Search

Background: An unusual 12-lead electrocardiographic pattern may be present in patients with cavotricuspid isthmus (CTI)-dependent flutter. Objective: Using baseline patient characteristics and echocardiography, we sought to study predictors of unusual electrocardiogram (ECG) characteristics in patients with CTI-dependent atrial flutter. Methods: This was a dual-center, retrospective cohort study of 147 patients undergoing electrophysiology study and ablation for CTI-dependent atrial flutter. Results: Among this cohort, 23 patients (16%) had unusual 12-lead ECG characteristics. Using multivariate logistic regression, we found two clinical predictors for having an unusual ECG pattern. A clockwise (CW) pattern at time of electrophysiology study was the strongest predictor of an unusual ECG pattern (odds ratio 15.3, 95% confidence interval [CI] 4.0-59.4, P < 0.005). In addition, patients with decreased systolic function had a 3.5 greater odds (95% CI 1.1-11.5, P = 0.037) of having an unusual ECG pattern. Conclusions: Our data demonstrate that among patients suffering from CTI-dependent atrial flutter who are referred for ablation, 16% will have unusual ECG patterns. Patients with CW atrial activation and left ventricle dysfunction have greater odds of manifesting unusual patterns by surface electrocardiogram. (PACE 2011; 34:1251-1257) [ABSTRACT FROM AUTHOR]

ECG and EGM of IIR. Introduction: Intra-isthmus reentry (IIR) is a circuit within the cavotricuspid isthmus (CTI). The purpose of this study is to prospectively define the electrogram and surface ECG characteristics of IIR, and its clinical implications. Methods and Results: Fourteen patients underwent electrophysiological studies and were found to have IIR. Detailed electrogram mapping of the CTI was available in all, electroanatomic mapping (EAM) in 8 of 14 (57%) patients. In all, entrainment mapping during tachycardia proved reentry, and showed that the anteroinferior CTI was out of the circuit and the septal CTI was in the circuit in 12 of 14 patients, whereas in 2, the circuit was confined within the mid and/or anteroinferior CTI. Fractionated potentials (FPs) spanning 34-71% of the tachycardia cycle length were recorded within the CTI in all, and double potentials were inscribed in 10 of 14 (71%). Analysis of the tricuspid annulus electrograms showed spontaneous shifts from a counterclockwise (CCW) to clockwise or fusion patterns. Surface ECGs showed either typical CCW pattern (12 patients) or atypical patterns (3 patients). The EAMs showed a focal pattern in 3, a CCW pattern in 5. The successful ablation site always occurred at the area with maximal FP duration. Over the same period, 33 of 384 (9%) patients who underwent ablation for CTI-dependent flutter had prior successful CTI ablation, 7 of 33 (21%) were found to have IIR during the redo procedure. Conclusions: (1) Electrogram and ECG patterns of IIR frequently show atypical flutter. (2) IIR was successfully ablated in an area of the CTI associated with maximal duration of FPs. (3) IIR is a significant cause of 'recurrent flutter' in patients with prior CTI ablation. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1099-1106) [ABSTRACT FROM AUTHOR]

Context: On October 6, 2014, the United States Drug Enforcement Administration (DEA) implemented a regulatory change for hydrocodone combination products (HCPs), moving them from Schedule III to II, in an effort to decrease drug overdoses. Existing research suggests this regulatory action reduced HCP prescribing and dispensing; however, there is limited research assessing its possible effects on overdoses and accidental exposures., Objective: To analyze the changes in opioid exposures reported to the California Poison Control System (CPCS) before and after DEA rescheduling of HCPs., Methods: We collected monthly exposure data reported to CPCS from 2012 to 2019 and conducted interrupted time series analyses to assess changes in exposures after rescheduling for HCPs, tramadol, oxycodone, morphine, codeine, fentanyl, and heroin. Additional analyses were done to assess any changes in exposures resulting in severe outcomes (moderate or major health effects). For HCPs, we also conducted logistic regressions to identify characteristics of exposures resulting in severe outcomes before and after rescheduling., Results: Overall monthly opioid exposures reported to CPCS decreased after DEA rescheduling of HCPs. These decreases were significant for HCP, tramadol, and morphine ( p  < 0.001). Exposures significantly increased for heroin and fentanyl ( p  < 0.001). There were no significant changes in the share of severe outcomes attributed to HCP exposures after rescheduling., Discussion: The DEA rescheduling of HCPs was associated with a significant decrease in HCP exposures and prescription opioid exposures overall, but was associated with increased fentanyl and heroin exposures. While other initiatives may have contributed to this decrease, our findings suggest that rescheduling may be a useful regulatory strategy to reduce drug exposures., Conclusion: DEA rescheduling of HCPs was associated with a significant reduction in prescription opioid exposures, suggesting that rescheduling high-risk drugs may be an effective strategy to improve public health.

We evaluate the impact of California Assembly Bill 394, which mandated maximum levels of patients per nurse in the hospital setting. When the law was passed, some hospitals already met the requirements, while others did not. Thus changes in staffing ratios from the pre- to post-mandate periods are driven in part by the legislation. We find persuasive evidence that AB394 had the intended effect of decreasing patient/nurse ratios in hospitals that previously did not meet mandated standards. However, these improvements in staffing ratios do not appear to be associated with relative improvements in measured patient safety in affected hospitals., (Copyright © 2012 Elsevier B.V. All rights reserved.)

The study of host shifts by herbivorous insects has played an important role in evolutionary biology, contributing to research in coevolution, ecological speciation, and adaptive radiation. As invasive plants become more abundant in many ecosystems, the potential for exotic host use by native insects increases. Graves and Shapiro (2003) have documented exotic host use by 34% of Californian butterflies, suggesting that the plants and butterflies of California might be an important model system for the colonization and utilization of novel resources. In this study, we analyze relationships among geographic range, native diet breadth, and the use of exotic hosts by Californian butterflies and skippers (Lepidoptera). Geographic range and, to a lesser extent, native diet breadth are significant predictors of exotic host use, with positive relationships found both before and after phylogenetic correction. These results give insight into the process of insect host range evolution, as geographically widespread generalists have an apparently greater tendency to use novel, exotic hosts than geographically constrained specialists. Increasing occurrences of exotic host use are expected and those species not capable of shifting to nonnative hosts are likely to have higher vulnerability to extirpation and extinction in the future., (© 2011 The Author(s).)

Background: The etiology of accessory pathway (AP) formation is generally unknown., Objective: The purpose of this study was to test the hypothesis that AP formation is genetically mediated by examining whether AP location differs by sex and/or race, using sex and race as proxies to distinguish genetically different individuals., Methods: This was a single-center, retrospective cohort study of 282 consecutive patients undergoing their first electrophysiology study that revealed at least one AP between 2004 and 2008. Sex and race were compared with AP location determined by invasive electrophysiology study., Results: Eighty-nine (52%) males and 40 (36%) females had a left posterior AP (P = .006). Sixty-four (57%) females had a right annular AP, compared with 55 (32%) males (P <.001). After adjusting for age and race, females had 2.8-fold greater odds of having a right annular AP compared with males (95% confidence interval [CI] 1.70-4.65 greater odds; P <.001). While right anterior (free-wall) pathways were rare in all other races (12%), a significantly larger proportion of Asians (n = 10, 26%) had a right anterior AP (P = .017). After adjusting for sex and age, Asians had 3.8-fold greater odds of having a right anterior AP compared with other races (95% CI 1.5-9.4 greater odds; P = .004)., Conclusions: Females more commonly had right annular APs, and Asians had right anterior APs substantially more frequently than other races. These findings suggest that the pathogenesis of AP formation may have a genetic component.

Background: Although evidence suggests that alcohol is associated with atrial fibrillation (AF), the association between alcohol and atrial flutter (AFL) has not been examined. The mechanism connecting alcohol and atrial arrhythmias is unknown., Methods: Alcohol intake was determined in 195 consecutive patients with AF and AFL. Control subjects included patients with other supraventricular arrhythmias (n = 132) and healthy subjects (n = 54). Because of important competing risk factors for atrial arrhythmias in the elderly, stratification by age was performed. In a subset, atrial effective refractory periods (AERPs) were obtained from the high right atrium and proximal and distal coronary sinus., Results: AF and AFL patients were significantly more likely to be daily alcohol drinkers (27% vs 14% of controls, P = 0.001). In multivariable analysis, AFL patients < or = 60 years of age were significantly more likely to be daily drinkers than to drink no alcohol compared to controls (odds ratio 17, 95% confidence interval 1.6-192.0, P = 0.019). Progressively more frequent alcohol intake was significantly associated with a progressively greater odds of AFL in patients < or = 60 years of age (P = 0.045). Neither AF subjects of any age nor AFL subjects > 60 years of age exhibited significant associations with alcohol after multivariable adjustment. Right AERPs shortened significantly with increasing amounts of alcohol intake (P = 0.025), whereas left AERPs were not associated with alcohol intake., Conclusions: Alcohol intake is positively associated with AFL in younger patients. The mechanism may be related to a shortening of the right AERP.

Background: To our knowledge, no detailed analysis exists of the incidence and mortality of hepatocellular carcinoma (HCC) among Hispanics in the United States. In previous studies, the rates for Hispanics have not been reported separately from other racial or ethnic groups., Methods: We used information on patients diagnosed as having HCC from 13 registries in the Surveillance Epidemiology and End Results (SEER) database of the National Cancer Institute to calculate race-specific, age-adjusted incidence rates (AIR) between 1992 and 2002. We also used California and Texas state death records from between 1979 and 2001 to calculate race-specific, age-adjusted mortality rates for liver cancer excluding intrahepatic cholangiocarcinoma. For Hispanics and Asians/Pacific Islanders, the rates were calculated for native-born subjects and immigrants separately., Results: In SEER, the yearly AIRs were higher by 1.2-fold in Hispanics than in blacks (6.3 vs 5.0 per 100 000 person-years of the underlying US population) and by 2.7-fold than in non-Hispanic whites (2.4 per 100 000 person-years) but lower than in Asians/Pacific Islanders (10.8 per 100 000 person-years). The median age at HCC diagnosis in Hispanics (64 years) was intermediate between whites (the oldest) and blacks (the youngest). Between the periods 1992-1995 and 2000-2002, there was a 31% increase in the incidence of HCC in Hispanic men and a 63% increase in Hispanic women. The race-specific, age-adjusted mortality rates were remarkably similar in California and Texas and were highest in immigrant Asian/Pacific Islanders followed by native Hispanics. The rates for native Hispanic men were more than twice as high as those for immigrant Hispanic men. For Texas, the rates for native Hispanic men were 65% higher than those for immigrant Hispanic men., Conclusion: Hispanics in the United States have high rates of HCC that are second only to Asians/Pacific Islanders.