Maria Winkler-Dworak

Union Instability as an Engine of Fertility? A Microsimulation Model for France

Opportunities for conceiving and bearing children are fewer when unions are not formed or are dissolved during the childbearing years. At the same time, union instability produces a pool of persons who may enter new partnerships and have additional children in stepfamilies. The balance between these two opposing forces and their implications for fertility may depend on the timing of union formation and parenthood. In this article, we estimate models of childbearing, union formation, and union dissolution for female respondents to the 1999 French Etude de l’Histoire Familiale. Model parameters are applied in microsimulations of completed family size. We find that a population of women whose first unions dissolve during the childbearing years will end up with smaller families, on average, than a population in which all unions remain intact. Because new partnerships encourage higher parity progressions, repartnering minimizes the fertility gap between populations with and those without union dissolution. Differences between the two populations are much smaller when family formation is postponed—that is, when union formation and dissolution or first birth occurs after age 30, or when couples delay childbearing after union formation.

Neuromuscular and cardiac comorbidity determines survival in 140 patients with left ventricular hypertrabeculation/noncompaction

BACKGROUND The prognosis of patients with left ventricular hypertrabeculation/noncompaction (LVHT) is controversial. We assessed cardiologic and neurologic predictors for mortality in LVHT patients and how many received implantable cardioverters/defibrillators(ICD) or cardiac resynchronization devices (CRT). METHODS AND RESULTS Included were patients with LVHT diagnosed echocardiographically between June 1995 and May 2009. All patients underwent a baseline cardiologic examination, and were invited for a neurological investigation. During June 2009, the patients were contacted by telephone and their records were screened if they had received ICD or CRT. In 140 patients (29% females, mean age 53 ± 16, range 14-94 years) LVHT was diagnosed. The neurologic investigation, carried out in 76%, disclosed a neuromuscular disorder of definite (n = 22) or unknown (n = 68) etiology or was normal (n = 16). During a follow-up of 4.5 years the mortality was 5.7%/year. Causes of death were heart failure(n = 11), pneumonia (n = 6), sudden cardiac death (n = 3), malignancy (n = 3), pulmonary embolism(n = 2), sepsis (n = 2), stroke (n = 2), hepatic failure (n = 1) or unknown (n = 6). Sixteen patients received devices (ICD n = 4, CRT n = 3, ICD plus CRT n = 9). Predictors for mortality were increased age (p = 0.0307), neuromuscular disorder of definite or unknown etiology (p = 0.0063), exertional dyspnea (p =0.0018), edema (p = 0.0000), heart failure (p = 0.0002), ventricular ectopic beats (p = 0.0119), atrial fibrillation (p = 0.0000), low voltage (p = 0.0139), presence of one or more ECG abnormalities (p = 0.0420), left ventricular fractional shortening <25% (p = 0.0046), extension of LVHT (p = 0.0063) and LVHT affecting the lateral wall (p = 0.0110). CONCLUSION Mortality in LVHT is high and due to cardiac and neuromuscular comorbidity, why monitoring and therapy, including device therapy, should be improved.

Sex Differences in Left Ventricular Noncompaction in Patients With and Without Neuromuscular Disorders

INTRODUCTION AND OBJECTIVES Left ventricular hypertrabeculation/noncompaction (LVHT/NC) is more prevalent in men and is frequently associated with neuromuscular disorders (NMDs). The aim of this study was to assess sex differences in a) the location and extent of LVHT/NC; b) left ventricular function; c) cardiac symptoms; d) electrocardiographic findings; e) the prevalence of NMD, and f) mortality. METHODS Between June 1995 and September 2006, 100 patients (mean age, 53[15] years, range 14-94 years, 29 female) were diagnosed echocardiographically with LVHT/NC. All underwent cardiologic investigation and were invited to undergo a neurologic examination. RESULTS The neurologic examination showed normal results in 14 patients, 21 were diagnosed with a specific form of NMD, and 44 had an NMD of unknown etiology. The other 21 refused to undergo the examination. Women presented more often with LVHT/NC affecting the anterior wall (10% vs. 0%; P< .05), the inferoposterior wall (28% vs. 10%; P< .05), and the lateral wall (72% vs. 31%; P< .001). In addition, on average 2.0 ventricular regions were affected in woman compared with 1.4 in men (P< .001). In contrast, apical LVHT/NC was slightly more common in men (97% versus 86%; P=.057). No differences were observed in age, symptoms, NMD prevalence, electrocardiographic findings, or mortality. CONCLUSIONS In adults with LVHT/NC, there were sex differences in the location and extent of the condition. However, these did not affect clinical, neurologic, echocardiographic or electrocardiographic parameters, or prognosis. The higher prevalence of LVHT/NC in males remains unexplained.

Association of Electrocardiographic Abnormalities with Cardiac Findings and Neuromuscular Disorders in Left Ventricular Hypertrabeculation/Non-Compaction

Introduction and Objectives: Left ventricular hypertrabeculation/non-compaction (LVHT) is a cardiac abnormality characterized by prominent trabeculations and intertrabecular recesses, and frequently associated with neuromuscular disorders (NMD). The aim of the study was to assess the prevalence of electrocardiographic (ECG) abnormalities in LVHT and its association with clinical symptoms, left ventricular size, wall thickness, systolic function, location and extension of LVHT and presence or absence of NMD. Methods and Results: In 86 patients LVHT was diagnosed echocardiographically between June 1995 and December 2004 (21 female, 65 male, age: 14–94 years, mean age: 52 ± 14 years). All patients underwent a baseline cardiologic investigation and were invited for a neurologic investigation. A specific NMD was diagnosed in 21 (metabolic myopathy, n = 14; Leber’s hereditary optic neuropathy, n = 3; myotonic dystrophy, n = 2; Becker muscular dystrophy, n = 1; Duchenne muscular dystrophy, n = 1), a NMD of unknown etiology in 32, the neurologic investigation was normal in 13, and 20 patients refused. Only 9 patients (10%) had normal ECGs. Frequent ECG abnormalities were tall QRS complexes (43%); ST/T-wave abnormalities (37%) and left bundle branch block (20%). ECG abnormalities were related with symptoms of heart failure and echocardiographic findings of systolic dysfunction and valvular abnormalities. Only atrial fibrillation (9%) was related to extension of LVHT. ECG abnormalities did not differ between patients with and without NMD. Conclusion: ECG abnormalities are frequent in LVHT. A normal ECG, however, does not exclude LVHT. No ECG pattern is typical for LVHT. ECG abnormalities occur independently of presence or absence of NMD, and thus all patients with LVHT should be referred to the neurologist.

Atrial fibrillation in left ventricular noncompaction with and without neuromuscular disorders is associated with a poor prognosis

AIMS The study in patients with left ventricular hypertrabeculation/noncompaction (LVHT) aimed to compare patients with and without atrial fibrillation (AF) regarding prevalence of neuromuscular disorders (NMD), cardiac symptoms, electrocardiographic (ECG) findings, left ventricular function, location and extension of LVHT and mortality. METHODS AND RESULTS LVHT was diagnosed in 102 patients (30 female, age 53+/-16 years) between June 1995 and November 2006. A specific NMD was diagnosed in 21, a NMD of unknown etiology in 47, the neurologic investigation was normal in 14, and 20 patients refused. The 15 patients with AF were older (65 versus 51 years, p<0.01), suffered more often from exertional dyspnoea (100 versus 62%, p<0.01), diabetes mellitus (33 versus 12%, p<0.05) and heart failure (100 versus 57%, p<0.01) than patients without AF. The prevalence of NMD was slightly higher in patients with than without AF (87 versus 82%, p=NS). AF patients had more frequent ECG abnormalities (2.3 versus 1.4, p<0.01), valvular abnormalities (93 versus 48%, p<0.01), lateral wall LVHT (87 versus 37%, p<0.01), more extensive LVHT (2.1 versus 1.5 ventricular parts, p<0.05), a worse left ventricular fractional shortening (14 versus 25%, p<0.01) and higher mortality during 3.8 years. CONCLUSION LVHT-patients with AF deserve special care because they have a worse prognosis than LVHT-patients without AF.

The standard family life course : An assessment of variability in life course pathways

Despite dramatic changes in family life over the past several decades, survey data demonstrate that a ‘standard’ family life course remains a goal for the vast majority. The ideal family life course is to have a stable partnership with two or more children, and to have all of one’s children with the same partner. Achievement of a standard family life course may, however, depend on the opportunities and constraints encountered along one’s life path, in particular those associated with the pursuit and attainment of higher education. Analyses of survey data from France, Sweden and the United States document the family experiences to age 40 of persons born in the 1950s. Overall, about half of the cohorts had experienced a standard family life course. For women, education had both positive and negative influences – greater childlessness but more stable childbearing unions. For French and Swedish men, fatherhood and union stability were both associated with higher education. Educational differences in family transitions – especially childbearing out of union and dissolution of unions with children – are much greater in the U.S. than in the other countries, resulting in a significant educational gap in the likelihood of achieving a standard family life course that is not observed in Sweden or France.

Cardiac and neuromuscular implications of left bundle branch block in left ventricular hypertrabeculation/noncompaction

BACKGROUND Left bundle branch block (LBB) is frequently found in left ventricular hypertrabeculation/noncompaction (LVHT). OBJECTIVES To compare LVHT patients with and without LBB regarding LVHT location and extension, left ventricular function, symptoms, electrocardiographic findings, prevalence of neuromuscular disorders (NMDs) and mortality during follow-up. METHODS The charts of patients who underwent transthoracic echocardiographic examination at the Krankenanstalt Rudolfstiftung (Wien, Austria) between June 1995 and November 2006 were examined. RESULTS LVHT was diagnosed in 102 patients (30 women) with a mean (+/- SD) age of 53+/-16 years (range 14 to 94 years). A specific NMD was diagnosed in 21 patients and an NMD of unknown etiology was diagnosed in 47. The neurological investigation was normal in 14 patients and 20 patients refused the investigation. The 24 patients with LBB were older (61 versus 51 years of age; P<0.01), and suffered from exertional dyspnea (96% versus 59%; P<0.01) and heart failure (79% versus 46%; P<0.01) more often than patients without LBB. LBB patients had less frequent tall QRS complexes (8% versus 47%; P<0.01) and ST-T wave abnormalities (4% versus 50%; P<0.01) than patients without LBB. Patients with LBB had a larger left ventricular end-diastolic diameter (73 mm versus 61 mm; P<0.01), worse left ventricular fractional shortening (15% versus 26%; P<0.01) and more extensive LVHT (1.8 versus 1.5 ventricular segments; P<0.05). The prevalence of NMDs did not differ between patients with and without LBB. Survival did not differ between patients with and without LBB during follow-up. CONCLUSIONS LBB is associated with increased age, decreased systolic function and increased extension of LVHT. Whether LBB is a prognostic factor in LVHT remains speculative.

Prevention of embolic stroke by catheter ablation of atrial fibrillation

Background and purpose:  Radiofrequency‐catheter‐ablation of atrial fibrillation is now commonly performed. Aim of this short review is to summarize questions and uncertainties concerning radiofrequency ablation of atrial fibrillation with respect to therapeutic mechanisms, long‐term efficacy and stroke‐prevention.

Production, distribution and insecurity of food: a dynamic framework

Abstract We study the impact of food distribution on the steady-state portion of food-insecure people in a stationary population. By applying a descriptive model we illustrate the positive feedback between food insecurity, low productivity in production, and inequalities in food distribution. Under these assumptions multiple steady states of the population distribution may result that differ from each other in the share of food-insecure people.

In- and outpatients with noncompaction: Differences in cardiac and neuromuscular co-morbidity

BACKGROUND AND METHODS The prognosis of patients with left ventricular hypertrabeculation/noncompaction (LVHT) is controversial. LVHT is associated with neuromuscular disorders (NMD) and diagnosed echocardiographically in in- as well as outpatients. We compared cardiologic and neurologic findings and mortality in LVHT-patients according to their diagnosis established as in- or outpatients. RESULTS Among 113 patients (33 females, mean-age 53 years), 91 were investigated neurologically. Fifty-nine inpatients were older (55 versus 50 years, p<0.05), more frequently referred because of heart failure (73 versus 37%, p<0.001), had more often diabetes (24 versus 7%, p<0.05), heart failure (81 versus 57%, p<0.01), a lower left-ventricular fractional-shortening (21 versus 26%, p<0.05) and more extensive LVHT (1.7 versus 1.5 affected walls, p<0.05). Fifty-four outpatients were referred more often because of chest-pain (33 versus 12%, p<0.01), myopathy (13 versus 2%, p<0.05), were more often neurologically normal (20 versus 7%, p<0.05) or had a specific NMD (28 versus 12%, p<0.05). During a mean follow-up of 3.8 years, mortality was 5.8%/year. Inpatients had a higher mortality (12.1 versus 2.1%/year, p=0.0002) and a shorter time between LVHT-diagnosis and death (1.7 versus 4.6 years, p=0.0197) than outpatients. CONCLUSIONS Outpatients with LVHT have a better prognosis than inpatients. Inpatients with LVHT should be closely monitored.