Podcasts about temporal trends

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances, discusses a recently published original research paper on Temporal Trends in Cardiovascular Events After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

In the September 24, 2024 issue of JACC, Dr. Valentin Fuster explores a pivotal study on Takotsubo Syndrome, revealing significant shifts in patient demographics, trigger types, and outcomes over nearly two decades. The research highlights an increase in physical triggers and short-term mortality, reflecting a more complex and severe understanding of the condition than previously recognized.

That's the worry. Even the humble eyeglass industry is dominated by a single firm. We look into the global spike in myopia, how the Lemtosh got its name, and what your eye doctor knows that you don't. (Part two of a two-part series.) SOURCES:Maria Liu, professor of clinical optometry at the University of California, Berkeley.Harvey Moscot, C.E.O. of MOSCOT Eyewear and Eyecare.Zachary Moscot, chief design officer of MOSCOT Eyewear and Eyecare.Cédric Rossi, equity research analyst at Bryan Garnier.Tim Wu, professor of law, science and technology at Columbia Law School. RESOURCES:"Meta in Talks to Buy Stake in Eyewear Giant EssilorLuxottica," by Salvador Rodriguez and Lauren Thomas (The Wall Street Journal, 2024)."The Story Behind Soaring Myopia Among Kids," by Manoush Zomorodi, Katie Monteleone, Sanaz Meshkinpour, and Rachel Faulkner White (Body Electric, 2024)."Why So Many People Need Glasses Now," by Christophe Haubursin (Vox, 2023)."Eyes on World Sight: Taking Action to Advance Eye Health in China," by EssilorLuxottica (2022)."Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050," by Brien A. Holden, Timothy R. Fricke, Serge Resnikoff, et al. (Ophthalmology, 2016)."Increased Prevalence of Myopia in the United States Between 1971-1972 and 1999-2004," by Susan Vitale, Robert D. Sperduto, and Frederick L. Ferris (Archives of Ophthalmology, 2009). EXTRAS:"The Economics of Eyeglasses," series by Freakonomics Radio (2024).

Florida Panthers (Puma concolor couguar) are a distinct population of pumas that live predominantly in southwest Florida. Pumas used to roam the entire United States, but habitat loss and overhunting in the 1800's and early 1900's caused them to disappear from much of their range. Every breeding population of pumas East of the Mississippi river vanished, except for one. South Florida, due to its wild and swampy nature, was able to thwart human development just enough for its inhabiting pumas to narrowly avoid oblivion. These surviving pumas, or Florida Panthers, represent the resiliency of wild south Florida. The decades since their near extinction have been filled with controversy, conservation, and politics. This iconic cat still has many challenges to face, and with only 200 or so remaining in the wild, their future is uncertain. Daniel was first introduced unofficially to this animal during his first trip to Everglades National Park in 2017. The Florida Panther and the swampy, remote areas in which they are found captivated Daniel's imagination. Every subsequent trip to the Everglades and southwest Florida had at least some time dedicated to searching for this cat, all to no avail. In January 2024, after spending months preparing and researching, Daniel embarked on a five-day solo trip in the backcountry of the Big Cypress National Preserve, with the sole objective of finally crossing paths with a panther.But what exactly IS a Florida Panther? Are they only found in Florida? Are they black? What is the difference between a Florida Panther and a mountain lion? And of course… do they eat people?! Luckily, Bill was able to meet Daniel in south Florida to record an episode about the Florida Panther and tackle the questions and misconceptions that leave this cat shrouded in mystery. This episode was recorded on January 8th, 2024 at Everglades National Park in Homestead, FL. Episode NotesWhen Daniel was talking about Florida Panther size, they were described as smaller than other pumas out west. It should also be noted that while they do fall to the bottom of the size and weight scale of pumas in North America, the populations of pumas closer to the equatorial rain forests in South America are even smaller. This reinforces the notion discussed in the podcast that pumas in colder climates or higher elevation tend to be larger than pumas in warmer climates and lower elevation. Also, Bill asked Daniel what their life span was, and Daniel was not sure. Bill guessed 20-30 years. According to Florida Fish and Wildlife Conservation Commission, “Panthers can live up to 20 years or more in the wild. Female kittens have a good chance of living 10 years or more. Males have a tougher time, but if they survive to five or six years old, they are likely to live even longer to 10 or more years.” Nicely done Bill!While discussing vehicular collisions as the number one cause of death of Florida Panther, Bill and Daniel discussed how in 2023, 13 Florida Panthers were killed by vehicular strikes. So far in 2024, there have been five. Bill and Daniel referred to the rule about animals being larger the farther you get from the equator, but they couldn't remember the name of the rule. It's Bergmann's Rule, and it's defined as: “one of the best-known generalizations in zoology. It is generally defined as a within-species tendency in homeothermic (warm-blooded) animals to have increasing body size with increasing latitude and decreasing ambient temperature. That is, Bergmann's rule states that among mammals and birds, individuals of a particular species in colder areas tend to have greater body mass than individuals in warmer areas. For instance, white-tailed deer are larger in Canada than in the Florida Keys, and the body size of wood rat populations are inversely correlated with ambient temperature. This principle is named after a nineteenth-century German biologist, Karl Bergmann, who published observations along these lines in 1847.” - from The New World EncyclopediaLinks Panther Pulse, the database containing documented Florida Panther deaths and depredations: https://myfwc.com/wildlifehabitats/wildlife/panther/pulse/Path of the Panther: https://pathofthepanther.com Sponsors and Ways to Support UsGumleaf Boots, USA (free shipping for patrons)Thank you to Always Wandering Art (Website and Etsy Shop) for providing the artwork for many of our episodes! Support us on Patreon!Check out the Field Guides merch at our Teespring store. It's really a great deal: you get to pay us to turn your body into a billboard for the podcast!Works CitedCaudill, Gretchen & Onorato, Dave & Cunningham, Mark & Caudill, Danny & Leone, Erin & Smith, Lisa & Jansen, Deborah. (2019). Temporal Trends in Florida Panther Food Habits. Human-Wildlife Interactions. 13. 87-97. 10.26076/kta5-cr93.Cox, J. J., Maehr, D. S., & Larkin, J. L. (2006). Florida Panther Habitat Use: New Approach to an Old Problem. The Journal of Wildlife Management, 70(6), 1778–1785. http://www.jstor.org/stable/4128112Frakes RA, Belden RC, Wood BE, James FE (2015) Landscape Analysis of Adult Florida Panther Habitat. PLOS ONE 10(7): e0133044. https://doi.org/10.1371/journal.pone.0133044Hostetler JA, Onorato DP, Nichols JD, Johnson WE, Roelke ME, O'Brien SJ, Jansen D, Oli MK. Genetic Introgression and the Survival of Florida Panther Kittens. Biol Conserv. 2010 Nov 1;143(11):2789-2796. doi: 10.1016/j.biocon.2010.07.028. PMID: 21113436; PMCID: PMC2989677.Johnson WE, Onorato DP, Roelke ME, Land ED, Cunningham M, Belden RC, McBride R, Jansen D, Lotz M, Shindle D, Howard J, Wildt DE, Penfold LM, Hostetler JA, Oli MK, O'Brien SJ. Genetic restoration of the Florida panther. Science. 2010 Sep 24;329(5999):1641-5. doi: 10.1126/science.1192891. PMID: 20929847; PMCID: PMC6993177.Land, Darrell & Shindle, David & Kawula, Robert & BENSON, JOHN & LOTZ, MARK & Onorato, Dave. (2010). Florida Panther Habitat Selection Analysis of Concurrent GPS and VHF Telemetry Data. The Journal of Wildlife Management. 72. 633 - 639. 10.2193/2007-136.Maehr, David S. (1997). The Florida Panther: Life and Death of a Vanishing Carnivore. Island Press ISBN 155963507X, 9781559635073Pienaar, Elizabeth & Rubino, Elena. (2016). Habitat Requirements of the Florida Panther. 10.13140/RG.2.1.1887.2722.Robert A. Frakes, Marilyn L. Knight, Location and extent of unoccupied panther (Puma concolor coryi) habitat in Florida: Opportunities for recovery, Global Ecology and Conservation, Volume 26, 2021, e01516, ISSN 2351-9894, https://doi.org/10.1016/j.gecco.2021.e01516. (https://www.sciencedirect.com/science/article/pii/S2351989421000664)Urbanizing Landscape. PLoS One. 2015 Jul 15;10(7):e0131490. doi: 10.1371/journal.pone.0131490. PMID: 26177290; PMCID: PMC4503643.Vickers TW, Sanchez JN, Johnson CK, Morrison SA, Botta R, Smith T, Cohen BS, Huber PR, Ernest HB, Boyce WM. Survival and Mortality of Pumas (Puma concolor) in a Fragmented, Urbanizing Landscape. PLoS One. 2015 Jul 15;10(7):e0131490. doi: 10.1371/journal.pone.0131490. PMID: 26177290; PMCID: PMC4503643.Photo Credithttps://commons.wikimedia.org/wiki/File:Everglades_National_Park_Florida_Panther.jpg?uselang=en#Licensing

Commentary by Dr. Valentin Fuster

Dr. Farrukh M. Koraishy summarizes the results of his study, "Geographic and Temporal Trends in COVID-Associated Acute Kidney Injury in the National COVID Cohort Collaborative," on behalf of his colleagues.

Commentary by Dr Adrian Low

In this podcast, Asma Ahmed discusses her paper 'Prevalence and temporal trends of cerebral palsy in children born from 2002 to 2017 in Ontario, Canada: a population-based cohort study'. The paper is available to read here: https://onlinelibrary.wiley.com/doi/10.1111/dmcn.15324 Subscribe to our channel for more:   https://bit.ly/2ONCYiC    ___  Listen to all our episodes:  https://bit.ly/2yPFgTC   __  DMCN Journal:  Developmental Medicine & Child Neurology (DMCN) has defined the field of paediatric neurology and childhood-onset neurodisability for over 60 years. DMCN disseminates the latest clinical research results globally to enhance the care and improve the lives of disabled children and their families.    DMCN Journal - https://onlinelibrary.wiley.com/journal/14698749  ___    Watch DMCN videos on our YouTube channel:  https://bit.ly/2ONCYiC    Find us on Twitter!  @mackeithpress - https://twitter.com/mackeithpress 

This week, please join author Vasan Ramachandran and Associate Editor Mercedes Carnethon as they discuss the article "Temporal Trends in the Remaining Lifetime Risk of Cardiovascular Disease Among Middle-Aged Adults Across 6 Decades: The Framingham Study." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast, summary and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center in Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor, Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Carolyn Lam: Greg, I'm so excited about today's feature paper. You see, I trained at the Framingham Heart Study and today's feature paper talks about the temporal trends in the remaining lifetime risk of cardiovascular disease among middle aged adults across six decades in the Framingham Heart Study. Truly a landmark study and a discussion nobody wants to miss. But first, let's talk about the other papers in today's issue, and I understand that you've got one ready. Dr. Greg Hundley: You bet Carolyn. I'll get started first. Thank you. So my first paper comes from Dr. Daniel Mark from Duke University and it refers to the ISCHEMIA trial. Dr. Carolyn Lam: Ooh, could you please first remind us what is the ISCHEMIA trial and are you presenting a substudy, is that correct? Dr. Greg Hundley: Right, Carolyn. So the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches, or ISCHEMIA, compared an initial invasive strategy with an initial conservative strategy in 5,179 participants with chronic coronary disease and moderate or severe ischemia. And this sub study of the ischemia research program included a comprehensive quality of life analysis. Dr. Carolyn Lam: So very interesting. What did they find Greg? Dr. Greg Hundley: Right, Carolyn. So this study included 1,819 participants. 907 in the invasive, 912 in the conservative. And collected a battery of disease specific and generic quality of life instruments by structured interviews at baseline. And then at three, 12, 24 and 36 months post randomization, and then finally at study closeout. Now Carolyn, these assessments included an angina related quality of life assessment from the 19 item Seattle Angina Questionnaire, a generic health status assessment, an assessment of depressive symptoms, and for North American patients, cardiac functional status from the Duke Activity Status Index, or DASI. In this study, Carolyn, in terms of results, the median age was 67 years and about 20% were women and about 16% were nonwhite. So Carolyn, getting to the results. The estimated mean difference for the SAQ 19 summary score favored invasive therapy. And remember the SAQ 19 was the Seattle Angina Questionnaire. Dr. Greg Hundley: Next, no differences were observed in patients with rare or absent baseline angina. Next, among patients with more frequent angina baseline, those randomized to invasive had a mean point higher score on the SAQ 19 summary score than the conservative approach, with consistent effects across all of the SAQ subscales including physical limitations, angina frequency and quality of life health perceptions. For the DASI, and remember DASI refers to the Duke Activity Status Index, no difference was estimated overall by treatment. But in patients with baseline marked angina, DASI scores were higher for the interventional arm. Whereas patients with rare or absent baseline angina showed really no treatment related differences. Dr. Carolyn Lam: Oh, okay. So a lot of results. What's the take-home message, Greg? Dr. Greg Hundley: Right, Carolyn. Glad you asked. So in the ISCHEMIA comprehensive quality of life substudy, patients with more frequent baseline angina reported greater improvements in the symptom physical functioning and psychological wellbeing dimensions of quality of life when treated with an invasive strategy. Whereas patients who had rare or absent angina baseline reported no consistent treatment related quality of life differences. Dr. Carolyn Lam: Wow. Thank you, Greg. Very interesting indeed. Now from angina to now cholesterol. Now, cholesterol guidelines typically prioritize primary prevention statin therapy based on 10 year risk of cardiovascular disease. Now the advent of generic pricing may in fact justify expansion of statin eligibility. Moreover, 10 year risk may not be the optimal approach for statin prioritization. So these issues were looked at in this next paper by authors led by Dr. Kohli Lynch from Northwestern University and colleagues who estimated the cost effectiveness of expanding preventive statin eligibility, and evaluated novel approaches to prioritization from a Scottish health sector perspective. A computer simulation model predicted long term health and cost outcomes in Scottish adults, age 40 years or more. Dr. Greg Hundley: So Carolyn, what did they find? Dr. Carolyn Lam: The advent of generic pricing has rendered preventive statin therapy cost effective for many adults. Absolute risk reduction guided statin therapy, which is based on 10 year cardiovascular disease risk and non HDL cholesterol levels, is cost effective and would improve population health. Whereas age stratified risk thresholds were more expensive and less effective than alternative approaches to statin prioritization. So guidelines committees may need to expand statin eligibility and consider new ways to allocate statins based on absolute risk reduction rather than 10 year risk thresholds. Dr. Greg Hundley: Very nice Carolyn. Always important, new information regarding statin therapy. Well Carolyn, my next paper comes to us from the world of preclinical science. And Carolyn, as you know, the regenerative capacity of the heart after myocardial infarction is limited. And these authors led by Dr. Tamer Mohamed from University of Louisville previously showed that ectopic introduction of Cdk1, CyclinB1 and Cdk4, CyclinD1 complexes and we'll refer to those now as 4F, promoted cardiomyocyte proliferation in 15 to 20% of infected cardiomyocytes in vitro and in vivo and improved cardiac function after MI in mice. So Carolyn, in this study using temporal single cell RNA sequencing, the investigative team aimed to identify the necessary reprogramming stages during the forced cardiomyocyte proliferation with 4F on a single cell basis. And also using rat and pig models of ischemic heart failure, they aim to start the first preclinical testing to introduce 4F gene therapy as a candidate for the treatment of ischemia induced heart failure. Dr. Carolyn Lam: Oh, wow Greg. So what did they find? Dr. Greg Hundley: Several things, Carolyn. First, temporal bulk and single cell RNA sequencing and further biochemical validations of mature HIPS cardiomyocytes treated with either LAcZ or 4F adenoviruses revealed full cell cycle reprogramming in 15% of the cardiomyocyte population at 48 hours post-infection with 4F. Which was mainly associated with sarcomere disassembly and metabolic reprogramming. Second Carolyn, transient overexpression of 4F specifically in cardiomyocytes was achieved using a polycistronic non-integrating lentivirus encoding the 4F with each driven by a TNNT2 promoter entitled TNNT2-4F polycistronic-NIL. Now this TNNT2-4F polycistronic-NIL or control virus was injected intra myocardial one week after MI in rats, so 10 per group, and pigs, six to seven per group. Dr. Greg Hundley: And four weeks post-injection the TNNT2-4F polycistronic-NIL treated animals showed significant improvement in left ventricular injection fraction and scar size compared with the control virus treated animals. And four months after treatment, the rats that received TNNT2-4F polycistronic-NIL still showed a sustained improvement in cardiac function without obvious development of cardiac arrhythmias or systemic tumorigenesis. And so Carolyn this study advances concepts related to myocellular regeneration by providing mechanistic insights into the process of forced cardiomyocyte proliferation and advances the clinical feasibility of this approach by minimizing the oncogenic potential of the cell factors, thanks to the use of a novel transient and cardiomyocyte specific viral construct. Dr. Carolyn Lam: Wow. What a rich study. Thanks so much, Greg. Dr. Greg Hundley: Well, Carolyn, how about if we see what else and what other articles are in this issue. And maybe I'll go first. So there's a research letter from Dr. Wu entitled Modeling Effects of Immunosuppressive Drugs on Human Hearts Using IPSC Derived Cardiac Organoids and Single Cell RNA Sequencing. Carolyn, there's an EKG challenge from Dr. Yarmohammadi, entitled “Fast and Furious, A Case of Group Beating in Cardiomyopathy.” And then finally from Dr. Tulloch, a really nice Perspective entitled “The Social Robots are Coming, Preparing For a New Wave of Virtual Care in Cardiovascular Medicine. Dr. Carolyn Lam: Oh, how interesting. Well, also in the mail back is an exchange of letters of among Drs. Lakkireddy, Dhruva, Natale, and Price regarding Amplatzer Amulet Left Atrial Appendage Occluder versus Watchman Device for stroke prophylaxis, a randomized control trial. All right. Thank you so much, Greg. Shall we go on to our feature discussion now? Dr. Greg Hundley: You bey. Welcome listeners to our feature discussion today. And we're so fortunate we have with us today, Dr. Vasan Ramachandran from Boston University and our own Associate Editor, Dr. Mercedes Carnethon from Northwestern University in Chicago. Welcome to you both. And Vasan, let's start with you. Could you describe for us some of the background information pertaining to your study and what was the hypothesis that you wanted to address? Dr. Vasan Ramachandran: Thank you, Greg, first of all for having me. So we know two facts. One is that heart disease and stroke disease death rates and incidents are declining over the last six decades in the United States. Juxtapose against that is also the observation that there is rising incidence of obesity and overweight, and also a rising burden of diabetes. There are a lot of advances in our ability to treat high blood pressure, high cholesterol, as well as high blood sugar. So we wanted to ask the question, given the historic trends in control awareness of risk factors and their control, interrupted by this escalating burden of obesity, overweight, and diabetes, what is the lived experiences of people over time in terms of the risk of developing heart disease or stroke using a metric we call as the remaining lifetime risk of developing heart disease or stroke. Dr. Greg Hundley: The hypothesis you wanted to address? Dr. Vasan Ramachandran: The hypothesis we wanted to address was that perhaps the decline in the incidence of heart disease and stroke may have decreased over time given the escalating burden of overweight, obesity and diabetes. Dr. Greg Hundley: Very nice. And can you describe for us your study population and your study design? Dr. Vasan Ramachandran: Thank you, Greg. So the Framingham Heart Study is one of the oldest running epidemiological studies in the world. We have multiple cohorts. The study began in 1948 with the original cohort, the offspring cohort enrolled in 1971, third generation cohort in 2002, and two minoritized cohorts in the 1990s and 2002. So we have an observation period of different cohorts over a six decade period. So we asked the question, if you were a participant in the Framingham study between 1960 and 1979 and then 1980 to 1999, and then 2000 to 2018, what was your lifetime risk of experiencing a heart disease or stroke in the three different time periods? Is it going down, is it steady or is it going up? Dr. Greg Hundley: Very nice. And so, Vasan, describe your study results. Dr. Vasan Ramachandran: Look, what we found was if you look at the first, the 20 year period from 1960 to 1979, and compare that with the latest, which is 2000 to 2018, in the initial time period, the lifetime risk of developing heart disease or stroke in a man was pretty high. It was about one in two. And that for a woman was about one in three. So when you come to the latest epoch, what we find that the risk of one in two men had dropped to about one in three men in the latest decade. For women, the risk declined from what was one in three in the earlier epoch to one in four. So approximately there was about a 36% reduction in the lifetime probability of developing heart disease or stroke across the six decade period of observation. Dr. Greg Hundley: Very nice. And so help us a little bit, put the context of your results into what that might mean for us today as we are managing patients with atherosclerotic disease. Dr. Vasan Ramachandran: Yes, Greg. What it means is that the permeation of the advances in science in terms of the screening of risk factors, awareness of risk factors, medications to lower these risk factors effectively, the clinical trials that have given us these new medications, they may have translated into a reduction in risk over time. That the lived experience of people in the later decades is better in terms of having a lower risk of heart disease or stroke as the consequence of multiple advances that have happened in heart disease and stroke. Dr. Greg Hundley: Well, thank you so much Vasan. Well listeners, now we're going to turn to our Associate Editor, Mercy Carnethon. And Mercy, you have many papers come across your desk. What attracted you to this particular paper and how do you put these results really in the context of other science pertaining to risk associated with populations that may have atherosclerotic cardiovascular disease? Dr. Mercedes Carnethon: Thanks so much for that question, Greg. And again, Vasan, I really thank you and your team for bringing forth such outstanding research. You know, as cardiovascular disease epidemiologists, we were all raised and taught that what we know about risk factors for cardiovascular disease are based on the Framingham cohort. And so I was really excited to see this very comprehensive piece of work that characterized what the Framingham study has identified and also leverages the unique characteristics of a study that started in 1948. Dr. Mercedes Carnethon: So, you know, we're almost 75 years in and actually has the ability that cross sectional studies don't have to look over longer periods of time at risk. And you know, when we think about papers that excite us, that we really want to feature in circulation, they are papers that teach us something new. And I will say there were aspects of this work that confirmed what I had heard but had not seen using empirical data. Namely that the remaining lifetime risks for developing cardiovascular disease were going down over time, and they were going down secondary to better management and recognition of the risk factors that the Framingham cohort study had really been instrumental in identifying in the first place. Dr. Mercedes Carnethon: There were surprising elements of the paper. The surprising elements being that I think as you brought up earlier, we were concerned that risk factors that were on the rise, such as obesity, were threatening these increases in life expectancy. And it was really nice to see that the findings held, even in the face of rising risk factors. And just to summarize, what I really like about this piece when we situate it within circulation, where we are addressing clinical treatment factors, where we're also featuring clinical trials and even other epidemiologic studies, is that your work identifies for us the overall context in which the clinicians who read the journal are thinking about managing patients and where we're going. It highlights our successes, but it also really brings up what we need to do next. And I look forward to hearing from you about where you think this may be headed. Dr. Greg Hundley: Well, Mercy, you're teeing us up for that next question. Vasan, what do you think is the next study or studies that need to be performed in this space? Dr. Vasan Ramachandran: Thank you, Greg and Mercy, for your kind comments. Like I shared, this is a success story for a predominantly white population in the Northeast. We are very much aware about the heterogeneity and the geographic variation in heart disease burden in our country. So one of the success stories interpretation might be this represents the upper bound. What can happen to a population that is compliant with screening of risk factors, awareness of risk factors, treatment and healthcare access. I think the next set of studies should broaden the study population to bring in additional populations that are more diverse, that are also followed up over a period of time to assess and put the current observations in the appropriate context. Do we see similar findings longitudinally in other cohorts with non-white participants? Is it different, is their lived experience different? If so, why? And that could inform us how we can reach the success story and replicate it across the entirety of our country. Dr. Greg Hundley: And Mercy, do you have anything to add? Dr. Mercedes Carnethon: I do. You know, I really like that focus on broadening to whom these results are applicable. We've undergone a lot of shifts within our country and also around the world. You know, circulation, we have a worldwide readership. I would love to see this sort of work replicated across different countries to the extent that we have the data to do so, recognizing that limitation. But I'd love to see work focus on comparing how these things change in low income countries, middle income and high income countries, so that we can really think about resource allocation and find strategies to try to replicate the successes that we are seeing based on the data from the Framingham heart and offspring studies. Dr. Greg Hundley: Excellent. Well listeners, we really appreciate the opportunity to get together today with Dr. Vasan Ramachandran from Boston University and our own Associate Editor, Dr. Mercedes Carnethon from Northwestern University in Chicago. And really appreciate them for bringing us these epidemiologic data from the Framingham cohort, indicating that over the past decades, mean life expectancy increased and the remaining lifetime risk of atherosclerotic cardiovascular disease decreased across individuals in the cohort, even after accounting for increasing incidences of other cardiovascular risk factors like obesity and smoking. Well on behalf of Carolyn and myself, we want to wish you a great week and we will catch you next week on the run. Dr. Greg Hundley This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

The Accelerators (Drs. Anna Laucis, Simul Parikh, and Matt Spraker) are joined by Drs. Jason Beckta, Emma Fields, Todd Scarborough, and Chirag Shah to discuss the #RadOnc job market.Join us on an epic journey through the past, present, and future of the job market. We  cover the highly variable written record of the #RadOnc workforce, how patient volumes are changing with hypofractionation, and the what the market will look like in the future.We close the show with a round robin on advice for young radiation oncologists heading into the field we all love. More information on the topics we discussed:Dr. Lawrence Davis in 1986: “The manpower crisis facing radiation oncology”Dr. Chirag Shah's letter: “Expanding the Number of Trainees in Radiation Oncology: Has the Pendulum Swung Too Far?”"In Regard to Shah"By Dr. Anthony Zietman By Dr. John LeungBy Drs. Dennis Hallahan and Stephanie Perkins By Dr. W. Robert Lee By Drs. Paul Wallner and Dennis Shrieve SDN Radiation Oncology Forum Medical School Reddit Dr. Ben Smith's team in 2010: "The Future of Radiation Oncology in the United States From 2010 to 2020: Will Supply Keep Pace With Demand?"Dr. Ben Smith's team in 2016: "The Radiation Oncology Job Market: The Economics and Policy of Workforce Regulation"Mudit Chowdhary's team in 2019: "The Impact of Graduates' Job Preferences on the Current Radiation Oncology Job Market"Follow Nicholas Zaorsky on TwitterUpdated ACGME Program Requirements for Radiation Oncology and FAQs Dr. Li's team in 2020: "Temporal Trends of Resident Experience in External Beam Radiation Therapy Cases: Analysis of ACGME Case Logs from 2007 to 2018"Podcast art generously donated by Dr. Danielle Cunningham**Update**Dr. Zaorsky comments with a thread of threads, packed with more info for a deeper dive on #RadOnc facility/utilization.Dr. Fuller tweets a deep pull from the archives.

Commentary by Dr. Olivier Florian Clerc

“For our children and grandchildren” was the dedication at the start of my next guests book, Countdown, by Dr Shanna Swan, and since reading the book I now understand why. Because a man today has only half the number of sperm his grandfather had. Essentially a 50% drop in sperm counts over the past four decades. But, as you will hear, this isn't just affecting male fertility.Dr Shanna H. Swan, Ph.D., is one of the world's leading environmental and reproductive epidemiologists. She is Professor of Environmental Medicine and Public Health at the Icahn School of Medicine at Mount Sinai in New York City where is also a member of the Transdisciplinary Center on Early Environmental Exposures and the Mindich Child Health and Development Institute.After reading a controversial paper reporting the decline in sperm quality in 1992 by Carlsen and colleagues, and being part of a group tasked with ratifying the results, Dr Swan has gone on to further study this dramatic decline in sperm count around the world.And for over twenty years, Dr. Swan and her colleagues have been studying the impact of environmental chemicals and pharmaceuticals on reproductive tract development and neurodevelopment. Her July 2017 paper “Temporal Trends in Sperm Count: a systematic review and meta-regression analysis” ranked #26 among all referenced scientific papers published in 2017 worldwide and shook the world with media outlets declaring “Who is killing our sperm”.Today's podcast is controversial and unpopular, but I can't hide away from this subject matter for fear of scare-mongering because it's one that could actually affect me personally. I'm yet to have children myself and the data is frankly scary. And if there are pragmatic decisions to make at an individual level, such as reducing exposure to plastics, petrochemicals and pesticides then I'm lucky to be in a position to actually do something about it and I'll share that with you the listener as well.Today you'll learn aboutThe 1% effectThe rise in testicular cancer, miscarriages, infertility as well as the reduction in sperm count and testosteroneEndocrine disrupting chemicals and their lack of regulationBody BurdenWhether phthalate or BPA free actually mean anything?What is the threshold for these chemicals and cumulative impact?The impact on menopause, erectile dysfunction, virility What do we need to be talking about and campaigning for Find out more about the book at thedoctorskitchen.com/podcasts, plus links to the studies and books mentioned in the show and sign up to the newsletter for a free 7 day meal plan. See acast.com/privacy for privacy and opt-out information.

As always, feel free to send us questions, comments or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through instagram or twitter, @nicupodcast. Or contact Ben and Daphna directly via their twitter profiles: @drnicu and @doctordaphnamd. Papers discussed in today's episode are listed and timestamped below.enjoy!--------------------------------------------------------------------------------------------------------------------Please find the titles and links to the articles mentioned in this week's journal club and timestamps for your convenience:02:30 - Effect of Systemic Hydrocortisone Initiated 7 to 14 Days After Birth in Ventilated Preterm Infants on Mortality and Neurodevelopment at 2 Years' Corrected Age: Follow-up of a Randomized Clinical Trial. https://jamanetwork.com/journals/jama/article-abstract/278231307:50 - Postnatal Corticosteroids to Prevent or Treat Bronchopulmonary Dysplasia. https://www.karger.com/Article/FullText/51595018:30 - Temporal Trends in Neurodevelopmental Outcomes to 2 Years After Extremely Preterm Birth. https://jamanetwork.com/journals/jamapediatrics/article-abstract/278214926:00 - An assessment of dexmedetomidine as an opioid-sparing agent after neonatal open thoracic and abdominal operations. https://www.nature.com/articles/s41372-021-01175-732:23 - Association of time of day and extubation success in very low birthweight infants: a multicenter cohort study. https://www.nature.com/articles/s41372-021-01168-639:27 - Caffeine citrate for apnea of prematurity—One dose does not fit all a prospective study. https://www.nature.com/articles/s41372-021-01172-w43:40 - Early High-Dose Caffeine Improves Respiratory Outcomes in Preterm Infants. https://www.mdpi.com/2227-9067/8/6/50148:35 - Low Rate of Spontaneous Closure in Premature Infants Discharged with a Patent Ductus Arteriosus: A Multicenter Prospective Study. https://jpeds.com/retrieve/pii/S002234762100702255:36 - Effects of single family room architecture on parent–infant closeness and family centered care in neonatal environments—a single-center pre–post study. https://www.nature.com/articles/s41372-021-01137-z60:53 - Asynchronous telemedicine for clinical genetics consultations in the NICU: a single center's solution. https://www.nature.com/articles/s41372-021-01070-164:00 - Cortical hemodynamic activity and pain perception during insertion of feeding tubes in preterm neonates: a randomized controlled cross-over trial. https://www.nature.com/articles/s41372-021-01166-8

Shanna H. Swan, PhD, is one of the world's leading environmental and reproductive epidemiologists and a professor of environmental medicine and public health at the Icahn School of Medicine at Mount Sinai in New York City. An award-winning scientist, her work examines the impact of environmental exposures, including chemicals such as phthalates and bisphenol A, on men's and women's reproductive health and the neurodevelopment of children. For more than twenty years, Dr. Swan and her colleagues have been studying the dramatic decline in sperm count around the world and the impact of environmental chemicals and pharmaceuticals on reproductive tract development and neurodevelopment. Her July 2017 paper “Temporal Trends in Sperm Count: A Systematic Review and Meta-Regression Analysis” ranked #26 among all referenced scientific papers published in 2017 worldwide. Dr. Swan has published more than two hundred scientific papers and myriad book chapters and has been featured in extensive media coverage around the world. Her appearances include ABC News, NBC Nightly News, 60 Minutes, CBS News, PBS, the BBC, PRI, and NPR, as well as in leading magazines and newspapers, ranging from the Washington Post to Bloomberg News to New Scientist. You can find her at shannaswan.com.

"Não assista à TV tão de perto, minha filha, vai acabar precisando de óculos!"Quem nunca ouviu algo parecido?Afinal, fazer isso causa miopia?Confira no papo entre o leigo curioso, Ken Fujioka, e o cientista PhD, Altay de Souza.Convidada:Dra. Camila Kase - Graduada em Medicina pela Universidade Federal de São Paulo - Escola Paulista de Medicina. Médica Oftalmologista, também com atuação e pesquisa na área de medicina do sono.OUÇA (53min 19s)*Naruhodo! é o podcast pra quem tem fome de aprender. Ciência, senso comum, curiosidades, desafios e muito mais. Com o leigo curioso, Ken Fujioka, e o cientista PhD, Altay de Souza.Edição: Reginaldo Cursino.naruhodo.b9.com.br*PARCERIA: ALURAA Alura tem mais de 1.000 cursos de diversas áreas e é a maior plataforma de cursos online do Brasil -- e você tem acesso a todos com uma única assinatura.Aproveite o desconto de R$100 para ouvintes Naruhodo no link:www.alura.com.br/promocao/naruhodo*REFERÊNCIASFactors Underlying Different Myopia Prevalence between Middle- and Low-income Provinces in Chinawww.sciencedirect.com/science/articl…61642014011968Effect of Time Spent Outdoors at School on the Development of Myopia Among Children in China A Randomized Clinical Trialjamanetwork.com/journals/jama/fullarticle/2441261Animal models in myopia researchonlinelibrary.wiley.com/doi/pdf/10.1111/cxo.12312Role of Educational Exposure in the Association Between Myopia and Birth Orderjamanetwork.com/journals/jamaopht…llarticle/2448580Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050www.sciencedirect.com/science/articl…61642016000257Age-Specific Prevalence of Visual Impairment and Refractive Error in Children Aged 3–10 Years in Shanghai, Chinaiovs.arvojournals.org/article.aspx?a…icleid=2585947Environmental factors explain socioeconomic prevalence differences in myopia in 6-year-old childrenbjo.bmj.com/content/102/2/243.abstractAn overview of myopia geneticswww.sciencedirect.com.sci-hub.tw/science/…19303136The Genetics of Myopialink.springer.com/chapter/10.1007/…-981-13-8491-2_5Meta-analysis of 542,934 subjects of European ancestry identifies new genes and mechanisms predisposing to refractive error and myopiawww.nature.com/articles/s41588-020-0599-0The Myopian Boomjournals.lww.com.sci-hub.tw/optvissci/A…THIN.5.aspxThe Transmission of Refractive Errors Within Eskimo Familiesjournals.lww.com/optvissci/Abstra…RS_WITHIN.5.aspxThe role of dopamine in sleep regulationjournals.plos.org/plosbiology/arti…nal.pbio.1001347Naruhodo #182 - A ordem do nascimento dos irmãos faz diferença?www.b9.com.br/shows/naruhodo/nar…aos-faz-diferenca/Naruhodo #193 - Como funciona o daltonismo?www.b9.com.br/shows/naruhodo/nar…iona-o-daltonismo/Podcasts das #Minas: SEXO EXPLÍCITO#MulheresPodcastersopen.spotify.com/show/5fmYyMcCMFMA92MOhqoBzX*APOIE O NARUHODO!Você sabia que pode ajudar a manter o Naruhodo no ar?Ao contribuir, você pode ter acesso ao grupo fechado no Telegram, receber conteúdos exclusivos e ter vantagens especiais.Assine o apoio mensal pelo PicPay: picpay.me/naruhodopodcast

https://accadandkoka.com/wp-content/uploads/2019/02/Pic-e1551227182690.jpg ()Rishi Wadhera, MD Bright clinicians who are also trained as rigorous scientists can put healthcare policy under scrutiny and show that the wisdom of the wonks frequently falls short.  Our guest on this episode is Dr. Rishi Wadhera, a prolific cardiology fellow currently in training at Brigham and Women’s Hospital in Boston and part of a team of health policy investigators at the Smith Center for Outcomes Research in Cardiology.  Dr. Wadhera obtained his medical degree from the Mayo Clinic, a Master’s in Public Health from the University of Cambridge, and a Master’s in Public Policy from the Harvard Kennedy School of Government.  He joins us to discuss 2 of his most recent papers which have made a big splash in the media. GUEST: Rishi Wadhera: https://twitter.com/rkwadhera (Twitter) LINKS: Wadhera RK, et al. https://www.ncbi.nlm.nih.gov/pubmed/30649146 (Association of State Medicaid Expansion With Quality of Care and Outcomes for Low-Income Patients Hospitalized With Acute Myocardial Infarction). (in JAMA Cardiology, January 2019) Wadhera RK, et al. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2718338 (Temporal Trends in Unstable Angina Diagnosis Codes for Outpatient Percutaneous Coronary Interventions) (in JAMA Internal Medicine, February 2019) Christian A. McNeely and David L. Brown. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2718337 (Gaming, Upcoding, Fraud, and the Stubborn Persistence of Unstable Angina) (editorial commentary in JAMA Internal Medicine, February 2019). RELATED EPISODES: https://accadandkoka.com/episode41/ (Ep. 41. Healthcare Policy in the Crosshairs: The Hospital Readmission Reductions Program) (with guest Ankur Gupta, MD) WATCH ON YOUTUBE: https://youtu.be/VOiWG-_KHsE (Watch the episode) on our YouTube channel. Support this podcast

3v's Dr Tim Wilson in conversation with Jack O'Sullivan, the author of our paper of the week: 'Temporal trends in use of tests in UK primary care' Reference: O’Sullivan Jack W, Stevens Sarah, Hobbs F D Richard, Salisbury Chris, Little Paul, Goldacre Benet al. Temporal trends in use of tests in UK primary care, 2000-15: retrospective analysis of 250 million tests BMJ 2018; 363 :k4666 More information here: www.3vh.org/essential-insights/

Interview with Robert W. Yeh, MD, MSc, MBA, author of Temporal Trends in Unstable Angina Diagnosis Codes for Outpatient Percutaneous Coronary Interventions, and David L. Brown, MD, FACC, author of Gaming, Upcoding, Fraud, and the Stubborn Persistence of Unstable Angina

Interview with Robert W. Yeh, MD, MSc, MBA, author of Temporal Trends in Unstable Angina Diagnosis Codes for Outpatient Percutaneous Coronary Interventions, and David L. Brown, MD, FACC, author of Gaming, Upcoding, Fraud, and the Stubborn Persistence of Unstable Angina

Paul Wang:         Welcome to the monthly podcast “On The Beat”, for Circulation: Arrhythmia and Electrophysiology. I am Dr. Paul Wang, Editor-in-Chief, with some of the key highlights from this month's issue. We'll also hear from Dr. Suraj Kapa, reporting on new research from the latest journal articles in the field.                                 In our first article, Adetola Ladejobi and associates studied 1,433 patients, between 2000 and 2012, who were discharged alive after sudden cardiac arrest. A reversible and correctable cause was identified in 792 patients, or 55%. A reversible cause for sudden cardiac arrest was defined as significant electrolyte or metabolic abnormality, evidence of acute myocardial infarction or ischemia, recent initiation of antiarrhythmic drug, or illicit drug use, or other reversible circumstances.                                 Of the 792 sudden cardiac arrest survivors, due to reversible or correctable cause, 207 or 26% of the patients received an ICD after their indexed sudden cardiac arrest. During a mean follow-up of 3.8 years, 319 or 40% of patients died. ICD implantation was highly associated with a lower all-cause mortality, p < 0.001, even after correcting for unbalanced baseline characteristics.                                 In subgroup analyses, only patients with sudden cardiac arrest, were not associated with myocardial infarction, extracted benefit from the ICD, p < 0.001.                                 The authors concluded that in survivors of sudden cardiac arrest, due to a reversible and correctable cause, ICD therapies associated with lower all-cause mortality, except if the sudden cardiac arrest was due to myocardial infarction.                                 Further prospect of multi-center randomized control trials will be needed to confirm this observation.                                 In our next study, Carlo Pappone and associates, studied 81 patients with persistent atrial fibrillation, randomized to undergo high density electrophysiological mapping, to identify repetitive regular activities, before modified circumferential pulmonary vein ablation, or modified circumferential pulmonary vein ablation alone. The primary endpoint was freedom from arrhythmia recurrence at one year.                                 In the 81 patients with persistent atrial fibrillation, there were 479 regions exhibiting repetitive regular activities in these patients, or 5.9 repetitive regular activities per patient. There were 232 regions in the mapping group, which consisted of 41 patients, and 247 regions in the control group, consisting of 40 patients. Overall, 39% of the repetitive regular activities were identified within pulmonary veins, whereas 61% were identified in non-pulmonary vein regions.                                 Mapping-guided ablation resulted in higher arrhythmia termination rate, as compared to conventional strategy, 61% vs. 30%, p < 0.007. Total RF duration, mapping, and fluoroscopy times were not significantly different between the groups. No major procedure related adverse events occurred.                                 After one year, 73% of the mapping group of patients were free of recurrences, compared to 50% of the control group, p = 0.03.                                 The authors concluded that targeted ablation of regions showing repetitive regular activities provided adjunctive benefit in terms of arrhythmia freedom at one year in treatment of patients with persistent atrial fibrillation. These findings should be confirmed by additional larger randomized multi-centered studies.                                 In the next article, Maciej Kubala and associates examine repolarization abnormalities in 40 patients with arrhythmogenic right ventricular cardiomyopathy, comparing extent and location of abnormal T-waves of one millimeter or greater in depth, downsloping elevated ST segment in two or more adjacent leads to the area and location of endocardial bipolar and unipolar, and epicardial bipolar voltage abnormalities. They found an abnormal unipolar right ventricular endocardial area of 33.4% with presence in eight patients without negative T-waves. Patients with negative T-waves extending beyond V3, seen in 20 patients, had larger low bipolar and unipolar endocardial areas, and larger epicardial low bipolar areas, compared to those with negative T-waves limited to leads V1 to V3.                                 ECG localization of negative T-waves regionalized to the location of substrate. Patients with downsloping elevated ST segment, all localized to leads V1, V2 had more unipolar endocardial abnormalities involving outflow in mid-right ventricle, compared to patients without downsloping elevated ST segment.                                 The authors concluded that in arrhythmogenic right ventricular cardiomyopathy, abnormal electric current areas were proportional to the extent of T-wave inversion on the 12 lead electrocardiogram. Marked voltage abnormalities can exist without repolarization changes. Downsloping elevated ST segment patterns in V1 and V2 occurs with more unipolar endocardial voltage abnormalities, consistent with more advanced trans neural disease.                                 In the next manuscript, Teresa Oloriz and associates examine the timing and value of program stimulation after catheter ablation for ventricular tachycardia. They performed 218 program ventricular stimulations six days after ablation in 210 consecutive patients, 48% with ischemic cardiomyopathy in the median left ventricular ejection fraction of 37%. After ablation, ICDs were programmed according to NIPS results. Class A were noninducible, Class B non documented inducible VT, and Class C documented inducible VT. Concordance between the programmed ventricular stimulation at the end of the procedure and at six days was 67%. The positive predictive value and negative predictive value were higher for the programmed ventricular stimulation at day six. Ischemic patients and those with preserved ejection fraction showed the highest negative predictive value.                                 Among noninducible patients at the end of the procedure, but inducible at day six, 59 patients had VT recurrence at one year follow-up. Recurrences were 9% when both studies were noninducible. There were no inappropriate shocks, incidents of syncope with 3%, none harmful. The rate of appropriate shocks per patient per month according to NIPS was significantly reduced, comparing the month before and after the ablation.                                 The authors concluded that programmed ventricular stimulation at day six predicts VT recurrence.                                 In the next study, Tor Biering-Sørensen and associates examined ECG global electrical heterogeneity, GEH, in its longitudinal changes, are associated with cardiac structure and function, in their Atherosclerosis Risk and Community study, ARIC, consisting of 5,114 patients, 58% which were female and 22% African Americans. Using the resting 12-lead ECGs, and echocardiographic assessments of left ventricular ejection fraction, global strain, left ventricular mass index, end diastolic volume index, end systolic volume index at visit five.                                 Longitudinal analysis included ARIC participants with measured GEH at visits one to four. GEH was quantified by spatial ventricular gradient, the QRST angle, and the sum of the absolute QRST integral. Cross sectional and longitudinal regressions were adjusted for manifest subclinical cardiovascular disease.                                 Having four abnormal GEH parameters was associated with a 6.4% left ventricular ejection fraction decline, a 24.2 gram/meter square increase in left ventricular mass index, a 10.3 milliliter/meter square increase in left ventricular end diastolic volume index, and a 7.8 milliliter/meter square increase in left ventricular end systolic index. All together, clinical and ECG parameters accounted for approximately one third of the left ventricular volume in 20% of the systolic function variability.                                 The associates were significantly stronger in patients with subclinical cardiovascular disease. The QRST integral increased by 20 millivolts/meter second for each three year period participants who demonstrated left ventricular dilatation at visit five. Sudden cardiac death victims demonstrated rapid GEH worsening, while those with left ventricular dysfunction demonstrated slow GEH worsening.                                 The authors concluded that GEH is a marker of subclinical abnormalities in cardiac structure and function.                                 In the next manuscript, Takumi Yamada and associates studied 19 patients with idiopathic ventricular arrhythmias, originating in the parietal band in 14 patients, in the septal band in 5 patients. Among 294 consecutive patients with right ventricular arrhythmia origins, parietal band and septal band ventricular arrhythmias exhibited a left bundle branch block, with left inferior in 12 patients', superior in 2 patients' axes, in left or right inferior axis pattern in four and one patients respectively.                                 In Lead 1, all parietal band ventricular arrhythmias exhibited R-waves, while septal band ventricular arrhythmias often exhibited S-waves. A QS pattern in lead AVR, in the presence of a knock in the mid QRS were common in all infundibular muscle ventricular arrhythmias. During infundibular muscle ventricular arrhythmias, a far-field ventricular electrogram, with an early activation, was always recorded in the His bundle region, regardless of the location of ventricular arrhythmia regions. With 9.2 radiofrequency applications in a duration of 972 seconds, catheter ablation was successful in 15 of the 19 patients. Ventricular arrhythmias recurred in four patients during a fallout period of 43 months.                                 In the next paper, Uma Mahesh Avula and associates examine the mechanisms underlying spontaneous atrial fibrillation, in an Ovine model of left atrial myocardial infarction. The left atrial myocardial infarction was created by ligating the atrial branch of the left anterior descending artery. ECG loop recorders were implanted to monitor atrial fibrillation episodes.                                 In seven sheep, Dantrolene, a Ryanodine receptor blocker, was administered in vivo, during the observation period. The left atrial myocardial infarction animals experienced numerous episodes of atrial fibrillation during the eight day monitoring period, that were suppressed by Dantrolene. Optical mapping showed spontaneous focal discharges originating through the ischemic/normal-zone border. These spontaneous focal discharges were calcium driven, rate dependent, and enhanced by isoproterenol, but suppressed by Dantrolene.                                 In addition, these spontaneous focal discharges initiated atrial fibrillation-maintaining reentrant rotors anchored by marked conduction delays at the ischemic/normal-zone border. Nitric oxide synthase one protein expression decreased in ischemic zone myocytes, or NADPA oxidase in xanthine oxidase enzyme activities in reactive oxygen species increased. Calmodulin aberrantly increased, Ryanodine binding to cardiac Ryanodine receptors in the ischemic zone. Dantrolene restored the physiologically binding of Calmodulin to the cardiac Ryanodine receptors.                                 The authors concluded that atrial ischemia causes spontaneous atrial fibrillation episodes in sheep, caused by spontaneous focal discharges that initiate re-entry. Nitroso redox imbalance in the ischemic zone is associated with intensive reactive oxygen species production, and altered the Ryanodine receptor responses to Calmodulin. Dantrolene administered normalize the Calmodulin response and prevents left atrial myocardial infarction, spontaneous focal discharges in atrial fibrillation initiation.                                 In the next study, Wouter van Everdingen and associates examine the use of QLV for achieving optimal acute hemodynamic response to CRT with a quadripolar left ventricular lead. 48 heart failure patients with left bundle branch block were studied. Mean ejection fraction 28%, mean QRS duration 176 milliseconds. Immediately after CRT implantation, invasive left ventricular pressure volume loops were recorded during biventricular pacing, with each separate electrode at four atrial ventricular delays.                                 Acute CRT response, measured as a change in stroke work compared to intrinsic conduction, was related to the intrinsic interval between the Q on the electrocardiogram and the left ventricular sensing delay, that is the QLV, normalized for the QRS duration, resulting in QLV over QRS duration in the electrode position.                                 QLV over QRS duration was 84% and variation between the four electrodes was 9%. The change in stroke work was 89% and varied by 39% between the electrodes. In univariate analysis, an anterolateral or lateral electrode position in a high QLV to QRS duration ratio had a significant association with a large change in stroke work, all P less than 0.01.                                 In a combined model, only QLV over QRS duration remained significantly associated with a change in stroke work, P less than 0.5. However, a direct relationship between QLV over QRS duration in stroke work was only seen in 24 patients, while 24 other patients had an inverse relation.                                 The authors concluded that a large variation in acute hemodynamic response indicates that the choice of stimulated electrode on the quadripolar electrode is important. Although QLV to QRS duration ratio was associated with acute hemodynamic response at a group level, it cannot be used to select the optimal electrode in the individual patient.                                 In the next study, Antonio Pani and associates conducted a multi-centered prospective study evaluating the determinance of zero-fluoroscopy ablation of supraventricular arrhythmias. They studied 430 patients with an indication for EP study and/or ablation of SVT. A procedure was defined as zero-fluoroscopy when no fluoroscopy was used. The total fluoroscopy time inversely was related to number of procedures previously performed by each operator since the study start. 289 procedures, or 67%, were zero-fluoro. Multi-variable analyses identified as predictors of zero-fluoro was the 30th procedure for each operator, as compared to procedures up to the ninth procedure, the type of arrhythmia, AVNRT having the highest probability of zero-fluoro, the operator, and the patient's age. Among operators, achievement of zero-fluoro varied from 0% to 100%, with 8 operators, or 23%, achieving zero-fluoro in 75% of their procedures. The probability of zero-fluoro increased by 2.8% as the patient's age decreased by one year. Acute procedural success was obtained in all cases.                                 The authors concluded that the use of 3D mapping completely avoided the use of fluoroscopy in most cases, with very low fluoro time in the remaining, and high safety and effectiveness profiles.                                 In the next paper, Demosthenes Katritsis and associates examine the role of slow pathway ablation from the septum as an alternative to right-sided ablation. Retrospectively, 1,342 undergoing right septal slow pathway ablation for AV nodal reentry were studied. Of these, 15 patients, 11 with typical and 4 with atypical AVNRT, had a left septal approach following unsuccessful right sided ablation, that is, the righted left group. In addition, 11 patients were subjected prospectively to a left septal only approach for slow pathway ablation, without previous right septal ablation, that is, left group. Fluoroscopy times in the right and left group, and the left groups were 30.5 minutes and 20 minutes respectively, P equals 0.6. The rate of [inaudible 00:18:24] current delivery time for comparable, 11.3 minutes and 10.0 minutes respectively.                                 There are no additional ablation lesions at other anatomical sites in either group, and no cases of AV block were encountered. Recurrence rate for arrhythmias in the right and left group was 6.7% and 0% in the left group, in the three months following ablation.                                 The authors concluded that the left septal anatomical ablation of the left inferior nodal extension is an alternative to ablation of both typical and atypical AV nodal reentry when ablation at the right posterior septum is ineffective.                                 In our next study, Mark Belkin and associates reported prior reports of new-onset device-detected atrial tachyarrhythmias. Despite the clear association between atrial fibrillation and the risk of thromboembolism, the clinical significance of new-onset device-detected atrial tachyarrhythmias and thromboembolism remains disputed.                                 The authors aim to determine the risk of thromboembolic events in these patients. Using the Ovid Medline, Cochrane, SCOPUS databases to identify 4,893 reports of randomized control trials, perspective or retrospective studies of pacemaker and defibrillator patients reporting the incidence of device detected atrial tachyarrhythmias.                                 The authors examine 28 studies, following a total of 24,984 patients. They had an average age of 69.9 years and a mean study duration of 21.8 months. New-onset device-detected atrial tachyarrhythmias was observed in 23% of patients. Among nine studies, consisting of 8,181 patients, reporting thromboembolism, the absolute incidence was 2.1%. Thromboembolic events were significantly greater among patients with new-onset device-detected arrhythmias, with a relative risk of 2.88, compared to those who had less than one minute of tachyarrhythmias, 1.77 risk ratio.                                 The authors concluded that new-onset device-detected atrial tachyarrhythmias is common, affecting close to one quarter of all patients with implanted pacemakers and defibrillators.                                 In our last paper, Sanghamitra Mohanty and associates performed a meta-analysis systematically evaluating the outcome of pulmonary vein isolation with and without thermoablation in patients with atrial fibrillation. For pulmonary vein ablation alone, only randomized trials conducted in the last three years reporting single procedure success rates, off antiarrhythmic drugs at 12 months or greater follow-up were included. In the PVI plus FIRM group, all public studies reporting a single procedure off antiarrhythmic drug success rate with at least one year follow-up were identified.                                 Meta-analytic estimates were derived, using the DerSimonian and Laird Random-effects Models, and pooled estimates of success rates. Statistical heterogeneity was assessed using the Cochran Q test and I-square. Study quality was assessed with the Newcastle-Ottawa Scale.                                 15 trials were included, 10 with PVI plus FIRM, with 511 patients, non-randomized perspective design, and 5 pulmonary vein isolation-only trials, consisting of 295 patients, all randomized.                                 All patients in the pulmonary vein only trials had 100% non paroxysmal atrial fibrillation, except for one study, and no prior ablations. About 24% of the PVI plus FIRM patients had paroxysmal atrial fibrillation.                                 After 15.9 months of follow-up, the off antiarrhythmic drug pooled success was 50% with FIRM plus PVI, compared to 58% in the PVI alone. The difference in the effect size between the groups was not statistically significant. No significant heterogeneity was observed in this meta-analysis.                                 The authors concluded that the overall pooled estimate did not show any therapeutic benefit of PVI FIRM over PVI alone.                                 That's it for this month, but keep listening. Suraj Kapa will be surfing all journals for the latest topics of interest in our field. Remember to download the podcast On The Beat. Take it away, Suraj. Suraj Kapa:          Thank you, Paul, and welcome back to “On The Beat”. Again, my name is Suraj Kapa and I'm here to review with you articles across the cardiac electrophysiology literature that were particularly hard hitting in the month of February.                                 To start, we review the area of atrial fibrillation, focusing on anticoagulation. Reviewing an article published in this past month's issue of the Journal of the American Heart Association, by Steinberg et al., entitled Frequency and Outcomes of Reduced Dose Non-Vitamin K Antagonist Anticoagulants, results from ORBIT AF II. The ORBIT AF II registry, also called the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, is a prospective national observational registry of AF patients.                                 The author sought to describe the frequency, appropriateness, and outcomes of patients prescribed reduced doses of NOACs in the community practice. They reviewed the records of almost 8,000 patients receiving NOACs and noted that the vast majority, nearly 84%, received a standard dose of NOACs, consistent with the U.S. FDA labeling. While only 16% received a reduced dose, only 43% of these were consistent with labeling instructions. Those who received reduced dose NOACs inappropriately more often tended to be younger and have, interestingly, lower overall bleeding risks scores.                                 Furthermore, compared with those appropriately receiving dosing, patients receiving inappropriately reduced dose NOACs had a higher unadjusted rates of thromboembolic events and death.                                 These data are important to understand, in that, discussion with patients, that inappropriate reduction of NOACs does not necessarily offer appropriate protection against long-term risk of thromboembolic events. Thus, close attention must be paid to consideration of the use cases and instructions for use.                                 While the registry cannot get into the details of why the dose was reduced in the spectrum of patients, it does highlight the fact that this continues to be a problem in general practice.                                 Further data is needed to understand what leads to inappropriate dose reduction, which could include factors such as patient preference, or physician education.                                 Staying within the realm of anticoagulation and understanding individual needs, we next review an article published in this past month's issue of Circulation, by Nielsen et al., entitled Female Sex Is a Risk Modifier Rather Than a Risk Factor for Stroke in Atrial Fibrillation. Should we use a CHA2DS2-VA score rather than CHA2DS2-VASc? In this review, the authors sought to evaluate whether female sex is truly an overall risk factor, as opposed to a risk modifier.                                 Using three nationwide registries, they identified patients with nonvalvular atrial fibrillation between 1997 and 2015, and they calculated two sets of scores. The first score, they termed a CHA2DS2-VA score, calculated for men and women with follow-up of one year in the Danish National Patient Registry. They wanted to calculate the risk based on this pseudo-value method. They then reviewed female sex as a prognostic factor by inclusion as an interaction term on the CHA2DS2-VA score, to calculate overall thromboembolic risk.                                 Amongst over 200,000 patients with atrial fibrillation, almost half of whom are women, they noted that the mean CHA2DS2-VA score, where sex is excluded, was a tad higher in women than men, namely 2.7 vs. 2.3. However, women had an overall higher one year thromboembolic rate of 7.3 vs. 5.7 per 100 person-years. Interestingly, with a CHA2DS2-VA score of zero, the absolute risk of thromboembolism was equal amongst men and women, around .5%. Once overall points increased above one, however, women exhibited a higher stroke risk. This interaction was statistically significant.                                 Thus, the authors indicated that female sex is a risk modifier for stroke in patients with atrial fibrillation, rather than a risk factor. The terminology is important to consider. Essentially, what they are noting is that at the lower risk level, female sex, in and of itself, is not something that necessarily puts somebody in the higher risk cohorts. Instead, at higher risk levels, because of other factors, a woman may have a higher overall risk of stroke than men. Thus, stroke risk is accentuated in women, who would have been eligible for oral anticoagulating treatment anyway, on the basis of a CHADS score above one.                                 These data highlight the importance of thinking about the fact that at the lower risk score level, female sex alone might not be sufficient to say that a patient has reached the CHA2DS2-VASc score of one and above. But, really, you need an overall CHA2DS2-VA score, or a risk score, inclusive of at least two other risk factors to indicate that now, being a female is going to modify the risk and further accentuate it.                                 Now, one thing to note is, these data are very consistent with the guidelines. The European guidelines indicates that female sex alone, which in the CHA2DS2-VASc score would confer a risk score of one, should not, by itself, construe the need to put somebody on anticoagulation.                                 However, it's important to highlight that these data show that at a CHA2DS2-VASc score of one in females, they should really be construed as equivalent to a CHA2DS2-VASc score of zero in men.                                 Using the CHA2DS2-VA score, where sex is excluded, but considering that women overall have a higher incidence of stroke at any given CHA2DS2-VA level above one, will help better counsel women about the importance of being on anticoagulants.                                 The next article we review relates to long-term risk related to atrial fibrillation, published in February's issue of Heart Rhythm, by Nishtala et al., entitled Atrial Fibrillation and Cognitive Decline in the Framingham Heart Study. While there's much out there about the potential long-term role of cognitive decline in atrial fibrillation patients, longitudinal research investigating the relationship is relatively sparse. Thus, the authors sought to investigate the association between atrial fibrillation and cognitive performance, cross-sectionally and longitudinally.                                 They chose patients within the Framingham study who are dementia and stroke-free at the time of baseline neuropsychological assessments. They evaluated atrial fibrillation status as a two level variable, namely prevalent atrial fibrillation vs. no atrial fibrillation in cross-sectional analyses. And they also separated into prevalent atrial fibrillation at baseline, interim development of atrial fibrillation, and those who didn't develop any atrial fibrillation in longitudinal analysis.                                 They studied 2,682 participants in the Framingham Heart study, including original and offspring cohorts. They noted that a baseline of about 4% had diagnosed atrial fibrillation. Prevalent AF was noted to be significantly associated with poorer attention. Interestingly, sex differences were noted, with men performing worse on test of abstract reasoning and executive function than women.                                 They noted that prevalent atrial fibrillation was significantly associated with the longitudinal decline in executive function, in both the original cohorts, as well as interim atrial fibrillation being significantly associated with longitudinal decline in executive function of the offspring cohorts. Thus, they noted that atrial fibrillation is associated with a profile of long-term change in cognitive function.                                 The importance of these data are to further highlight the potential contribution of atrial fibrillation to cognitive decline. While the exact mechanisms remain to be fully elucidated, the question of how to get ahead of the cognitive decline associated with atrial fibrillation is further put out by these data.                                 Whether the relationship between atrial fibrillation and cognitive decline is due to recurrent thromboembolic events vs. the therapies used vs. other factors such as humid anatomic factors resulting in poor brain perfusion, are relatively unclear.                                 Certainly it is also possible that atrial fibrillation simply reflects a process associated with other factors that might lead to cognitive decline. However, again, further mechanistic studies and potential treatment interventions to mitigate the risk of cognitive decline are still needed.                                 Speaking of this, we next review a paper published in the European Heart Journal this past month, by Friberg and Rosenqvist, entitled Less Dementia with Oral Anticoagulation in Atrial Fibrillation.                                 Speaking of treatments to avoid long-term cognitive decline, the authors sought to evaluate if oral anticoagulant treatment might offer protection against long-term dementia risk in atrial fibrillation.                                 These retrospective registry studies of patients with the hospital diagnoses of atrial fibrillation and no prior diagnosis of dementia in Sweden, including patients between 2006 and 2014. The study included a total of 444,106 patients over 1.5 million years. They noted that patients who were on anticoagulant treatment at baseline were associated with a 29% lower risk of dementia than patients without anticoagulant treatments. Thus, there is an overall 48% lower risk on treatments with the appropriate anticoagulation. There is no difference on whether Warfarin or the newer oral anticoagulants were used.                                 Thus, the authors concluded that the risk of dementia is higher without oral anticoagulant treatment in patients with atrial fibrillation, suggesting that early initiation of anticoagulant treatment in patients with atrial fibrillation could be of value to preserve long-term cognitive function.                                 This relates directly back to the previous paper, which focused more on the epidemiologic risk, while this paper focuses on elements that might construe mechanism or treatment options.                                 Many authors have concluded the incredible importance of early recognition of the need for anticoagulant initiation in patients with atrial fibrillation. While the exact mechanism of cognitive decline and dementia in atrial fibrillation remains to be completely elucidated, certainly recurrent thromboembolic events that might be relatively silent as they occur, but result in a long-term cumulative risk might be helped by placing patients on anticoagulants.                                 This becomes another reason to counsel patients on the importance of long-term anticoagulant therapy. Certainly, the limitations of these studies, however, are the retrospective nature and the fact that there might be some subtle differences that may not be otherwise able to be construed from retrospective registry data regarding the relative role of anticoagulants in truly protecting against long-term cognitive decline. However, the data are certainly provocative.                                 Continuing within realm and discussing outcomes associated atrial fibrillation, we next review an article by Leung et al., entitled The Impact of Atrial Fibrillation Clinical Subtype on Mortality, published in JACC: Clinical Electrophysiology this past month.                                 The author sought to investigate the prognostic implications of a subtype of atrial fibrillation, paroxysmal or persistent, on long-term prognosis. They sought to evaluate differences in mortality between paroxysmal or persistent atrial fibrillation amongst 1,773 patients. They adjusted for comorbid diseases associated with atrial fibrillation, as well as CHA2DS2-VASc score. In the study, a total of about 1,005 patients or about 57% had persistent atrial fibrillation. Over the follow-up period, about 10% of those with paroxysmal atrial fibrillation and 17% of those with persistent atrial fibrillation died.                                 They noted that persistent atrial fibrillation, after correcting for other comorbidities, was independently associated with worse survival. Thus, they concluded that persistent atrial fibrillation is independently associated with increased mortality in the long term.                                 These data are relevant in that they highlight that persistent atrial fibrillation in its nature might construe an overall higher risk cohort. It remains to be fully understood what are the true mechanistic differences between persistent and paroxysmal atrial fibrillation. Overall, however, the community grossly agrees that persistent atrial fibrillation likely suggests a higher degree of atrial myopathy. If we believe this, then it is reasonable to believe that the risk associated with this specific form of atrial fibrillation might result in higher long-term harm.                                 Of course, these data are subject to the same limitations of all retrospective data. Namely, these persistent atrial fibrillation patients might have received different therapies or been more sick to start with that cannot be construed by comorbidities alone.                                 Furthermore, these data do not necessarily get to the point of whether treating atrial fibrillation in the persistent patient more aggressively necessarily reduces the risk equivalent to that of paroxysmal patients. Thus, further understanding is needed to understand how to use these data to reduce this mortality difference.                                 Continuing within the realm of epidemiology of atrial fibrillation, we next review an article published in this past month's issue of Circulation, by Mandalenakis et al., entitled Atrial Fibrillation Burden in Young Patients with Congenital Heart Disease. It is assumed that patients with congenital heart disease are vulnerable to atrial fibrillation because of multiple factors. These include residual shunts, hemodynamic issues, atrial scars from previous heart surgery, valvulopathy and other factors.                                 However, there's limited data on the overall risk of developing atrial fibrillation and complications associated with it, especially in children and young adults with congenital heart disease. Furthermore, these children and young adults with congenital heart disease have never been compared with overall risk and control subjects.                                 The authors use the Swedish Patient and Cause of Death Registries to identify all patients with diagnoses of congenital heart disease born from 1970 to 1993. They then matched these patients with control subjects from the Total Population Register in Sweden. They noted amongst almost 22,000 patients with congenital heart disease and almost 220,000 matched control subjects that 654 patients amongst the congenital heart disease cohort developed atrial fibrillation, while only 328 amongst the larger control group developed atrial fibrillation. The mean follow-up overall was 27 years.                                 They noted the risk of developing atrial fibrillation was almost 22 times higher amongst patients with congenital heart disease than control subjects. They noted the highest risk with a hazard ratio of over 84 was noted in patients with conotruncal defects. Furthermore, at the age of 42 years, over 8% of patients with congenital heart disease had a recorded diagnosis of atrial fibrillation.                                 Interestingly, heart failure was a particularly important complication in patients with congenital heart disease and atrial fibrillation, with over 10% of patients developing atrial fibrillation and [inaudible 00:38:20] congenital heart disease developing a diagnosis of heart failure as well.                                 These data are important in that they help in counseling the importance of close follow-up of patients with congenital heart disease and their long-term risk of other complications. Even if patients might be perceivably well managed, incident atrial fibrillation might increase risk of stroke in these patients. It is further important to note that many of these patients cannot be evaluated according to traditional risk or evaluations. Thus, it is important to consider whether or not a patient should be treated with anticoagulation once they develop atrial fibrillation.                                 The high risk of overall atrial fibrillation incidents, particularly in patients with more complex congenital defects, needs to be taken into consideration when advising on the frequency of follow-up.                                 It is important to further note that we must think of this overall risk as the minimum possible risk, namely, counseling a congenital heart disease patient that up to one in ten of them may develop atrial fibrillation by the age of 42 years, is likely the minimum amount. The reason for this is many patients, due to either lack of follow-up or lack of sufficient monitoring, and the asymptomatic nature of atrial fibrillation in many patients might have not been diagnosed.                                 Implications or treatments remain to be seen, and whether or not there are methods to reduce the overall risk of atrial fibrillation is unclear. However, engaging congenital heart disease experts and advising patients, especially at younger ages, on the importance of close electrocardiographic monitoring for a potential atrial fibrillation risk is critical.                                 Next within the realm of atrial fibrillation, we switch to the topic of ablation. And review an article by Pallisgaard et al., published in this last month's issue of European Heart Journal, entitled Temporal Trends in Atrial Fibrillation Recurrence Rates After Ablation, between 2005 and 2014: a nationwide Danish cohort study.                                 Ablation has been increasingly used as a rhythm control strategy for patients with atrial fibrillation. Over this time, we have all noted evolution in both the experience and the techniques used. Thus, the authors sought to evaluate whether recurrence rate of atrial fibrillation has changed over the last decade. They included all patients with first-time AF ablation done between 2005 and 2014 in Denmark. They then evaluated recurrent atrial fibrillation based on a one year follow-up. They included a total of 5,425 patients undergoing first-time ablation.                                 They noted, interestingly, that the patient median age increased over time, and the median AF duration prior to ablation decreased over time. However, the rates of recurrent atrial fibrillation decreased from 45% in 2005 to 31% in the more recent years of 2013, 2014. With the relative risk of recurrent atrial fibrillation almost being cut in half.                                 They noted that female gender, hypertension, atrial fibrillation duration more than two years, and cardioversion with one year prior to ablation were all associated with an increased risk of recurrent atrial fibrillation, regardless of year.                                 These data, again, are retrospective and thus must be taken in the context of that consideration. However, they highlight that it is possible either our selection of appropriate patients for atrial fibrillation ablation or our techniques have improved overall success.                                 The fact that atrial fibrillation ablation is still a relatively young field, with evolving approaches and evolving techniques, needs to be taken into consideration when advising patients on success rates. Using data from many years prior to informed discussion today is fraught with potential error, especially as our catheter design and mapping system use and understanding of appropriate lesion set changes.                                 Of course, some criticism is required as well. While the patients included were relatively older in more recent years, the total AF duration prior to ablation decreased over the years. This suggests that patients are being ablated earlier than they were in the early days of atrial fibrillation ablation.                                 There is some data out there to suggest that earlier ablation for atrial fibrillation might result in a lower long-term recurrence rate. Thus, this might account for some of the difference. However, it is unlikely that it accounts for all of it, given the degree of reduction in overall risk of occurrence.                                 Staying within the trend of talking about changes in techniques for atrial fibrillation ablation, we next review an article published in this past month's issue of Heart Rhythm, by Conti et al., entitled Contact Force Sensing for Ablation of Persistent Atrial Fibrillation: A Randomized, Multicenter Trial. Contact force sensing is one of the newer techniques being used to optimize the success rates for atrial fibrillation ablation. It is generally felt that understanding when one is in contact will optimize atrial fibrillation ablation outcomes by ensuring the physician knows each time they are in contact, and also potentially reducing complications by avoiding excessive contact.                                 Thus, the authors designed the TOUCH AF trial to compare contact force sensing-guided ablation vs. contact force sensing-blinded ablation. They included a total of 128 patients undergoing first-time ablation for persistent atrial fibrillation, and thus randomized them to a situation where the operator was aware of the contact force vs. blinded to the contact force. While the force data was hidden in the blinded cohort, it was still recorded on the backend.                                 In all patients, wide antral pulmonary vein isolation plus a roof line was performed, and patients were followed at 3, 6, 9, and 12 months, with clinical visits, ECGs, and 48-hour Holter monitoring.                                 The primary endpoint was cumulative radio frequency time for procedures, and atrial arrhythmia is greater than 30 seconds after three months is considered a recurrence.                                 They noted that average force was higher in the contact force-guided arm than contact force-blinded arm, though not statistically significant, with an average of 12 grams in the latter and 14 grams in the former.                                 Interestingly, the total time of ablation did not differ between the two groups. Furthermore, there was no difference in the single procedure freedom from atrial arrhythmia, computing to about 60% in the contact force-guided arm vs. the 63% in the contact force-blinded arm. They did notice, however, that lesions with associated gaps were associated with significantly less force and less force-time integral.                                 The authors concluded from this, the contact force-guided ablation did not result in significant decrease in total radio frequency time or 12-month outcomes in terms of freedom from atrial arrhythmias.                                 These data are important to help guide us in terms of thinking about how the tools we use, as they change, actually alter outcomes. Sometimes we may perceive benefits based on logical thinking that's knowing more about what is happening when we are performing a procedure should optimize that procedure. However, this is not necessarily always the case, and thus highlights the importance of randomized trials to directly compare different situations, such as awareness of contact force vs. lack of awareness of contact force.                                 The relevance of these particular articles is that when we compare catheters with different designs, it does not necessarily highlight the importance of the force number itself. Namely, comparing a contact force catheter vs. non-contact force catheter implicates use of essentially two completely different catheters. To understand the incremental utility of force in making decisions, it is important to consider the same catheter, but simply with awareness or lack of awareness of the actual force number.                                 One of the limitations, however, is that individuals who might have been trained on using the same force sensing catheter might have some degree of tactile feedback and understanding of the amount of force being applied to the tip of the catheter, based on having been repeatedly exposed to contact force numbers during use of said catheter. Thus, there might be a difference in being blinded to contact force in early stage operators than in later stage operators who might have been trained based on repeated feedback.                                 Thus, it's difficult to conclude, necessarily, that contact force is not offering mental benefit. In fact, there's a fair chance that it does. However, offering a skeptical viewpoint to help guide the importance of continually evolving technology in actually improving outcomes is important.                                 Finally, within the realm of atrial fibrillation, we review an article published by Pathik et al., in this past month's issue of Heart Rhythm, entitled Absence of Rotational Activity Detected Using 2-Dimensional Phase Mapping and the Corresponding 3-Dimensional Phase Maps in Human Persistent Atrial Fibrillation.                                 Current clinically used phase mapping systems involve 2-dimensional maps. However, this process may affect accurate detection of rotors. The authors sought to develop 3-dimensional phase mapping technique that uses a 3D location of the same basket electrodes that are used to create the currently available 2-dimensional maps. Specifically, they wanted to determine whether the rotors detected in 2D phase maps were present in the corresponding time segments and anatomical locations in 3D phase maps.                                 They used one minute left atrial atrial fibrillation recordings obtained in 14 patients, using the basket catheter, and analyzed them offline, using the same phase values, based on 2-dimensional vs. 3-dimensional representations.                                 They noted rotors in 3.3% using 2D phase mapping, 9 to 14 patients demonstrated about 10 transient rotors, with a mean rotor duration of about 1.1 seconds. They noted none of the 10 rotors, however, were seen at the corresponding time segments and anatomical locations in 3D phase maps. When looking at 3D phases maps, 4 of the 10 corresponded with single wavefronts, 2 of 10 corresponded with simultaneous wavefronts, 1 of 10 corresponded with disorganized activity, and 3 of 10 had no coverage by the basket catheter at the corresponding 3D anatomical locations.                                 These data are important, in that they highlight the importance of when we consider reflecting 2-dimensional systems in a 3-dimensional world of atrial fibrillation. The role of ablating rotors is still in question. However, it is still an important question, and it requires continued study. The best way of identifying a rotor, knowing a rotor is a rotor, and understanding where the rotor is, are going to be critical to further evaluating whether actual ablation of these rotors has any relevance to long-term atrial fibrillation ablation.                                 The truth is, that we need to be sure that we are properly identifying all the rotors in order to help guide whether or not we are actually being successful in ablating atrial fibrillation. The importance of the study is in reflecting whether 2-dimensional representations of the 3-dimensional geometry is sufficient to reflect what is actually happening in that 3-dimensional geometry. These authors suggest that it is not.                                 One of the limitations, however, might be that when we wrap a 2-dimensional framework into 3 dimensions and perform additional post-processing, this might result in some degree of attenuation of the data. However, it does highlight the importance for continued rigorous evaluation of current approaches to phase mapping.                                 Several articles have been published in recent months as well, about different single processing techniques to evaluate whether or not a rotor is, in fact, a rotor and to help optimize identification of them.                                 The jury is still out on whether or not targeted ablation of rotors will, in fact, improve overall long-term atrial fibrillation ablation outcomes. The limitations might not necessarily be that rotors are not an appropriate target, but that we just don't understand entirely where rotors are, based on limited single processing options, or based on limitations of anatomical localization.                                 Next, delving into the realm of ablation at large, we review an article by Iwasawa et al., published in this past month's issue of Europace, entitled Trans Cranial Measurement of Cerebral Microembolic Signals During Left-Sided Catheter Ablation with the Use of Different Approaches - the Potential Microembolic Risk of a Transseptal Approach.                                 The authors note the importance of considering microemolization in subclinical brain damage during catheter ablation procedures. They evaluated microembolic signals detected by transcranial Doppler during ablation of supraventricular or ventricular arrhythmias with the use of either a transseptal or a retrograde approach.                                 The study set was small, only including 36 patients who underwent catheter ablation. They noted in about 11 patients left-sided ablation was done with transaortic approach, and in 9 patients a transseptal approach was used. The other 16 patients were not included, as they only had right-sided ablation.                                 The total amount of microembolic signature, based on transcranial Doppler were counted throughout the procedure and then analyzed offline. There is no significant difference in number of radio frequency applications, total energy delivery time, total application of energy, or total procedure time between the different groups. However, they did note that the mean total number of microembolic signals was highest in those undergoing transseptal approach to left-sided ablation. It was significantly lower in those having retrograde aortic approach, and lowest in those having right-sided only ablation.                                 Interestingly, many of the microembolic signals were detected during the transseptal puncture period, and then during the remainder of the procedure there was relatively even distribution of emboli formation. A frequency analysis suggested that the vast majority of microembolic signals are gaseous, in particularly Group 1 and Group 3, though only 91% in Group 2. No neurological impairment was observed in any of the patients after the procedure.                                 Recently, there's been a lot of focus on the potential long-term risk of cognitive impairments due to microembolic events in the setting of ablation. At least one recent paper in ventricular arrhythmias and several recent papers in atrial fibrillation ablation have suggested a fairly high risk of incidence cerebral emboli noted on MRI post ablation. While these results do not necessarily get at MRI lesions, they do suggest microembolic events. And what is most interesting, they look at microembolic events that occur throughout the entire ablation period with different approaches.                                 Interestingly, there is a massive spike in overall microembolic signals during the transseptal puncture period, and relatively even distribution throughout ablation, irrespective of application of radio frequency or not. Furthermore, while nearly all microembolic signals are gaseous, based on frequency analysis, with retroaortic approach or in those having right-sided only ablation, significantly less seem to be due to gaseous events in those having a transseptal approach.                                 It is known that there's possible damage to the internal dilation system when exposing it to transseptal needles or wires. Thus, one has to wonder whether some of the embolization could be from material associated with the actual transseptal puncture, either from portions of the punctured septum itself, or perhaps from the plastic material that which is being pushed transseptally.                                 These data still need to be considered and we have yet to see what the long-term applications of these kinds of findings are. It may be possible that while transseptal approach seems to offer more instant microembolic signals, if the long-term risk is no different, does it really matter?                                 However, these findings are provocative in the sense that they highlight potential significant differences and the risk of silent cerebral damage, based on the approach we use to ablation.                                 Changing gears, we next focus on the role of devices. And the first paper review is in the last month issue of JACC: Heart Failure, by Gierula et al., entitled Rate Response Programming Tailored to the Force Frequency Relationship Improves Exercise Tolerance in Chronic Heart Failure.                                 The authors sought to examine whether the heart rate at which the force frequency relationship slope peaks can be used to tailor heart rate response in chronic heart failure patients with cardiac pacemakers, and to see whether this favorably influences exercise capacity.                                 They performed an observational study in both congestive heart failure and healthy subjects with pacemaker devices. They then evaluated in a double-blind, randomized, controlled crossover study, the effects of tailored pacemaker rate response programming on the basis of a calculation of force frequency relationship based on critical heart rate, peak contractility, and the FFR slope.                                 They enrolled a total of 90 patients with congestive heart failure into the observational study cohorts, and 15 control subjects with normal LLV function. A total of 52 patients took part in the crossover study. They noted that those who had rate response settings limiting heart rate rise to below the critical heart rate were associated with greater exercise time and higher peak oxygen consumption, suggesting the tailored rate response program can offer significant benefit, particularly in congestive heart failure patients.                                 The importance of this trial is in that it highlights the importance of thoughtful decision-making in programming devices, and that group decision-making involving exercise physiologists, alongside pacemaker programming, and involving our congestive heart failure specialists might be the most critical in optimizing the approach to programming.                                 It might be that more aggressive measures are needed in congestive heart failure patients to decide on what optimal programming is, than it is in otherwise normal patients.                                 Staying within the realm of devices, we next focus on a publication by Sanders et al., published in this past month's issue of JACC: Clinical Electrophysiology, entitled Increased Hospitalizations and Overall Healthcare Utilization in Patients Receiving Implantable Cardioverter-Defibrillator Shocks Compared With Antitachycardia Pacing.                                 The authors sought to evaluate the effect of different therapies and healthcare utilization in a large patient cohorts. Specifically comparing antitachycardia pacing with high voltage shocks. They used the PROVIDE registry, which is a prospective study of patients receiving ICDs for primary prevention in 97 U.S. centers. They categorized these patients by type of therapy delivered, namely no therapy, ATP only, or at least one shock. They then adjudicated all ICD therapies, hospitalizations, and deaths.                                 Of the 1,670 patients included, there was a total follow-up of over 18 months. The vast majority, 1,316 received no therapy, 152 had ATP only, and 202 received at least one shock.                                 They noted that patients receiving no therapy and those receiving only ATP had a lower cumulative hospitalization rate and had a lower risk of death or hospitalization. The cost of hospitalization was known to be significantly higher for those receiving at least one shock than for those receiving only ATP therapy.                                 They noted no difference in outcomes or cost between patients receiving only ATP and those without therapy. Thus, the authors concluded that those receiving no therapy or those receiving only ATP therapy had similar outcomes, and had significantly reduced hospitalizations, mortality, and costs compared to those who received at least one high voltage shock.                                 The relevant findings from this study is similar to prior studies that suggest that any shock over follow-up is associated with potential increase in long-term mortality. The difficulty in assessing this, however, is the fact that it might be that those who have VT that can be appropriately ATP terminated, might be at a somewhat lower risk than those who need to be shocked to get out of their VT. Thus, the presumption of needing a shock to restore normal rhythm might suggest a higher risk cohort, it cannot be gleaned from traditional evaluation of morbid risk factors.                                 This is why the importance of considering how devices are programmed and whether or not a patient who has received shocks can be reprogrammed to offer ATP only therapy to terminate those same VTs, needs to be taken into consideration. How to best tailor this therapy, however, is still remaining to be determined, though more and more clinical trials are coming out to suggest in terms of optimal overall population-wide programming for devices.                                 Staying with the realm of devices, we next review an article by Koyak et al., in this past month's issue of Europace, entitled Cardiac Resynchronization Therapy in Adults with Congenital Heart Disease.                                 Heart failure is one of the leading causes of morbidity and mortality amongst patients with congenital heart disease. But there's limited experience in the role of cardiac resynchronization therapy amongst these patients. Thus, the authors sought to evaluate the efficacy of CRT in adults with congenital heart disease.                                 They performed a retrospective study on a limited number of 48 adults with congenital heart disease who received CRT, amongst four tertiary referral centers. They have defined responders as those who showed improvement in NYHA functional class or improvement in systemic ventricular ejection fraction. The median age at CRT implant was 47 years, with 77% being male. There was a variety of syndromes included.                                 They noted that the majority of patients, nearly 77%, responded to CRT, either by definition of improvement of NYHA functional class, or systemic ventricular function, with a total of 11 non-responders.                                 They noted that CRT was accomplished with a success rate comparable to those with acquired heart disease. However, the anatomy is much more complex and those technical challenges in achieving success o

Moderator: BobbieJean Sweitzer, M.D. Participants: Rebecca A. Schroeder, M.D. and Michael F. Aziz, M.D Articles Discussed: Temporal Trends in Difficult and Failed Tracheal Intubation in a Regional Community Anesthetic Practice Advancing Patient Safety in Airway Management Transcript

Commentary by Dr. Valentin Fuster

Happy Holidays PEC Podcast Listeners!!! We hope your holidays have been filled with family fun while being safe :).   To help bring in 2018, we reviewed the most recent Prehospital Emergency Care Journal.  Manuscripts range from Mobile Integrated Healthcare to Wilderness Medicine.  Right-click here to download now! In this episode we interview: Pediatric Prehospital Refusal of Medical Assistance: Association with Suspected Abuse or Neglect Matthew Sztajnkrycer MD, PhD @NoobieMatt   Patient Characteristics and Temporal Trends in Police Transport of Blunt Trauma Patients: A Multicenter Retrospective Cohort Study Daniel N Holena MD MCSE   We hope you enjoy this podcast and THANK YOU For listening! Happy Holidays!!! Hawnwan Philip Moy MD (@pecpodcast) Scott Goldberg MD, MPH (@EMS_Boston) Jeremiah Escajeda MD, MPH (@jerescajeda) Joelle Donofrio DO (@PEMems)

Interview with Ahmedin Jemal, DVM, PhD, author of Temporal Trends in Mortality in the United States, 1969-2013, and J. Michael McGinnis, MD, MPP, author of Mortality Trends and Signs of Health Progress. Also in this episode is a conversation with Christopher J.L. Murray, MD, DPhil, a Professor of Global Health at the University of Washington and Institute Director of the Institute for Health Metrics and Evaluation. CME for this activity is available here.

Interview with Ahmedin Jemal, DVM, PhD, author of Temporal Trends in Mortality in the United States, 1969-2013

Interview with Ahmedin Jemal, DVM, PhD, author of Temporal Trends in Mortality in the United States, 1969-2013, and J. Michael McGinnis, MD, MPP, author of Mortality Trends and Signs of Health Progress. Also in this episode is a conversation with Christopher J.L. Murray, MD, DPhil, a Professor of Global Health at the University of Washington and Institute Director of the Institute for Health Metrics and Evaluation.

Aims: To assess temporal trends in birth weight and pregnancy weight gain in Bavaria from 2000 to 2007. Methods: Data on 695,707 mother and infant pairs (singleton term births) were available from a compulsory reporting system for quality assurance, including information on birth weight, maternal weight at delivery and at booking, maternal smoking, age, and further anthropometric and lifestyle factors. Pregnancy weight gain was defined as: weight prior to delivery minus weight at first booking minus weight of the newborn. Results: Although mean weight gain during pregnancy increased considerably from 10.10 to 10.73 kg in seven years, the mean birth weight in mature singletons decreased slightly from 3433 to 3414 g. These trends could not be explained by concurrent changes in the rates of primiparity, smoking and gestational diabetes. Conclusions: These German data confirm an increased weight gain during pregnancy with adjustment for potential confounders.