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The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial was the first randomized prospective study to compare the conventional strategy of 3 weeks of anticoagulation before direct current cardioversion (DCC) for atrial fibrillation (AF) to a transesophageal echocardiography (TEE) guided approach with an expedited course of anticoagulation. This was a multicenter, international study with 70 sites enrolling 1222 patients between 1994-1999. The primary endpoint of composite embolic events and secondary endpoints including bleeding, functional status, prevalence of sinus rhythm, and death were assessed at 8 weeks following randomization. The ACUTE trial demonstrated that the TEE guided approach was safe and effective. There was no difference in the primary outcome of embolic events for the 2 strategies (0.8% TEE group vs. 0.5% conventional group, p =.50). There was a difference between the groups with respect to the number of bleeding events, with minor and major bleeding seen in 2.9% of patients in the TEE guided group and 5.5% in the conventional group (relative risk 0.53, 95% confidence interval 0.30-0.93, p = 0.03). The remaining secondary endpoints did not differ. Clinicians now have a viable alternative approach to cardioversion for patients with AF. Several factors influence the choice of strategies including (1) severity of symptoms and hemodynamic effect; (2) level and chronicity of anticoagulation; (3) risks of bleeding; (4) duration of AF and likelihood of reversion; and (5) risk and likelihood of left atrial thrombi. Future studies, such as ACUTE II are ongoing, with the aim of using low molecular weight heparin to further streamline the TEE guided approach to DCC and shorten hospital stay and costs.

ASHER, C.R., ET AL.: Transesophageal Echocardiography in Patients with Atrial Fibrillation. Over the past decade transesophageal echocardiography (TEE) has become an integral tool in the management of patients with AF. Thrombi can be readily detected and the function of the left atrium and left atrial appendage (LAA) can be easily assessed by this modality. With this knowledge, informed decisions regarding anticoagulation, cardioversion, and the likelihood of restoring and maintaining sinus rhythm can be made. An alternative TEE-guided strategy for achieving sinus rhythm in patients with AF is now available with efficacy and safety similar to the conventional approach. Refinements of this strategy may include the use of low molecular weight heparin to avoid hospitalization in patients planned for cardioversion. Further uses of TEE in patients with AF are in their early stages including evaluation of patients following pulmonary vein radiofrequency ablation and those undergoing percutaneous or surgical closure of the LAA.

STUPEFIED BY MESSAGES OF FEAR, PROPAGANDA AND OUTRIGHT FALSEHOOD, THE CITIZENS OF THE UNITED STATES FOLLOW A LEADERSHIP UNABLE OR UNWILLING TO DISTINGUISH BETWEEN TRUE STRENGTH AND RAW POWER

Although loneliness is a normative experience, there is reason to be concerned about children who are chronically lonely in school. Research indicates that children have a fundamental understanding of what it means to be lonely, and that loneliness can be reliably measured in children. Most of the research on loneliness in children has focused on the contributions of children's peer relations to their feelings of well-being at school. Loneliness in children is influenced by how well accepted they are by peers, whether they are overtly victimized, whether they have friends, and the durability and quality of their best friendships. Findings from this emerging area of research provide a differentiated picture of how children's peer experiences come to influence their emotional well-being.

Are positive illusions about the self adaptive? Controversy surrounding this question can be traced to two features of past research. First, different researchers have used different criteria to assess bias in self-evaluation. Some have relied on normative models, whereas others have relied on social consensus. We identify problems associated with each of these subjective methods and suggest the use of objective or operational criteria. Second, bias in self-evaluation can result from different motivations. In some cases, overly positive self-reports may reflect self-protective or avoidance motivations, whereas in other cases they may reflect self-enhancement or approach motivations. We argue that it is not the level of self-evaluation bias, per se, that determines whether such bias is associated with positive or negative consequences. Instead, consequences are related to the specific motivation underlying this bias. Two studies examine these issues in the context of self-evaluation and academic performance in college.

The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial compared cardioversion following transesophageal echocardiography (TEE) against conventional management of atrial fibrillation (ie, cardioversion following 3 weeks of anticoagulation) in patients scheduled to undergo electrical cardioversion.

OBJECTIVE: We sought to assess whether aortic valve replacement (AVR) among patients with severe aortic stenosis (AS), severe left ventricular (LV) dysfunction and a low transvalvular gradient (TVG) is associated with improved survival. BACKGROUND: The optimal management of patients with severe AS with severe LV dysfunction and a low TVG remains controversial. METHODS: Between 1990 and 1998, we evaluated 68 patients who underwent AVR at our institution (AVR group) and 89 patients who did not undergo AVR (control group), with an aortic valve area < or = 0.75 cm(2), LV ejection fraction < or = 35% and mean gradient < or = 30 mm Hg. Using propensity analysis, survival was compared between a cohort of 39 patients in the AVR group and 56 patients in the control group. RESULTS: Despite well-matched baseline characteristics among propensity-matched patients, the one- and four-year survival rates were markedly improved in patients in the AVR group (82% and 78%), as compared with patients in the control group (41% and 15%; p < 0.0001). By multivariable analysis, the main predictor of improved survival was AVR (adjusted risk ratio 0.19, 95% confidence interval 0.09 to 0.39; p < 0.0001). The only other predictors of mortality were age and the serum creatinine level. CONCLUSIONS: Among select patients with severe AS, severe LV dysfunction and a low TVG, AVR was associated with significantly improved survival.

In a recent EPR study, Gross et al. (B. Gross, H. Dilger, R. Scheuermann, M. Pach and E. Roduner, J. Phys. Chem. A, 2001, 105, 10012) found that hydrogen atoms trapped in silasesquioxanes unexpectedly exhibit g-values significantly larger than the free-electron value, with an appreciable dependence on the external substituents of the cage. Here it is shown by density functional calculations and detailed analyses of the g-values that (a) the positive g-shifts are predominantly due to spin–orbit coupling from the cage oxygen atoms; (b) in second-order perturbation theory the g-shifts arise mainly from couplings of t1g oxygen-based cage orbitals to the a1g singly occupied molecular orbital, and (c) the reduction of the g-shifts by external substituents is mainly caused by lower spin density on the cage oxygen atoms, due in part to reduced delocalization of the singly occupied MO onto the cage. Calculations with the hydrogen atom displaced from the center of the cage provide explanations for the negligible temperature dependence of the g-values compared to an experimentally notable dependence of the hyperfine couplings. Large direct halogen spin–orbit contributions and negative g-shifts are predicted for systems with heavy halogen atoms as external substituents. Comparison of different exchange-correlation functionals, and of spin-restricted and -unrestricted calculations reveals unexpected trends for spin density distribution and g-values: Spin polarization increases the computed g-shifts, whereas the admixture of Hartree–Fock exchange in hybrid functionals decreases them.

Patients with prosthetic heart valves require regular examinations and echocardiograms, antithrombotic therapy, and appropriate antibiotic prophylaxis against endocarditis. Physicians must also be on the alert for several uncommon but potentially devastating complications: valve structural failure, thrombosis, embolism, endocarditis, paravalvular leak, and hemolytic anemia.

Background Treatment options for wild-type BRAF melanoma patients remain limited. Selumetinib, a MEK 1/2 inhibitor, suppresses pERK levels independent of BRAF and NRAS mutation status, and combination with docetaxel has demonstrated synergy in xenograft models. The aim of this study was to assess the efficacy and safety of selumetinib plus docetaxel as first-line treatment in patients with wild-type BRAF advanced melanoma. Patients and methods In this double-blind multicentre phase II trial patients with wild-type BRAF melanoma were randomized (1:1) to docetaxel with selumetinib or placebo. Docetaxel 75 mg/m2 was administered intravenously every 3 weeks up to six cycles. Selumetinib 75 mg or placebo was given orally twice daily until disease progression or unacceptable toxicity. The primary end point was progression-free survival (PFS). Tumour NRAS mutation status was analysed retrospectively and correlated with treatment outcomes. Results Eighty-three patients were randomized to docetaxel plus selumetinib (n = 41) or docetaxel plus placebo (n = 42). The PFS hazard ratio (HR) (selumetinib:placebo) was 0.75 [90% confidence interval (CI) 0.50–1.14; P = 0.130], with a median PFS of 4.23 months (90% CI 3.63–6.90) for docetaxel plus selumetinib and 3.93 months (90% CI 2.07–4.16) for docetaxel alone. There was no significant difference in overall survival. The objective response rate was 32% with selumetinib versus 14% with placebo (P = 0.059). In a retrospective subset analysis, NRAS mutation status did not affect significantly upon clinical outcomes in either arm. The combination of docetaxel and selumetinib could be administered effectively to patients with metastatic melanoma, although the combination was less well tolerated than docetaxel alone. Conclusions The combination of docetaxel with selumetinib showed no significant improvement in PFS compared with docetaxel alone, although more patients showed a response to combination therapy. We found no evidence to support using tumour NRAS mutation as a basis for selecting patients for combined MEK inhibitor and chemotherapy. Clinical trial DOC-MEK (EudraCT no: 2009-018153-23).

The purposes of this study were to learn whether children’s beliefs about the legitimacy of aggression can be reliably assessed and whether these beliefs relate to children’s everyday social behavior with peers, as well as their responses to hypothetical ambiguous provocation situations. Fourth- and fifth-grade students (n = 781) responded to a 16-item questionnaire designed to measure children’s beliefs about the legitimacy of aggression. Children’s behavioral orientation was assessed using two methods: (1) children’s responses to ten hypothetical situations involving ambiguous provocation, and (2) peer evaluations of children’s aggressive, withdrawn, and prosocial behavior. Results indicated that children’s beliefs about the legitimacy of aggression were reliably measured. Furthermore, results from both measures of behavioral style showed that children who believed strongly in the legitimacy of aggression were more aggressive, less withdrawn, and less prosocial. The findings suggest that one focus of efforts to decrease children’s aggression should be the modification of their beliefs about the legitimacy of aggressive actions.

Background —Cardiac papillary fibroelastoma (CPF) is a primary cardiac neoplasm that is increasingly detected by echocardiography. The clinical manifestations of this entity are not well described. Methods and Results —In a 16-year period, we identified patients with CPF from our pathology and echocardiography databases. A total of 162 patients had pathologically confirmed CPF. Echocardiography was performed in 141 patients with 158 CPFs, and 48 patients had CPFs that were not visible by echocardiography ( Conclusions —CPFs are generally small and single, occur most often on valvular surfaces, and may be mobile, resulting in embolization. Because of the potential for embolic events, symptomatic patients, patients undergoing cardiac surgery for other lesions, and those with highly mobile and large CPFs should be considered for surgical excision.

Objectives: We sought to develop and validate a model that estimates the risk of obstructive coronary artery disease in patients undergoing operations for mitral valve degeneration and to demonstrate its potential clinical utility. Methods: A total of 722 patients (67% men; age, 61 ± 12 years) without a history of myocardial infarction, ischemic electrocardiographic changes, or angina who underwent routine coronary angiography before mitral valve prolapse operations between 1989 and 1996 were analyzed. A bootstrap-validated logistic regression model on the basis of clinical risk factors was developed to identify low-risk (≤5%) patients. Obstructive coronary atherosclerosis was defined as 50% or more luminal narrowing in one or more major epicardial vessels, as determined by means of coronary angiography. Results: One hundred thirty-nine (19%) patients had obstructive coronary atherosclerosis. Independent predictors of coronary artery disease include age, male sex, hypertension, diabetes mellitus,and hyperlipidemia. Two hundred twenty patients were designated as low risk according to the logistic model. Of these patients, only 3 (1.3%) had single-vessel disease, and none had multivessel disease. The model showed good discrimination, with an area under the receiver-operating characteristic curve of 0.84. Cost analysis indicated that application of this model could safely eliminate 30% of coronary angiograms, corresponding to cost savings of $430,000 per 1000 patients without missing any case of high-risk coronary artery disease. Conclusion: A model with standard clinical predictors can reliably estimate the prevalence of obstructive coronary atherosclerosis in patients undergoing mitral valve prolapse operations. This model can identify low-risk patients in whom routine preoperative angiography may be safely avoided. (J Thorac Cardiovasc Surg 2001;121:894-901)

To validate a previously proposed simplified proximal flow convergence method for calculating mitral regurgitant orifice area (ROA), a prospective study was conducted in ambulatory patients and in patients undergoing open heart surgery. Assuming a pressure difference between the left ventricle and left atrium of approximately 100 mm Hg (jet velocity [v(p)] 500 cm/s) and setting the color aliasing velocity (v(a)) to 40 cm/s, we simplified the conventional proximal convergence method formula (ROA = 2pi(r2)v(a)/v(p)) to r2/2, where r is the radius of the proximal convergence isovelocity hemisphere. For 57 ambulatory patients with a wide range of mitral regurgitant severity (1 to 4+), ROA was calculated by the conventional (x) and simplified (y) methods, demonstrating excellent accuracy (r = 0.92; P

Previous studies have reported the clinical and echocardiographic findings of patients with left atrial spontaneous echo contrast (SEC) and thrombi. We sought to study these characteristics in patients with right atrial SEC and thrombi.We reviewed 580 consecutive patients from the ACUTE (Assessment of Cardioversion Using Transesophageal Echocardiography) Registry and found 79 patients (14%, aged 67 +/-13 years, 67 male) with transesophageal echocardiography (TEE) findings of right atrial SEC or thrombi (group 1). This group was compared with a control group of 75 consecutive patients (group 2) (aged 68 +/- 13 years, P = not significant; 49 male, P.005) from the registry with no TEE findings of SEC or thrombi in the left or right atrium.Atrial fibrillation was present in 60 of 79 group 1 patients (76%). Five right atrial (6%) and 11 left atrial (14%) thrombi were identified. Both left ventricular ejection fraction (39% +/- 16% versus 47% +/- 14%; P =.0005) and presence of right ventricular dysfunction (n = 44 versus 18; P =.0001) differed significantly between groups 1 and 2, respectively. Right atrial area (24 +/- 6 cm(2) versus 22 +/- 6 cm(2); P = .02) was larger in patients in group 1. Left atrial SEC was present in 68 of 79 group 1 patients (86%). Patients with right atrial thrombi and right atrial SEC had a longer duration of arrhythmia (524 +/-812 days versus 147 +/-368 days, P.05) than patients with right atrial SEC only.Right atrial SEC has a prevalence of 14% in patients with atrial arrhythmia who undergo TEE-guided cardioversion. Right atrial thrombi are a rare finding and were seen in fewer than 1% (5/580) of patients with atrial arrhythmia. Right atrial thrombi among patients on anticoagulation therapy were not associated with clinically significant pulmonary embolism.

Identification of thrombus-related mechanical prosthetic valve dysfunction (MPVD) has important therapeutic implications. We sought to develop an algorithm, combining clinical and echocardiographic parameters, for prediction of thrombus-related MPVD in a series of 53 patients (24 men, age 52 +/- 16 years) who had intraoperative diagnosis of thrombus or pannus from 1992 to 1997. Clinical and echocardiographic parameters were analyzed to identify predictors of thrombus and pannus. Prevalence of thrombus and diagnostic yields relative to the number of predictors were determined. There were 22 patients with thrombus, 19 patients with pannus, and 12 patients with both. Forty-two of 53 masses were visualized using transesophageal echocardiography (TEE), including 29 of 34 thrombi or both thrombi and panni and 13 of 19 isolated panni. Predictors of thrombus or mixed presentation include mobile mass (p = 0.009), attachment to occluder (p = 0.02), elevated gradients (p = 0.04), and an international normalized ratio ofor = 2.5 (p = 0.03). All 34 patients with thrombus or mixed presentation hador = 1 predictor. The prevalence of thrombus in the presence ofor = 1, 2, andor = 3 predictors is 14%, 69%, and 91%, respectively. Thus, TEE is sensitive in the identification of abnormal mass in the setting of MPVD. An algorithm based on clinical and transesophageal echocardiographic predictors may be useful to estimate the likelihood of thrombus in the setting of MPVD. In the presence ofor = 3 predictors, the probability of thrombus is high.

BACKGROUND: Transesophageal echocardiography (TEE) is the gold standard for evaluation of the left atrium and the left atrial appendage (LAA) for the presence of thrombi. Anticoagulation is conventionally used for patients with atrial fibrillation to prevent embolization of atrial thrombi. The mechanism of benefit and effectiveness of thrombi resolution with anticoagulation is not well defined. METHODS AND RESULTS: We used a TEE database of 9058 consecutive studies performed between January 1996 and November 1998 to identify all patients with thrombi reported in the left atrium and/or LAA. One hundred seventy-four patients with thrombi in the left atrial cavity (LAC) and LAA were identified (1.9% of transesophageal studies performed). The incidence of LAA thrombi was 6.6 times higher than LAC thrombi (151 vs 23, respectively). Almost all LAC thrombi were visualized on transthoracic echocardiography (90.5%). Mitral valve pathology was associated with LAC location of thrombi (P

Background . Atrial pacing is often used empirically to suppress atrial ectopy and prevent atrial fibrillation after coronary artery bypass grafting. Methods . To determine whether atrial overdrive pacing reduces atrial fibrillation and atrial ectopy after coronary artery bypass grafting, 100 patients were randomized to no atrial pacing (Control) versus AAI pacing at 10 beats/min or more above the resting heart rate (Paced), started by postoperative day 1 and continued through day 4. Major end points were new atrial fibrillation and frequency of atrial ectopy during the first 4 days after coronary artery bypass grafting. Results . Atrial fibrillation occurred by day 4 in 13 of 51 (25.5%) Paced and in 14 of 49 (28.6%) Control patients, p = 0.90. Control patients who developed atrial fibrillation had significantly more atrial ectopy than those who did not. Atrial ectopy was paradoxically more frequent in the Paced group (2,106 ± 428 versus 866 ± 385 per 24 hours, p = 0.0001). Loss of capture, sensing, and consistent atrial pacing occurred frequently during atrial pacing. Conclusions . Contrary to prevailing opinion and practice, postoperative atrial overdrive pacing significantly increases atrial ectopy and does not reduce the likelihood of atrial fibrillation.

Chronic severe mitral regurgitation is a surgically correctable disorder. Advances in cardiac surgery (including mitral valve repair and less invasive operations), a low postoperative complication rate, and improved long-term prognosis have reduced the threshold for surgical referral. Choosing the optimal timing for surgery remains the cardinal problem. Clinical and diagnostic imaging information is essential to the detection of occult myocardial decompensation, for which surgical correction should be sought. Surgery is not generally recommended in asymptomatic patients without signs of progressive disease. The final decision regarding timing of surgery should be made based on all the clinical data, the patient's choice, and the available surgical expertise. The use of medical therapy to delay the time to surgery is not supported by large trials; however, small short-term studies of chronic vasodilator therapy show favorable hemodynamic effects.

Background Disparities in prognosis for black and white patients with coronary heart disease have been widely reported. For several reasons it is unclear to what extent biologic factors contribute to these differences. Methods The current medical literature regarding the pathophysiologic characteristics of cardiovascular disease is reviewed with emphasis on how racially mediated biologic differences may affect the manifestation, treatment, and prognosis of patients with coronary heart disease, particularly patients with acute coronary syndromes. Results Black patients with coronary heart disease have a higher prevalence of ischemic heart disease risk factors, including hypertension, left ventricular hypertrophy, diabetes, and tobacco use. Other factors related to atherosclerosis, vascular reactivity, and thrombolysis that quantitatively and functionally differ among racial groups are identified. Prospective, randomized trials comparing outcomes among patients with acute coronary syndromes have included only a fraction of the available black population, although they reveal a similar short-term mortality rate for black and white patients. Several factors, including enhanced fibrinolysis among black patients with acute myocardial infarction, may in part counterbalance better understood and more prevalent comorbidities to equalize short-term (30-day) survival. All-cause, long-term (1-year) mortality appears worse for black patients compared with white patients with similar cardiovascular risk profiles. Conclusion As racially mediated biologic differences between black and white patients become better understood, targeted interventions to prevent coronary heart disease and treat acute coronary syndromes in black patients can be developed. (Am Heart J 1999;138:1073-81.)

Developing a more comprehensive understanding of social competence and the reasons for social relationship difficulties requires attention to the kinds of goals children are pursuing in specific social situations. In this article, the authors describe several theoretical models of social information processing, each of which includes goals as a crucial component in motivating children's behavior. The authors also review evidence from studies of children who are aggressive, withdrawn/submissive, or prosocial that points to an association between children's goals, their strategies for coping with problematic social tasks, and their ultimate success or failure in social relationships. Attention is also given to various social-cognitive processes that may be linked to children's tendencies to formulate adaptive versus maladaptive goals. Finally, the implications of a social goals perspective for interventions with children with emotional and behavioral problems is discussed.

The minimally invasive procedure is a new surgical technique that uses a small sternal incision. Because of limited surgical exposure, removal of intracavitary air and visual assessment of cardiac function are not possible. We studied the utility of intraoperative transesophageal echocardiography (IOE) before and after cardiopulmonary bypass in 112 patients (mean age 53.1 ± 15.2 years, 74 males) who underwent minimally invasive valvular surgery. Surgical procedures included 52 isolated mitral valve procedures (49 repairs, 3 prostheses), 58 isolated aortic valve procedures (16 repairs, 26 prostheses, 16 homografts), and 2 combined aortic and mitral valve repairs. Prepump IOE was useful to confirm valve dysfunction and assist determination of arterial cannulation site. Postpump IOE identified intracardiac air in all patients, which was defined as extensive in 58 (52%) cases. Postoperatively, new left ventricular dysfunction was noted in 22 (20%) patients, more often in the group with extensive air by IOE (17 [30%] of 58 patients) compared with those without extensive air (5 [10%] of 54 patients, P = .01). Second pump runs were required in 7 (6%) of 112 patients: 3 cases of residual aortic regurgitation, 1 case of residual mitral regurgitation, and 3 cases with new ventricular dysfunction. No deaths occurred. We conclude that IOE is essential in minimally invasive valvular surgery because it detects problems that require immediate remedy. IOE allows real-time assessment of ventricular filling, ventricular and valvular function, and intracardiac air. (J Am Soc Echocardiogr 1999;12:231-6.)

Children with Language disorders boom higher than average rates of peer relationship problems, suggesting that they are also AC risk far loneliness, A review or research on loneliness as an emotional consequence of peer relationship difficulties in childhood is preceded by a discussion of the Funicular relevance of this literature for children with language difficulties. Evidence from research on loneliness indicates the peer acceptance participation in friendship, friendship quality, and victimization by peers each contribute to children’s feelings of loneliness at school. Suggestions are made concerning intervention efforts to reduce loneliness for children with language problems.

Little is known about the skills required for friendship, as distinct from those required for peer acceptance. The present study examined whether children's goals and strategies in friendship conflict situations are predictive of their friendship adjustment, after accounting for level of peer acceptance. Fourth- and 5th-grade children (N = 696) responded to 30 hypothetical situations in which they were having a conflict with a friend. Results indicated that children's goals were highly related to their strategies and that children's goals and strategies were predictive of their real-life friendship adjustment. Pursuing the goal of revenge toward a friend was the goal or strategy most strongly associated with lacking friends and having poor-quality friendships. Gender differences were also found for each goal and strategy, with girls displaying a more prosocial goal and strategy orientation than boys.

Objectives: We aimed to evaluate left atrial appendage (LAA) exclusion in patients undergoing mitral valve surgery with respect to thromboembolic events. Background: LAA is the predominant source of emboli in patients with atrial fibrillation. Prophylactic LAA exclusion at the time of heart surgery has been recommended to reduce the risk of future thromboembolism. Methods: An observational cohort of 136 patients undergoing LAA exclusion during mitral valve surgery was identified between May 1993 and November 1998 at our institution. Results: During a mean follow-up of 3.6 ± 1.3 years, there were 14 (12.3%) thromboembolic events. Compared with patients who received warfarin upon hospital discharge, there were more thromboembolic events in patients not prescribed warfarin upon hospital discharge (n = 7/67, 10% vs n = 6/40, 15%, respectively). The warfarin status was not known for one patient. The majority of thromboembolic events (n = 10/14, 71%) occurred in those who underwent mitral valve repair. Conclusion: In this observational study, patients who undergo LAA exclusion during mitral valve surgery to reduce the risk of thromboembolism have a significant incidence of thromboembolic events, especially when warfarin therapy is not prescribed upon hospital discharge.

Atrial fibrillation (AF) commonly develops after cardiac valvular surgery. The objective of this study was to identify risk factors for postoperative AF following valvular surgery. A cohort of 915 consecutive adult patients undergoing isolated valvular surgery with preoperative sinus rhythm was analyzed. Univariate and independent multivariate risk factors for postoperative AF were determined. A second cohort of 305 patients with the same inclusion criteria was used to validate the multivariate predictors. Patients studied had a mean age of 56.1 +/- 14.7 years, 57.9% were men, 79.6% had a normal left ventricular ejection fraction, and their mean left atrial size was 46.2 +/- 9.3 mm. The incidence of postoperative AF was 36.7%. Independent predictors of postoperative AF included: advanced age (odds ratio [OR] 1.506 per decade, 95% confidence interval, [CI] 1.35 to 1.68, p = 0.0001); mitral stenosis (OR 2.066, CI 1.21 to 3.52, p = 0.0077); left atrial enlargement (OR 1.468, CI 1.07 to 2.01, p = 0.0165); use of systemic hypothermia (OR 0.572, CI 0.422 to 0.776, p = 0.0003); and a history of cardiac surgery (OR 0.676, CI 0.465 to 0.981, p = 0.0393). Among these variables, advanced age, mitral stenosis, and left atrial enlargement were confirmed as independent risk factors in the validation cohort.

Our objective was to assess gender differences in mortality 1 year after acute myocardial infarction (MI). The Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occl...

NMR spin-spin couplings through a hydrogen bond in the free-base and protonated forms of the complete series of [(15)N2]-N-methylated 1,8-diaminonaphthalenes have been analyzed using quantum chemistry tools. The dominating role of the overlap of the coupling pathway orbitals has been demonstrated. The correlation of the sum of the (13)C NMR shifts of the naphthalene ring C(1,8) carbons directly attached to the interacting nitrogens with the J(N-N) values and the degree of methylation found earlier by G. C. Lloyd-Jones et al. [Chem.-Eur. J. 2003, 9, 4523] have been reexamined. It has been found that the correlations of J(N-N) and [ΔΣC(1,8)] with the degree of methylation have different reasons. While the former is mostly connected with the structural changes due to the solvent effect, the latter is attributed to the changes in the paramagnetic contributions from the C-N and C-C bonds caused by the replacement of a hydrogen by a methyl group.

This study examined whether children who vary in their behavioral responses (aggression vs. withdrawal vs. problem solving) to ambiguous provocation but who are similar in their attributional processes differ in their social goals and self-efficacy perceptions. In response to 10 hypothetical situations involving ambiguous provocation, fourth- and fifth-grade students (n = 781) indicated whether or not the protagonist intended to cause the harm and reported how they would respond to the protagonist's action. Newly developed measures assessed children's situated social goals and self-efficacy perceptions. Results indicated that the aggressive, withdrawn, and problem-solving responders differed in their social goals and self-efficacy perceptions. The strength of the findings, compared to earlier work on children's goals and self-efficacy perceptions, suggests the importance of a situated social-cognitive assessment in which children's thoughts are measured in a specific kind of social situation and are related to their reported behavior in the same type of situation.

Real-time 3-dimensional echocardiography was performed in 10 patients with obstructive hypertrophic cardiomyopathy (HC) before and after myectomy and in 6 controls. The exact location of systolic anterior motion of the mitral leaflet was shown in all patients with HC with a predominant involvement of the medial portion in 4 patients and the middle portion in 6 patients. The smallest area of the left ventricular outflow tract was significantly smaller in patients with HC than in controls (1.4 +/- 0.7 vs 5.1 +/- 1.2 cm(2), p0.01), significantly increased after myectomy (4.8 +/- 1.8 cm2, p0.01) and was associated with a reduction of the pressure gradient at rest from 63 +/- 41 to 15 +/- 5 mm Hg (p0.01).

The baseline characteristics, complications, and survival of 489 black and 6,890 non-black patients with acute coronary syndromes were studied. Important racial differences were observed in demographic features, atherosclerosis risk factors, and treatment strategies; however, despite these differences, no independent difference was observed in clinical outcomes according to race. The 1-year mortality rate was 2.9% for black patients and 2.5% for non-black patients (p = 0.93).

Aims: To determine the prognostic value of SLNB in patients with thick melanoma in terms of overall survival (OS) and recurrence-free survival (RFS). Methods: 136 patients with primary tumours (Breslow thickness ≥4.0 mm) underwent SLNB. OS and RFS were calculated and a multivariate Cox regression model used to determine the important prognostic factors for predicting OS and RFS. Results: Median Breslow thickness was 5.5 mm and 60% were ulcerated. Median follow up was 4 years (95% CI = 4-5) with 54 patients having died at the time of analysis. 5-year OS for SLNB positive patients was 32%, compared to 78% for negative patients. The significant predictors of poorer OS were increasing age (p = 0.03), increasing Breslow thickness (p = 0.03) and SLNB positivity (p < 0.0001). 5 year RFS was significantly worse in the SLNB positive population compared to the negative patients (p < 0.0001); 27% versus 66% respectively. Conclusions: Patients with a thick melanoma and a positive SLNB have a significantly worse RFS and OS compared to those with a negative SLNB. Over three-quarters of patients with a negative SLNB survived five years. These findings have implications for the subpopulations included in adjuvant therapy trials and we advocate SLNB be recommended in patients with thick melanomas. © 2012 Elsevier Ltd. All rights reserved.

The risk factors for aortic and mitral valve diseases that require surgical repair such as congenital bicuspid aortic valve (BAV) and mitral valve prolapse include acquired clinical factors and genetic influences. Whether race affects the prevalence of certain valvular diseases has not been sufficiently investigated. Through the Cleveland Clinic's Cardiovascular Information Registry, we evaluated the data from 40,419 patients who had undergone aortic valve surgery, mitral valve surgery, and/or coronary artery bypass grafting from 1993 to 2007. Of these patients, 38,366 were white and 2,053 were black. The prospective evaluation of valvular disease was coded, identifying the etiology and morphology by echocardiographic, surgical, and pathologic inspection. At baseline, compared to white patients, the black patients were younger, more often women, had a greater body mass index, and a greater prevalence of hypertension, diabetes, tobacco use, and renal disease. The prevalence of congenital BAV and mitral valve prolapse was considerably lower in blacks than in whites (9% vs 25%, p0.001, and 27% vs 52%, p0.001, respectively), as was the presence of calcific aortic stenosis (14% vs 28%; p0.001), pathologically determined aortic valve calcium (50% vs 67%; p0.001), and mitral valve chordal rupture (13% vs 31%; p0.001). In conclusion, in the present large surgical series, the valve etiologies and morphology differed among blacks and whites. Despite an adverse cardiovascular risk profile, blacks had a significantly lower prevalence of valvular calcium and degeneration than did the whites and a lower prevalence of congenital BAV and mitral valve prolapse. Our findings offer insight into the influence of race on the development of mitral valve disease and congenital BAV.

Loneliness is a sad, even painful emotional experience that is thought to result from deficiencies in the quantity or quality of one's social relationships. Assessments of loneliness have evolved to typically include diverse item content that assesses the causes of loneliness as well as the emotional experience of loneliness itself. This embedding of hypothesized causes in the assessment of loneliness creates pervasive problems in drawing valid conclusions from empirical research on loneliness. In this chapter, we review major historical and contemporary perspectives on loneliness and then describe how widely used assessments have led to the development of a literature in which key questions about the causes of loneliness, the influence of gender on the experience of loneliness, and the developmental course of loneliness remain unanswered. We argue for the use of loneliness assessments that focus purely on the emotional experience of loneliness without including hypothesized causes.

Loneliness is a sad, even painful emotional experience that is thought to result from deficiencies in the quantity or quality of one's social relationships. Assessments of loneliness have evolved to typically include diverse item content that assesses the causes of loneliness as well as the emotional experience of loneliness itself. This embedding of hypothesized causes in the assessment of loneliness creates pervasive problems in drawing valid conclusions from empirical research on loneliness. In this chapter, we review major historical and contemporary perspectives on loneliness and then describe how widely used assessments have led to the development of a literature in which key questions about the causes of loneliness, the influence of gender on the experience of loneliness, and the developmental course of loneliness remain unanswered. We argue for the use of loneliness assessments that focus purely on the emotional experience of loneliness without including hypothesized causes.

Background. It has been observed that African American race is associated with a lower prevalence of atrial fibrillation (AF) compared to Caucasian race. To better quantify the association between African American race and AF, we performed a meta-analysis of published studies among different patient populations which reported the presence of AF by race. Methods. A literature search was conducted using electronic databases between January 1999 and January 2011. The search was limited to published studies in English conducted in the United States, which clearly defined the presence of AF in African American and Caucasian subjects. A meta-analysis was performed with prevalence of AF as the primary endpoint. Results. In total, 10 studies involving 1,031,351 subjects were included. According to a random effects analysis, African American race was associated with a protective effect with regard to AF as compared to Caucasian race (odds ratio 0.51, 95% CI 0.44 to 0.59, 𝑃 < 0 . 0 0 1 ). In subgroup analyses, African American race was significantly associated with a lower prevalence of AF in the general population, those hospitalized or greater than 60 years old, postcoronary artery bypass surgery patients, and subjects with heart failure. Conclusions. In a broad sweep of subjects in the general population and hospitalized patients, the prevalence of AF in African Americans is consistently lower than in Caucasians.

The correlation between formal coronary artery calcium scoring (CACS) determined by multi-detector CT (MDCT) and the presence of coronary calcium on standard non-gated CT chest examinations was evaluated. In 163 consecutive healthy participants, we performed screening same-day standard non-gated, non-enhanced CT chest exams followed by high-resolution, ECG-synchronized MDCT exams for CACS. For the standard CT examinations, a scoring system (Weston score, range 0-12) was developed assigning a score (0-3) for each coronary vessel including the left main trunk. Overall, 30% and 39% of patients had CAC on standard CT and MDCT exams, respectively (P = 0.13). CAC on standard CT was highly correlated to the Agatston CACS on the MDCT (Spearman correlation coefficient 0.83, P0.001). Absence of calcium on the standard CT exam was associated with a very low CACS (mean Agatston 0.5, range 0-19). A Weston score2 identified a CACS100 with an area under the curve of 0.976, sensitivity of 100%, and specificity of 85%. A Weston score7 identified a CACS400 with an area under the curve of 0.991, sensitivity of 100%, specificity of 98%. The intra-observer variability was low as was the inter-observer variability between a cardiac specialized radiologist and a non-specialized reader. A visual coronary artery scoring system on standard, non-gated CT correlates well with traditional methods for CACS. Further, a non-expert cardiac radiologist performed equally well to a cardiac expert. This information suggests that a visual scoring system, at least in a descriptive manner can be utilized for a general statement about coronary artery calcification seen on standard CT imaging to guide clinicians in risk stratification.

A method for flow-through purification of viruses and virus like nano-particles using a combination of binding and size-exclusion chromatography was developed. This technique relies on minimizing the external surface area per unit volume available for virus binding by increasing the mean diameter of the beads used in the column. At the same time the impurity binding capacity of the column is maximized by utilizing beads with multiple functionalities of the optimum size. Purification of different types of viruses and virus-like-particles could be achieved using this technique. Flow-through purification of influenza virus using this technique yielded virus recoveries greater than 70-80% coupled with impurity removal greater than 80%. Finally an approach to optimize and facilitate process development using this technology is presented. Since the impurity binding occurs via a non-specific mechanism and virus recovery is achieved through reduced surface area, the technique is not limited to specific types of viruses and offers the potential as a universal purification tool.

The distinction between friendship adjustment and acceptance by the peer group was examined. Third- through 5th-grade children (N = 881) completed sociometric measures of acceptance and friendship, a measure of loneliness, a questionnaire on the features of their very best friendships, and a measure of their friendship satisfaction. Results indicated that many low-accepted children had best friends and were satisfied with these friendships. However, these children's friendships were lower than those of other children on most dimensions of quality. Having a friend, friendship quality, and group acceptance made separate contributions to the prediction of loneliness

A dangerous interaction can arise if the culprit drug is overlooked because it is part of a combination product.