement in KCCQ-CSS versus placebo (+1.03, +1.24 and +1.50 at 12, 32 and 52 weeks, respectively P<0.01); similar results were seen for TSS and OSS. At 12 weeks, patients on empagliflozin had higher odds of improvement ≥5 points (OR 1.23; 95%CI 1.10, 1.37), ≥10 points (1.15; 95%CI 1.03, 1.27), and ≥15 points (1.13; 95%CI 1.02, 1.26) and lower odds of deterioration ≥5 points in KCCQ-CSS (0.85; 95%CI 0.75, 0.97). A similar pattern was seen at 32 and 52 weeks, and results were consistent for TSS and OSS. Conclusions: In patients with HFpEF, empagliflozin reduced the risk for major HF outcomes across the range of baseline KCCQ scores. Empagliflozin improved HRQoL, an effect that appeared early and was sustained for at least one year.