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Introduction: A hybrid convergent approach (endocardial and epicardial ablation) demonstrated superior effectiveness in a recent randomized study for long‐standing persistent atrial fibrillation (LSPAF). Yet, there is a lack of real‐world, long‐term evidence as to which patients are best candidates for a hybrid convergent approach compared to standard endocardial cryoballoon pulmonary vein isolation (CB PVI). Methods and Results: This single‐center, retrospective analysis spanning from 2010 to 2015 compared two distinctly different atrial fibrillation (AF) cohorts; one treated with stand‐alone cryoablation and one treated with a hybrid convergent approach. Baseline characteristics described candidates for each approach. The following criteria were utilized to determine CB PVI candidacy: (1) paroxysmal AF (PAF) (stage 3A) with failed class I/III antiarrhythmic drug (AAD) or (2) persistent/LSPAF (stage 3B/3C/3D) with failed class I/III AAD unwilling to undergo hybrid procedure. Selection criteria for the hybrid procedure included: (1) PAF refractory to both class I/III AAD and prior CB PVI (stage 3D) or (2) persistent/LSPAF (stage 3B/3C/3D) with failed class I/III AAD agreeable to hybrid procedure. Prior sternotomy was excluded. Serial electrocardiograms and continuous monitoring evaluated primary efficacy outcome of time‐to‐first recurrence of atrial arrhythmia after a 90‐day blanking period. Secondary outcomes were procedure‐related complications and AAD use (at discharge, 12, and 36 months). Kaplan‐Meier methods evaluated arrhythmia recurrence. Of 276 patients, 197 (64.2 ± 10.6 years old; 66.5% male; 74.1% 3A‐PAF; 18.3% 3B/3D‐persistent AF; 1.0% 3C‐LSPAF; 6.6% undetermined) underwent CB PVI and 79 (61.4 ± 8.1 years old; 83.5% male; 41.8% 3D‐PAF; 45.5% 3B/3D‐persistent AF; 12.7% 3C/3D‐LSPAF) underwent hybrid procedure. Arrhythmia freedom through 36 months was 55.2% for CB PVI and 50.4% for hybrid (p =.32). Class I AAD utilization at discharge occurred in 38 (19.3%) patients in the CB PVI group and 5 (6.3%) patients in the hybrid group (p =.01). CB PVI class I AAD utilization at 12 months occurred in 14 (9.0) patients versus 0 patients for hybrid convergent (p =.004). Patients with one or more adverse event were as follows: two (1.0%) in the CB PVI group (both transient phrenic nerve palsy) and three (3.7%) in the hybrid group (two with significant bleeding and one with wound infection) (p =.14). Conclusion: This study demonstrated that patients with more complex forms of AF (3D‐PAF or 3B/3C/3D‐persistent/LSPAF) could be well managed with a convergent approach. In a real‐world evaluation, outcomes match safety and efficacy thresholds achieved for patients with earlier, less complex AF etiologies treated by CB PVI alone. [ABSTRACT FROM AUTHOR]

The public procurement sector has a high impact on the environment including pollution from manufacturing. Competition is the primary way that the United States government ensures that the most efficient facilities receive contracts, but whether this competition leads to more, or less, pollution is unknown. We explore the impact of competition for contracts on contractor pollution in sectors that handle chromium, a toxic, yet necessary, component in many goods. We find that competition alone has negligible impact on overall chromium releases among contractors; however, the way chromium is used in the manufacturing process does. Contractors that use chromium as a component report higher releases of chromium waste than contractors that only use chromium in non-incorporative ways. However, when contractors face higher competition for contracts, pollution levels significantly decrease. This suggests that both competition and the use of the metal are important. Findings support a complex association between competition and pollution generation. [ABSTRACT FROM AUTHOR]

Public procurement is a large sector of the economy with most procurement going to the defense sector. Procurement by the defense sector includes purchases made through contracts to private businesses that manufacture durable goods. Manufacturing of these goods results in pollution production with toxic wastes being among the most dangerous pollutants for public health. Despite green purchasing policy goals, most transactions in the United States through defense contracts result in disproportionately high‐toxic pollution releases by manufacturers. We find that persistent exemptions granted defense agencies from following green purchasing policy result in a landscape where contractor environmental performance is unchanging with defense contractors persistently polluting in high amounts. Further, we find that defense contractors are linked to most toxic releases from procurement meaning that exemptions may be hindering potential advancements from green purchasing policy. Results can inform the design of new guidance about procurement and expand understanding of environmental inequality. [ABSTRACT FROM AUTHOR]

Wastewater surveillance for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been shown to be a valuable source of information regarding SARS-CoV-2 transmission and coronavirus disease 2019 (COVID-19) cases. Although the method has been used for several decades to track other infectious diseases, there has not been a comprehensive review outlining all of the pathogens that have been surveilled through wastewater. Herein we identify the infectious diseases that have been previously studied via wastewater surveillance prior to the COVID-19 pandemic. Infectious diseases and pathogens were identified in 100 studies of wastewater surveillance across 38 countries, as were themes of how wastewater surveillance and other measures of disease transmission were linked. Twenty-five separate pathogen families were identified in the included studies, with the majority of studies examining pathogens from the family Picornaviridae, including polio and nonpolio enteroviruses. Most studies of wastewater surveillance did not link what was found in the wastewater to other measures of disease transmission. Among those studies that did, the value reported varied by study. Wastewater surveillance should be considered as a potential public health tool for many infectious diseases. Wastewater surveillance studies can be improved by incorporating other measures of disease transmission at the population-level including disease incidence and hospitalizations. [ABSTRACT FROM AUTHOR]