Transvenous Before Surgical Hybrid Procedure.

BACKGROUND: Historically, persistent atrial fibrillation (PeAF) and long standing persistent atrial fibrillation (LSPeAF) have demonstrated limited clinical success despite hybrid approaches. OBJECTIVE: We describe our experience with the endocardial-before-epicardial approach defined by a comprehensive endovascular approach preceding and guiding the epicardial approach which includes an extensive posterior wall ablation. METHODS: 40 patients were followed over a 12 month period. The procedure was performed in a single center. Patients had a mean duration of atrial fibrillation of 6.0 ± 4.5 years with 22.5% having undergone prior ablations. Mean age was 61.7 ± 7.9 years with a mean left atrial volume of 131.5 ± 46.9 mL. The endovascular procedure remained uniform with antral pulmonary vein isolation, posterior left atrial roof and right atrial cavo-tricuspid isthmus (CTI) linear lesions with mapping and ablation of left atrial complex electrograms (CFAEs) and prior existing atrial arrhythmias. The epicardial procedure included a thorascopic approach with ganglionated plexus (GP) mapping and ablation, left atrial posterior wall ablation, directed CFAE ablation and left atrial appendage ligation. All patients received implantable cardiac monitoring. RESULTS: All 40 patients remained in sinus rhythm at their 12 month follow-up. During the monitoring period, episodes of paroxysmal atrial arrhythmias including fibrillation were documented, without persistence, after discontinuation of oral antiarrhythmic medications. CONCLUSION: The endo-before-epi approach resulted in improved management of persistent and long standing persistent atrial fibrillation over reported results for conventional approaches with no procedural complications, making this a promising option for the management of these arrhythmias.

Archaeology as a social science.

Because of advances in methods and theory, archaeology now addresses issues central to debates in the social sciences in a far more sophisticated manner than ever before. Coupled with methodological innovations, multiscalar archaeological studies around the world have produced a wealth of new data that provide a unique perspective on long-term changes in human societies, as they document variation in human behavior and institutions before the modern era. We illustrate these points with three examples: changes in human settlements, the roles of markets and states in deep history, and changes in standards of living. Alternative pathways toward complexity suggest how common processes may operate under contrasting ecologies, populations, and economic integration.

ECG of the Month: ECG in an 81-Year-Old Woman.

DIAGNOSIS: Sinus bradycardia (48 beats/min), long P-R interval (0.29 s), long QT interval (0.53 s with QTc of 0.47 s), and prominent J waves suggest hypothermia; non-specific ST abnormality.

Hongshan chiefly communities in Neolithic northeastern China.

The Hongshan societies of northeastern China are among East Asia's earliest complex societies. They have been known largely from elaborate burials with carved jades in ceremonial platforms. The most monumental remains are concentrated in a "core zone" in western Liaoning province. Residential remains are less well known and most investigations of them have been in peripheral regions outside the core zone. Recent regional settlement pattern research around the well known ceremonial site of Dongshanzui has begun to document the communities that built and used Hongshan core zone monuments and to assess their developmental dynamics. The core zone, like the Hongshan periphery, appears to have been organized into a series of small chiefly districts within which ceremonial activities were important integrative forces. Their estimated populations of less than 1,000 are not much larger than those of districts in the periphery, and the evidence does not suggest that these districts were integrated into any larger political entity. The greater elaboration of core zone monumental architecture is thus not attributable to demographically larger communities or to larger-scale political integration. Future research should focus on documenting the organization of statuses and economic activities within these core zone communities to assess potential differences from peripheral communities in these regards.

Local economies and household spacing in early chiefdom communities.

Archaeological research has by now revealed a great deal of variation in the way early complex societies, or chiefdoms, developed. This variation is widely recognized, but our understanding of the forces that produced it remains relatively undeveloped. This paper takes aim at such understanding by exploring variation in the local economies of six early chiefdoms; it considers what implications this variation had for trajectories of chiefdom development, as well as the source of that variation. Economic exchange is a primary form of local interaction in all societies. Because of distance-interaction principles, closer household spacing within local communities facilitated more frequent interaction and thus encouraged productive differentiation, economic interdependence, and the development of well-integrated local economies. Well-integrated local economies, in turn, provided ready opportunities for aspiring leaders to accumulate wealth and fund political economies, and pursuit of these opportunities led to societies with leaders whose power had a direct economic base. Wider household spacing, on the other hand, impeded interaction and the development of well-integrated local economies. In such contexts, aspiring leaders were able to turn to ritual and religion as a base of social power. Even when well-integrated local economies offered opportunities for wealth accumulation and a ready source of funding for political economies, these opportunities were not always taken advantage of. That variation in the shapes of early chiefdoms can be traced back to patterns of household spacing highlights the importance of settlement and interaction in explaining not just chiefdom development, but societal change more generally.

Serum sepsis, not sickness.

Rarely taught in medical schools, clinical reasoning is the ability to discern the important from the unimportant and to arrive at accurate and efficient clinical conclusions. Identifying errors in reasoning is difficult; however, undetected clinical reasoning errors can have exponential consequences. As quality and patient safety come into focus, identifying and preventing clinical reasoning errors have become imperative. The authors present a case of a man sent for admission from a subspecialty clinic diagnosed with infliximab-induced serum sickness. Not countering the expert's diagnosis, initial workup failed to diagnose joint abscess and sepsis. Heuristics are mental shortcuts used to make decision making more efficient but can lead to error. The anchoring heuristic, premature closure, confirmation bias and the blind obedience heuristic are examples. Introspective surveillance and interactive hypothesis testing defend against heuristics. The authors conclude by discussing 4 types of hypersensitivity reactions, serum sickness in particular, and the chimeric nature of infliximab.

Patterned variation in prehistoric chiefdoms.

Comparative study of early complex societies (chiefdoms) conjures visions of a cultural evolutionary emphasis on similarities and societal typology. Variation within the group has not been as systematically examined but offers an even more productive avenue of approach to fundamental principles of organization and change. Three widely separated trajectories of early chiefdom development are compared here: the Valley of Oaxaca (Mexico), the Alto Magdalena (Colombia), and Northeast China. Archaeological data from all three regions are analyzed with the same tools to reveal variation in human activities, relationships, and interactions as these change in the emergence of chiefly communities. Patterning in this variation suggests the operation of underlying general principles, which are offered as hypotheses that merit further investigation and evaluation in comparative study of a much larger number of cases.