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Introduction: Incomplete anchoring of the Watchman left atrial appendage closure (LAAO) device can result in substantial device migration or device embolization (DME) requiring percutaneous or surgical retrieval. Methods: We performed a retrospective analysis of Watchman procedures (January 2016 through March 2021) reported to the National Cardiovascular Data Registry LAAO Registry. We excluded patients with prior LAAO interventions, no device released, and missing device information. In‐hospital events were assessed among all patients and postdischarge events were assessed among patients with 45‐day follow‐up. Results: Of 120 278 Watchman procedures, the in‐hospital DME rate was 0.07% (n = 84) and surgery was commonly performed (n = 39). In‐hospital mortality rate was 14% among patients with DME and 20.5% among patients who underwent surgery. In‐hospital DME was more common: at hospitals with a lower median annual procedure volume (24 vs. 41 procedures, p <.0001), with Watchman 2.5 versus Watchman FLX devices (0.08% vs. 0.04%, p =.0048), with larger LAA ostia (median 23 vs. 21 mm, p =.004), and with a smaller difference between device and LAA ostial size (median difference 4 vs. 5 mm, p =.04). Of 98 147 patients with 45‐day follow‐up, postdischarge DME occurred in 0.06% (n = 54) patients and cardiac surgery was performed in 7.4% (n = 4) of cases. The 45‐day mortality rate was 3.7% (n = 2) among patients with postdischarge DME. Postdischarge DME was more common among men (79.7% of events but 58.9% of all procedures, p =.0019), taller patients (177.9 vs. 172 cm, p =.0005), and those with greater body mass (99.9 vs. 85.5 kg, p =.0055). The rhythm at implant was less frequently AF among patients with DME compared to those without (38.9% vs. 46.9%, p =.0098). Conclusion: While Watchman DME is rare, it is associated with high mortality and frequently requires surgical retrieval, and a substantial proportion of events occur after discharge. Due to the severity of DME events, risk mitigation strategies and on‐site cardiac surgical back‐up are of paramount importance. [ABSTRACT FROM AUTHOR]

Introduction: Direct oral anticoagulants (DOACs) have partial renal clearance and generally require dosage adjustments based on renal function. While current US and European guidance recommends dose adjustments in patients with moderate chronic kidney disease (CKD), it is unclear how often this is done appropriately in routine clinical practice. Methods: We examined rates of appropriate and inappropriate dosing in patients with atrial fibrillation (AF) and moderate CKD, as determined by creatinine clearance (CrCl) of 30–50 mL/min calculated with the Cockcroft–Gault formula. Descriptive statistics were used to describe the rate of appropriate and inappropriate dosing as well as event rates. Results: Among 1134 patients (8.5% of the overall ORBIT-AF II registry) with AF and CrCl 30–50 mL/min, the median age was 82 (25th, 75th percentile: 78, 86), 38% were male, and the median CHA2DS2VASC score was 4 (25th, 75th percentile: 4, 5). At baseline, more than one-third (34%) of patients with moderate CKD were inappropriately dosed with DOACs. When evaluating the specific prescribed doses in those with moderate CKD, 15% (N = 170/1134) were underdosed, 66% (743/1134) were appropriately dosed, and 20% (N = 221/1134) were overdosed. There were no significant differences in comorbid medical conditions between patients with moderate CKD who were appropriately and inappropriately dosed with a DOAC. Conclusion: In routine clinical practice, prescribing of DOACs in patients with AF with moderate CKD is often inconsistent with drug labeling, with up to one-third of patients being inappropriately dosed. [ABSTRACT FROM AUTHOR]

Background: Cardioversion is common among patients with atrial fibrillation (AF). We hypothesised that novel oral anticoagulants (NOAC) used in clinical practice resulted in similar rates of stroke compared with vitamin K antagonists (VKA) for cardioversion.Methods: Using the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II, patients with AF who had a cardioversion, follow-up data and an AF diagnosis within 6 months of enrolment were identified retrospectively. Clinical outcomes were compared for patients receiving a NOAC or VKA for 1 year following cardioversion.Results: Among 13 004 patients with AF, 2260 (17%) underwent cardioversion. 1613 met the inclusion criteria for this analysis. At the time of cardioversion, 283 (17.5%) were receiving a VKA and 1330 (82.5%) a NOAC. A transoesophageal echocardiogram (TOE) was performed in 403 (25%) cardioversions. The incidence of stroke/transient ischaemic attack (TIA) at 30 days was the same for patients having (3.04 per 100 patient-years) or not having (3.04 per 100 patient-years) a TOE (p=0.99). There were no differences in the incidence of death (HR 1.19, 95% CI 0.62 to 2.28, p=0.61), cardiovascular hospitalisation (HR 1.02, 95% CI 0.76 to 1.35, p=0.91), stroke/TIA (HR 1.18, 95% CI 0.30 to 4.74, p=0.81) or bleeding-related hospitalisation (HR 1.29, 95% CI 0.66 to 2.52, p=0.45) at 1 year for patients treated with either a NOAC or VKA.Conclusions: Cardioversion was a low-risk procedure for patients treated with NOAC, and there were statistically similar rates of stroke/TIA 30 days after cardioversion as for patients treated with VKA. There were no statically significant differences in death, stroke/TIA or major bleeding at 1 year among patients treated with NOAC compared with VKA after cardioversion. [ABSTRACT FROM AUTHOR]

Background: Left atrial appendage occlusion (LAAO) to prevent stroke in patients with atrial fibrillation has been evaluated in 2 randomized trials; post-approval clinical data are limited.Objectives: The purpose of this study was to describe the National Cardiovascular Data Registry (NCDR) LAAO Registry and present patient, hospital, and physician characteristics and in-hospital adverse event rates for Watchman procedures in the United States during its first 3 years.Methods: The authors describe the LAAO Registry structure and governance, the outcome adjudication processes, and the data quality and collection processes. They characterize the patient population, performing hospitals, and in-hospital adverse event rates.Results: A total of 38,158 procedures from 495 hospitals performed by 1,318 physicians in the United States were included between January 2016 and December 2018. The mean patient age was 76.1 ± 8.1 years, the mean CHA2DS2-VASc (congestive heart failure, hypertension, 65 years of age and older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, 65 to 74 years of age, female) score was 4.6 ± 1.5, and the mean HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly) score was 3.0 ± 1.1. The median annual number of LAAO procedures performed for hospitals was 30 (interquartile range: 18 to 44) and for physicians was 12 (interquartile range: 8 to 20). Procedures were canceled or aborted in 7% of cases; among cases in which a device was deployed, 98.1% were implanted with <5-mm leak. Major in-hospital adverse events occurred in 2.16% of patients; the most common complications were pericardial effusion requiring intervention (1.39%) and major bleeding (1.25%), whereas stroke (0.17%) and death (0.19%) were rare.Conclusions: The LAAO Registry has enrolled >38,000 patients implanted with the device. Patients were generally older with more comorbidities than those enrolled in the pivotal trials; however, major in-hospital adverse event rates were lower than reported in those trials. [ABSTRACT FROM AUTHOR]

Objective: Chronic obstructive pulmonary disease (COPD) is associated with the development of atrial fibrillation (AF), and may complicate treatment of AF. We examined the association between COPD and symptoms, quality of life (QoL), treatment and outcomes among patients with AF.Methods: We compared patients with and without a diagnosis of COPD in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, a prospective registry that enrolled outpatients with AF not secondary to reversible causes, from both academic and community settings.Results: Among 9749 patients with AF, 1605 (16%) had COPD. Relative to patients without COPD, those with COPD were more likely to be older, current/former smokers (73% vs 43%), have heart failure (54% vs 29%) and coronary artery disease (49% vs 34%). Oral anticoagulant and beta blocker use were similar, whereas digoxin use was more common among patients with COPD. Symptom burden was generally higher, and QoL worse, among patients with COPD (median Atrial Fibrillation Effect on QualiTy-of-Life score 76 vs 83). Patients with COPD had higher risk of all-cause mortality (adjusted HR 1.52 (95% CI 1.32 to 1.74)), cardiovascular mortality (adjusted HR 1.51 (95% CI 1.24 to 1.84)) and cardiovascular hospitalisation (adjusted HR 1.15 (95% CI 1.05 to 1.26)). Patients with COPD also had higher risk of major bleeding events (adjusted HR 1.25 (95% CI 1.05 to 1.50)). There did not appear to be associations between COPD and AF progression, ischaemic events or new-onset heart failure.Conclusions: Among patients with AF, COPD is associated with higher symptom burden, worse QoL, and worse cardiovascular and bleeding outcomes. These associations were not fully explained by cardiovascular risk factors, AF treatment or smoking history.Clinical Registration Number: NCT01165710. [ABSTRACT FROM AUTHOR]

Given the current political climate following the election of Trump to the White House, it is important to ensure that Schools of Social Work are responding in a way that is promoting social justice, advocacy, and opposition to any form of oppression. This reflective narrative discusses how three assistant professors who are faculty in Schools of Social Work at Historically Black Colleges and Universities (HBCUs) engaged their students in transformational learning to embrace the aftermath of the election results. This is a reflection about empowerment and preparing future social workers to address social justice issues. [ABSTRACT FROM AUTHOR]

Background: Data are lacking on national trends for atrial fibrillation (AF) hospitalization, particularly with regard to long-term outcomes including readmission and mortality.Methods: We studied all Medicare fee-for-service beneficiaries between 1999 and 2013, and we evaluated rates of hospitalization for AF, in-hospital mortality, length of stay, and hospital payments. We then evaluated rates of long-term outcomes, including 30-day readmission, 30-day mortality, and 1-year mortality. To evaluate changes in rates of AF hospitalization and mortality, we used mixed-effects models, adjusting for age, sex, race, and comorbidity. To assess changes in rates of 30-day readmission, we constructed a Cox proportional hazards model adjusting for age, sex, race, and comorbidity.Results: Adjusted rates of hospitalization for AF increased by ≈1% per year between 1999 and 2013, and although geographic variation was present, this trend was consistent nationwide. Median hospital length of stay remained unchanged at 3.0 (interquartile range 2.0-5.0) days, but median Medicare inpatient expenditure per beneficiary increased from $2932 (interquartile range $2232-$3870) to $4719 (interquartile range $3124-$7209) per stay. During the same period, the rate of inpatient mortality during AF hospitalization decreased by 4% per year, and the rate of 30-day readmission decreased by 1% per year. The rates of 30-day and 1-year mortality decreased more modestly by 0.4% and 0.26% per year, respectively.Conclusions: Between 1999 and 2013, among Medicare fee-for-service beneficiaries, patients were hospitalized more frequently and treated with more costly inpatient therapies such as AF catheter ablation, but this finding was associated with improved outcomes, including lower rates of in-hospital mortality, 30-day readmission, 30-day mortality, and 1-year mortality. [ABSTRACT FROM AUTHOR]

Background: The Food and Drug Administration approved left atrial appendage occlusion with the Watchman device for patients who are at increased stroke risk and are suitable for oral anticoagulation but who have an appropriate reason to seek a nondrug alternative. These broad criteria raise the question of their interpretation in clinical practice. There is a lack of studies comprehensively evaluating the indications for Watchman implantation among a large series of patients from contemporary, real-world practice in the United States.Methods: We used the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry to identify Watchman procedures performed between 2016 and 2018. We assessed procedural indications for Watchman implantation in the United States and evaluated the association between procedural indications and in-hospital adverse events.Results: A total of 38 314 procedures were included. The mean patient age was 76.1±8.1 years, and 58.9% were men. The mean CHA2DS2-VASc score was 4.8±1.5, whereas the mean hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol (HAS-BLED) score was 3.0±1.1. Prior stroke or transient ischemic attack was reported in 40.2% and prior bleeding in 70.1%, with gastrointestinal bleeding being most common (41.9%). The most common site-reported procedural indications for Watchman implantation were increased thromboembolic risk (64.8%) and history of major bleed (64.3%), followed by high fall risk (35.5%). Most (71.9%) had ≥2 procedural indications. Patients with high fall risk had increased risk of in-hospital adverse events (adjusted OR, 1.12; P=0.025), but no other differences were found in the risk of in-hospital adverse events by procedural indication.Conclusions: Among patients in the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry, the most common procedural indications for Watchman implantation were increased thromboembolic risk, history of major bleed, and high fall risk. A majority of patients had multiple procedural indications. High fall risk conferred a modestly increased risk of in-hospital adverse events. [ABSTRACT FROM AUTHOR]

The article explores the reasons for the popularity of U.S. Republican presidential candidate Donald Trump, who uses divisive and hateful speech to boost his candidacy, and highlights the need for educators to help inform the public about the real state of the country through informed and civil democratic discourse.

In this article, the author stresses that Trumpism can be considered as conservatism.

The article discusses how implicit bias, involving discrimination based upon race and ethnicity, influence the housing and land use decisions in the U.S. and explore information on the biased policing against Native Hawaiians and Pacific Islanders in the country.

U.S. Forest Service managers are required to incorporate social and biophysical science information in planning and environmental analysis. The use of science is mandated by the National Environmental Policy Act, the National Forest Management Act, and U.S. Forest Service planning rules. Despite the agency's emphasis on 'science-based' decision-making, little is known about how science is actually used in recreation planning and management. This study investigated the perceptions of Forest Service interdisciplinary (ID) team leaders for 106 NEPA projects dealing with recreation and travel management between 2005 and 2008. Our survey data show how managers rate the importance of social and biophysical science compared to other potential 'success factors' in NEPA assessments. We also explore how team leaders value and use multi-disciplinary tools for recreation-related assessments. Results suggest that managers employ a variety of recreation planning tools in NEPA projects, but there appears to be no common understanding or approach for how or when these tools are incorporated. The Recreation Opportunity Spectrum (ROS) was the most frequently used planning tool, but the Visitor Experience and Resource Protection (VERP) framework was the most consistently valued tool by those who used it. We recommend further evaluation of the strengths and weaknesses of each planning tool and future development of procedures to select appropriate planning tools for use in recreation-related NEPA assessments. [ABSTRACT FROM AUTHOR]

Interdisciplinary (ID) teams were created by the US Forest Service in response to environmental legislation. In 2008, we surveyed ID team leaders for National Environmental Policy Act (NEPA) analysis of 106 recreation-related projects conducted between 2005 and 2008. Results were compared with current workforce data and previous studies of ID team leadership and composition for NEPA assessments. ID teams were large in size and diverse in composition, with representatives of a broad range of disciplines and functional areas. The composition of ID teams may be changing from traditional natural resource management to more discipline-specific expertise. The role of social scientists and other human dimension specialists remains modest, despite the importance of social science questions inherent in recreation projects. Results reflect changes in agency hiring practices in the last 20 years and raise questions about the interdisciplinary nature of US Forest Service ID teams. [ABSTRACT FROM AUTHOR]

Abstract: College students select majors for a variety of reasons, including expected returns in the labor market. This paper demonstrates an empirical method linking a census of US degrees and fields of study with measures of the knowledge content of jobs. The study combines individual wage and employment data from the Current Population Survey (CPS) with ratings on 27 knowledge content areas from the Occupational Information Network (O*NET), thus providing measures of the economy-wide knowledge content of jobs. Fields of study and corresponding BA degree data from the Digest of Education Statistics for 1976–1977 through 2001–2002 are linked to these 27 content areas. We find that the choice of college major is responsive to changes in the knowledge composition of jobs and, more problematically, the wage returns to types of knowledge. Women''s degree responsiveness to knowledge content appears to be stronger than men''s, but their response to wage returns is weak. [Copyright &y& Elsevier]

In this article the authors evaluate the impact of globalization on the economic performance of small and medium sized business enterprises in the United States. The article evaluates the effect of globalization on such companies that are white owned and those that are owned by minorities. Total exports, exports by businesses meeting the size criteria of the article and the assets of multinational corporations are cited as benchmarks the study is based on. The job creation activities of small and medium sized business are evaluated.

Provides information on a study which investigated the impact of the case mix-adjusted reimbursement policy and market factors on the performance of nursing home care in the United States. Analysis of fixed-effects regression; Details on a decrease in excess or empty nursing home beds; Information on Medicaid residents; Methodology used to conduct the study; Results of the study.

Discusses the experiences of nonpassenger shippers and receivers, private, common and contract carriers after a year of deregulation in Florida. Overall carrier and shipper perceptions of deregulation; Comparison of carriers and shippers by regulatory preferences; Differences between the opponents and proponents of deregulation with respect to rate setting and profit levels.

This study examines representation and portrayal of African Americans in magazine ads in light of readership profiles. General-readership and primarily African American-readership magazines were selected to represent women's, men's, business, and general interests. African Americans were underrepresented in general-readership magazine ads relative to their readership levels while no underrepresentation was evident for European Americans. Both African Americans and European Americans were either proportionately represented or overrepresented relative to their respective readership levels in African American-readership magazines. No racial biases were evident in ad role portrayals in either general- or African American-readership magazines. Efforts to increase representation of African Americans in magazine ads would serve both marketing interests and social concerns. [ABSTRACT FROM AUTHOR]

Discusses works on the motor carrier service to the rural shipper/receivers (S/R) and the agricultural commodity S/R under regulated and unregulated environments in the United States. Effect of the Motor Carrier Act on rural and agricultural S/R; Economic arguments in the regulatory debate; Perceptions of rural S/R on the quantity of motor carrier service offered after deregulation or relaxation of regulation; Discrimination of small S/R.

Examines the influence of excess demand on nursing home costs. Analysis of 1989 data from a sample of 179 Kentucky nursing homes; Assertion that excess demand constrains market competition and patient care expenditures; Factors that may counteract the influence of excess demand; Role of competition in nursing home markets.

Background: Atrial fibrillation (AF) adversely impacts health-related quality of life (hrQoL). While some patients demonstrate improvements in hrQoL, the factors associated with large improvements in hrQoL are not well described.Methods: We assessed factors associated with a 1-year increase in the Atrial Fibrillation Effect on Quality-of-Life score of 1 SD (≥18 points; 3× clinically important difference), among outpatients in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation I registry.Results: Overall, 28% (181/636) of patients had such a hrQoL improvement. Compared with patients not showing large hrQoL improvement, they were of similar age (median 73 versus 74, P=0.3), equally likely to be female (44% versus 48%, P=0.3), but more likely to have newly diagnosed AF at baseline (18% versus 8%; P=0.0004), prior antiarrhythmic drug use (52% versus 40%, P=0.005), baseline antiarrhythmic drug use (34.8% versus 26.8%, P=0.045), and more likely to undergo AF-related procedures during follow-up (AF ablation: 6.6% versus 2.0%, P=0.003; cardioversion: 12.2% versus 5.9%, P=0.008). In multivariable analysis, a history of alcohol abuse (adjusted OR, 2.41; P=0.01) and increased baseline diastolic blood pressure (adjusted OR, 1.23 per 10-point increase and >65 mm Hg; P=0.04) were associated with large improvements in hrQoL at 1 year, whereas patients with prior stroke/transient ischemic attack, chronic obstructive pulmonary disease, and peripheral arterial disease were less likely to improve (P<0.05 for each).Conclusions: In this national registry of patients with AF, potentially treatable AF risk factors are associated with large hrQoL improvement, whereas less reversible conditions appeared negatively associated with hrQoL improvement. Understanding which patients are most likely to have large hrQoL improvement may facilitate targeting interventions for high-value care that optimizes patient-reported outcomes in AF. Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01165710. [ABSTRACT FROM AUTHOR]