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Background: Whether there is an association between dietary choline intake and non-alcoholic fatty liver disease (NAFLD) in American adults remains unclear. Methods: Data came from the National Health and Nutrition Examination Survey 2017–2018. Choline intake was defined by the mean amounts of two 24 h dietary recalls, and choline intake was categorized into three groups according to the quartiles: inadequate (25), average (P25–P75), and optimal (>P75). Hepatic steatosis was assessed with FibroScan®, in which VCTE was employed with controlled attenuation to derive the controlled attenuation parameter (CAP), and NAFLD was defined as a CAP score ≥285 dB/m. Multivariable linear regression was performed to assess the linear relationship between choline intake and CAP. Multivariable logistics regression models were conducted to assess the association between choline intake status and NAFLD in the final sample and subgroup analysis was then performed in men and women. Results: The amount of dietary choline was inversely associated with CAP score (β = −0.262, 95% CI: −0.280, −0.245). Compared to inadequate choline intake, optimal choline intake was related to a lower risk of NAFLD (OR: 0.705, 95% CI: 0.704–0.706) in the final sample. Subgroup analysis by gender revealed that the highest choline intake status was associated with a lower risk of NAFLD both in females (OR: 0.764, 95% CI: 0.762–0.766), and males (OR: 0.955, 95% CI: 0.953–0.958) when compared to the lowest choline intake. Conclusions: With the latest NHANES data, we found that higher dietary choline was associated with a lower risk of NAFLD in American adults, and such a relationship exists in both females and males. [ABSTRACT FROM AUTHOR]

Purpose: Various studies have analyzed sepsis subtypes, yet the reproducibility of such results remains unclear. This study aimed to determine the reproducibility of sepsis subtypes across multiple cohorts. Methods: The study examined 63,547 sepsis patients from six distinct cohorts who had similar sepsis-related characteristics (vital signs, lactate, sequential organ failure assessment score, bilirubin, serum, urine output, and Glasgow coma scale). Identical cluster analysis techniques were used, employing 27 clustering schemes, and normalized mutual information (NMI), a metric ranging from 0 to 1 with higher values indicating better concordance, was employed to quantify the clustering solutions' reproducibility. Principal component analysis (PCA) was utilized to obtain the disease axis, and its uniformity across cohorts was evaluated through patterns of feature loading and correlation. Results: The reproducibility of sepsis clustering subtypes across the various studies was modest (median NMI ranging from 0.08 to 0.54). The top-down transfer learning method (model trained on cohorts with greater severity was transferred to cohorts with lower severity score) had a higher NMI value than the bottom-up approach (median [Q1, Q3]: 0.64 [0.49, 0.78] vs. 0.23 [0.2, 0.31], p < 0.001). The reproducibility was greater when the transfer solution was performed within United States (US) cohorts. The PCA analysis revealed that the correlation pattern between variables was consistent across all cohorts, and the first two disease axes were the "shock axis" and "systemic inflammatory response syndrome (SIRS) axis." Conclusions: Cluster analysis of sepsis patients across various cohorts showed modest reproducibility. Sepsis heterogeneity is better characterized through continuous disease axes that coexist to varying degrees within the same individual instead of mutually exclusive subtypes. [ABSTRACT FROM AUTHOR]

Aims: To evaluate the association of physical activity (PA) with atrial fibrillation (AF) incidence in an elderly population.Methods: We studied 5166 participants of the Atherosclerosis Risk in Communities cohort examined in 2011-2013 free of AF. Self-reported PA was evaluated with a validated questionnaire. Weekly minutes of leisure-time moderate to vigorous physical activity (MVPA) were calculated and categorized using the 2018 Physical Activity Guidelines for Americans (no activity [0 min/week], low [> 0- < 150 min/week], adequate [150- < 300 min/week], high [≥ 300 min/week]). Incident AF through 2019 was ascertained from hospital discharges and death certificates. Cox models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for AF by levels of physical activity adjusting for potential confounders.Results: The mean (SD) age for the sample was 75 (5) years (59% female, 22% Black). During a mean (SD) follow-up time of 6.3 (2.0) years, 703 AF events were identified. The association of MVPA with AF incidence showed a U-shaped relationship. Compared to those not engaging in MVPA, individuals with low MVPA had a 23% lower hazard of AF (HR = 0.77; 95% CI 0.61, 0.96), while those with adequate MVPA had a 14% lower hazard (HR 0.86; 95% CI 0.69, 1.06). High levels of MVPA were not associated with AF risk (HR 0.97; 95% CI 0.78, 1.20).Conclusion: This study suggests that being involved in low to moderate levels of MVPA is associated with lower AF risk, with no evidence of increased risk of AF in those with higher levels of MVPA. [ABSTRACT FROM AUTHOR]

Did regulatory reforms that lowered barriers to competition increase or decrease the quality of information that banks disclose to the public? By integrating the gravity model of investment with the state-specific process of bank deregulation that occurred in the United States from the 1980s through the 1990s, we develop a bank-specific, time-varying measure of deregulation-induced competition. We find that an intensification of competition reduced abnormal accruals of loan loss provisions and the frequency with which banks restate financial statements. The results suggest that competition reduces bank opacity, potentially enhancing the ability of markets to monitor banks. [ABSTRACT FROM AUTHOR]

Background: Social determinants of health are relevant to cardiovascular outcomes but have had limited examination in atrial fibrillation (AF).Objectives: The purpose of this study was to examine the association of annual household income and cardiovascular outcomes in individuals with AF.Methods: We analysed administrative claims for individuals with AF from 2009 to 2015 captured by a health claims database. We categorised estimates of annual household income as <$40 000; $40-$59 999; $60-$74 999; $75-$99 999; and ≥$100 000. Covariates included demographics, education, cardiovascular disease risk factors, comorbid conditions and anticoagulation. We examined event rates by income category and in multivariable-adjusted models in reference to the highest income category (≥$100 000).Results: Our analysis included 336 736 individuals (age 72.7±11.9 years; 44.5% women; 82.6% white, 8.4% black, 7.0% Hispanic and 2.1% Asian) with AF followed for median (25th and 75th percentile) of 1.5 (95% CI 0.6 to 3.0) years. We observed an inverse association between income and heart failure and myocardial infarction (MI) with evidence of progressive risk across decreased income categories. Individuals with household income <$40 000 had the greatest risk for heart failure (HR 1.17; 95% CI 1.05 to 1.30) and MI (HR 1.18; 95% CI 0.98 to 1.41) compared with those with income ≥$100 000.Conclusions: We identified an association between lower household income and adverse outcomes in a large cohort of individuals with AF. Our findings support consideration of income in the evaluation of cardiovascular risk in individuals with AF. [ABSTRACT FROM AUTHOR]

We queried hospital patients about international travel in the previous 30 days to assess potential importation of emerging infections. We used 12 months of deidentified data to analyze patient demographics, travel destinations, and diagnoses for exposure to Zika virus. Our approach could be used to analyze potential infectious disease exposures. [ABSTRACT FROM AUTHOR]

Objectives: To determine, using systematic review of the biomedical literature, whether pacing reduces risk of recurrent syncope and relevant clinical outcomes among adult patients with reflex-mediated syncope.Methods: MEDLINE (through PubMed), EMBASE, and the Cochrane Central Register of Controlled Trials (through October 7, 2015) were searched for randomized trials and observational studies examining pacing and syncope, and the bibliographies of known systematic reviews were also examined. Studies were rejected for poor-quality study methods and for the lack of the population, intervention, comparator, or outcome(s) of interest.Results: Of 3188 citations reviewed, 10 studies met the inclusion criteria for systematic review, including a total of 676 patients. These included 9 randomized trials and 1 observational study. Of the 10 studies, 4 addressed patients with carotid sinus hypersensitivity, and the remaining 6 addressed vasovagal syncope. Among the 6 open-label (unblinded) studies, we found that pacing was associated with a 70% reduction in recurrent syncope (relative risk [RR]: 0.30; 95% confidence interval [CI]: 0.15-0.60). When the 2 analyzable studies with double-blinded methodology were considered separately, there was no clear benefit (RR: 0.73; 95% CI: 0.25-2.1), but confidence intervals were wide. The strongest evidence was from the randomized, double-blinded ISSUE-3 (Third International Study on Syncope of Uncertain Etiology) trial, which demonstrated a benefit of pacing among patients with recurrent syncope and asystole documented by implantable loop recorder.Conclusions: There are limited data with substantive evidence of outcome ascertainment bias, and only 2 studies with a double-blinded study design have been conducted. The evidence does not support the use of pacing for reflex-mediated syncope beyond patients with recurrent vasovagal syncope and asystole documented by implantable loop recorder. [ABSTRACT FROM AUTHOR]

In this paper, we examine why Chinese reverse merger (RM) firms have lower financial reporting quality than U.S. IPO firms. We find that the financial reporting quality of U.S. RM firms is similar to that of matched U.S. IPO firms, but Chinese RM firms exhibit lower financial reporting quality than Chinese ADR firms. We also find that Chinese RM firms exhibit lower financial reporting quality than U.S. RM firms. These results indicate that the use of the RM process is associated with poor financial reporting quality only in firms from China, where legal enforcement and investor protection are weak. In addition, we find that compared with Chinese ADR firms, Chinese RM firms have weaker bonding incentives (as measured by CEO turnover-performance sensitivity) and poorer corporate governance. These factors, in turn, contribute to the lower financial reporting quality of Chinese RM firms. Overall, our results suggest that the less scrutinized RM process allows the Chinese firms with weak bonding incentives and poor governance to gain access to U.S. capital markets, resulting in poor financial reporting quality. [ABSTRACT FROM AUTHOR]

Aims: To assess the prospective association between circulating 25-hydroxyvitamin D [25(OH)D] and atrial fibrillation (AF) risk.Methods and Results: We studied 12 303 participants from the Atherosclerosis Risk in Communities study without baseline AF (1990-92). Baseline serum total 25(OH)D was measured using mass spectrometry. Incident AF cases were identified from electrocardiograms, hospital discharge codes, and death certificates through 2012. We estimated hazard ratios (HRs) and 95% confidence intervals (95% CIs) of AF across clinical categories of serum 25(OH)D concentrations with multivariable Cox models, and tested interactions by age, race, and sex. We meta-analysed our results with those from published prospective studies that reported associations between 25(OH)D and AF risk. During a median follow-up of 21 years, we identified 1866 AF events. In multivariable models, deficient 25(OH)D status (<20 ng/mL), compared with optimal levels (≥30 ng/mL), was not associated with AF risk (HR, 95% CI: 1.10, 0.96-1.26). A significant interaction of 25(OH)D concentrations with age (P = 0.01), but not with race or sex (P > 0.40), was identified, with higher risk of AF among those with deficient 25(OH)D status in younger (HR, 95% CI: 1.35, 1.05-1.73) but not older individuals (HR, 95% CI: 1.02, 0.86-1.21). A meta-analysis of these results and four prospective studies did not support a clinically relevant association of circulating 25(OH)D with AF risk [pooled HR, 95%CI: 1.04, 1.00-1.08, per 1 SD lower 25(OH)D].Conclusion: Low serum 25(OH)D was not associated with incident AF in a community-based cohort and in a meta-analysis of prospective studies. A possible association in younger individuals warrants further investigation. [ABSTRACT FROM AUTHOR]

Problem, research strategy, and findings:Parks provide important physiological and psychological benefi ts to seniors, improving their quality of life; they are particularly important for low-income, inner-city seniors who lack access to open and green space. However, seniors do not often use parks partly because park design and programming are not responsive to their diverse needs and values. To identify what low-income, inner-city seniors seek and value in neighborhood parks, and to provide guidance to planners on how to better design senior-friendly parks, we conducted a literature review and held focus groups with 39 low-income, ethnically diverse seniors in an inner-city neighborhood in Los Angeles (CA). We asked these seniors about their preferences as well as the challenges and barriers they encounter in using neighborhood parks. Seniors report many impediments to park use; they are not provided appropriate programming that allows opportunities for socializing, safety, and security within the park and along access routes; opportunities for exercise and walking; and aesthetic and natural elements that provide contact with nature. Takeaway for practice:Park planners and designers should seek to incorporate senior voices in park design and programming in four ways by developing appropriate programming sensitive to diverse needs, accommodating the desire for “seniors-only” parks, promoting security and safety in the park and along access routes, and offering open and green space. We also fi nd the need for additional research on seniors from different racial and ethnic backgrounds. [ABSTRACT FROM AUTHOR]

The soaring cost of healthcare service demands alternative payment schemes to control expenditures while maintaining quality of service. The capitation payment scheme is a tentative substitute for the Fee-For-Service (FFS) scheme. A pilot capitation program study was conducted by the Bureau of National Health Insurance (BNHI) to evaluate the feasibility of a national rollout. Estimating the potential outcomes of a specific pilot program, the multi-agent simulation approach is used to model and simulate the service system under different settings. In this study, we chose the Zhishan Community Healthcare Group (CHG) service system as an example. The model was built and validated according to publicly available statistical and transactional data from Zhishan-CHG, and estimated the system's financial sustainability under different conditions. Five scenarios were explored in the experiment, simulating the capitation payment scheme over a period of three years. The results are summarized as follows: (1) medical cost expenditure per person can be reduced as more patients are enrolled in the capitation program; (2) the service model with a health promotion agent outperforms the model without one in an FFS cost control system; (3) higher quality and retention rate improve capitation income; (4) the financial risk of the CHG service system can be mitigated by excluding inpatient medical costs from the virtual points assigned by BNHI, and (5) simulation results show a positive financial outcome for Zhishan-CHG. These simulation results could be potentially used by the BNHI to revise its policy in terms of the population for one CHG and the coverage of medical services of a capitation payment system, such that the financial risk of the CHG could be reduced and the capitation policy sustained. [ABSTRACT FROM AUTHOR]

Purpose -- The purpose of this paper is to examine the cultural influences on young consumers' loyalty tendency and evaluations of the relative importance of apparel retail store attributes in Taiwan and the USA. Design/methodology/approach -- A structured questionnaire was developed to collect the data. Factor analysis was employed to identify dimensions of apparel retail store image attributes. Pillai's Trace multivariate analysis of variance and hierarchical multiple regression analysis were used to examine the hypotheses. Findings -- Results of the study showed that American consumers have significantly greater collectivistic characteristics than Taiwanese. The paper also found that country of residence is a significant and stronger indicator in predicting loyalty tendency than individualism and collectivism dimensions. The results of the study showed that evaluation of the relative importance of retail store attributes was influenced by culture. Among the five apparel retail store attribute dimensions identified in the study, Taiwanese and US respondents' evaluation of the importance of "convenience", "product" and "information communication" factors of retail store image attributes differed significantly. Research limitations/implications -- The paper may contribute to international retailers' understanding of the similarities and differences between Taiwanese and US markets and in determining the ideal components for these retailers to create an optimized apparel retail store image in two different countries' markets. The findings from the study could serve as an important benchmark for retailing strategy, helping retailers to effectively redesign their apparel stores to attract consumers in different markets and foster consumers' loyal to the company. Originality/value -- Despite the growing internationalization of fashion retailing, this particular sector has attracted little research attention, and no research has been done to investigate the cultural differences of consumers' evaluations of apparel retail store image attributes. [ABSTRACT FROM AUTHOR]

This study investigates the daily dynamic relation between returns and institutional and individual trades in the TAIEX futures market. I find that both past individual and institutional buys and sells have no predictive power for index returns; both individual and institutional trading activities are strongly related to their own past trades, and individual open-buy trading is also influenced by institutional open-buy trading, and vice versa. However, this does not occur in terms of open-sell trading. In the context of close trading, individual prior close-buy leads to institutional close-buy trading; on the contrary, institutional close-sell affects individual close-sell trading. Individual investors are contrarians, but institutional investors are positive feedback traders. Finally, the average return of each contract for individuals is negative but institutions have positive returns, suggesting that individual investors are less-informed. But individual trading activity is more aggressive for their higher proportions of market order and shorter holding time of a round trade. [ABSTRACT FROM AUTHOR]

This study examined American young adults' written accounts of intergenerational communication with a focus on factors that initiate conflict. Analysis of the conflict scenarios in intergenerational relationships revealed seven types of initiating factors. Results also indicated that the type of relationship with older adults was associated with the frequency distribution of five of the seven initiating factors. Specifically, young adults perceived they were criticized and rebuffed by nonfamily elders more frequently than by family elders, whereas young people tended to disagree with and rebuff family elders more than nonfamily elders. Furthermore, young people reported more incidents of illegitimate demand from family elders than from nonfamily elders. Results are discussed with respect to intergenerational communication research and the communication predicament of aging model. [ABSTRACT FROM AUTHOR]

The prevalence of atrial fibrillation (AF) increases with age. Recent population-based data indicate a trend of increasing incidence and prevalence of AF that is incompletely explained by an aging population. A recent population study estimated that the number of Americans afflicted by AF will increase from the current 2.3 million to more than 10 million by 2050. Novel risk factors—obesity and sleep apnea—may partially account for the current AF epidemic. Ethnic differences in the epidemiology of AF have been suggested but not clearly elucidated by population-based studies. The heritability of AF in the general population is strongly supported by population-based data. Genetic epidemiological studies on AF can potentially yield important mechanistic insights that may ultimately lead to novel preventative and therapeutic strategies. [Copyright &y& Elsevier]

The current technologies to treat hypersaline produced water (PW), such as thermal evaporation, are usually energy-intensive and cost-prohibitive. This study developed a low-cost, robust, solar-driven carbon black and airlaid paper-based evaporator (CAPER) for desalination of PW in the Permian Basin, United States. The study aims to better understand the removal of aromatic organic compounds and heavy metals during solar distillation, water output, and heat transfer. Outdoor experiments using CAPER assisted with polystyrene foam in a single slope, single basin solar still achieved an enhanced average evaporation rate of 2.23 L per m2 per day, 165% higher than that of a conventional solar still. Analysis of heat transfer models demonstrated that CAPER solar evaporation achieved an evaporative heat transfer coefficient of ∼28.9 W m−2·K−1, 27.9% higher than without CAPER. The maximum fractional energy of evaporation and convection heat transfer inside the solar still with and without CAPER was ∼81.4% and ∼78.2%, respectively. For the PW with a total dissolved solids concentration of 134 g L−1, solar distillation removed 99.97% salts and over 98% heavy metals. The high removal efficiency of 99.99% was achieved for Ca, Na, Mg, Mn, Ni, Se, Sr, and V. Organic characterization revealed that solar distillation removed over 83% aromatic compounds. Solar desalination using CAPER provides a low-cost and high-performance process to treat PW with high salinity and complex water chemistry for potential fit-for-purpose beneficial uses. Image 1 • A carbon black and airlaid paper-based solar evaporator (CAPER) was developed. • Outdoor distillation of produced water (PW) achieved evaporation of 2.23 L m−2·d−1. • The evaporation rate of PW with CAPER is 165% higher than without CAPER. • Heat transfer coefficient with CAPER is 27.9% higher than without CAPER. • 99.97% salts, 98% metals, >83% aromatic compounds removed from 134 g L−1 TDS PW. [ABSTRACT FROM AUTHOR]

Investigates the effects of frequent classroom testing on students in the U.S. Effects of adjunct questions on learning; Research on mastery testing and classroom quizzes and examinations; Variation in examination performance; Model relating test frequency and classroom learning; Students' attitudes toward instruction after they were exposed to different testing conditions.

Fraxinus pennsylvanica is distributed in the central and eastern USA and Canada. It is assessed as Critically Endangered (CR). In this study, the complete chloroplast (cp) genome sequence of F. pennsylvanica was determined using next-generation sequencing. The entire cp genome was determined to be 155,543 bp in length. It contained large single-copy (LSC) and small single-copy (SSC) regions of 86,389 and 17,806 bp, respectively, which were separated by a pair of 25,674 bp inverted repeat (IR) regions. The genome contained 132 genes, including 87 protein-coding genes, 37 tRNA genes, and eight rRNA genes. The overall AT content of the genome is 37.8%. A phylogenetic tree reconstructed by 10 chloroplast genomes reveals that F. pennsylvanica is most related with F. chiisanensis. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "Hepatitis B screening in US travelers seen at the Boston area travel medicine network," in the 2013 issue is presented.

We queried hospital patients about international travel in the previous 30 days to assess potential importation of emerging infections. We used 12 months of deidentified data to analyze patient demographics, travel destinations, and diagnoses for exposure to Zika virus. Our approach could be used to analyze potential infectious disease exposures. [ABSTRACT FROM AUTHOR]

High serum phosphorus levels have been linked with vascular calcification and greater cardiovascular morbidity and mortality. We assessed whether serum phosphorus was associated with the atrial fibrillation (AF) incidence in a large community-based cohort in the United States. Our analysis included 14,675 participants (25% black, 45% men) free of AF at baseline (1987 to 1989) and with measurements of fasting serum phosphorus from the Atherosclerosis Risk In Communities (ARIC) study. The incidence of AF was ascertained through the end of 2008 from study visit electrocardiograms, hospitalizations, and death certificates. Cox proportional hazard models were used to estimate the hazard ratios of AF by the serum phosphorus levels, adjusting for potential confounders. During a median follow-up of 19.7 years, we identified 1,656 incident AF cases. Greater serum phosphorus was associated with a greater AF risk: the hazard ratio of AF with a 1-mg/dl increase in serum phosphorus was 1.13 (95% confidence interval 1.02 to 1.26). No significant interaction was seen by race (p[0.88) or gender (p[0.51). The risk of AF was increased in association with greater serum phosphorus in those with an estimated glomerular filtration rate of ‡90 ml/min/1.72 m2 but not among those with an estimated glomerular filtration rate of <90 ml/min/1.72 m2. The total corrected calcium levels were not related to AF risk; however, greater levels of the calcium-phosphorus product were associated with greater AF risk. In conclusion, in the present large population-based study, greater levels of serum phosphorus and the related calcium-phosphorus product were associated with a greater incidence of AF. [ABSTRACT FROM AUTHOR]

There is conflicting evidence that operative technique affects the risk of atrial tachyarrhythmia after orthotopic heart transplantation (OHT). We sought to determine whether OHT by bicaval (BC) technique is associated with a lower risk of atrial tachyarrhythmia than biatrial (BA) technique. Consecutive patients who underwent OHT between 1997 and 2007 at the University of Minnesota were included in this retrospective cohort study with follow-up through December 31, 2011. We included 260 OHT recipients (BA, 155; BC, 105). Fifty-nine patients (22.7%) developed early atrial tachyarrhythmias. The multivariable odds ratio (95% confidence interval [CI]) of BC technique for early atrial tachyarrhythmias was 0.85 (0.46-1.57), P=0.59. After a median follow-up of 4.9 years, 40 (15.4%) patients developed late atrial tachyarrhythmias. The multivariable hazard ratio (HR) (95% CI) of BC technique for late atrial tachyarrhythmias was 0.99 (0.50-1.96), P=0.98. Graft rejection was found to be a multivariate predictor of late atrial tachyarrhythmias (HR, 2.89; 95% CI, 1.48-5.65; P=0.002). In contrast to prior reports, we did not find an association between operative technique and early or late atrial tachyarrhythmias after OHT. Graft rejection is a risk factor for late atrial tachyarrhythmias after OHT. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is a common cardiac arrhythmia affecting over 6 million people in the U.S. Fatigue is a frequent symptom of AF, yet no underlying biological mechanisms have been identified in AF-related fatigue as in other chronic conditions such as cancer or HIV fatigue (inflammation, tissue injury). We aimed to identify biomarkers and correlates of AF-fatigue in ARIC participants., Methods: Participants with AF from ARIC visit 5 (2011-2013) were included in the study. Multiple linear regression was used to estimate the association of high sensitivity troponin (hs-TnT), N-terminal fragment B-type natriuretic peptide (NT-proBNP) and high sensitivity C-reactive protein (hsCRP) levels with self-reported fatigue (SF-12 and PROMIS Fatigue Scale), depressive symptoms (Center for Epidemiological Studies Depression survey), and physical functioning (Short Physical Performance Battery) scores. All biomarkers underwent natural-log transformation., Results: There were 446 participants (mean age: 78 y ± 5; 44% women). In adjusted analyses, NT-proBNP was associated with AF-fatigue (β: 0.11, 95% CI: 0.03, 0.19), increased depressive symptoms (β: 0.44, 95% CI: 0.19, 0.70), and decreased physical function (β: -0.48, 95% CI: -0.72, -0.23). Hs-TnT was also associated with elevated AF-fatigue (β: 0.24, 95% CI: 0.09, 0.39) along with decreased physical function (β: -1.19, 95% CI: -1.64, -0.75). No significant associations were found with hsCRP and fatigue., Conclusion: Increased levels of cardiac injury biomarkers, depressive symptoms, and decreased physical function were associated with AF-fatigue. Inflammation was not associated with AF-fatigue; other physiological pathways, such as cardiac overload or myocardial injury may be more relevant in AF-fatigue., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Deep terminal negative of the P wave in V1 (DTNPV1) is a marker of left atrial remodeling. We aimed to evaluate the association of DTNPV1 with incident ischemic stroke., Methods: The Atherosclerosis Risk in Communities study is a prospective community-based cohort study. All participants at visit 4 (1996-1998) except those with prevalent stroke, missing covariates, and missing or uninterpretable ECG were included. DTNPV1 was defined as the absolute value of the depth of the terminal negative phase >100 μV in the presence of biphasic P wave in V1. Association between DTNPV1 as a time-dependent exposure variable and incident ischemic stroke was evaluated. The accuracy of the prediction model consisting of DTNPV1 and CHA 2 DS 2 -VASc variables in predicting ischemic stroke was analyzed., Results: Among 10,605 participants (63 ± 6 years, 56% women, 20% Black), 803 cases of ischemic stroke occurred over a median follow-up of 20.19 years. After adjusting for demographics, DTNPV1 was associated with an increased risk of stroke (HR 1.96, [95% CI 1.39-2.77]). After further adjusting for stroke risk factors, use of aspirin and anticoagulants, and time-dependent atrial fibrillation, DTNPV1 was associated with a 1.50-fold (95% CI 1.06-2.13) increased risk of stroke. When added to the CHA 2 DS 2 -VASc variables, DTNPV1 did not significantly improve stroke prediction as assessed by C-statistic. However, there was improvement in risk classification for participants who did not develop stroke., Conclusion: DTNPV1 is significantly associated with higher risk of ischemic stroke. Since DTNPV1 is a simplified electrocardiographic parameter, it may help stroke prediction, a subject for further research., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Patients are increasingly using the internet to obtain health care information. US News and World Report Best Hospital rankings received more than 103 million views in 2021. Considering 21% of thoracic surgery patients are minorities, 27.9% are in the bottom quartile of household income, and 70% have Medicare/Medicaid or no insurance, online patient educational materials (PEMs) should be accessible and written at a level easily understood by majority of patients. We performed a comprehensive analysis of readability of websites containing patient-centered resources across all adult thoracic surgery areas., Methods: Online PEMs on thoracic surgical procedures were collected from top 50 hospitals for pulmonology and lung surgery ranked by US News and World Report Best Hospital as of December 1, 2021. Text pertaining to thoracic surgical procedures was collected and divided into 4 procedural genres: esophageal, lung, transplant procedures, and other. Texts were analyzed using OleanderSoftware's Readability Suite through the Raygor readability test., Results: Three hundred seventy-two articles met criteria for analysis. Websites were difficult to read; mean (standard deviation) readability score for all content required a 13.9 (3.6) grade level for comprehension. The mean (standard deviation) readability for esophageal, lung, lung transplant, and other surgeries were 14.5 (3.6), 13.1 (3.6), 11.5 (3.9), and 13.4 (3.7), respectively., Conclusions: Online PEMs required at least a college reading level to comprehend, well exceeding the sixth-grade level recommended by the American Medical Association. As digital health becomes increasingly relevant, improving the readability of online PEMs in adult cardiac surgery will facilitate equitable access to high-quality care., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Among patients with atrial fibrillation (AF), a nonpharmacologic option (e.g., percutaneous left atrial appendage occlusion [LAAO]) is needed for patients with oral anticoagulant (OAC) contraindications. Among beneficiaries in the Medicare fee-for-service coverage 20% sample databases (2015-18) who had AF and an elevated CHA 2 DS 2 -VASc score, we assessed the association between percutaneous LAAO versus OAC use and risk of stroke, hospitalized bleeding, and death., Methods: Patients undergoing percutaneous LAAO were matched to up to five OAC users by sex, age, date of enrollment, index date, CHA 2 DS 2 -VASc score, and HAS-BLED score. Overall, 17 156 patients with AF (2905 with percutaneous LAAO) were matched (average ± SD 78 ± 6 years, 44% female). Cox proportional hazards model were used., Results: Median follow-up was 10.3 months. After multivariable adjustments, no significant difference for risk of stroke or death was noted when patients with percutaneous LAAO were compared with OAC users (HRs [95% CIs]: 1.14 [0.86-1.52], 0.98 [0.86-1.10]). There was a 2.94-fold (95% CI: 2.50-3.45) increased risk for hospitalized bleeding for percutaneous LAAO compared with OAC use. Among patients 65 to <78 years old, those undergoing percutaneous LAAO had higher risk of stroke compared with OAC users. No association was present in those ≥78 years., Conclusion: In this analysis of real-world AF patients, percutaneous LAAO versus OAC use was associated with similar risk of death, nonsignificantly elevated risk of stroke, and an elevated risk of bleeding in the post-procedural period. Overall, these results support results of randomized trials that percutaneous LAAO may be an alternative to OAC use for patients with contraindications., (© 2024 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.)

Background: In 2007, congenital cardiac surgery became a recognized fellowship by the American Council of Graduate Medical Education (ACGME). Beginning in 2023, the fellowship transitioned from a 1-year to a 2-year program. Our objective is to provide current benchmarks by surveying current training programs and assessing characteristics contributing to career success., Methods: This was a survey-based study in which tailored questionnaires were distributed to program directors (PDs) and graduates of the ACGME accredited training programs. Data collection included responses to multiple-choice and open-ended questions relevant to didactics, operative training, training center characteristics, mentorship, and employment characteristics. Results were analyzed using summary statistics and subgroup and multivariable analyses., Results: The survey yielded responses from 13 of 15 PDs (86%) and 41 of 101 graduates (41%) from ACGME accredited programs. Perceptions among PDs and graduates were somewhat discordant, with PDs more optimistic than graduates. Of PDs, 77% (n = 10) believed current training adequately prepares fellows and is successful in securing employment for graduates. The responses from graduates demonstrated 30% (n = 12) were dissatisfied with operative experience and 24% (n = 10) with overall training. Being supported during the first 5 years of practice was significantly associated with retention in congenital cardiac surgery and greater practicing case volumes., Conclusions: Dichotomous views exist between graduates and PDs regarding success in training. Mentorship during the early career was associated with increased case volumes, career satisfaction, and retention in the congenital cardiac surgery field. Educational bodies should incorporate these elements during training and after graduation., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Dengue is currently a global concern. The range of dengue vectors is expanding with climate change, yet United States of America (USA) studies on dengue epidemiology and burden are limited. This systematic review sought to characterize the epidemiology and disease burden of dengue within the USA., Methods: Studies evaluating travel-related and endemic dengue in US states and territories were identified and qualitatively summarized. Commentaries and studies on ex-US cases were excluded. MEDLINE, Embase, Cochrane Library, Latin American and Caribbean Center of Health Sciences Information, Centre for Reviews and Dissemination and Clinicaltrials.gov were searched through January 2022., Results: 116 studies were included. In US states, dengue incidence was generally low, with spikes occurring in recent years in 2013-16 (0.17-0.31 cases/100,000) and peaking in 2019 (0.35 cases/100,000). Most cases (94%, n = 7895, 2010-21) were travel related. Dengue was more common in Puerto Rico (cumulative average: 200 cases/100,000, 1980-2015); in 2010-21, 99.9% of cases were locally acquired. There were <50 severe cases in US states (2010-17); fatal cases were even rarer. Severe cases in Puerto Rico peaked in 1998 (n = 173) and 2021 (n = 76). Besides lower income, risk factors in US states included having birds in residence, suggesting unspecified environmental characteristics favourable to dengue vectors. Commonly reported symptoms included fever, headache and rash; median disease duration was 3.5-11 days. Hospitalization rates increased following 2009 World Health Organization disease classification changes (pre-2009: 0-54%; post-2009: 14-75%); median length of stay was 2.7-8 days (Puerto Rico) and 2-3 days (US states). Hospitalization costs/case (2010 USD) were$14 350 (US states),$1764-$5497 (Puerto Rico) and$4207 (US Virgin Islands). In Puerto Rico, average days missed were 0.2-5.3 (work) and 2.5 (school)., Conclusions: Though dengue risk is ongoing, treatments are limited, and dengue's economic burden is high. There is an urgent need for additional preventive and therapeutic interventions., (© International Society of Travel Medicine 2023. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Problem/condition: During 2012-2021, the volume of international travel reached record highs and lows. This period also was marked by the emergence or large outbreaks of multiple infectious diseases (e.g., Zika virus, yellow fever, and COVID-19). Over time, the growing ease and increased frequency of travel has resulted in the unprecedented global spread of infectious diseases. Detecting infectious diseases and other diagnoses among travelers can serve as sentinel surveillance for new or emerging pathogens and provide information to improve case identification, clinical management, and public health prevention and response., Reporting Period: 2012-2021., Description of System: Established in 1995, the GeoSentinel Network (GeoSentinel), a collaboration between CDC and the International Society of Travel Medicine, is a global, clinical-care-based surveillance and research network of travel and tropical medicine sites that monitors infectious diseases and other adverse health events that affect international travelers. GeoSentinel comprises 71 sites in 29 countries where clinicians diagnose illnesses and collect demographic, clinical, and travel-related information about diseases and illnesses acquired during travel using a standardized report form. Data are collected electronically via a secure CDC database, and daily reports are generated for assistance in detecting sentinel events (i.e., unusual patterns or clusters of disease). GeoSentinel sites collaborate to report disease or population-specific findings through retrospective database analyses and the collection of supplemental data to fill specific knowledge gaps. GeoSentinel also serves as a communications network by using internal notifications, ProMed alerts, and peer-reviewed publications to alert clinicians and public health professionals about global outbreaks and events that might affect travelers. This report summarizes data from 20 U.S. GeoSentinel sites and reports on the detection of three worldwide events that demonstrate GeoSentinel's notification capability., Results: During 2012-2021, data were collected by all GeoSentinel sites on approximately 200,000 patients who had approximately 244,000 confirmed or probable travel-related diagnoses. Twenty GeoSentinel sites from the United States contributed records during the 10-year surveillance period, submitting data on 18,336 patients, of which 17,389 lived in the United States and were evaluated by a clinician at a U.S. site after travel. Of those patients, 7,530 (43.3%) were recent migrants to the United States, and 9,859 (56.7%) were returning nonmigrant travelers.Among the recent migrants to the United States, the median age was 28.5 years (range = <19 years to 93 years); 47.3% were female, and 6.0% were U.S. citizens. A majority (89.8%) were seen as outpatients, and among 4,672 migrants with information available, 4,148 (88.8%) did not receive pretravel health information. Of 13,986 diagnoses among migrants, the most frequent were vitamin D deficiency (20.2%), Blastocystis (10.9%), and latent tuberculosis (10.3%). Malaria was diagnosed in 54 (<1%) migrants. Of the 26 migrants diagnosed with malaria for whom pretravel information was known, 88.5% did not receive pretravel health information. Before November 16, 2018, patients' reasons for travel, exposure country, and exposure region were not linked to an individual diagnosis. Thus, results of these data from January 1, 2012, to November 15, 2018 (early period), and from November 16, 2018, to December 31, 2021 (later period), are reported separately. During the early and later periods, the most frequent regions of exposure were Sub-Saharan Africa (22.7% and 26.2%, respectively), the Caribbean (21.3% and 8.4%, respectively), Central America (13.4% and 27.6%, respectively), and South East Asia (13.1% and 16.9%, respectively). Migrants with diagnosed malaria were most frequently exposed in Sub-Saharan Africa (89.3% and 100%, respectively).Among nonmigrant travelers returning to the United States, the median age was 37 years (range = <19 years to 96 years); 55.7% were female, 75.3% were born in the United States, and 89.4% were U.S. citizens. A majority (90.6%) were seen as outpatients, and of 8,967 nonmigrant travelers with available information, 5,878 (65.6%) did not receive pretravel health information. Of 11,987 diagnoses, the most frequent were related to the gastrointestinal system (5,173; 43.2%). The most frequent diagnoses among nonmigrant travelers were acute diarrhea (16.9%), viral syndrome (4.9%), and irritable bowel syndrome (4.1%).Malaria was diagnosed in 421 (3.5%) nonmigrant travelers. During the early (January 1, 2012, to November 15, 2018) and later (November 16, 2018, to December 31, 2021) periods, the most frequent reasons for travel among nonmigrant travelers were tourism (44.8% and 53.6%, respectively), travelers visiting friends and relatives (VFRs) (22.0% and 21.4%, respectively), business (13.4% and 12.3%, respectively), and missionary or humanitarian aid (13.1% and 6.2%, respectively). The most frequent regions of exposure for any diagnosis among nonmigrant travelers during the early and later period were Central America (19.2% and 17.3%, respectively), Sub-Saharan Africa (17.7% and 25.5%, respectively), the Caribbean (13.0% and 10.9%, respectively), and South East Asia (10.4% and 11.2%, respectively).Nonmigrant travelers who had malaria diagnosed were most frequently exposed in Sub-Saharan Africa (88.6% and 95.9% during the early and later period, respectively) and VFRs (70.3% and 57.9%, respectively). Among VFRs with malaria, a majority did not receive pretravel health information (70.2% and 83.3%, respectively) or take malaria chemoprophylaxis (88.3% and 100%, respectively)., Interpretation: Among ill U.S. travelers evaluated at U.S. GeoSentinel sites after travel, the majority were nonmigrant travelers who most frequently received a gastrointestinal disease diagnosis, implying that persons from the United States traveling internationally might be exposed to contaminated food and water. Migrants most frequently received diagnoses of conditions such as vitamin D deficiency and latent tuberculosis, which might result from adverse circumstances before and during migration (e.g., malnutrition and food insecurity, limited access to adequate sanitation and hygiene, and crowded housing,). Malaria was diagnosed in both migrants and nonmigrant travelers, and only a limited number reported taking malaria chemoprophylaxis, which might be attributed to both barriers to acquiring pretravel health care (especially for VFRs) and lack of prevention practices (e.g., insect repellant use) during travel. The number of ill travelers evaluated by U.S. GeoSentinel sites after travel decreased in 2020 and 2021 compared with previous years because of the COVID-19 pandemic and associated travel restrictions. GeoSentinel detected limited cases of COVID-19 and did not detect any sentinel cases early in the pandemic because of the lack of global diagnostic testing capacity., Public Health Action: The findings in this report describe the scope of health-related conditions that migrants and returning nonmigrant travelers to the United States acquired, illustrating risk for acquiring illnesses during travel. In addition, certain travelers do not seek pretravel health care, even when traveling to areas in which high-risk, preventable diseases are endemic. Health care professionals can aid international travelers by providing evaluations and destination-specific advice.Health care professionals should both foster trust and enhance pretravel prevention messaging for VFRs, a group known to have a higher incidence of serious diseases after travel (e.g., malaria and enteric fever). Health care professionals should continue to advocate for medical care in underserved populations (e.g., VFRs and migrants) to prevent disease progression, reactivation, and potential spread to and within vulnerable populations. Because both travel and infectious diseases evolve, public health professionals should explore ways to enhance the detection of emerging diseases that might not be captured by current surveillance systems that are not site based., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

The pursuit for blood a substitute has spanned over a century, but a majority of the efforts have been disappointing. As of today, there is no widely accepted product used as an alternative to human blood in clinical settings with severe anemic condition(s). Blood substitutes are currently also termed oxygen therapeutics. There are two major categories of oxygen therapeutics, hemoglobin-based and perfluorocarbon-based products. In this article, we reviewed the most developed but failed products and products still in active clinical research in the category of hemoglobin-based oxygen carriers. Among all of the discussed hemoglobin-based oxygen therapeutics, HemAssist, PolyHeme, Hemolink, Hemospan, and Hemoximer were discontinued. Hemopure is in clinical use in South Africa and Russia. Oxyglobin, the sister product of Hemopure, has been approved for veterinary use in the European Union and the United States. HemO2life has recently been approved for organ preservation in organ transplantation in the European Union. OxyVita and Sanguinate are still undergoing active clinical studies. The field of oxygen therapeutics seems to be entering a phase of rapid growth in the coming 10-20 years.

Background: Secondhand tobacco smoke (SHS) exposure may reduce heart rate variability and lead to atrial fibrillation (AF); however prior study findings have not been confirmed using objective measures for both SHS and AF events., Methods: We prospectively examined the association between SHS exposure and incident AF in 5731 participants, ages of 45-84 years and free of known AF and other cardiovascular diseases (CVD) at baseline (2000-2002), who were followed through 2015 in the Multi-Ethnic Study of Atherosclerosis (MESA). SHS weekly exposure time was identified by self-report. Urine cotinine was collected in a cohort subset of 3237 current non-smoking cohort participants. AF events were identified using Medicare claims, hospital records, and 12‑lead electrocardiographic findings. A multivariable Cox proportional hazards regression analysis was used with simultaneous adjustment for demographic factors, educational level, health insurance status, active smoking status, tobacco pack-years, traditional CVD risk factors, depressive symptoms and medications., Results: During a median follow-up of 14.0 years, 856 and 452 AF events were identified in the overall and the cohort subset, respectively. No association of SHS exposure time or urine cotinine with incident AF was observed. However, a higher AF risk with greater urine cotinine (8.53-442.0 ng/mL) compared with lower urine cotinine (≤7.07 ng/mL) was observed in never smokers [hazard ratios (HR) and 95% confidence intervals: 1.60 (1.16, 2.19)], but not in former smokers [HR: 0.88 (0.63, 1.23)] (p-value for multiplicative interaction: 0.009 and for additive interaction: 0.017, respectively)., Conclusion: Objectively measured greater SHS exposure expressed by urine cotinine might be associated with 1.6-fold higher risk of incident AF in never smokers., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Although dementia and atrial fibrillation (AF) are common in older adults, risk factors for dementia have not been sufficiently characterized in patients with AF. We studied 621,773 patients with AF without dementia at the time of AF diagnosis who were enrolled in the MarketScan Commercial and Medicare Supplemental databases from 2007 to 2015. Dementia incidence and presence of predictors at the time of AF diagnosis (cardiometabolic conditions, mental and neurologic disorders, and other chronic conditions) were based on International Classification of Diseases, Ninth Revision, Clinical Modification codes in outpatient and inpatient claims, whereas medication usage was based on outpatient pharmacy claims. A frailty score was calculated using a previously established algorithm. The associations between the predictors of interest and dementia were assessed with multivariable Cox models. Patients had a mean age of 68 years (SD 14 years) and 41% were women. During a mean follow-up of 2.0 years, there were 16,073 cases of dementia. The strongest predictors of dementia were frailty (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.40 to 1.45, per 1-SD increase in the score), cognitive impairment (HR 1.50, 95% CI 1.36 to 1.65), mood disorders (HR 1.49, 95% CI 1.32 to 1.70), schizophrenia (HR 1.86, 95% CI 1.75 to 1.98), and substance abuse (HR 1.58, 95% CI 1.39 to 1.80). Among cardiometabolic conditions, only stroke (HR 1.17, 95% CI 1.13 to 1.22) and diabetes mellitus (HR 1.14, 95% CI 1.11 to 1.18) were associated with small increases in dementia risk after adjusting for demographics, frailty, co-morbidities, and medications. We have identified several risk factors for dementia in patients with AF., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The Life's Simple 7 (LS7) metric consists of 7 modifiable health behaviors and measures that are known health factors for cardiovascular wellness. Relatively little is known about the association of LS7 score with cardiac arrhythmias. In the setting of the Multi-Ethnic Study of Atherosclerosis, we studied the LS7 score (range 0 to 14), assessed at the 2010 to 2102 study visit, in relation to cardiac arrhythmias assessed by Zio Patch ambulatory electrocardiographic monitoring in 2016 to 2018. In participants free of clinically recognized cardiovascular disease and atrial fibrillation, we used logistic and linear regression to examine the association of total LS7 score with atrial fibrillation, supraventricular ectopy, and ventricular ectopy. In 1,329 participants in the analysis, the mean (SD) age was 67 (8) years and 48% were men. A more favorable total LS7 score was associated with fewer premature ventricular contractions (PVCs) per hour (ratio of geometric means for optimal [11 to 14] versus inadequate [0 to 7] score 0.52 [95% confidence interval 0.34 to 0.81]). After adjustment for sociodemographic characteristics, the association was attenuated (0.66 [0.43 to 1.01]). =Among the LS7 components, a more favorable body mass index was associated with less ventricular ectopy. We did not detect associations of total LS7 score with atrial arrhythmias. In conclusion, in this longitudinal study of older participants free of clinically recognized cardiovascular disease, there was little evidence of association of the LS7 cardiovascular health score with subclinical cardiac arrhythmias. However, there was a suggestion that a more favorable LS7 score was associated with fewer PVCs and specifically, that a more favorable body mass index was associated with fewer PVCs., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background Long-term data to study recent trends in the incidence of atrial fibrillation (AF), overall and among sex and race groups, are scarce. We evaluated the 30-year trends in the incidence of AF in the ARIC (Atherosclerosis Risk in Communities) study cohort and explored race and sex differences in these trends. Methods and Results We included 15 343 men and women aged 45 to 64 years in 1987 to 1989 without AF from 4 US communities in the ARIC cohort. Incident AF was identified based on study ECGs, hospital discharge codes, and death certificates through 2017. We calculated age and period-specific incidence rates (IRs) of AF. We used Poisson regression to calculate IR ratios of AF over time adjusting for age, sex, and race. A total of 3241 AF cases were identified during a mean (SD) follow-up of 22 years (8.4 years) (599 in Black participants, 2642 in White participants, 1582 in women, and 1659 in men). Overall, the IR of AF in the ARIC cohort was 9.6 per 1000 person-years (6.9 in Black participants, 10.5 in White participants, 8.1 in women, and 11.6 in men). Age-specific IR by time period did not show significant changes over time. In a model adjusted for sex, race, and age group, the rate of AF did not change significantly from 1987 to 1991 compared with 2012 to 2017 (IR ratio, 1.10 [95% CI, 0.88-1.36] comparing 2012-2017 with 1987-1991). Similarly, no evidence of changes over time in AF rates were identified in men and women or White and Black participants separately. Conclusions Even though IRs of AF increase as age increases, our analysis provided evidence suggesting that the overall IRs of AF have not changed over time in a multicenter cohort of Black and White individuals in the United States from 1987 to 2017.

Background: Data are needed on the use of oral anticoagulation in patients with atrial fibrillation (AF) in rural versus urban areas, including the initiation of direct oral anticoagulants (DOACs)., Objective: We used Medicare data to examine rural/urban differences in anticoagulation use in patients with AF., Methods: We identified incident AF in a 20% sample of fee-for-service Medicare beneficiaries (aged ≥ 65 years) from 2011 to 2016 and collected ZIP code and covariates at the time of AF. We identified the first anticoagulant prescription filled, if any, following AF diagnosis. We categorized beneficiaries into four rural/urban areas using rural-urban commuting area codes and used Poisson regression models to compare anticoagulant use., Results: We included 447,252 patients with AF (mean age 79 ± 8 years), of which 82% were urban, 9% large rural, 5% small rural, and 4% isolated. The percentage who initiated an anticoagulant rose from 34% in 2011 to 53% in 2016, paralleling the uptake of DOACs. In a multivariable-adjusted analysis, those in rural areas (vs. urban) were more likely to initiate an anticoagulant. However, rural beneficiaries (vs. urban) were less likely to initiate a DOAC; those in isolated areas were 17% less likely (95% confidence interval [CI] 13-20), those in small rural areas were 12% less likely (95% CI 9-15), and those in large rural areas were 10% less likely (95% CI 8-12)., Conclusion: Among Medicare beneficiaries with AF, anticoagulation use was low but increased over time with the introduction of DOACs. Rural beneficiaries were less likely to receive a DOAC., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Women with atrial fibrillation (AF) experience greater symptomatology, worse quality of life, and have a higher risk of stroke as compared to men, but are less likely to receive rhythm control treatment. Whether these differences exist in elderly patients with AF, and whether sex modifies the effectiveness of rhythm versus rate control therapy has not been assessed., Methods: We studied 135,850 men and 139,767 women aged ≥ 75 years diagnosed with AF in the MarketScan Medicare database between 2007 and 2015. Anticoagulant use was defined as use of warfarin or a direct oral anticoagulant. Rate control was defined as use of rate control medication or atrioventricular node ablation. Rhythm control was defined by use of anti-arrhythmic medication, catheter ablation or cardioversion. We used multivariable Poisson and Cox regression models to estimate the association of sex with treatment strategy and to determine whether the association of treatment strategy with adverse outcomes (bleeding, heart failure and stroke) differed by sex., Results: At the time of AF, women were on average (SD) 83.8 (5.6) years old and men 82.5 (5.2) years, respectively. Compared to men, women were less likely to receive an anticoagulant or rhythm control treatment. Rhythm control (vs. rate) was associated with a greater risk for heart failure with a significantly stronger association in women (HR women = 1.41, 95% CI 1.34-1.49; HR men = 1.21, 95% CI 1.15-1.28, p < 0.0001 for interaction). No sex differences were observed for the association of treatment strategy with the risk of bleeding or stroke., Conclusion: Sex differences exist in the treatment of AF among patients aged 75 years and older. Women are less likely to receive an anticoagulant and rhythm control treatment. Women were also at a greater risk of experiencing heart failure as compared to men, when treated with rhythm control strategies for AF. Efforts are needed to enhance use AF therapies among women. Future studies will need to delve into the mechanisms underlying these differences., (© 2021. The Author(s).)

Plasma proteomic profiling may aid in the discovery of novel biomarkers upstream of the development of atrial fibrillation (AF). We used data from the Atherosclerosis Risk in Communities study to examine the relation between large-scale proteomics and incident AF in a cohort of older-aged adults in the United States. We quantified 4,877 plasma proteins in Atherosclerosis Risk in Communities participants at visit 5 (2011-2013) using an aptamer-based proteomic profiling platform. We used Cox proportional hazards models to assess the association between protein levels and incident AF, and explored relation of selected protein biomarkers using annotated pathway analysis. Our study included 4,668 AF-free participants (mean age 75 ± 5 years; 59% female; 20% Black race) with proteomic measures. A total of 585 participants developed AF over a mean follow-up of 5.7 ± 1.7 years. After adjustment for clinical factors associated with AF, N-terminal pro-B-type natriuretic peptide (NT-proBNP) was associated with the risk of incident AF (hazard ratio, 1.82; 95% CI, 1.68 to 1.98; p, 2.91 × 10 -45 per doubling of NT-proBNP). In addition, 36 other proteins were also significantly associated with incident AF after Bonferroni correction. We further adjusted for medication use and estimated glomerular filtration rate and found 17 proteins, including angiopoietin-2 and transgelin, that remained significantly associated with incident AF. Pathway analyses implicated the inhibition of matrix metalloproteases as the top canonical pathway in AF pathogenesis. In conclusion, using a large-scale proteomic platform, we identified both novel and established proteins associated with incident AF and explored mechanistic pathways of AF development., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To examine associations of cumulative exposure to proton pump inhibitors (PPIs) with total cardiovascular disease (CVD; composed of stroke, coronary heart disease, and heart failure [HF]) and HF alone in a cohort study of White and African American participants of the Atherosclerosis Risk in Communities (ARIC) study., Methods: Use of PPIs was assessed by pill bottle inspection at visit 1 (January 1, 1987 to 1989) and up to 10 additional times before baseline (visit 5; 2011 to 2013). We calculated cumulative exposure to PPIs as days of use from visit 1 to baseline. Participants (n=4346 free of total CVD at visit 5; mean age, 75 years) were observed for incident total CVD and HF events through December 31, 2016. We used Cox regression to measure associations of PPIs with total CVD and HF., Results: After adjustment for potential confounding variables, participants with a cumulative exposure to PPIs of more than 5.1 years had a 2.02-fold higher risk of total CVD (95% CI, 1.50 to 2.72) and a 2.21-fold higher risk of HF (95% CI, 1.51 to 3.23) than nonusers., Conclusion: Long-term PPI use was associated with twice the risk of total CVD and HF compared with nonusers. Our findings are in concordance with other research and suggest another reason to be cautious of PPI overuse., (Copyright © 2021 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)