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Implant site hematoma is a known complication of cardiac device procedures and can lead to major consequences.To evaluate risk factors for hematoma and further understand the relationship between anticoagulant (AC), antiplatelet (AP) use, and hematoma development.We included 6800 patients from the WRAP-IT trial. To assess baseline and procedural characteristics associated with hematoma within the first 30 days postprocedure, a stepwise Cox regression model was implemented with minimal Akaike information criterion. Cox regressions were also used to evaluate AC/AP use and hematoma risk.The overall rate of hematoma was 2.2%. The model identified 11 baseline and procedural characteristics associated with hematoma risk. AC use (hazard ratio [HR]: 2.44,The results of this analysis highlight risk factors associated with the development of hematoma in patients undergoing CIED procedures and can inform antithrombotic management.

Aim The Prevention of Arrhythmia Device Infection Trial (PADIT) infection risk score, developed based on a large prospectively collected data set, identified five independent predictors of cardiac implantable electronic device (CIED) infection. We performed an independent validation of the risk score in a data set extracted from U.S. healthcare claims. Methods and results Retrospective identification of index CIED procedures among patients aged ≥18 years with at least one record of a CIED procedure between January 2011 and September 2014 in a U.S health claims database. PADIT risk factors and major CIED infections (with system removal, invasive procedure without system removal, or infection-attributable death) were identified through diagnosis and procedure codes. The data set was randomized by PADIT score into Data Set A (60%) and Data Set B (40%). A frailty model allowing multiple procedures per patient was fit using Data Set A, with PADIT score as the only predictor, excluding patients with prior CIED infection. A data set of 54 042 index procedures among 51 623 patients with 574 infections was extracted. Among patients with no history of prior CIED infection, a 1 unit increase in the PADIT score was associated with a relative 28% increase in infection risk. Prior CIED infection was associated with significant incremental predictive value (HR 5.66, P, Graphical Abstract

Supplemental Digital Content is available in the text., Background: In the WRAP-IT trial (Worldwide Randomized Antibiotic Envelope Infection Prevention), adjunctive use of an absorbable antibacterial envelope resulted in a 40% reduction of major cardiac implantable electronic device infection without increased risk of complication in 6983 patients undergoing cardiac implantable electronic device revision, replacement, upgrade, or initial cardiac resynchronization therapy defibrillator implant. There is limited information on the cost-effectiveness of this strategy. As a prespecified objective, we evaluated antibacterial envelope cost-effectiveness compared with standard-of-care infection prevention strategies in the US healthcare system. Methods: A decision tree model was used to compare costs and outcomes of antibacterial envelope (TYRX) use adjunctive to standard-of-care infection prevention versus standard-of-care alone over a lifelong time horizon. The analysis was performed from an integrated payer-provider network perspective. Infection rates, antibacterial envelope effectiveness, infection treatment costs and patterns, infection-related mortality, and utility estimates were obtained from the WRAP-IT trial. Life expectancy and long-term costs associated with device replacement, follow-up, and healthcare utilization were sourced from the literature. Costs and quality-adjusted life years were discounted at 3%. An upper willingness-to-pay threshold of $150 000 per quality-adjusted life year was used to determine cost-effectiveness, in alignment with the American College of Cardiology/American Heart Association practice guidelines and as supported by the World Health Organization and contemporary literature. Results: The base case incremental cost-effectiveness ratio of the antibacterial envelope compared with standard-of-care was $112 603/quality-adjusted life year. The incremental cost-effectiveness ratio remained lower than the willingness-to-pay threshold in 74% of iterations in the probabilistic sensitivity analysis and was most sensitive to the following model inputs: infection-related mortality, life expectancy, and infection cost. Conclusions: The absorbable antibacterial envelope was associated with a cost-effectiveness ratio below contemporary benchmarks in the WRAP-IT patient population, suggesting that the envelope provides value for the US healthcare system by reducing the incidence of cardiac implantable electronic device infection. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02277990.

Background: The World-wide Randomized Antibiotic Envelope Infection Prevention trial reported a 40% reduction in major cardiac implantable electronic device (CIED) infections within 12 months of the procedure with the use of an antibacterial-eluting envelope (TYRX Absorbable Antibacterial Envelope, Medtronic, Mounds View, MN). Objective: The purpose of this report was to describe the longer-term (>12 months) envelope effects on infection reduction and complications. Methods: All trial patients who underwent CIED replacement, upgrade, revision, or initial cardiac resynchronization therapy – defibrillator implantation received standard-of-care infection prophylaxis and were randomized in a 1:1 ratio to receive the envelope or not. CIED infection incidence and procedure and system-related complications were characterized through all follow-up (36 months) by using Cox proportional hazards regression modeling. Results: In total, 6800 patients received their intended randomized treatment (3371 envelope; 3429 control; mean follow-up period 21.0 ± 8.3 months). Major CIED-related infections occurred in 32 envelope patients and 51 control patients (Kaplan-Meier [KM] estimate 1.3% vs 1.9%; hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.41–0.99; P = .046). Any CIED-related infection occurred in 57 envelope patients and 84 control patients (KM estimate 2.1% vs 2.8%; HR 0.69; 95% CI 0.49–0.97; P = .030). System- or procedure-related complications occurred in 235 envelope patients and 252 control patients (KM estimate 8.0% vs 8.2%; HR 0.95; 95% CI 0.79–1.13; P < .001 for noninferiority); the most common were lead dislodgment (1.1%), device lead damage (0.5%), and implant site hematoma (0.4%). Implant site pain occurred less frequently in the envelope group (0.1% vs 0.4%; P = .067). There were no (0.0%) reports of allergic reactions to the components of the envelope (mesh, polymer, or antibiotics). Conclusion: The effects of the TYRX envelope on the reduction of the risk of CIED infection are sustained beyond the first year postprocedure, without an increased risk of complications.

Tourism is used as an engine for economic growth and is considered a source of income and employment generation. However, like any other human activity, it causes changes to its surroundings. Planners often plan for growth and development of tourism, ignoring the rights of local communities, who are custodians of the resources and are dependent on them. Local communities are most harshly affected by tourism-induced changes. The concept of tourism carrying capacity tries to identify how much change is acceptable change, which would then guide planning and management of tourism in the area. In this chapter, the authors explore the different methodologies that have been developed for assessment of tourism carrying capacity and suggest a suitable framework for the Indian context.

Tourism has emerged as a major player and an increasing threat to the Western Ghats, its ecological landscape, the diverse ecosystems associated with it, and the many groups of indigenous (Adivasi) and other traditional forest-dwelling communities living in it. Unregulated growth and overly ambitious developmental plans in environmentally fragile areas have many strong and often irreversible fallouts: increased deforestation, fragmentation of wildlife habitats, closing of critical links between habitats, loss of people's access to and control over resources being among some of them. In 2010, EQUATIONS initiated a study that aimed to understand the impacts of tourism on the Sigur Plateau in the Western Ghats in the southern state of Tamil Nadu, taking into consideration the impacts of tourism on the biodiversity, natural resources, and the communities that live in and around the area. The scope of the study was to assess tourism in the realms of economic, environmental, and social impacts. For the purposes of this chapter, the environmental impacts have been focused on.

Purpose To compare retinal microvascular function in healthy individuals with and without a positive family history (FH) of cardiovascular disease (CVD). Methods Retinal vessel reactivity was assessed by means of dynamic retinal vessel analysis in 38 healthy subjects aged between 30 and 66 years with a positive FH of CVD and 37 age‐ and gender‐matched control subjects. Other assessments included blood pressure (BP) profiles, blood glucose and lipid metabolism markers, Framingham risk scores (FRS), carotid intima‐media thickness (c‐IMT) and brachial flow‐mediated dilation (FMD). Results Family history‐positive subjects showed decreased retinal arterial baseline diameter fluctuation, dilation amplitude, percent dilation, and overall constriction response slope (p = 0.001; p = 0.015; p = 0.001; and p < 0.001, respectively) and increased percent constriction (p = 0.008). On the venous side, baseline‐corrected flicker response and dilation response slope were decreased in the FH‐positive group (p = 0.009 and p = 0.010, respectively). There were no significant differences between groups in c‐IMT scores or FMD parameters (all p > 0.05). The arterial MC% correlated negatively with decreased high‐density lipoprotein cholesterol (r = −0.52, p = 0.002) in only FH‐positive group. Conclusion Although macrovascular function is preserved in individuals with FH positive for CVD but with low FRS, there are, however, functional impairments at the retinal microvascular level that correlate with established plasma markers for cardiovascular risk.

Recent studies have demonstrated that lymphocyte-derived microparticles (LMPs) impair endothelial cell function. However, no data currently exist regarding the contribution of LMPs in the regulation of angiogenesis. In the present study, we investigated the effects of LMPs on angiogenesis in vivo and in vitro and demonstrated that LMPs strongly suppressed aortic ring microvessel sprouting and in vivo corneal neovascularization. In vitro, LMPs considerably diminished human umbilical vein endothelial cell survival and proliferation in a concentration-dependent manner. Mechanistically, the antioxidants U-74389G and U-83836E were partially protective against the antiproliferative effects of LMPs, whereas the NADPH oxidase (NOX) inhibitors apocynin and diphenyleneiodonium significantly abrogated these effects. Moreover, LMPs increased not only the expression of the NOX subunits gp91phox, p22phox, and p47phox, but also the production of ROS and NOX-derived superoxide (O2−). Importantly, LMPs caused a pronounced augmentation in the protein expression of the CD36 antiangiogenic receptor while significantly downregulating the protein levels of VEGF receptor type 2 and its downstream signaling mediator, phosphorylated ERK1/2. In summary, LMPs potently suppress neovascularization in vivo and in vitro by augmenting ROS generation via NOX and interfering with the VEGF signaling pathway.

Purpose: To investigate the relationship between retinal microvascular reactivity, circulatory markers for CVD risk and systemic antioxidative defence capacity in healthy middle-aged individuals with low to moderate risk of CVD. Methods: Retinal vascular reactivity to flickering light was assessed in 102 healthy participants (46-60 years) by means of dynamic retinal vessel analysis (DVA). Other vascular assessments included carotid intima-media thickness (C-IMT) and blood pressure (BP) measurements. Total cholesterol (CHOL), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG) and blood glutathione levels in its reduced (GSH) and oxidized (GSSG) forms were also determined for each participant, along with Framingham risk scores (FRS). Results: Retinal arterial baseline diameter fluctuation (BDF) was independently, significantly and negatively influenced by LDL-C levels (β = -0.53, p = 0.027). Moreover, the arterial dilation slope (SlopeAD) was independently, significantly and positively associated with redox index (GSH: GSSG ratio, β = 0.28, p = 0.016), while the arterial constriction slope (SlopeAC) was significantly and negatively influenced by blood GSH levels (β = -0.20, p = 0.042), and positively associated with FRS (β = 0.25, p = 0.009). Venous BDF and dilation amplitude (DA) were also negatively influenced by plasma LDL-C levels (β = -0.83, p = 0.013; and β = -0.22, p = 0.028, respectively). Conclusions: In otherwise healthy individuals with low to moderate cardiovascular risk, retinal microvascular dilation and constriction responses to stress levels are influenced by systemic antioxidant capacity, and circulating markers for cardiovascular risk.

Purpose To assess the relationship between retinal vessel reactivity and oxidative stress markers in the systemic circulation. Methods Two hundred and twenty four healthy volunteers (aged 20-70 years) free of cardiovascular risk factors based on medical history, lipid profiles, blood pressure, and body mass index were included in this study. Measurements included plasma cholesterol, blood glucose, triglycerides, oxidized (GSSG) and reduced (GSH) forms of glutathione. Arterial and venous retinal vessel reactivity was assessed using the dynamic retinal vessel analyser (DVA, IMEDOS, Germany) according to an already established protocol. Results A simple correlation model showed that arterial and venous dilation amplitude was inversely with correlated with age (r= -0.4041, p= 0.0001; r= -.4045, p= 0.0001, respectively). Forward step-wise multiple linear regression analysis revealed that independent of age and other systemic influences, blood GSH levels were positively correlated with arterial and venous percent dilation (β= 0.158, p= 0.0133; β= 0.224, p= 0.0004, respectively), and overall dilation amplitude (β= 0.245, p = 0.0003; β= 0.230, p= 0.0006, respectively). In addition, blood GSH levels negatively influenced the arterial constriction response slope (SlopeAC: β= -1.722, p= 0.0024), while GSH and overall redox status (GSH/GSSG) influenced percent constriction in both the artery (β= -0.345, p=0.0002, β= -0.229, p= 0.0462, respectively) and vein (β= -0.253, p= 0.0001; β= -0.156, p= 0.0177, respectively). Conclusion In otherwise healthy individuals, retinal microvascular function is influenced by systemic anti-oxidative capacity.

International audience; Purpose: Retinopathy of prematurity (ROP) is a major cause of visual handicap in the pediatric population. To date, this disorder is thought to stem from deficient retinal vascularization. Intriguingly, functional electrophysiological studies in patients with mild or moderate ROP and in the oxygen-induced retinopathy (OIR) model in rats reveal central photoreceptor disruption that overlies modest retinal vessel loss; a paucity of retinal vasculature occurs predominantly at the periphery. Given that choroidal circulation is the major source of oxygen and nutrients to the photoreceptors, the authors set out to investigate whether the choroidal vasculature system may be affected in OIR.Methods: Rat models of OIR treating newborn animals with 80% or 50/10% alternated oxygen level for the first two postnatal weeks were used to mimic ROP in humans. Immunohistology staining and vascular corrosion casts were used to investigate the vessel layout of the eye. To investigate the effect of 15-deoxy-Δ12,14-PGJ(2) (15d-PGJ(2); a nonenzymatic product of prostaglandin D(2)) on endothelial cells, in vitro cell culture and ex vivo choroid explants were employed and intravitreal injections were performed in animals.Results: The authors herein demonstrate that deficient vascularity occurs not only in the retinal plexus but also in the choroid. This sustained, marked choroidal degeneration is specifically confined to central regions of the retina that present persistent photoreceptor loss and corresponding functional deficits. Moreover, the authors show that 15d-PGJ(2) is a prominent contributor to this choroidal decay.Conclusions: The authors demonstrate for the first time pronounced, sustained choroidal vascular involution during the development of ROP. Findings also suggest that effective therapeutic strategies to counter ROP should consider choroidal preservation.