Looking Beyond the Chair: Psycho-Perceptual Predictors of Sexual Distress and Sexual Satisfaction in Individuals with Spinal Cord Injury.

Despite a large body of biomedical research, little is known about the psychological and perceptual predictors of sexual satisfaction (SS) and sexual distress (SD) post spinal cord injury (SCI). Guided by a bio-psycho-perceptual framework, this cross-sectional research aimed at assessing SS and SD in a large SCI sample using validated patient-reported outcome measures (PROM). Significant correlates and predictors of SS and SD were also identified. Ninety-one men and women with SCI completed PROMs of SS and SD, as well as psychological (mood, sexual and body esteem) and perceptual (interoceptive awareness, trait mindfulness, sexual mindfulness) factors. Neurological profiles were also assessed, along with experience of orgasm. Correlates of SS and SD were first identified using Pearson's correlations, then multiple hierarchical regression models were computed to isolate predictors. Orgasm experience and psychological factors emerged as moderate correlates of both SS and SD, while neurological factors did not. Interoceptive awareness and trait mindfulness showed weak associations with SD and none with SS. Among the tested predictors, experience of orgasm emerged as the strongest for SS (ß = -.29, p < .01), followed by mood, which predicted SS and SD. Sexual and body esteem was predictive of SD only. In sexually active participants, sexual mindfulness predicted both SS (ß = 0.55, p < .001) and SD (ß = -0.56, p < .001) above and beyond all other variables. This study reveals unique aspects of SS and SD postinjury and supports further consideration of psychological and perceptual dimensions of SCI sexuality in rehabilitation research.

A Diary Study on When and With Whom Recovery Experiences Modulate Daily Stress and Worry During a COVID-19 Lockdown.

In April 2020, almost six out of 10 people around the world were in lockdown due to the COVID-19 pandemic. Being locked down usually has a deleterious effect on the confined individual's mental health. In this exceptionally challenging context, finding ways to minimize negative mood about the pandemic is essential. Pandemic-related negative states ("negative mood") and recovery experiences were investigated in a sample of 264 individuals who completed daily surveys four times per day over 7 consecutive days. MSEMs analyses revealed that negative mood persisted from moment-to-moment through the day, thus showing a response lag effect. Further analyses revealed that when someone experienced pandemic-related psychological detachment, relaxation, mastery, control, pleasure, or relatedness at specific periods of the day, mood had improved at the next measured time period, suggesting a protective effect. However, the pattern displayed by singles with dependents suggests that some recovery experiences at specific periods during the day seem to have a backfiring effect and worsen subsequent mood. These findings bring new insight into the role of recovery experiences during lockdowns and suggest that many could benefit from such experiences throughout the day when self-isolating. However, for individuals with multiple risk factors such as being single with dependents, some recovery experiences, at specific periods during the day, might not bring the desired outcome and future research is needed to examine if guilt or domestic burden may explain this finding. Results contribute to our understanding of how to take care of one's mental health during the current pandemic, and concrete recommendations adapted to individual contexts are provided.

ECG Features Associated With Adverse Cardiovascular Outcomes in Patients With Atrial Fibrillation: A Combined AFFIRM and AF-CHF Analysis.

BACKGROUND: The association between standard parameters from a simple 12-lead ECG (i.e., QRS duration and PR, JT, and QT intervals) and adverse cardiovascular outcomes (cardiovascular mortality, all-cause mortality, arrhythmic mortality, and hospitalizations) in patients with a history of atrial fibrillation (AF) has not been previously studied. METHODS AND RESULTS: A pooled analysis of patient-level data was conducted on 5,436 patients, age 68.2 ± 8.3 years, 34.8% female, with a history of non-permanent AF randomized in AFFIRM and AF-CHF trials. The predictive value of ECG parameters was assessed in AF and sinus rhythm in multivariate Cox regression models. During a follow-up of 40.8 ± 16.3 months, QRS duration >120 milliseconds was independently associated with all-cause mortality (hazard ratio [HR] 1.46, 95% confidence interval [CI; 1.21-1.76] in AF, P < 0.001), cardiovascular mortality (HR 1.75, 95% CI (1.15-2.65) in sinus rhythm, P = 0.009; HR 1.56, 95% CI [1.27-1.93] in AF, P < 0.001), arrhythmic mortality (HR 1.90, 95% CI [1.09-3.32] in sinus, P = 0.024; HR 1.84, 95% CI [1.35-2.51] in AF, P < 0.001), any hospitalization (HR 1.15, 95% CI [1.02-1.29] in AF, P = 0.027), and cardiovascular hospitalization (HR 1.21, 95% CI [1.06-1.37] in AF; P = 0.004). Increased PR interval (>200 milliseconds) was independently associated with cardiovascular (HR 1.56, 95% CI [1.11-2.21], P = 0.010) and arrhythmic (HR 1.91, 95% CI [1.14-3.18], P = 0.004) mortality. The JT and QTc intervals were not predictive of mortality. CONCLUSIONS: Simple parameters from standard ECGs are significantly and independently associated with adverse cardiovascular outcomes in patients with a history of AF.

Heart rate and adverse outcomes in patients with atrial fibrillation: A combined AFFIRM and AF-CHF substudy.

BACKGROUND: An elevated resting heart rate has been associated with adverse cardiovascular outcomes. Its prognostic value has not specifically been examined in patients with atrial fibrillation. OBJECTIVE: The purpose of this study was to assess the relationship between resting heart rate measured in sinus rhythm and in atrial fibrillation and subsequent hospitalizations and death. METHODS: An analysis of individual patient-level data from subjects enrolled in the AFFIRM and AF-CHF trials was conducted to determine the impact of resting heart rate on hospitalizations and mortality. Separate analyses were performed in atrial fibrillation and sinus rhythm. A total of 7159 baseline ECGs (4848 in atrial fibrillation, 2311 in sinus rhythm) were analyzed in 5164 patients (34.8% female, age 68.2 ± 8.3 years). RESULTS: During mean follow-up of 40.8 ± 16.3 months, 1016 patients died (668 cardiovascular deaths), and 3150 required at least 1 hospitalization (2215 cardiovascular). An elevated baseline heart rate in sinus rhythm was associated with increased all-cause mortality [hazard ratio (HR) 1.24 per 10 bpm increase, 95% confidence interval (CI) 1.14-1.36, P < .0001]. In contrast, a baseline heart rate in atrial fibrillation was not associated with mortality. However, compared to heart rates 90-114 bpm in atrial fibrillation, a heart rate >114 bpm was independently associated with all-cause (HR 1.18, 95% CI 1.06-1.31, P = .0018) and cardiovascular (HR 1.25, 95% CI 1.10-1.42, P = .0005) hospitalizations. CONCLUSION: In patients with a history of atrial fibrillation, an elevated baseline heart rate in sinus rhythm is independently associated with mortality. In contrast, the baseline heart rate in atrial fibrillation is not associated with mortality but predicts hospitalizations.

Treatment Failure With Rhythm and Rate Control Strategies in Patients With Atrial Fibrillation and Congestive Heart Failure: An AF-CHF Substudy.

INTRODUCTION: Rate and rhythm control strategies for atrial fibrillation (AF) are not always effective or well tolerated in patients with congestive heart failure (CHF). We assessed reasons for treatment failure, associated characteristics, and effects on survival. METHODS AND RESULTS: A total of 1,376 patients enrolled in the AF-CHF trial were followed for 37  ±  19 months, 206 (15.0%) of whom failed initial therapy leading to crossover. Rhythm control was abandoned more frequently than rate control (21.0% vs. 9.1%, P < 0.0001). Crossovers from rhythm to rate control were driven by inefficacy, whereas worsening heart failure was the most common reason to crossover from rate to rhythm control. In multivariate analyses, failure of rhythm control was associated with female sex, higher serum creatinine, functional class III or IV symptoms, lack of digoxin, and oral anticoagulation. Factors independently associated with failure of rate control were paroxysmal (vs. persistent) AF, statin therapy, and presence of an implantable cardioverter-defibrillator. Crossovers were not associated with cardiovascular mortality (hazard ratio [HR] 1.11 from rhythm to rate control; 95% confidence interval [95% CI, 0.73-1.73]; P = 0.6069; HR 1.29 from rate to rhythm control; 95% CI, 0.73-2.25; P = 0.3793) or all-cause mortality (HR 1.16 from rhythm to rate control, 95% CI [0.79-1.72], P = 0.4444; HR 1.15 from rate to rhythm control, 95% [0.69, 1.91], P = 0.5873). CONCLUSIONS: Rhythm control is abandoned more frequently than rate control in patients with AF and CHF. The most common reasons for treatment failure are inefficacy for rhythm control and worsening heart failure for rate control. Changing strategies does not impact survival.

Blood Pressure and Atrial Fibrillation: A Combined AF-CHF and AFFIRM Analysis.

BACKGROUND: Hypertension is an established risk factor for new-onset atrial fibrillation (AF). However, the relationship between blood pressure and recurrent AF is less well understood. METHODS AND RESULTS: A pooled analysis of patient-level data from AFFIRM and AF-CHF trials was conducted on all 2,715 patients with paroxysmal or persistent AF, 68 ± 8 years, 66% male, randomized to rhythm control and followed for 40.6 ± 16.5 months. We assessed the impact of a baseline systolic blood pressure (SBP; <120 mmHg [N = 1,008], 120-140 mmHg [N = 930], >140 mmHg [N = 777]) on recurrent AF and proportion of time spent in AF. In patients with LVEF >40% (N = 1,719), SBP was not associated with recurrent AF in multivariate regression analyses (P = 0.752). In contrast, in patients with LVEF ≤40% (N = 996), the AF recurrence rate was higher in those with an SBP >140 mmHg compared to 120-140 mmHg (hazard ratio 1.47; 95% CI [1.12-1.93], P = 0.005). The rate of recurrent AF was similar in patients with SBP <120 mmHg compared to 120-140 mmHg (hazard ratio 1.15; 95% CI [0.92-1.43], P = 0.225). Consistently, the proportion of time spent in AF was not influenced by SBP in patients with LVEF >40% (P = 0.645). However, in patients with LVEF ≤40%, the adjusted mean proportion of time spent in AF was 17.2% if SBP was <120 mmHg, 15.4% for SBP 120-140 mmHg, and 24.0% for SBP >140 mmHg (P = 0.025). CONCLUSION: Systolic blood pressure is an important determinant of recurrent AF and overall AF burden in patients with left ventricular dysfunction (LVEF≤40%) but not in those with preserved ventricular function.

Systolic blood pressure and mortality in patients with atrial fibrillation and heart failure: insights from the AFFIRM and AF-CHF studies.

AIMS: To investigate the association between baseline systolic blood pressure levels and mortality in patients with AF with or without LV dysfunction. Hypertension leads to cardiovascular disease but, in specific groups, low blood pressure has been associated with a paradoxical increase in mortality. In patients with AF and heart failure, the relationship between blood pressure and death remains largely unknown. METHODS AND RESULTS: We conducted a post-hoc combined analysis on pooled data from AFFIRM and AF-CHF trials and assessed the relationship between baseline systolic blood pressure (SBP) and mortality and hospitalizations. Patients were classified according to LVEF (>40%, ≤40%) and baseline SBP (<120 mmHg, 120-140 mmHg, >140 mmHg). A total of 5436 patients with non-permanent AF were followed for 41 ± 16 months. In patients with LVEF >40%, baseline SBP was not related to mortality using multivariate Cox regression analyses to adjust for baseline differences (P = 0.563). In contrast, in patients with LVEF ≤40% (n = 1980), SBP <120 mmHg and SBP >140 mmHg were both associated with a significant increase in total mortality compared with SBP 120-140 mmHg [hazard ratio (HR) 1.75, 95% confidence interval (CI) 1.41-2.17; and HR 1.40, 95% CI 1.04-1.90, respectively]. Hospitalizations were unrelated to SBP regardless of LVEF. CONCLUSIONS: Mortality is modulated by baseline SBP levels in patients with AF and depressed EF but not in patients with normal EF. Targeted therapy of AF patients based on SBP merits further prospective investigation.

Estimating the basic reproduction number from surveillance data on past epidemics.

In this paper, we consider the basic reproduction number, R0, a parameter that characterizes the transmission potential of an epidemic, and explore a novel way for estimating it. We introduce a stochastic process which takes as starting points the classical SIR (susceptibles-infected-removed) models, deterministic and stochastic. The estimation method rests on an extremum property of the deterministic SIR model, and could be applied to past surveillance data on epidemic outbreaks, data gathered at different locations or in different years. Our estimators take into account some practical limitations, in particular the fact that data are collected at preassigned times. We derive asymptotic properties of the estimators and perform a simulation study to assess their small sample behavior. We illustrate the method on real data (from the USA Centers for Disease Control and Prevention site) and we point to various extensions to our approach, as well as practical implementation issues.

Aortic coarctation and the retinal microvasculature.

BACKGROUND: Aortic coarctation has been associated with generalized vascular disease, yet little is known about retinal vascular patterns and their changes over time. OBJECTIVES: The aim of this study is to characterize the nature and extent of retinal vascular disease in adults with aortic coarctation, and explore age-related effects and associations with cardiovascular outcomes. METHODS: A prospective cross-sectional seroepidemiological study was conducted on 60 consecutive adults with repaired aortic coarctation, age 42.4±14.1 years, 61.7% male. In addition to detailed questionnaires, imaging studies, and laboratory testing, high-quality retinal images were acquired by 45° nonmydriatic digital funduscopy. RESULTS: No patient had evidence of hypertensive retinopathy. A distinctive vascular pattern characterized by bilaterally symmetric tortuosity of retinal arteries and veins was observed. Arterial tortuosity was abnormal in 98.3% of patients and decreased with age (P=0.0005). In patients≥45 years, a 1-point increase in the arterial tortuosity score was associated with a 1.5-fold higher risk of cardiovascular complications (i.e., acute coronary syndrome, stroke, cerebral aneurysm, aortic dissection/rupture) [odds ratio 1.50, 95% CI (1.01, 2.24), P=0.0496]. Abnormal venous tortuosity was present in 75.0% of patients and non-significantly correlated with higher levels of serum inflammatory markers (C-reactive protein, fibrinogen, interleukin-6, and tumor necrosis factor-alpha). A higher venous tortuosity score was likewise associated with an increased risk of cardiovascular complications [odds ratio 1.86, 95% CI (1.03, 3.35), P=0.0392]. CONCLUSIONS: Adults with repaired aortic coarctation exhibit a unique retinal vascular pattern characterized by excessive arterial and venous tortuosity that regresses with age. Greater tortuosity is associated with adverse cardiovascular outcomes in patients≥45 years.

Prognostic value of the physical examination in patients with heart failure and atrial fibrillation: insights from the AF-CHF trial (atrial fibrillation and chronic heart failure).

OBJECTIVES: This study sought to assess the prognostic value of physical examination in a modern treated heart failure population. BACKGROUND: The physical examination is the cornerstone of the evaluation and monitoring of patients with heart failure. Yet, the prognostic value of congestive signs (i.e., peripheral edema, jugular venous distension, a third heart sound, and pulmonary rales) has not been assessed in the current era. METHODS: A post-hoc analysis was conducted on all 1,376 patients, 81% male, mean age 67 ± 11 years, with symptomatic left ventricular systolic dysfunction enrolled in the AF-CHF (Atrial Fibrillation and Congestive Heart Failure) trial. The prognostic value of baseline physical examination findings was assessed in univariate and multivariate Cox regression analyses. RESULTS: Peripheral edema was observed in 425 (30.9%), jugular venous distension in 297 (21.6%), a third heart sound in 207 (15.0%), and pulmonary rales in 178 (12.9%) patients. Death from cardiovascular causes occurred in 357 (25.9%) patients over a mean follow-up of 37 ± 19 months. All 4 physical examination findings were associated with cardiovascular mortality in univariate analyses (all p values <0.01). In multivariate analyses, taking all 4 signs as potential covariates, only rales (hazard ratio 1.41; 95% confidence interval: 1.07 to 1.86; p = 0.013) and peripheral edema (hazard ratio: 1.25; 95% confidence interval: 1.00 to 1.57; p = 0.048) were associated with cardiovascular mortality, independent of other variables. CONCLUSIONS: In the modern era, congestive signs on the physical examination (i.e., peripheral edema, jugular venous distension, a third heart sound, and pulmonary rales) continue to provide important prognostic information in patients with congestive heart failure.

Pulmonary vein isolation using a second-generation cryoballoon catheter: a randomized comparison of ablation duration and method of deflation.

INTRODUCTION: Optimal cryoballoon ablation parameters for pulmonary vein (PV) isolation remain to be defined. We conducted a randomized preclinical trial to compare 2- versus 4-minute ablation lesions and assess the safety of active (forced) cryoballoon deflation. METHODS AND RESULTS: Thirty-two dogs underwent PV isolation with a second-generation 23 mm cryoballoon catheter. The left superior (LSPV) and inferior (LIPV) PVs were randomized in a factorial design to (1) a single 2- versus 4-minute cryoapplication, and (2) passive versus active cryoballoon deflation. Animals were survived for 30 days, after which histopathologic analysis was performed. Acute PV isolation was attained in 89.8% of PVs after a single application (93.8% LSPV, 85.2% LIPV; P = 0.2823). Mean time to PV isolation was 29.5 ± 18.5 seconds. Although 4-minute lesions were associated with a thicker neointima than 2-minute lesions (223.8 µm versus 135.6 µm; P = 0.007), no differences were observed in procedural characteristics (freezing temperature, rewarming time), rates of acute PV isolation, or the achievement of complete circumferentially transmural lesions at 30 days (78.7% overall; 86.2% for 2 minutes vs 70.0% for 4 minutes; P = 0.285). Active deflation was associated with faster balloon rewarming but not with significant differences in mean or maximum neointimal thickness. CONCLUSION: A single application with the second-generation cryoballoon catheter results in a high rate of PV isolation. The degree of vascular injury was not increased by active balloon deflation and no differences in acute efficacy or mature transmural circumferential lesions were observed with 2- versus 4-minute applications.

All-cause mortality and cardiovascular outcomes with prophylactic steroid therapy in Duchenne muscular dystrophy.

OBJECTIVES: This study sought to determine the impact of steroid therapy on cardiomyopathy and mortality in patients with Duchenne muscular dystrophy (DMD). BACKGROUND: DMD is a debilitating X-linked disease that afflicts as many as 1 in 3,500 boys. Although steroids slow musculoskeletal impairment, the effects on cardiac function and mortality remain unknown. METHODS: We conducted a cohort study on patients with DMD treated with renin-angiotensin-aldosterone system antagonists with or without steroid therapy. RESULTS: Eighty-six patients, 9.1 ± 3.5 years of age, were followed for 11.3 ± 4.1 years. Seven of 63 patients (11%) receiving steroid therapy died compared with 10 of 23 (43%) not receiving steroid therapy (p = 0.0010). Overall survival rates at 5, 10, and 15 years of follow-up were 100%, 98.0%, and 78.6%, respectively, for patients receiving steroid therapy versus 100%, 72.1%, and 27.9%, respectively, for patients not receiving steroid therapy (log-rank p = 0.0005). In multivariate propensity-adjusted analyses, steroid use was associated with a 76% lower mortality rate (hazard ratio: 0.24; 95% confidence interval: 0.07 to 0.91; p = 0.0351). The mortality reduction was driven by fewer heart failure-related deaths (0% vs. 22%, p = 0.0010). In multivariate analyses, steroids were associated with a 62% lower rate of new-onset cardiomyopathy (hazard ratio: 0.38; 95% confidence interval: 0.16 to 0.90; p = 0.0270). Annual rates of decline in left ventricular ejection fraction (-0.43% vs. -1.09%, p = 0.0101) and shortening fraction (-0.32% vs. -0.65%, p = 0.0025) were less steep in steroid-treated patients. Consistently, the increase in left ventricular end-diastolic dimension was of lesser magnitude (+0.47 vs. +0.92 mm per year, p = 0.0105). CONCLUSIONS: In patients with DMD, steroid therapy is associated with a substantial reduction in all-cause mortality and new-onset and progressive cardiomyopathy.

Impaired arm development after Blalock-Taussig shunts in adults with repaired tetralogy of Fallot.

BACKGROUND: Many adults with repaired tetralogy of Fallot have had prior Blalock-Taussig shunts. These shunts may theoretically hinder growth and development of the ipsilateral arm. METHODS: We prospectively enrolled consecutive patients with tetralogy of Fallot in a cross-sectional study to measure arm length and assess handgrip strength. Bilateral handgrip strength was quantified by a dynamometer in a standing position after instructing patients to clench each hand tightly in succession. The maximum force achieved, in kilograms, was measured. RESULTS: A total of 80 consecutive adults with tetralogy of Fallot, aged 36.0 ± 12.5 years, 49% female, were prospectively enrolled. Thirty-eight (47.5%) patients had prior Blalock-Taussig shunts at a median age of 1.0 year. Twenty-one (55.3%) were left-sided and 23 (60.5%) were classic shunts. All but six patients with right-sided shunts and one without a prior shunt were right-handed. The shunts were present for a median of 4.0 years prior to takedown during corrective surgery. The arm ipsilateral to the shunt was significantly shorter than the contralateral arm (71.5 ± 6.1 versus 73.6 ± 5.6 cm, P<0.0001). Handgrip strength was significantly weaker on the ipsilateral versus contralateral side (median [IQR], 26.5 [14.0-41.5] versus 31.0 [18.0-46.0] kg, P<0.0001) and the ipsilateral-to-contralateral handgrip ratio was lower with classic versus modified shunts (median [IQR], 1.05 [1.02-1.14] versus 1.19 [1.07-1.33] kg, P=0.0541). CONCLUSION: In patients with tetralogy of Fallot, Blalock-Taussig shunts may impair normal development of the ipsilateral arm with repercussions in adulthood that include shorter limb length and reduced handgrip strength. These changes are most pronounced in patients with classic end-to-side anastomoses.