Simulating Healthy Participant Pharmacokinetics for Renal and Hepatic Impairment Studies: Retrospective Assessment of the Approach.

The recruitment of a parallel, healthy participants (HPs) arm in renal and hepatic impairment (RI and HI) studies is a common strategy to assess differences in pharmacokinetics. Limitations in this approach include the underpowered estimate of exposure differences and the use of the drug in a population for which there is no benefit. Recently, a method was published by Purohit et. al. (2023) that leveraged prior population pharmacokinetic (PopPK) modeling-based simulation to infer the distribution of exposure ratios between the RI/HI arms and HPs. The approach was successful, but it was a single example with a robust model having several iterations of development and fitting to extensive HP data. To test in more studies and models at different stages of development, our catalogue of RI/HI studies was searched, and those with suitable properties and from programs with available models were analyzed with the simulation approach. There were 9 studies included in the analysis. Most studies were associated with models that would have been available at the time (ATT) of the study, and all had a current, final model. For 3 studies, the HP PK was not predicted well by the ATT (2) or final (1) models. In comparison to conventional analysis of variance (ANOVA), the simulation approach provided similar point estimates and confidence intervals of exposure ratios. This PopPK based approach can be considered as a method of choice in situations where the simulation of HP data would not be an extrapolation, and when no other complicating factors are present.

Emergency Department Trauma Activation Fees by Payer Type.

This cross-sectional study examines the wide variations in prices of emergency medical services at US hospitals.

Research on sustainable green building space design model integrating IoT technology.

"How can the integration of Internet of Things (IoT) technology enhance the sustainability and efficiency of green building (G.B.) design?" is the central research question that this study attempts to answer. This investigation is important because it examines how green building and IoT technology can work together. It also provides important information about how to use contemporary technologies for environmental sustainability in the building sector. The paper examines a range of IoT applications in green buildings, focusing on this intersection. These applications include energy monitoring, occupant engagement, smart building automation, predictive maintenance, renewable energy integration, and data analytics for energy efficiency enhancements. The objective is to create a thorough and sustainable model for designing green building spaces that successfully incorporates IoT, offering industry professionals cutting-edge solutions and practical advice. The study uses a mixed-methods approach, integrating quantitative data analysis with qualitative case studies and literature reviews. It evaluates how IoT can improve energy management, indoor environmental quality, and resource optimization in diverse geographic contexts. The findings show that there has been a noticeable improvement in waste reduction, energy and water efficiency, and the upkeep of high-quality indoor environments after IoT integration. This study fills a major gap in the literature by offering a comprehensive model for IoT integration in green building design, which indicates its impact. This model positions IoT as a critical element in advancing sustainable urban development and offers a ground-breaking framework for the practical application of IoT in sustainable building practices. It also emphasizes the need for customized IoT solutions in green buildings. The paper identifies future research directions, including the investigation of advanced IoT applications in renewable energy and the evaluation of IoT's impact on occupant behavior and well-being, along with addressing cybersecurity concerns. It acknowledges the challenges associated with IoT implementation, such as the initial costs and specialized skills needed.

The spatial spillover effects of clean energy consumption and production on sustainable economic development in China.

The massive consumption of fossil energy has resulted in high CO2 emissions, posing a formidable challenge to global sustainable economic development (SED). As countries endeavor to shift from fossil to clean energy sources to achieve SED, research on the impact of clean energy is scarce, and quantitative analysis is lacking. This study measured China's SED and used a spatial econometric model to examine the impact of clean energy consumption and production on SED across 30 provinces in China from 2008 to 2020. Results show that (1) China's SED exhibits significant positive spatial autocorrelation characteristics, forming a "point-to-area" development pattern. (2) Clean energy consumption, production, and consumption structure all contribute to the promotion of SED in the region and have positive spatial spillover effects. (3) A considerable regional disparity exists in the spatial impact of clean energy on SED. The eastern and central regions have significant positive spatial spillover effects, whereas the western region is opposite. Notably, the estimated coefficient of the spatial Durbin model is relatively small, reflecting China's ongoing transition to clean energy and its limited role in promoting economic sustainability. Joint efforts and differentiated policies are essential to develop clean energy and sustainable economic.

Spending on Dual Over-the-Counter and Prescription Drugs in the Medicare Part D Program.

This study compares Medicare and patient spending for dual over-the-counter and prescription drugs with their over-the-counter cash prices.

Characteristics of Prescription Drug Fills Using Pharmacy-Pharmacy Benefit Manager Discount Programs: The "GoodRx" Model.

OBJECTIVES: This study aimed to characterize products using pharmacy-pharmacy benefit manager (PBM) discounts and to estimate the association among such discounts, prescription utilization, and out-of-pocket costs. METHODS: This is a retrospective cohort study using IQVIA's Formulary Impact Analyzer, which contains anonymized, individual-level pharmacy claims representing US retail pharmacy transactions. We focused on 20 products with the greatest number of transactions using a pharmacy-PBM discount. Our unit of analysis was a treatment episode, defined as the length of time from an incident fill to no continuous use for 60 consecutive days after allowing for indefinite stockpiling. Outcome measures included products with greatest pharmacy-PBM discount use, characteristics of treatment episodes, and out-of-pocket costs with and without pharmacy-PBM discount. RESULTS: Across all products, 3.82% of transactions and 7.69% of treatment episodes were accompanied by a pharmacy-PBM discount. Commonly discounted products included generic treatments for chronic disease (lisinopril, levothyroxine, metformin) and neuropsychiatric conditions (alprazolam, amphetamine, buprenorphine, hydrocodone). The median postdiscount out-of-pocket cost was >2.5-fold higher during treatment episodes with a discount than those without ($15.15, interquartile range [IQR] $8.53-32.00, vs $5.88, IQR $1.40-15.00). Median treatment episode duration was 249 days (IQR 132-418) with discount use compared with 236 days (IQR 121-396) without discount use, although treatment episodes that began with a discount had fewer transactions per treatment episode and were shorter (median 212 days, IQR 114-360) than those that did not (313 days, IQR 178-500). CONCLUSIONS: Pharmacy-PBM discounts may foster market competition and improve access for under- and uninsured individuals; however, these programs may not generate savings for many insured individuals.

Spinal posture assessment and low back pain.

Postural assessment can help doctors and therapists identify risk factors for low back pain and determine appropriate follow-up treatment. Postural alignment is not perfectly symmetrical, and small asymmetries can instead represent norms and criteria for postural evaluation. It is necessary to comprehensively observe patients' posture in all directions and analyze the factors related to posture evaluation. The results of reliability show that in general intra-rater reliability is higher than inter-rater reliability, and inclinometers are being more reliable than other instrumentations. Some common postural problems can cause lumbar discomfort, and prolonged poor posture is a potential risk factor for lumbar spine injuries. On the basis of previous studies on posture evaluation, a unified standardized method for posture evaluation must be established in future research.

Comparison of Commercial Negotiated Price and Cash Price Between Physician-Owned Hospitals and Other Hospitals in the Same Hospital Referral Region.

This cross-sectional study compares commercial negotiated prices and cash prices between physician-owned hospitals and other hospitals in the same hospital referral region (HRR) using price information available through the Hospital Price Transparency Rule.

A hybrid MCDM model combining Fuzzy-Delphi, AEW, BWM, and MARCOS for digital economy development comprehensive evaluation of 31 provincial level regions in China.

With the deepening of a new round of technological revolution and industrial reform, digital technology has been continuously innovated and widely penetrated into various economic fields. The digital economy (DE) is gradually becoming the focus of China's economic development planning and a new engine to enhance national strength. Evaluating the development level of DE in various regions is conducive to timely discover the shortcomings in China's DE development, as well as provide an important basis for putting forward corresponding policy suggestions. This investigation established a hybrid multi-criteria decision making (MCDM) model for evaluating DE development of 31 provincial level regions in China ranging from 2015 to 2020. Firstly, the evaluation indicator system is established from digital infrastructure, integrated development, social benefits, innovation ability, and electronic-commerce dimensions containing 17 quantitative sub-criteria based on Fuzzy-Delphi method. Secondly, integrated weights of 17 sub-criteria from 2015 to 2020 are computed in terms of objective weights calculated by the anti-entropy weight (AEW) approach from 2015 to 2020 and subjective weights obtained via the best-worst method (BWM). Thirdly, MARCOS model is applied to evaluate the DE development degree of various regions in China ranging from 2015 to 2020. Case analysis illustrates that the DE development of Guangdong, Jiangsu, Zhejiang, and Beijing always maintain in the top four from 2015 to 2020, while the southwest and northwest regions in China are obviously fall behind others. And the DE development degree of various regions is primarily affected under the integrated development performance, innovation ability performance, and social benefits performance. Therefore, the backward regions should emphasize the development of software industry and information technology industry. The robustness of the proposed MCDM model combining Fuzzy-Delphi, AEW, BWM and MARCOS is discussed employing three similarity coefficients of rankings. And it is verified that the proposed MCDM model has superior robustness and validity in evaluating DE development.

Diagrammatic quantum Monte Carlo toward the calculation of transport properties in disordered semiconductors.

A new diagrammatic quantum Monte Carlo approach is proposed to deal with the imaginary time propagator involving both dynamic disorder (i.e., electron-phonon interactions) and static disorder of local or nonlocal nature in a unified and numerically exact way. The establishment of the whole framework relies on a general reciprocal-space expression and a generalized Wick's theorem for the static disorder. Since the numerical cost is independent of the system size, various physical quantities, such as the thermally averaged coherence, Matsubara one-particle Green's function, and current autocorrelation function, can be efficiently evaluated in the thermodynamic limit (infinite in the system size). The validity and performance of the proposed approach are systematically examined in a broad parameter regime. This approach, combined with proper numerical analytic continuation methods and first-principles calculations, is expected to be a versatile tool toward the calculation of various transport properties, such as mobilities in realistic semiconductors involving multiple electronic energy bands, high-frequency optical and low-frequency acoustic phonons, different forms of dynamic and static disorders, and anisotropy.

Intra-rater and inter-rater reliability of pressure pain threshold assessment in stroke patients.

BACKGROUND: As pain is a common symptom following a stroke, pressure pain threshold (PPT) assessment can be used to evaluate pain status or pain sensitivity of patients. However, the reliability of PPT test in stroke patients is still unknown. AIM: To examine the intra- and inter-rater reliability of PPT measurements in poststroke survivors and explore their factors. DESIGN: An observational study. SETTING: The setting of the study is a rehabilitation hospital. POPULATION: The population of the study was represented by a total of 54 patients after stroke. METHODS: The study included 16 measured points on the affected and unaffected sides. PPT was assessed by two raters in turn. Intra- and inter-rater reliability was evaluated by intraclass correlation coefficients (ICC). RESULTS: All intra-rater (ICC=0.84-0.97) and inter-rater (ICC=0.83-0.95) reliability for PPT assessment were good or excellent in stroke patients. Of the 16 points, 12 showed higher intra-rater ICC values than inter-rater, whereas no evident difference was observed between the affected and unaffected sides. Furthermore, patients who were male, ischemic, or with higher motor function generally performed higher ICC values than those who were female (24 out of 32 results), hemorrhagic (28 out of 32 results), or mobility dysfunction (26 out of 32 results), respectively. CONCLUSIONS: PPT assessment with good or excellent reliability can be used in stroke patients. Neither of the two sides (affected or unaffected) affects PPT reliability, and intra-rater reliability is better than inter-rater reliability. In addition, gender, stroke type, and motor function can affect the reliability of measuring mechanical pain threshold in poststroke survivors. CLINICAL REHABILITATION IMPACT: The pressure algometer can be used as a reliable and portable tool to assess the mechanical pain tolerance and sensory function in stroke patients in clinics.

The Cook Score: A Novel Assessment for the Prediction of Liver-Associated Clinical Events in a Diverse Population.

BACKGROUND AND AIMS: Transient elastography (TE) provides accurate quantification of liver fibrosis. Its usefulness could be significantly amplified in terms of predicting liver-associated clinical events (LACE). Our aim was to create a model that accurately predicts LACE by combining the information provided by TE with other variables in patients with chronic liver disease (CLD). METHODS: We retrospectively reviewed the electronic medical records of patients who underwent liver elastography, at John H. Stroger Hospital in Cook County, Chicago, IL. The incidences of LACE were documented including decompensation of CLD, new hepatocellular carcinoma, and liver-associated mortality. Significant predicting factors were identified through a forward stepwise Cox regression model. We used the beta-coefficients of these risk factors to construct the Cook Score for prediction of LACE. Receiver-operating characteristic (ROC) curves were plotted for Cook Score to evaluate its efficiency in prediction, in comparison with MELD-Na Score and FIB-4 Score. RESULTS: A total of 3097 patients underwent liver elastography at our institution. Eighty-eight LACE were identified. Age (hazard ratio (HR) 1.04, p = 0.002), aspartate aminotransferase to alanine aminotransferase ratio (HR 2.61, p < 0.001), platelet count (HR 0.98, p < 0.001), international normalized ration (INR) (HR 17.80, p < 0.001), and liver stiffness measurement (HR1.04, p < 0.001) were identified as significant predictors. The Cook Score was constructed with two optimal cut-off points to stratify patients into low-, intermediate-, and high-risk groups for LACE. The Cook Score proved superior than MELD-Na Score and FIB4 Score in predicting LACE with an area under curve of 0.828. CONCLUSION: This novel score based on a large robust sample would provide accurate prediction of prognosis in patients with chronic liver disease and guide individualized surveillance strategy once validated with future studies.

Factors Associated with Compliance to the Hospital Price Transparency Final Rule: a National Landscape Study.

BACKGROUND: The Hospital Price Transparency Final Rule, effective January 1, 2021, requires hospitals to post online a machine-readable file that includes payer-specific negotiated commercial prices for all services. The regulation aims to improve the affordability of hospital care by promoting price competition. However, a low compliance level among hospitals would compromise the operational effectiveness of this regulation. Understanding hospitals' compliance status to the regulation has important implications for its enforcement effort and effectiveness assessment. OBJECTIVE: To analyze nationwide hospitals' compliance status to the Hospital Price Transparency Rule. DESIGN: Cross-sectional observational study. PARTICIPANTS: A total of 3558 Medicare-certified general acute-care hospitals were examined. MAIN MEASURES: A binary compliance rating was generated by using data collected by Turquoise Health. "Noncompliance" means that no machine-readable file was posted or the posted file contains no commercial negotiated prices. "Compliance" means that a machine-readable file was posted with commercial negotiated prices for at least one insurance plan. KEY RESULTS: As of June 1, 2021, 55% of the 3558 Medicare-certified general acute-care hospitals we examined had not posted a machine-readable file containing commercial negotiated prices. Wide variations of compliance existed across states and hospital referral regions. A hospital's compliance status is strongly associated with the average compliance status of peer hospitals in the same market. Hospitals with greater IT preparedness, for-profit hospitals, system-affiliated hospitals, large hospitals, and non-urban hospitals had greater compliance. More concentrated hospital markets had greater average compliance. CONCLUSIONS: Hospitals take into consideration the behavior of their peers in the same market when making price disclosure decisions. Compliant hospitals are likely to have better IT preparedness, more financial resources and personnel expertise to mitigate the cost required for the implementation of the Price Transparency Rule. The compliance cost, therefore, might be a barrier for some hospitals.

Balancing Efficiency and Fairness in Liver Transplant Access: Tradeoff Curves for the Assessment of Organ Distribution Policies.

BACKGROUND: Current distribution policies have resulted in persistent geographic disparity in access to donated livers across the country for waitlisted candidates. METHODS: Using mathematical optimization, and subsequently the Liver Simulation Allocation Model, the following organ distribution concepts were assessed: (1) current policy, (2) proposed alternative models, and (3) a novel continuous distribution model. A number of different scenarios for each policy distribution concept were generated and analyzed through efficiency-fairness tradeoff curves. RESULTS: The continuous distribution concept allowed both for the greatest reduction in patient deaths and for the most equitable geographic distribution across comparable organ transportation burden. When applied with an Optimized Prediction of Mortality allocation scheme, continuous distribution allowed for a significant reduction in number of deaths-on the order of 500 lives saved annually (https://livervis.github.io/). CONCLUSIONS: Tradeoff curves allow for a visualized understanding on the efficiency/fairness balance, and have demonstrated that liver candidates awaiting transplant would benefit from a model employing continuous distribution as this holds the greatest advantage for mortality reduction. Development and implementation of continuous distribution models for all solid organ transplants may allow for minimization of the geographic disparity in organ distribution, and allow for efficient and fair access to a limited national resource for all candidates.

Chemical composition of precipitation in Shenzhen, a coastal mega-city in South China: Influence of urbanization and anthropogenic activities on acidity and ionic composition.

Rainwater samples from Shenzhen in south China were collected over the period of a year, and the chemical compositions were measured with the main purpose of understanding the acidification of rainwater and the controlling factors. The pH value of precipitation ranged from 3.72 to 6.77, with a volume-weighted mean (VWM) value of 4.29, and the acid rain frequency was 97%. The VWM concentrations of anions and cations followed the order of SO42- > Cl- > NO3- and Na+ > Ca2+ > NH4+ > Mg2+ > K+, respectively. Air mass back-trajectory and positive matrix factorization analyses indicated that sources of ions in rainwater were mainly from sea salt, soil dust and anthropogenic activities. Compared with other areas in China, the rainwater of Shenzhen has the lowest values of the NP/AP, ∆pH and NF values of Ca2+ and NH4+, indicating that the lack of the capacity for neutralization could be the main reason for the severe acid rain problem. It is noteworthy that the rain acidification tendency is obvious, and the pH value has reduced by 1.0 units since the 1980s. Based on a comparison of the chemical compositions of the rainwater from different historical periods, the NO3- concentration was found to have increased consistently, whereas the NH4+ concentration maintained a decreasing trend since 1980. On the other hand, the nss-SO42- and nss-Ca2+ concentrations increased after 1980 and then decreased after 1994. Meanwhile, the decreasing pH was accompanied by a decreasing NP/AP ratio. These results suggest that the changes in human activities at different stages of urban development can lead to a synergistic change in the chemical characteristics of precipitation. Both an increase in the acidic species emissions (especially NOX) due to rapid economic development and a decrease in the alkaline ions concentration due to urbanization have resulted in the rain acidification tendency in Shenzhen.

Improvement in the sensitivity of newborn screening for Fabry disease among females through the use of a high-throughput and cost-effective method, DNA mass spectrometry.

Many female carriers of Fabry disease are likely to develop severe morbidity and mortality. However, by our own estimation, around 80% of female newborns are missed by our current enzyme-based screening approach. Our team's aim was to develop an improved cost-effective screening method that is able to detect Fabry disease among female newborns. In Taiwan, based on a database of 916,000 newborns, ~98% of Fabry patients carry mutations out of a pool of only 21 pathogenic mutations. An Agena iPLEX platform was designed to detect these 21 pathogenic mutations using only a single-assay panel. A total of 54,791 female infants were screened and 136 female newborns with the IVS4 + 919G > A mutation and one female newborn with the c.656T > C mutation were identified. Using the current enzyme-based newborn screening approach as baseline, around 83% of female newborns are being missed. Through a family study of the IVS4 female newborns, 30 IVS4 adult family members were found to have left ventricular hypertrophy. Ten patients received endomyocardial biopsy and all were found to have significant globotriaosylceramide (Gb3) accumulation in their cardiomyocytes. All of these individuals now receive enzyme replacement therapy. We have demonstrated that the Agena iPLEX assay is a powerful tool for detecting females with Fabry disease. Furthermore, through this screening, we also have been able to identify many disease-onset adult family members who were originally undiagnosed for Fabry disease. This screening helps them to receive treatment in time before severe and irreversible cardiac damage has occurred.

Synthesis of Four Monoterpene-Derived Organosulfates and Their Quantification in Atmospheric Aerosol Samples.

Monoterpenes, a major class of biogenic volatile organic compounds, are known to produce oxidation products that further react with sulfate to form organosulfates. The accurate quantification of monoterpene-derived organosulfates (OSs) is necessary for quantifying this controllable aerosol source; however, it has been hampered by a lack of authentic standards. Here we report a unified synthesis strategy starting from the respective monoterpene through Upjohn dihydroxylation or Sharpless asymmetric dihydroxylation followed by monosulfation with the sulfur trioxide-pyridine complex. We demonstrate the successful synthesis of four monoterpene-derived OS compounds, including α-pinene OS, ß-pinene OS, limonene OS, and limonaketone OS. Quantification of OSs is commonly achieved using liquid chromatography-mass spectrometry (LC-MS) by either monitoring the [M-H]- ion or through multiple reaction monitoring (MRM) of mass transitions between the [M-H]- and m/z 97 ions. Comparison between the synthesized standards and previously adopted quantification surrogates reveals that camphor-10-sulfonic acid is a better quantification surrogate using [M-H]- as the quantification ion, while the highly compound-specific nature of MRM quantification makes it difficult to choose a suitable surrogate. Both could be rationalized in accordance to their respective MS quantification mechanisms. The in-house availability of the authentic standards enables us to discover that ß-pinene OS, due to the sulfate group at the primary carbon, partially degrades to a dehydrogenated OS compound during LC/MS analysis and a hydroperoxy OS over a prolonged storage period (>5 month) and forms a regioisomer through intermolecular isomerization. Limonene OS was positively identified for the first time in ambient samples and found to be more abundant than α-/ß-pinene OS in the Pearl River Delta, China. This work highlights the critical importance of having authentic standards in advancing our understanding of the interactions between biogenic VOC emissions and anthropogenic sulfur pollution.

Adductor Canal Block With Bupivacaine Liposome Versus Ropivacaine Pain Ball for Pain Control in Total Knee Arthroplasty: A Retrospective Cohort Study.

BACKGROUND: Appropriate postoperative pain control following total knee arthroplasty is important in patient recovery. Adductor canal block (ACB) is a novel method to deliver anesthesia. There are currently no studies using bupivacaine liposome with ACB while also taking into account cost. OBJECTIVE: To compare the efficacy and cost of using bupivacaine liposome to ropivacaine pain ball (RPB) for postsurgical pain control in total knee replacement surgery. The primary efficacy endpoint is mean pain score. Secondary endpoints include opioid and nonopioid pain medication consumption and cost per patient case. METHODS: This was a retrospective, matched cohort study with data collected from electronic medical records from February 2013 to June 2014. Mean pain score was measured by the 11-point Visual Analogue Scale over a 72-hour period. Cost analysis was also done looking at medication, direct, indirect, and total cost per patient case. RESULTS: Mean pain score over the 72 hours was 3.24 in the bupivacaine liposome group compared with 3.83 in the RPB group (P < 0.001). Lower mean pain scores were found in the bupivacaine liposome group during the first 36-hour interval postsurgery (3.1 vs 4.0, respectively, P < 0.001). Mean total cost was $20,919.53 with bupivacaine liposome versus $22,574.17 with RPB (P = 0.03). CONCLUSION: Liposomal bupivacaine demonstrated statistically significant impact in pain control in the first 36 hours, but by the end of the 72-hour interval, it was comparable to RPB in postoperative pain management. Using bupivacaine liposome did provide direct and total cost savings compared with RPB.

Increased risk of first-ever stroke in younger patients with atrial fibrillation not recommended for antithrombotic therapy by current guidelines: a population-based study in an East Asian cohort of 22 million people.

OBJECTIVE: To assess the risk of first-ever ischemic stroke in younger patients with atrial fibrillation (AF) who have none of the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category [female sex]) risk factors (excluding female sex) by using the National Health Insurance research database in Taiwan. PATIENTS AND METHODS: From 22,842,778 insured people, we identified 24,612 hospitalized patients with newly diagnosed AF between January 1, 2002, and December 31, 2004, as the AF group and randomly selected 98,448 age- and sex-matched persons without AF as the non-AF group. Both groups were followed up until December 31, 2010, to estimate ischemic stroke incidences in relation to other stroke risk factors. RESULTS: During a follow-up period of 89,468 person-years, the stroke rate was higher in patients with AF than in those without AF (5.79 per 100 person-years vs 2.25 per 100 person-years). The higher prevalence of CHA2DS2-VASc comorbidities (heart failure, hypertension, diabetes, coronary artery disease, and peripheral artery disease) in patients with AF further increased the stroke risk. In 790 patients with AF aged 30 to 55 years who had none of the CHA2DS2-VASc comorbidities at baseline and retained a "low risk," that is, those with a CHA2DS2-VASc score of 0 in men and 1 in women during follow-up, the stroke rate remained considerably higher than that in their non-AF counterparts (1.00 per 100 person-years vs 0.25 per 100 person-years), with a sex-adjusted hazard ratio of 4.09 (95% CI, 2.97-5.62). CONCLUSION: This study finds an increased risk of stroke in younger patients with AF who are not recommended for prevention of thromboembolism by current guidelines. Better stroke risk stratification tools are needed to prioritize younger patients with AF for thromboprophylactic therapy in this population.