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Background Determining the presence of modifiable risk factors for atrial fibrillation (AF), such as sleep apnea is of clinical importance due to the potential impact targeting these risk factors can have on the progression and burden of AF. Using new digital-based technology is a promising solution to the underreporting of sleep apnea highlighted by academical societies in recent years. The aim of this study is to report the prevalence and severity of sleep apnea in patients with AF and, secondarily, assess the accuracy and feasibility of a new home-screening device for sleep apnea (NightOwl™ by Ectosense). Methods DAN-APNO is a cross-sectional study at the Department of Cardiology, Herlev-Gentofte Hospital recruiting patients with AF referred to anticoagulation initiation aged 18 to 90 years without known sleep apnea. At least 150 patients will be recruited and undergo medical history, clinical evaluation, several sleep-apnea questionnaires, and a sleep-recording evaluation for four nights with sleep apnea home-monitoring device NightOwl™. Additionally, the first 20 participants and participants with moderate-severe sleep apnea by screening are referred to cardio-respiratory monitoring (CRM). This clinical evaluation allows the comparison of standard evaluation method and the NightOwl™. Clinical measures include Apnea–Hypopnea Index (AHI), Oxygen Desaturation Index (ODI), pulse rate, as well as questionaries about sleep apnea assessment and the clinical feasibility of the NightOwl™ device. Main outcomes comprise analysis of the prevalence and severity of sleep apnea, and clinical and demographic predictors of moderate and severe sleep apnea. In addition, correlation analyses for accuracy measures between CRM and NightOwl™ will be conducted along with patient ease-of-use and satisfaction questionnaires. Discussion This study is limited by selection bias; only patients with atrial fibrillation from anticoagulation clinic is asked to participate, which could limit the generalizability of our results. However, this study aims to test whether a miniaturized simple home-monitoring device for detecting sleep apnea in patients with AF potentially can evaluate sleep apnea more conveniently and easier. Trial Registration The study is registered the 18-02-2021 at clinicaltrials.gov with registration number: NCT04760002.

Syncope could be related to high risk of falls and injury in adults, but documentation is sparse. We examined the association between syncope and subsequent fall-related injuries in a nationwide cohort. By cross-linkage of nationwide registers, all residents ≥18 years with a first-time diagnosis of syncope were identified between 1997-2012. Syncope patients were matched 1:1 with individuals from the general population. The absolute one-year risk of fall-related injuries, defined as fractures and traumatic head injuries requiring hospitalization, was calculated using Aalen-Johansen estimator. Ratios of the absolute one-year risk of fall-related injuries (ARR) were assessed by absolute risk regression analysis. We identified 125,763 patients with syncope: median age 65 years (interquartile range 46-78). At one year, follow-up was complete for 99.8% where a total of 8394 (6.7%) patients sustained a fall-related injury requiring hospitalization, of which 1606 (19.1%) suffered hip fracture. In the reference group, 4049 (3.2%) persons had a fall-related injury. The one-year ARR of a fall-related injury was 1.79 (95% confidence interval 1.72-1.87, P<0.001) in patients with syncope compared with the reference group; however, increased ARR was not exclusively in older patients. Factors independently associated with increased ARR of fall-related injuries in the syncope population were: injury in past 12 months, 2.39 (2.26-2.53, P<0.001), injury in relation to the syncope episode, 1.62 (1.49-1.77, P<0.001), and depression, 1.37 (1.30-1.45, P<0.001). Patients with syncope were at 80% increased risk of severe fall-related injuries within the year following discharge. Notably, increased risk was not exclusively in older patients.

Recurrent syncope is a major cause of hospitalizations and may be associated with cardiovascular co-morbidities. Despite this, prognostic factors and the clinical characteristics among patients are not well described. Therefore, we identified and analyzed data on all patients >50 years of age discharged after a first-time episode of syncope in the period 2001 to 2009 through nationwide administrative registries. We identified the clinical characteristics of 5,141 patients ≥85 years of age and 23,454 patients <85 years of age. Multivariate Cox models were used to assess prognostic factors associated with the end point of recurrent syncope according to age. We found that those with syncope and ≥85 years were more often women (65% vs 47%) and generally had a greater prevalence of noncardiovascular co-morbidities, whereas the prevalence of cardiovascular co-morbidities was more heterogeneously distributed across age groups. Overall, significant baseline predictors of recurrent syncope were aortic valve stenosis (hazard ratio [HR] 1.48, 95% confidence interval [CI] 1.31 to 1.68), impaired renal function (HR 1.34, 95% CI 1.15 to 1.58), atrioventricular or left bundle branch block (HR 1.32, 95% CI 1.16 to 1.51), male gender (HR 1.18, 95% CI 1.12 to 1.24), chronic obstructive pulmonary disorder (HR 1.10, 95% CI 1.02 to 1.19), heart failure (HR 1.10, 95% CI 1.02 to 1.21), atrial fibrillation (HR = 1.09, 95% CI 1.01 to 1.19), age per 5-year increment (HR 1.09, 95% CI 1.07 to 1.10), and orthostatic medications per increase (HR 1.06, 95% CI 1.03 to 1.09). Atrial fibrillation and impaired renal function both exhibited less prognostic importance for recurrent syncope in the elderly compared with younger population (p for interactions <0.01). In conclusion, predictive factors of recurrent syncope were closely associated with increased cardiovascular risk profile age and gender. The use of multiple orthostatic medications additively increased the risk of recurrences representing a need for strategies to reduce unnecessary polypharmacy.

Recurrence of syncope is a common event, but the influence of recurrent syncope on the risk of death has not previously been investigated on a large scale. We examined the prognostic impact of recurrent syncope in a nationwide cohort of patients with syncope. All patients (n = 70,819) hospitalized from 2001 to 2009 in Denmark with a first-time diagnosis of syncope aged from 15 to 90 years were identified from national registries. Recurrence of syncope was incorporated as a time-dependent variable in multivariable-adjusted Cox models on the outcomes of 30-day, 1-year, and long-term all-cause mortality and cardiovascular death. During a mean follow-up of 3.9 ± 2.6 years, a total of 11,621 patients (16.4%) had at least 1 hospitalization for recurrent syncope, with a median time to recurrence of 251 days (33 to 364). A total of 14,270 patients died, and 3,204 deaths were preceded by a hospitalization for recurrent syncope. The long-term risk of all-cause death was significantly associated with recurrent syncope (hazard ratio 2.64, 95% confidence interval 2.54 to 2.75) compared with those with no recurrence. On 1-year mortality, recurrent syncope was associated with a 3.2-fold increase in risk and on 30-day mortality associated with a threefold increase. The increased mortality risk was consistent over age groups 15 to 39, 40 to 59, and 60 to 89 years, and a similar pattern of increase in both long-term and short-term risk of cardiovascular death was evident. In conclusion, recurrent syncope is independently associated with all-cause and cardiovascular mortality across all age groups exhibiting a high prognostic influence. Increased awareness on high short- and long-term risk of adverse events in subjects with recurrent syncope is warranted for future risk stratification.

Terror and Irish Modernism offers a synoptic overview of modern Irish fiction. Covering more than two centuries of literary production, Jim Hansen locates the root structure of modern Irish fiction in the masculine gender anxiety of one of the nineteenth century's most popular literary genres: the Gothic. Addressing both the decolonization of Ireland and the politics of literary form, Hansen sheds new light on canonical works by Maria Edgeworth, C. R. Maturin, Oscar Wilde, James Joyce, and Samuel Beckett by reading them all as part of the generic tradition of the Irish Gothic. He focuses in particular on how the Irish Gothic tradition translated the English Gothic's female-confinement narrative into a story about confined, feminized male protagonists. In reading this male gender-disorientation as the foundational condition of modern Irish political identity, Terror and Irish Modernism provides a thoroughly new genealogy of modern Irish fiction.

Background Pulsed field ablation (PFA) is a novel method of cardiac ablation demonstrated in early pre-clinical and clinical settings. The aim of this study was to report the safety and clinical efficacy of pulmonary vein isolation (PVI) with PFA for real-world atrial fibrillation (AF) patients. Methods All-comer AF patients ( n  = 121, 59% paroxysmal) were prospectively included and underwent PFA with 100% high-density voltage maps performed after PVI. Clinical outcomes were gathered by chart review. Results PVI was achieved with PFA-only in 119 (98%) of the cases. During the implementation phase the mean procedure and fluoroscopy time was reduced from 85 ± 34 to 72 ± 18 min ( p  = 0.044) and 22 ± 9 to 16 ± 4 ( p  = 0.034). We observed one phrenic nerve palsy with only partial remission at follow-up. Other adverse events were numerically comparable to standard PVI procedures. Over a mean follow-up of 308 ± 87 days, a total of 22/121 (18.2%) cases experienced clinically significant recurrence or initiation of anti-arrhythmic drugs with Kaplan–Meier event-free estimate at 365 days of 80% (88% for paroxysmal versus 69% for persistent). In five of eight re-do procedures, gaps were primarily located at the right pulmonary veins. Conclusions PFA was a highly efficient method to achieve PVI with reductions in procedure time and fluoroscopy over the implementation period. The procedural data and clinical recurrence rates from initial trials were confirmed in real-life non-selected AF patients. More data is needed to establish lesion durability and limitations of PFA.

Pulsed field ablation (PFA) is an emerging technology for the treatment of atrial fibrillation (AF), for which pre-clinical and early-stage clinical data are suggestive of some degree of preferentiality to myocardial tissue ablation without damage to adjacent structures. Here in the MANIFEST-17K study we assessed the safety of PFA by studying the post-approval use of this treatment modality. Of the 116 centers performing post-approval PFA with a pentaspline catheter, data were received from 106 centers (91.4% participation) regarding 17,642 patients undergoing PFA (mean age 64, 34.7% female, 57.8% paroxysmal AF and 35.2% persistent AF). No esophageal complications, pulmonary vein stenosis or persistent phrenic palsy was reported (transient palsy was reported in 0.06% of patients; 11 of 17,642). Major complications, reported for ~1% of patients (173 of 17,642), were pericardial tamponade (0.36%; 63 of 17,642) and vascular events (0.30%; 53 of 17,642). Stroke was rare (0.12%; 22 of 17,642) and death was even rarer (0.03%; 5 of 17,642). Unexpected complications of PFA were coronary arterial spasm in 0.14% of patients (25 of 17,642) and hemolysis-related acute renal failure necessitating hemodialysis in 0.03% of patients (5 of 17,642). Taken together, these data indicate that PFA demonstrates a favorable safety profile by avoiding much of the collateral damage seen with conventional thermal ablation. PFA has the potential to be transformative for the management of patients with AF. In a post-approval study including more than 17,000 patients on the safety of pulsed field ablation, a new method for treatment of atrial fibrillation, the procedure was found to have a low rate of adverse events but was associated with some unexpected rare complications that will need further study.

Early Jewish mentions of heaven and the afterlife are sparse, but Jews in the Second Temple period began to understand that God would bring righteous individuals back to life to dwell in heaven with Him, and they increasingly embraced ideas of a complex heavenly afterlife of differing glories during the Apocalyptic Period (300 BC–200 AD). Jesus embraced and taught apocalyptic messages, and the parable of the Sower (Matt 13, Mark 4, Luke 8) is especially intriguing as viewed through an apocalyptic/eschatological lens, seeing the end state of humanity as inhabiting different glories or degrees of reward in the afterlife. Later Christian theologians drew on Jesus and Pauline traditions to teach a heaven of degrees, and Christianity would continue to embrace a complex structure of heaven throughout the Middle Ages until the Reformation. Reformed Theology veered away from degrees of glory in heaven, as Protestant rejection of Purgatory and the merit of works in salvation led to a binary (Heaven/Hell) concept of the afterlife. In 1830, Joseph Smith established the Church of Jesus Christ of Latter-day Saints intending it to be a restoration of Christ’s primitive church. Smith’s efforts conveyed his own apocalyptic leanings, as he saw the restoration of the New Testament church as a necessary precedent to the Parousia and Millennial reign of the Christ. In 1832, Smith claimed to receive a sweeping vision of the nature of heaven with an afterlife of no glory for the most evil and escalating degrees of glory in three heavenly kingdoms as the inheritance for almost all of humanity. While there is no evidence that Joseph Smith viewed Jesus’ parable of the Sower in an eschatological context, the similarities between apocalypticism, the parable of the Sower, and Smith’s 1832 vision of heaven are striking. This study performed a comparative analysis of an apocalyptic interpretation of the parable of the Sower with Smith’s 1832 vision of heaven. It also related the development of the doctrine of degrees of glory within the Church Educational System in the Church of Jesus Christ of Latter-day Saints. The study acknowledged that many similarities exist between the nature of heaven in the apocalyptic literature, an apocalyptic view of the parable of the Sower, and the 1832 Vision of Joseph Smith. The study also revealed a few departure points among these writings. This study aspires to contribute to the Christian literature. It may be insightful to students of early Christianity, as modern scholars do not yet fully grasp how Jews and Christians in the centuries before and after Jesus understood the nature of heaven. It may also contribute to the nascent body of literature on the parables of Jesus as viewed through an apocalyptic lens, deducing what Jesus’ original intent may have been based on his own apocalyptic worldview. Finally, the study may benefit members of the Church of Jesus Christ of Latter-day Saints, as Smith’s vision of degrees of glory in heaven is a core theological tenet of the Church, and finding similar views of heaven within Jesus’ and Paul’s teachings lends validity to Smith’s restorative claims.

Background Pulsed field ablation (PFA) is a novel method of cardiac ablation where there is insufficient knowledge on the durability and reconnection patterns after pulmonary vein isolation (PVI). The aim of this study was to characterize the electrophysiological findings at time of repeat procedure in real-world atrial fibrillation (AF) patients. Methods Patients who underwent a repeat procedure ( n =26) for symptomatic recurrent arrhythmias after index first-time treatment with single-shot PFA PVI ( n =266) from July 2021 to June 2023 were investigated with 3D high-density mapping and ad-hoc re-ablation by radiofrequency or focal PFA. Results Index indication for PVI was persistent AF in 17 (65%) patients. The mean time to repeat procedure was 292 ± 119 days. Of the 26 patients (104 veins), complete durable PVI was observed in 11/26 (42%) with a durable vein isolation rate of 72/104 (69%). Two patients (8%) had all four veins reconnected. The posterior wall was durably isolated in 4/5 (80%) of the cases. The predominant arrhythmia mechanism was AF in 17/26 (65%) patients and regular atrial tachycardia (AT) in 9/26 (35%). Reconnection was observed 9/26 (35%) in right superior, 11/26 (42%) in right inferior, 7/26 (27%) in left superior, 5/26 (19%) in left inferior, p =0.31 between veins. The gaps were significantly clustered in the right-sided anterior carina compared to other regions ( P =0.009). Conclusions Durable PVI was observed in less than half of the patients at time of repeat procedure. No significant difference in PV reconnection pattern was observed, but the gap location was preferentially located at the anterior aspects of the right-sided PVs. Predominant recurrence was AF. More data is needed to establish lesion formation and durability and AT circuits after PFA.

Purpose - The purpose of this paper is to quantify the implications of China's recently adopted agricultural policies on domestic and international commodity markets.Design methodology approach - A systematic, quantitative analysis is applied to address whether China's recent trade and production policies distort China's domestic and international commodity markets. The paper provides a clear picture of how trade-restricting policies affect markets using a 42-country partial equilibrium global dynamic agricultural simulation model.Findings - The paper shows that recent agricultural policy reforms increase China's production slightly, causing imports to decrease while exports decline because of input subsidies, export taxes and the reduction of export value added tax rebates. Domestic prices to consumers decrease in real terms. The effects on world markets are small as the set of policies adopted partially offset each other in the international arena.Research limitations implications - The paper indicates that the adoption of the policy reforms lower price levels domestically and benefit lower income urban and rural households, whose diets are largely based on rice and wheat as staple foods. Future model enhancements should include measures of producer and consumer welfare in order to capture the total impacts of policies and policy changes in China.Originality value - The paper quantifies the potential implications of the recent agricultural policy reforms in China. This contributes to the investigation of the effects of these policies implemented by the Chinese Government to achieve the country's policy objectives. Owing to the dynamics of China's policy implementation an in-depth analysis sheds light and contributes to capturing the impacts of policy reforms on the domestic and international markets.