BACKGROUND:Postural orthostatic tachycardia syndrome (POTS) is characterized by an excessive orthostatic heart rate increase and lacks approved pharmacologic therapies. OBJECTIVES:The objective of the study was to compare hemodynamic effects of ivabradine and propranolol and assess medication preferences in patients with POTS. METHODS:In a randomized, placebo-controlled, crossover trial, patients with POTS completed three 4-week treatment phases (ivabradine, propranolol, and placebo). Each phase concluded with a 10-minute head-up tilt test with continuous beat-to-beat hemodynamic monitoring. Analyses included 28 participants (mean age 33 ± 9 years, 100% female). The prespecified primary outcome was delta heart rate during tilt. Head-up tilt test hemodynamics were described as minute-by-minute averages, deltas from supine baseline, and peak heart rate (HRPeak) in the last 5 to 10 minutes. Prespecified within-participant comparisons were performed between treatments. Treatment preference was recorded at each phase end. RESULTS:Compared to placebo, HRPeak was lower for ivabradine (99 ± 3 vs 118 ± 3 beats/min; P < 0.001) and propranolol (100 ± 3 vs 118 ± 3 beats/min; P < 0.001). ΔHRPeak (standing - supine) was lower for ivabradine (27 ± 2 vs 36 ± 2 beats/min; P = 0.001) and propranolol (28 ± 2 vs 36 ± 2 beats/min; P = 0.003) vs placebo. Ivabradine showed a greater increase in Δ systolic blood pressure compared to propranolol (4.9 mm Hg vs 1.9 mm Hg; P = 0.001) but no significant difference in either HRPeak or ΔHRPeak between them. Among 22 preferences, all participants preferred ivabradine (P < 0.001) or propranolol (P < 0.001) over placebo, without differences between active treatments (59% vs 41%; P = 0.52). CONCLUSIONS:Ivabradine and propranolol reduce orthostatic tachycardia vs placebo, lowering heart rate below POTS diagnostic criteria. Ivabradine elevates systolic blood pressuremore than propranolol, supporting personalized drug selection. Importantly, heart rate lowering was consistent whereas symptom and quality-of-life effects were more selective, supporting individualized treatment.

This research examines non-profit organizations’ (NPOs) attitudes and intentions for engaging in business partnerships for their first time. A randomly selected, nationally representative survey of NPOs in the United States ( N = 533), Canada ( N = 399), and France ( N = 139) was conducted online. Scales were created to assess NPO perceptions along three dimensions: relational, avoiding exploitation, and functional. Scales created herein are shown to be a valid means of assessing partnership perceptions, and the research results replicated across these three developed countries. Results demonstrate that NPOs considering business partnerships for the first time are primarily seeking concrete, functional benefits. They approach business partnerships with optimism, expecting positive relationships with little fear of exploitation. This suggests an inclination to participate. It also suggests potential vulnerability at the hands of a stronger business partner.

Background:Postural orthostatic tachycardia syndrome (POTS) is a chronic form of orthostatic intolerance that primarily affects female patients. Despite the severity of POTS, there are no approved medications for use in patients with this disorder. Compression garments are a commonly prescribed nonpharmacological treatment, but little is known about the patient experience with compression. In this study we aimed to evaluate the patient experience with compression garments using a structured survey and semistructured telephone interviews. Methods:A focused survey was designed as a component of a larger clinical trial on compression garment use in patients diagnosed with POTS. Building on the survey, semistructured telephone interviews were conducted with POTS patients. Recorded interviews were transcribed and coded in a thematic analysis using a descriptive-interpretive approach. Results:A total of 27 participants completed the survey, and 20 participants completed the telephone interview. Patient experiences with compression were variable, with some participants experiencing significant benefits, and others reporting minimal to no benefits. Six themes that influenced garment use were identified: the potential benefit of the garment to improve symptoms, specific activities patients will be undertaking, environmental conditions, garment attributes, psychological and cognitive aspects, and financial considerations. Conclusions:Participants engage in a daily cost-benefit analysis when making decisions to use a compression garment. Clinicians should be aware of the benefits of and factors that limit use of compression garments as a treatment for POTS.

BACKGROUND:Initial orthostatic hypotension (IOH) is a form of orthostatic intolerance defined by a transient decrease in blood pressure upon standing. Current clinical recommendations for managing IOH includes standing up slowly or lower body muscle tensing (TENSE) after standing. Considering that IOH is likely due to a large muscle activation response resulting in excessive vasodilation with a refractory period (<2 minutes), we hypothesized that preactivating lower body muscles (PREACT) before standing would reduce the drop in mean arterial pressure (MAP) upon standing and improve presyncope symptoms. OBJECTIVE:The purpose of this study was to provide IOH patients with effective symptom management techniques. METHODS:Study participants completed 3 sit-to-stand maneuvers, including a stand with no intervention (Control), PREACT, and TENSE. Continuous heart rate and beat-to-beat blood pressure were measured. Stroke volume and cardiac output were then estimated from these waveforms. RESULTS:A total of 24 female IOH participants (mean ± SD: 32 ± 8 years) completed the study. The drops in MAP following PREACT (-21 ± 8 mm Hg; P <.001) and TENSE (-18 ± 10 mm Hg; P <.001) were significantly reduced compared to Control (-28 ± 10 mm Hg). The increase in cardiac output was significantly larger following PREACT (2.6 ± 1 L/min; P <.001) but not TENSE (1.9 ± 1 L/min; P = .2) compared to Control (1.4 ± 1 L/min). The Vanderbilt Orthostatic Symptom Score following PREACT (9 ± 8 au; P = .033) and TENSE (8 ± 8 au; P = .046) both were significantly reduced compared to Control (14 ± 9 au). CONCLUSION:Both the drop in MAP and symptoms upon standing improved with either PREACT or TENSE. These maneuvers provide novel symptom management techniques for patients with IOH.

Supplemental Digital Content is available in the text. Background: Initial orthostatic hypotension (IOH) is defined by a large drop in blood pressure (BP) within 15 s of standing. IOH often presents during an active stand, but not with a passive tilt, suggesting that a muscle activation reflex involving lower body muscles plays an important role. To our knowledge, there is no literature exploring how sympathetic activation affects IOH. We hypothesized involuntary muscle contractions before standing would significantly reduce the drop in BP seen in IOH while increasing sympathetic activity would not. Methods: Study participants performed 4 sit-to-stand maneuvers including a mental stress test (serial 7 mental arithmetic stress test), cold pressor test, electrical stimulation, and no intervention. Continuous heart rate and beat-to-beat BP were measured. Cardiac output and systemic vascular resistance were estimated from these waveforms. Data are presented as mean±SD. Results: A total of 23 female IOH participants (31±8 years) completed the study. The drops in systolic BP following the serial 7 mental arithmetic stress test (−26±12 mm Hg; P=0.004), cold pressor test (−20±15 mm Hg; P<0.001), and electrical stimulation (−28±12 mm Hg; P=0.01) were significantly reduced compared with no intervention (−34±11 mm Hg). The drops in systemic vascular resistance following the serial 7 mental arithmetic stress test (−391±206 dyne×s/cm5; P=0.006) and cold pressor test (−386±179 dyne×s/cm5; P=0.011) were significantly reduced compared with no intervention (−488±173 dyne×s/cm5). Cardiac output was significantly increased upon standing (7±2 L/min) compared with during the sit (6±1 L/min; P<0.001) for electrical stimulation. Conclusion: Sympathetic activation mitigates the BP response in IOH, while involuntary muscle contraction mitigates the BP response and reduces symptoms. Active muscle contractions may induce both of these mechanisms of action in their pretreatment of IOH. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03970551.

Protocols that support paramedics to assess, treat and refer low-risk syncope (fainting) may allow for ED transport of only high-risk patients. The development and uptake of such protocols is limited by a dearth of information about factors patients consider when deciding to seek EMS care following syncope. We explored decision-making processes of individuals with syncope regarding whether (or not) to call EMS after fainting as a starting point in the development of prehospital risk-stratification protocols for syncope. Twenty-five Canadian adults (aged 18–65 years) with a history of ≥ 1 syncopal episode were recruited. Individual semi-structured interviews were conducted, recorded, and transcribed. Straussian grounded theory methods were used to identify common themes and a core (overarching) category. Four themes were identified: (a) previous experiences with the healthcare system (e.g., feeling dismissed), (b) individual patient factors (e.g., age, medical history), (c) attitudes and beliefs (e.g., burdening the health care system, syncope is “not serious”), and (d) contextual factors (e.g., influence of important others, symptom severity). Perceived judgement, including judgement from EMS and negative self-evaluations, was identified as the core category that influenced patients’ decisions to seek care. We theorize that, while patients consider many factors in deciding to contact EMS for syncope, previous experiences of feeling judged and unfavorable beliefs about syncope may interfere with patients’ receptiveness to traditional EMS protocols for syncope. The findings highlight potential patient needs that program developers may wish to consider in the development of prehospital protocols to improve care and satisfaction among patients with syncope.

A historical analysis of the discourse of the purpose of higher education provides a typology of four distinct discourses which reflect the social, political, and economic context within which the changing rationale for funding universities has been defined. By analyzing where a technology-driven, international university could be located in the interstices of these competing discourses, the typology can assist educational leaders, administrators, and policymakers to more readily identify key obstacles to be overcome, opportunities that could be developed, and the latent dysfunctions that need to be anticipated to avoid both collateral damage and the resulting determined pushback. Forewarned is forearmed, and understanding which aspects of which discourses lend support or undermine such a project could greatly assist proponents in seeking support and avoiding missteps.

This study applies the attitudinal dimension of the theory of reasoned action to the decision-making process undertaken by parents when they remove children from school for vacation travel. A qualitative thematic analysis of online discussion posted to two blogs hosted by The Wall Street Journal and one blog hosted by Gawker reveals salient attitudes regarding the value of education as it relates to travel. Attitudes toward removing children from school for family travel were strongly linked to parental attitude toward the education system and toward the value of travel. Responses were categorized as supportive, ambivalent, or opposed. Those who strongly support the education system were more likely to view traditional schooling as an important component for socialization. This group felt that family vacation was not a justifiable reason for school absence. Those who view life experience as educational tended to feel that school absence was acceptable if the travel had an educational component. Finally, about 20

Mary and Robert Runté's chapter illustrates how teaching excellence is both historically and culturally situated. Through an examination of four discourses on the purpose of higher education: enlightenment, human capital, manpower, and consumerism, they identify the shifts in purpose of higher education according to the re-alignment of vested interests between the student and the state over time. From a playground for the privileged to explore according to whim, to satisfying the need for competent graduates ready to enter professional careers, these shifts have significant impact on how excellent teaching is defined and determined. Importantly, the authors contend that measures of teaching excellence need to align sector, institutional, staff and student expectations if they are to successfully drive up excellence.

Cause-related marketing (CRM) is a popular business strategy to improve brand image and increase profitability while raising funds and awareness for charitable causes. This practice involves a company and charity partnering on a market-oriented endeavor to benefit both parties. Increasingly, businesses are conducting a form of CRM at the cash register by requesting point-of-sale donations (POSD) for a cause or nonprofit, as customers pay for their purchases. This research examines frontline perception of this practice. Specifically, we examine how both customers and cashiers view POSD requests. Very little academic research to date has examined this topic. Extant POSD research primarily involves surveys from the practitioner realm. These offer valuable insights but remain at a somewhat general level. To gain a deeper understanding of how those most intimately impacted by the solicitation process view it, we adopt a qualitative research approach. Two customer focus groups and three cashier focus groups were conducted to explore this issue. Results suggest that both customers and cashiers find the practice to be somewhat uncomfortable. Participants on both sides of the cash register want more information on how the money is used and if the efforts genuinely benefit the targeted cause. Additionally, to some extent both customers and cashiers feel that the cashiers do not have sufficient information about these efforts to share with customers. Finally, both customers and cashiers are generally supportive of POSD efforts, despite their apprehensions. Thus, the ends (helping a worthy cause) appear to justify the means (POSD). This may explain the apparent discrepancy between our somewhat negative findings and the relatively positive findings of extant surveys. By adopting a qualitative approach, we have exposed certain negative process components that rarely surface through other means.

A brief historical overview of the evolution of the public discourse of the purpose of higher education is undertaken to provide context for current debates over investment in, and reform of, post-secondary education. Four separate discourses are identified: higher education for enlightenment, to develop human capital, as manpower management, and as consumerism. The dominant discourse of the purpose of higher education is shown to have changed from learning for its own sake to an emphasis on manpower planning and consumerism. The separate assumptions and implications of these distinct discourses are often confabulated with little apparent awareness of the contradictory nature of rhetoric drawn from more than one discourse at a time. The authors provide a simple analytical framework to cut through the confusion.