This article assesses the status of hierarchical leisure constraints theory (Crawford & Godbey, 1987; Crawford, Jackson, & Godbey, 1991) regarding many issues. Such issues include clarification and ...elaboration of some aspects of the original model, a review of studies which have used or examined the model and the extent to which they are confirmatory, critiques of the original model by various authors, and avenues for further research. Conclusions drawn include that the model is cross culturally relevant, that the model may examine forms of behavior other than leisure, and that, while research to date has been largely confirmatory, there is a high potential for the theory to be expanded in order to advance leisure constraints research to the next level.
Efficacy of Bio‐Absorbable Antibacterial Envelope
Introduction
Cardiac implantable electronic device (CIED) infections are potentially preventable complications associated with high morbidity, ...mortality, and cost. A recently developed bio‐absorbable antibacterial envelope (TYRX™‐A) might prevent CIED infections in high‐risk subjects. However, data regarding safety and efficacy have not been published.
Methods and Results
In a single‐center retrospective cohort study, we compared the prevalence of CIED infections among subjects with ≥2 risk factors treated with the TYRX™‐A envelope (N = 135), the nonabsorbable TYRX™ envelope (N = 353), and controls who did not receive an envelope (N = 636). Infection was ascertained by individual chart review. The mean (95% confidence interval) number of risk factors was 3.08 (2.84–3.32) for TYRX™‐A, 3.20 (3.07–3.34) for TYRX™, and 3.09 (2.99–3.20) for controls, P = 0.3. After a minimum 300 days follow‐up, the prevalence of CIED infection was 0 (0%) for TYRX™‐A, 1 (0.3%) for TYRX™, and 20 (3.1%) for controls (P = 1 for TYRX™‐A vs. TYRX™, P = 0.03 for TYRX™‐A vs. controls, and P = 0.002 for TYRX™ vs. controls). In a propensity score‐matched cohort of 316 recipients of either envelope and 316 controls, the prevalence of infection was 0 (0%) and 9 (2.8%), respectively, P = 0.004. When limited to 122 TYRX™‐A recipients and 122 propensity‐matched controls, the prevalence of CIED infections was 0 (0%) and 5 (4.1%), respectively, P = 0.024.
Conclusions
Among high‐risk subjects, the TYRX™‐A bio‐absorbable envelope was associated with a very low prevalence of CIED related infections that was comparable to that seen with the nonabsorbable envelope.
Experimental data suggest ryanodine receptor-mediated intracellular calcium leak is a mechanism for atrial fibrillation (AF), but evidence in humans is still needed. Propafenone is composed of two ...enantiomers that are equally potent sodium-channel blockers; however,
)-propafenone is an ryanodine receptor inhibitor whereas
)-propafenone is not. This study tested the hypothesis that ryanodine receptor inhibition with
)-propafenone prevents induction of AF compared to
)-propafenone or placebo in patients referred for AF ablation.
Participants were randomized 4:4:1 to a one-time intravenous dose of
)-propafenone,
)-propafenone, or placebo. The study drug was given at the start of the procedure and an AF induction protocol using rapid atrial pacing was performed before ablation. The primary endpoint was 30 s of AF or atrial flutter.
A total of 193 participants were enrolled and 165 (85%) completed the study protocol (median age: 63 years, 58% male, 95% paroxysmal AF). Sustained AF and/or atrial flutter was induced in 60 participants (84.5%) receiving
)-propafenone, 60 (80.0%) receiving
)-propafenone group, and 12 (63.2%) receiving placebo. Atrial flutter occurred significantly more often in the
)-propafenone (N=23, 32.4%) and
)-propafenone (N=26, 34.7%) groups compared to placebo (N=1, 5.3%,
=0.029). There was no significant difference between
)-propafenone and
)-propafenone for the primary outcome of AF and/or atrial flutter induction in univariable (
=0.522) or multivariable analysis (
=0.199, adjusted for age and serum drug level).
There is no difference in AF inducibility between
)-propafenone and
)-propafenone at clinically relevant concentrations. These results are confounded by a high rate of inducible atrial flutter due to sodium-channel blockade.
https://clinicaltrials.gov; Unique Identifier: NCT02710669.
The prognostic significance of the preoperative electrocardiogram (ECG), particularly intraventricular conduction delays (IVCDs), on postoperative outcomes among patients undergoing noncardiac ...surgery is uncertain. In a retrospective cohort, we evaluated the risk associated with preoperative IVCDs on in-hospital death and postoperative myocardial infarction (POMI). The 152,479 patients who underwent noncardiac surgery were categorized by preoperative electrocardiographic findings: normal (36.1%), left bundle branch block (LBBB, 1.2%), right bundle branch block (2.9%), nonspecific IVCD (3.3%), and any other ECG abnormality (56.5%). The primary and secondary outcomes were postoperative in-hospital mortality and POMI, respectively. In multivariable-adjusted models, compared with normal ECGs, each electrocardiographic abnormality category was associated with increased risk of postoperative death: LBBB odds ratio (OR) 1.89 (95% confidence interval CI 1.35 to 2.65), right bundle branch block OR 1.73 (95% CI 1.33 to 2.24), nonspecific IVCD OR 1.95 (95% CI 1.53 to 2.48), and other abnormal ECG OR 1.94 (95% CI 1.68 to 2.25). ECGs with conduction delays did not confer increased risk of postoperative death compared with other ECG abnormalities. Moreover, receiver operating characteristic analysis of models incorporating demographic and co-morbidity data demonstrated marginal additive benefit of any electrocardiographic data. Risk of POMI was not significantly increased among ECGs with conduction delays compared with both normal and other abnormal ECGs. In conclusion, patients with intraventricular conduction disease, including LBBB, on preoperative ECG are not at greater risk of postoperative in-hospital death or POMI compared with patients with other ECG abnormalities. Furthermore, any preoperative electrocardiographic abnormalities, including intraventricular delays, provide marginal clinical utility beyond demographic and clinical history for predicting postoperative in-hospital death or POMI.
Intimate partner violence (IPV) and psychological distress (PD) are major public health concerns among emerging adult women. Emerging adulthood presents a complex set of new experiences and ...challenges that pose a risk to normative development. In particular, an increased prevalence of IPV and PD during this time period may lead to long-term health consequences.
Data from the Relationship Dynamics and Social Life study, a longitudinal study of a racially and socioeconomically diverse population-representative random sample of 726 partnered women, aged 18-19, residing in a Michigan county, and followed for 2.5 years, were used to investigate the relationship between IPV and PD. Logistic regression models predicted each measure of PD (depression, stress, loneliness, self-esteem) as a function of past IPV (none, psychological violence only, any physical violence), and multinomial logistic regression models predicted subsequent weekly IPV as a function of each measure of PD.
PD and IPV were prevalent among emerging adult women. Past psychological IPV was associated with experiencing all four distress measures. Past physical IPV was also associated with depression, stress, and loneliness, but not self-esteem. Women with each PD were more likely to subsequently experience psychological violence, and women who reported stress were more likely to subsequently experience any physical violence.
The IPV-PD relationship is bidirectional. Women who experienced past IPV were more likely to report PD. Conversely, women who experienced PD were at a greater risk of subsequent IPV.
This study aimed to review the utility of quinidine in patients presenting with recurrent sustained ventricular arrhythmia (VA) and limited antiarrhythmic drug (AAD) options.
Therapeutic options are ...often limited in patients with structural heart disease and recurrent VAs. Quinidine has an established role in rare arrhythmic syndromes, but its potential use in other difficult VAs has not been assessed in the present era.
We performed a retrospective analysis of 37 patients who had in-hospital quinidine initiation after multiple other therapies failed for VA suppression at our tertiary referral center. Clinical data and outcomes were obtained from the medical record.
Of 30 patients with in-hospital quantifiable VA episodes, quinidine reduced acute VA from a median of 3 episodes (interquartile range IQR: 2 to 7.5) to 0 (IQR: 0 to 0.5) during medians of 3 days before and 4 days after quinidine initiation (p < 0.001). VA events decreased from a median of 10.5 episodes per day (IQR: 5 to 15) to 0.5 episodes (IQR: 0 to 4) after quinidine initiation in the 12 patients presenting with electrical storm (p = 0.004). Among the 24 patients discharged on quinidine, 13 (54.2%) had VA recurrence during a median of 138 days. Adverse effects in 9 of the 37 patients (24.3%) led to drug discontinuation, most commonly gastrointestinal intolerance.
In patients with recurrent VAs and structural heart disease who have limited treatment options, quinidine can be useful, particularly as a short-term therapy.
Atrial fibrillation (AF) is a mechanistically heterogeneous disorder, and the ability to identify sub-phenotypes ("endophenotypes") of AF would assist in the delivery of personalized medicine. We ...used the clinical response to pulmonary vein isolation (PVI) to identify a sub-group of patients with non-PV mediated AF and sought to define the clinical associations.
Subjects enrolled in the Vanderbilt AF Ablation Registry who underwent a repeat AF ablation due to arrhythmia recurrence were analyzed on the basis of PV reconnection. Subjects who had no PV reconnection were defined as "non-PV mediated AF". A comparison group of subjects were identified who had AF that was treated with PVI-only and experienced no arrhythmia recurrence >12 months. They were considered a group enriched for "PV-mediated AF". Univariate and multivariable binary logistic regression analysis was performed to investigate clinical associations between the PV and non-PV mediated AF groups.
Two hundred and twenty nine subjects underwent repeat AF ablation and thirty three (14%) had no PV reconnection. They were compared with 91 subjects identified as having PV-mediated AF. Subjects with non-PV mediated AF were older (64 years IQR 60,71 vs. 60 52,67, P = 0.01), more likely to have non-paroxysmal AF (82% N = 27 vs. 35% N = 32, P<0.001), and had a larger left atrium (LA) (4.2cm 3.6,4.8 vs. 4.0 3.3,4.4, P = 0.04). In univariate analysis, age (per decade: OR 1.56 95% CI: 1.04 to 2.33, P = 0.03), LA size (per cm: OR 1.8 1.06 to 3.21, P = 0.03) and non-paroxysmal AF (OR 8.3 3.10 to 22.19, P<0.001) were all significantly associated with non-PV mediated AF. However, in multivariable analysis only non-paroxysmal AF was independently associated with non-PV mediated AF (OR 7.47 95% CI 2.62 to 21.29, P<0.001), when adjusted for age (per decade: OR 1.25 0.81 to 1.94, P = 0.31), male gender (OR 0.48 0.18 to 1.28, P = 0.14), and LA size (per 1cm: 1.24 0.65 to 2.33, P = 0.52).
Non-paroxysmal AF was the only clinical variable found to be independently associated with non-PV mediated AF. We demonstrated that analysis of AF ablation outcomes data can serve as a tool to successfully identify a sub-phenotype of subjects who have non-PV mediated AF.
ClinicalTrials.gov ID # NCT02404415.
In 1967, researchers in The Netherlands and France independently reported a new technique, later called programmed electrical stimulation. The ability to reproducibly initiate and terminate ...arrhythmias heralded the beginning of invasive clinical cardiac electrophysiology as a medical discipline. Over the next fifty years, insights into the pathophysiologic basis of arrhythmias would transform the field into an interventional specialty with a tremendous armamentarium of procedures. In 2015, the variety and complexity of these procedures were major reasons that led to the recommendation for an increase in the training period from one year to two years. The purpose of this manuscript is to present fifty manuscripts from the early invasive clinical cardiac electrophysiology era, between 1967 and 1992, to serve as an educational resource for current and future electrophysiologists. It is our hope that reflection on the transition from a predominantly noninvasive discipline to one where procedures are commonly utilized will lead to more thoughtful patient care today and to inspiration for innovation tomorrow. In the words of the late Dr. Mark E. Josephson, “It is only by getting back to the basics that the field of electrophysiology will continue to grow instead of stagnate.”
Experimental evidence suggests genetic variation in 4q25/PITX2 modulates pulmonary vein (PV) myocardial sleeve length. Although PV sleeves are the main target of atrial fibrillation (AF) ablation, ...little is known about the association between different PV sleeve characteristics with ablation outcomes.
This study sought to evaluate the association between clinical and genetic (4q25) risk factors with PV sleeve length in humans, and to evaluate the association between PV sleeve length and recurrence after AF ablation.
In a prospective, observational study of patients undergoing de novo AF ablation, PV sleeve length was measured using electroanatomic voltage mapping before ablation. The sentinel 4q25 AF susceptibility single nucleotide polymorphism, rs2200733, was genotyped. The primary analysis tested the association between clinical and genetic (4q25) risk factors with PV sleeve length using a multivariable linear regression model. Covariates included age, sex, body mass index, height, and persistent AF. The association between PV sleeve length and atrial arrhythmia recurrence (>30 seconds) was tested using a multivariable Cox proportional hazards model.
Between 2014 and 2019, 197 participants were enrolled (median age 63 years IQR: 55 to 70 years, 133 male 67.5%). In multivariable modeling, men were found to have PV sleeves 2.94 mm longer than women (95% CI: 0.99-4.90 mm; P < 0.001). Sixty participants (30.5%) had one 4q25 risk allele and 6 (3.1%) had 2 alleles. There was no association between 4q25 genotype and PV sleeve length. Forty-six participants (23.4%) experienced arrhythmia recurrence within 3 to 12 months, but there was no association between recurrence and PV sleeve length.
Common genetic variation at 4q25 was not associated with PV sleeve length and PV sleeve length was not associated with ablation outcomes. Men did have longer PV sleeves than women, but more research is needed to define the potential clinical significance of this observation.
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