A Dual-Chamber Leadless Pacemaker

BACKGROUND

Single-chamber ventricular leadless pacemakers do not support atrial pacing or consistent atrioventricular synchrony. A dual-chamber leadless pacemaker system consisting of two devices implanted percutaneously, one in the right atrium and one in the right ventricle, would make leadless pacemaker therapy a treatment option for a wider range of indications.

METHODS

We conducted a prospective, multicenter, single-group study to evaluate the safety and performance of a dual-chamber leadless pacemaker system. Patients with a conventional indication for dual-chamber pacing were eligible for participation. The primary safety end point was freedom from complications (i.e., device- or procedure-related serious adverse events) at 90 days. The first primary performance end point was a combination of adequate atrial capture threshold and sensing amplitude at 3 months. The second primary performance end point was at least 70% atrioventricular synchrony at 3 months while the patient was sitting.

RESULTS

Among the 300 patients enrolled, 190 (63.3%) had sinus-node dysfunction and 100 (33.3%) had atrioventricular block as the primary pacing indication. The implantation procedure was successful (i.e., two functioning leadless pacemakers were implanted and had established implant-to-implant communication) in 295 patients (98.3%). A total of 35 device- or procedure-related serious adverse events occurred in 29 patients. The primary safety end point was met in 271 patients (90.3%; 95% confidence interval [CI], 87.0 to 93.7), which exceeded the performance goal of 78% (P<0.001). The first primary performance end point was met in 90.2% of the patients (95% CI, 86.8 to 93.6), which exceeded the performance goal of 82.5% (P<0.001). The mean (±SD) atrial capture threshold was 0.82±0.70 V, and the mean P-wave amplitude was 3.58±1.88 mV. Of the 21 patients (7%) with a P-wave amplitude of less than 1.0 mV, none required device revision for inadequate sensing. At least 70% atrioventricular synchrony was achieved in 97.3% of the patients (95% CI, 95.4 to 99.3), which exceeded the performance goal of 83% (P<0.001).

CONCLUSIONS

The dual-chamber leadless pacemaker system met the primary safety end point and provided atrial pacing and reliable atrioventricular synchrony for 3 months after implantation. (Funded by Abbott Medical; Aveir DR i2i ClinicalTrials.gov number, NCT05252702.).

Genomic analysis of early-stage lung cancer reveals a role for TP53 mutations in distant metastasis

Patients with non-small cell lung cancer (NSCLC) who have distant metastases have a poor prognosis. To determine which genomic factors of the primary tumor are associated with metastasis, we analyzed data from 759 patients originally diagnosed with stage I-III NSCLC as part of the AACR Project GENIE Biopharma Collaborative consortium. We found that TP53 mutations were significantly associated with the development of new distant metastases. TP53 mutations were also more prevalent in patients with a history of smoking, suggesting that these patients may be at increased risk for distant metastasis. Our results suggest that additional investigation of the optimal management of patients with early-stage NSCLC harboring TP53 mutations at diagnosis is warranted in light of their higher likelihood of developing new distant metastases.

Culpability and Compensation in Canadian Health Care: Much Ado About No-Fault?

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Heavy mining vehicle controls and skidding accidents

This paper examines various control locations in heavy mining vehicles. Three trucks have been tested on a skid pad in both clockwise and anticlockwise directions. The skid lengths were measured after each trial. The primary focus of the study was the positioning of various controls and their relevance to various skid lengths. Some additional measures such as NASA-TLX scales were also used to make subjective evaluations. The results are presented in this paper. The findings clearly indicate the relevance of control locations to actual skid lengths. The poorly located controls resulted in greater skid lengths. This is an important finding as skid lengths are related to greater reaction times in a skidding situation and hence greater risk of accidents on relevant trucks. Such accidents can incur large repair bills for damaged equipment whereas more importantly, jeopardizing the life and safety of heavy mining vehicle drivers.

The secretory carrier membrane protein family: structure and membrane topology

Secretory carrier membrane proteins (SCAMPs) are integral membrane proteins found in secretory and endocytic carriers implicated to function in membrane trafficking. Using expressed sequence tag database and library screens and DNA sequencing, we have characterized several new SCAMPs spanning the plant and animal kingdoms and have defined a broadly conserved protein family. No obvious fungal homologue has been identified, however. We have found that SCAMPs share several structural motifs. These include NPF repeats, a leucine heptad repeat enriched in charged residues, and a proline-rich SH3-like and/or WW domain-binding site in the N-terminal domain, which is followed by a membrane core containing four putative transmembrane spans and three amphiphilic segments that are the most highly conserved structural elements. All SCAMPs are 32-38 kDa except mammalian SCAMP4, which is approximately 25 kDa and lacks most of the N-terminal hydrophilic domain of other SCAMPs. SCAMP4 is authentic as determined by Northern and Western blotting, suggesting that this portion of the larger SCAMPs encodes the functional domain. Focusing on SCAMP1, we have characterized its structure further by limited proteolysis and Western blotting with the use of isolated secretory granules as a uniformly oriented source of antigen and by topology mapping through expression of alkaline phosphatase gene fusions in Escherichia coli. Results show that SCAMP1 is degraded sequentially from the N terminus and then the C terminus, yielding an approximately 20-kDa membrane core that contains four transmembrane spans. Using synthetic peptides corresponding to the three conserved amphiphilic segments of the membrane core, we have demonstrated their binding to phospholipid membranes and shown by circular dichroism spectroscopy that the central amphiphilic segment linking transmembrane spans 2 and 3 is alpha-helical. In the intact protein, these segments are likely to reside in the cytoplasm-facing membrane interface. The current model of SCAMP1 suggests that the N and C termini form the cytoplasmic surface of the protein overlying a membrane core, which contains a functional domain located at the cytoplasmic interface with little exposure of the protein on the ectodomain.

Digital radiology in skeletal trauma: assessment of casualty officers' performance

Radiographic images can now be produced without the requirement of film processing and development, and can be displayed rapidly on a computer monitor. We assessed junior doctors' performance in interpreting images from 25 patients being investigated for possible fracture and also compared the diagnostic abilities of casualty officers with those of radiology specialist registrars. For interpretation of images viewed at a workstation or as filmed laser images, respectively, sensitivities were 75% and 78%, and specificities were 65% and 76%. These differences were not significant. There was a tendency for radiology specialist registrars to be less specific when reviewing images at a workstation. The demonstration that there is no loss in diagnostic quality when casualty officers interpret fracture images in a purely digitally acquired and viewed format forms a robust basis for economic evaluation of the technology.

Characterization of and the influence of calcium channel blockers on the renal excretion of pyrimidine anticancer agents

The renal handling of two anticancer (a-Ca) pyrimidines 5-fluorodeoxyuridine (FUdR) and 5-fluorouracil (5-FU) was investigated in clearance experiments in CF-1 mice using specific inhibitors of classical renal transport systems. The 5-FU was derived from the metabolism of FUdR. Based on the FUdR:inulin clearance ratio and 5-FU:inulin clearance ratio, it was determined that FUdR was secreted into renal tubules while 5-FU underwent reabsorption. The secretion of FUdR was inhibited by cimetidine and dipyridamole but not by probenecid or phloridzin. While the clearance ratio of 5-FU:inulin was significantly reduced by phloridzin, it (i.e., the ratio) was not affected by cimetidine, dipyridamole, or probenecid. The impact of two calcium channel blockers, diltiazem (DZM) and verapamil (VER), on the renal handling of FUdR and 5-FU was also examined. VER increased the secretion of FUdR without affecting the reabsorption of 5-FU while DZM slightly decreased the secretion of FUdR and prevented the reabsorption of 5-FU. These data suggest that the organic cation carrier and a dipyridamole-sensitive nucleoside transporter are involved in the renal excretion of FUdR; that the renal transport of both FUdR and 5-FU is associated with the calcium channel; and that 5-FU utilizes, at least in part, the glucose transporter for its reabsorption.

Heterotopic ossification after femoral intramedullary rodding

Heterotopic ossification (HO) after femoral intramedullary rodding is a significant complication of the procedure. One hundred eighteen cases of femoral roddings performed on 113 patients were available for review. The data were computerized and evaluated using univariate analysis and multivariate regression analysis. A statistically significant increase of HO was found with male gender, increased delay to surgery, and in patients requiring prolonged intubation because of their multiple injuries. HO was classified using a modified version of the method of Brumback et al. (grades 0-IV). A strong correlation of HO with brain injury documented by computed tomography scan was also found to be statistically significant for the more severe grades of HO. This group of patients had not previously been identified as being at high risk for HO.

Leurosine biotransformations: an unusual ring-fission reaction catalyzed by peroxidase

The dimeric Vinca alkaloid leurosine undergoes an unusual fission of the piperidine ring of the Iboga substructure when reacted with horseradish peroxidase and hydrogen peroxide. A preparative-scale oxidation of leurosine provided 15'-hydroxycatharinine, which was identified by infrared and proton and carbon-13 NMR spectroscopies and high-resolution mass spectrometry. A proposed pathway for the formation of 15'-hydroxycatharinine involves radical and iminium intermediates and cleavages of a putative diol. The enzymatic transformation product is 3 orders of magnitude less active than leurosine or vinblastine in vitro, in inhibiting the polymerization of tubulin.

Laryngocele--a study of five cases with reference to the radiological features

Arising from the ventricle of the larynx are small saccules, usually less than 10 mm in length. Occasionally the saccules may enlarge and the term laryngocele is applied. Five symptomatic cases are described with the radiological findings, which in each case contributed to the diagnosis established at operation.

Ligation of the patent ductus arteriosus in newborn respiratory failure

Patent ductus arteriosus (PDA) is commonly associated with respiratory disease in newborn infants and may require ligation. Surgical ligation of the PDA can be done in small infants with low operative risk and minimal complications. The outcome of patients after ligation depends primarily on the severity of the underlying pulmonary disease. One hundred fifty-one patients have undergone ligation in an eight-year period at this center. A simplified technique performed in the neonatal intensive care unit with the use of local anesthesia and conventional ventilator management is described.

Early and late results of resection of abdominal aortic aneurysms

Resection of the abdominal aortic aneurysm is being performed with decreasing operative mortality and morbidity. Among 190 patients undergoing this procedure at the Ottawa Civic Hospital between 1970 and 1975, 53 (28%) had a ruptured aneurysm and 137 (72%), a nonruptured aneurysm. Mean age of the patients was 66.2 years. Concomitant disease was frequent, 73% of patients having two or more associated diseases; the average number of associated diseases per patient was 2.25. Operative mortality in the group with ruptured aneurysms was 51%, and in the group with nonruptured aneurysms, 4%. Postoperative morbidity was 85% among those with a ruptured aneurysm, 67% among those with imminent rupture before operation and 34% among the others with a nonruptured aneurysm. Graft complications occurred in 15% of those with a ruptured aneurysm and 9% of those with a nonruptured aneurysm. Among survivors of the operation 73% and 81% of those with a ruptured and a nonruptured aneurysm, respectively, are known to be alive. In both groups causes of late death included infection or thrombosis of the graft and mesenteric thrombosis, as well as causes unrelated to the operation. Surgical management of the abdominal aortic aneurysm is advocated in all but patients at poor risk for operation who have asymptomatic aneurysms less than 6 cm in diameter.

The growth and development of low birth weight infants receiving intensive neonatal care. Preliminary observations on 28 such infants

This study reports the growth and development of 28 survivors who had a birth weight of less than or equal to 1,000 g and were cared for at a Regional Neonatal Intensive Care Unit. Only eight (30%) had neurologic abnormalities including spastic hemiparesis, retrolental fibroplasia, hydrocephalus, motor retardation, and some delay in language skills. The other survivors had normal physical examinations and developmental progress judged by a variety of screening examinations up to age four years, three months. The average caloric intake during the first week was 61 kg/da, although over half never reached that level until day 4. Nearly all the infants have had standard growth patterns thus far.