Client ghosting, defined as the sudden and unexplained cessation of contact, may be experienced as a relational rupture in psychotherapy. While common in digital communication, its impact on developing therapists within the person-centered approach remains underexplored. This grounded theory study explored the experiences of seven trainee person-centered counselors encountering client ghosting. The analysis revealed a transformative process summarized by the core category: 'Transforming relational rupture into professional growth.' Trainees initially described feeling emotional shock, self-doubt, and questioning of professional competence, following the unexpected termination of contact. Supervision and personal therapy assisted trainees in validating and normalizing their experience. Trainees gradually reframed the experience, shifting the focus from personal failure to understanding ghosting as a manifestation of client avoidance. This reflective process ultimately supported the integration of the ghosting experience into professional growth, reinforcing their resilience and deepening the internalization of the person-centered core conditions, specifically enhancing empathy and affirming unconditional positive regard. The findings highlight that, when processed through reflective practice, client ghosting is not merely client dropout but a powerful developmental milestone that fosters a more mature and compassionate professional identity.
BACKGROUND:Current society guidelines recommend physiological assessment of intermediate coronary lesions to guide revascularization. Data regarding revascularization guided by vessel fractional flow reserve (vFFR), derived from three-dimensional quantitative coronary angiography without the need for a pressure wire or hyperemic agent, as compared with pressure-wire-based fractional flow reserve (FFR), are lacking. METHODS:We conducted an international, open-label, randomized, noninferiority trial at 37 sites in Europe. Patients with intermediate coronary-artery lesions (diameter stenosis of 30 to 80%) who presented with chronic or acute coronary syndromes were randomly assigned in a 1:1 ratio to undergo either vFFR-guided or FFR-guided revascularization of the intermediate coronary-artery lesions. The primary end point was a composite of death from any cause, any myocardial infarction, or any revascularization at 1 year. The noninferiority margin was 3.0 percentage points. RESULTS:The primary end point was assessed in 1116 patients in the vFFR group and 1095 in the FFR group. The mean age of the patients was 67 years, 24.3% were women, 18.7% presented with an acute coronary syndrome, and 26.6% had diabetes mellitus. At 1 year, a primary end-point event had occurred in 80 patients (Kaplan-Meier estimate, 7.5%) in the vFFR group and in 79 patients (Kaplan-Meier estimate, 7.5%) in the FFR group (risk difference, -0.02 percentage points; 95% confidence interval, -2.25 to 2.21; P = 0.004 for noninferiority). The incidence of serious adverse events appeared to be similar in the two groups. CONCLUSIONS:Among patients with intermediate coronary lesions, vFFR-guided revascularization was noninferior to FFR-guided revascularization with respect to a composite of death, myocardial infarction, or revascularization at 1 year. (Funded by Pie Medical Imaging and Siemens Healthineers; FAST III ClinicalTrials.gov number, NCT04931771.).
BACKGROUND:In patients with coronary artery disease, diabetes increases the risk of restenosis and adverse cardiovascular events after percutaneous coronary intervention (PCI). The Abluminus DES+ is a thin-strut cobalt-chromium sirolimus-eluting stent (SES) with abluminal and balloon-surface coating intended to enhance drug delivery to the vessel wall. We aimed to compare the efficacy and safety of the Abluminus DES+ SES versus the XIENCE durable-polymer everolimus-eluting stent (EES) in patients with diabetes undergoing PCI. METHODS:ABILITY Diabetes Global was a multicentre, prospective, open-label, randomised controlled trial conducted at 74 sites in 16 countries. Adults (aged ≥18 years) with type 1 or type 2 diabetes undergoing PCI for at least one de novo coronary lesion due to chronic coronary syndrome or non-ST-elevation acute coronary syndrome were eligible. Patients were randomly assigned (1:1) to the Abluminus DES+ SES or the XIENCE EES. Randomisation was stratified by site using a secure web-based system with concealed allocation and randomly varying block sizes (4, 6, and 8). Operators were unmasked to allocation; staff performing clinical follow-up and the independent clinical events committee were masked. For the Abluminus DES+ SES, a balloon inflation time of at least 45 s was recommended to facilitate drug transfer; dual antiplatelet therapy was prescribed to all patients according to clinical guidelines and local practice. The primary hypothesis of the study was the non-inferiority of the Abluminus DES+ SES compared with the XIENCE EES for the two coprimary endpoints at 12 months (in the per-protocol population): ischaemia-driven target-lesion revascularisation (2·8% non-inferiority margin) and target-lesion failure (3·0% margin), defined as a composite of cardiovascular death, target-vessel myocardial infarction, or ischaemia-driven target-lesion revascularisation. Time-to-event analyses were conducted with Kaplan-Meier estimates and Cox proportional hazards models. This trial is registered with ClinicalTrials.gov (NCT04236609) and is complete. FINDINGS:Between June 12, 2020, and Sept 9, 2022, 3032 patients were randomly assigned to the Abluminus DES+ SES (n=1514) or XIENCE EES (n=1518). 2931 (96·7%) of 3032 patients completed follow-up to death or 24-month follow-up. Median age was 68·0 years (IQR 60-74). 879 (29·0%) of 3032 patients were female and 2153 (71·0%) were male. At 12 months, in the per-protocol analysis, the Abluminus DES+ SES did not meet the criteria for non-inferiority for ischaemia-driven target-lesion revascularisation compared with XIENCE EES (67 of 1421 patients [Kaplan-Meier estimate 4·8%, 95% CI 3·9-6·2] vs 30 of 1446 [2·1%, 95% CI 1·6-3·2]; absolute risk difference 2·7%, 95% CI 1·3-4·1; pnon-inferiority=0·44) and target lesion failure (137 [9·7%, 8·4-11·5] vs 89 [6·2%, 5·3-7·8]; 3·5%, 1·5-5·5; pnon-inferiority=0·68). For both endpoints, the lower bound of the 95% CI for the absolute risk difference excluded zero. Target-vessel myocardial infarction occurred more frequently in the Abluminus DES+ SES group (73 of 1421 patients [Kaplan-Meier estimate 5·2%, 95% CI 4·1-6·5] vs 44 of 1446 patients [3·1%, 2·4-4·3]) but there were no significant differences in cardiovascular death (41 of 1421 patients [2·9%, 2·1-3·9] vs 30 of 1446 patients [2·1%, 1·5-3·0]) and all-cause death (52 of 1421 patients [3·7%, 2·8-4·8] vs 48 of 1446 patients [3·3%, 2·5-4·4]). Results were consistent at 24 months in the intention-to-treat analysis, however no significant differences were observed between the two groups in landmark analyses between 12 and 24 months. INTERPRETATION:In patients with diabetes undergoing PCI, the Abluminus DES+ SES was not non-inferior to the XIENCE EES, resulting in higher rates of ischaemia-driven target-lesion revascularisation and target lesion failure at 12-month follow-up. Event rates between 12 and 24 months were similar between groups. These findings highlight the persistent challenge of optimising outcomes in patients with diabetes and underscore the need for continued innovation in stent design and adjunctive pharmacotherapy to reduce residual ischaemic risk in this population. FUNDING:Concept Medical.
Introduction Although global circumferential strain (stress-GCS) measured during vasodilator stress cardiovascular magnetic resonance (CMR) has incremental prognostic value for prediction of major adverse cardiovascular events (MACE) above traditional stress CMR factors, no study has investigated the optimal cut-off of stress-GCS for MACE. Objective To determine the optimal cut-off point of stress-GCS for predicting MACE in a consecutive cohort of patients with normal stress CMR. Method Between 2017 and 2018, all consecutive patients with normal stress CMR defined by the absence of inducible ischemia and late gadolinium enhancement (LGE) were recruited retrospectively. Stress-GCS was measured using a fully automated machine-learning algorithm based on featured-tracking imaging from short-axis cine images. The primary composite outcome was MACE defined by cardiovascular death or nonfatal myocardial infarction. The survival tree method was used to identify the optimal cut-off for stress-GCS. Results In 1,321 patients (65±12 years, 67% men), 52 (3.9%) experienced a MACE after a median follow-up of 5.1 (4.8–5.4) years. The best cut-off of stress-GCS to predict MACE was −10%. After adjustment for traditional risk factors and stress CMR findings (LVEF), stress-GCS≥−10% was independently associated with MACE (adjusted HR, 12.4 [95% CI, 5.89–26.1], p<0.001, Fig. 1A). The annualized rate of MACE in patients with stress-GCS≥–10% was significantly higher than patients with stress-GCS<−10% (Fig. 1B). An increased stress-GCS≥−10% showed the best improvement in model discrimination and reclassification above traditional and stress CMR findings (C-statistic improvement: 0.14; NRI=0.430; IDI=0.089, all p<0.001; LR-test p<0.001). Conclusion Using the optimal cut-off of stress-GCS, a stress-GCS value≥−10% is independently associated with MACE in patients with normal stress CMR, with an incremental prognostic value over traditional risk factors and stress CMR findings.
Introduction End-stage hypertrophic cardiomyopathy (HCM) is a distinct and advanced form of the disease, defined by a left ventricular ejection fraction (LVEF)<50% and associated with a markedly poor prognosis. Cardiovascular magnetic resonance (CMR) has become a key imaging tool, particularly for assessing myocardial fibrosis through late gadolinium enhancement (LGE), a known prognostic marker in earlier stages of HCM. However, evidence on the prognostic relevance of LGE presence and distribution in end-stage HCM remains limited. Objective To evaluate the prognostic value of the “LGE granularity” concept including its extent, location and pattern in end-stage HCM with LVEF<50%. Method All patients referred for CMR assessment of HCM at three French tertiary centers between 2008 and 2024 were retrospectively screened and all patients with HCM confirmed and a LVEF value<50% were included. The concept of “LGE granularity” was defined as a model combining LGE extent (>3 segments), location (septal), and pattern (subepicardial and/or midwall). The primary endpoint was all-cause mortality, obtained from the French National Death Registry. Univariable and multivariable Cox proportional hazards models were used to assess the prognostic value of LGE features. Results Among 2,875 patients with HCM, 691 (53±7 years, 54% male) had a LVEF<50% and were included in the study. After a median follow-up of 8.5 years (IQR 5.9–11.0), 226 patients died (32%). Using CMR, the presence of LGE was detected in 259 patients (37%) and was strongly associated with mortality ((HR 3.37, 95% CI 2.57–4.42, p<0.001, Figure 1), and remained significant after adjustment for known prognostic factors, including LVEF (HR 1.47, 95% CI 1.01–2.04, p=0.047). Each component of the LGE granularity model were all independently associated with mortality after adjustment: LGE extent (HR 1.70, 95% CI 1.11–2.61), midwall pattern (HR 3.97, 95% CI 1.72–9.14), and septal location (HR 1.77, 95% CI 1.13–2.78, and all p<0.001) (Figure 2a, b and c). Conclusion In a large HCM cohort of end-stage HCM, LGE emerged as a strong and independent predictor of all – cause mortality. Moreover, among LGE – positive patients, the individual components of the “LGE granularity” concept were all associated with adverse prognosis.
