Peak Endocardial Acceleration-Based Clinical Testing of the "BEST" DDDR Pacemaker

The peak endocardial acceleration (PEA, unit g) shows a near correlation with myocardial contractility during the isometric systolic contraction of the heart (dP/dtmax), with sympathetic activity and, thus, with physiological heart rate modulation. The (Biomechanical Endocardial Sorin Transducer (BEST) sensor is incorporated in the tip of a pacing lead and measures PEA directly near the myocardium. In an international study, the lead was implanted with the dual chamber pacemaker Living-1 (Sorin) in 105 patients. The behavior of the PEA signal was tested under conditions of physical and mental stress and during daily life activities by 24-hour recordings of PEA (PEA Holter) at 1 to 2 months and approximately 1 year after implantation. Implantation of the BEST lead was performed without complications in all patients. The sensor functioned properly in the short- and long-term in 98% of patients. Although PEA values differed from patient to patient, the values closely reflected the variations in sympathetic activity due to physical and mental stress in each patient. During exercise and during daily life activities a close correlation between PEA and heart rate was observed among patients with normal sinus rhythm. Peak endocardial acceleration allows a nearly physiological control of the pacing rate.     

Direct and Telemetered Lead Impedance

Objectives: We undertook this study to determine whether telemetered lead impedance measurements (LIM) can be correlated with direct LIM and to determine the stability of LIM over time when measured directly and via telemetry. Methods: Direct LIM and telemetered LIM were measured in 91 patients; 101 leads during initial implantation and 40 leads during pulse generator replacement. Differences in direct LIM measured during initial implant and pulse generator replacement (direct-direct) were compared in 41 patients (28 atrial leads and 37 ventricular leads). The stability of telemetered LIM obtained immediately postoperatively, at 1 month and 1 year, postimplantation was assessed in 50 patients (23 atrial and 49 ventricular leads). Results: In atrial leads acute direct LIM was 633.9 ± 18.4 Ω versus 575.8 ± 18.5 Ω for telemetered LIM (r = 0.58), and chronic direct LIM was 670.9 ± 49.3 Ω versus 607.0 ± 36.3 Ω for telemetered LIM (r = 0.87). In ventricular leads acute direct LIM was 747.3 ± 16.9 Ω and 684.7 ± 16.4 Ω for telemetered LIM (r = 0.69), and chronic direct LIM was 674.8 ± 29.9 Ω and 625.2 ± 28.5 Ω for telemetered LIM (r = 0.68). The mean direct–direct UM rose 124 Ω (P < 0.001) in atrial leads and 10 Ω (P = NS) in ventricular leads. Telemetered LIM for atrial leads was 581.0 ± 27.6 Ω immediately postimplantation compared to 625.7 ± 34.8 Ω at 1 month and 754.1 ± 43.0 Ω at 1 year. Telemetered LIM for ventricular leads was 661.3 ± 17.5 Ω at implant, 684.6 ± 20.7 Ω at 1 month and 724.7 ± 22.7 Ω at 1 year. Conclusions: There is a good but limited correlation between direct and telemetered LIM. Mean direct LIM obtained at initial implantation is similar to that measured at pulse generator replacement. The telemetered LIM is stable over the first month postimplantation but tends to rise during the first year of follow-up and substantial changes in impedance are not uncommon in individuals with normal function. There is a tendency for LIM to rise with lead maturation. If telemetered LIM is to be followed over time, a baseline telemetered value should be obtained immediately postoperatively.     

The structure of human skin collagen as studied with the electron microscope

1. The structure of the collagen fibrils of normal human skin corium has been investigated with the electron microscope. 2. Under the conditions of observation the fibrils ranged in width from about 700 to 1,400 A with 1,000 A as the value occurring most frequently. They showed little tendency to fray longitudinally as is characteristic of tendon fibrils; when fracture of fibrils occurred it was usually in planes transverse to the axis. 3. The axial repeating periods observed in fibrils stained with phosphotungstic acid or shadowed with chromium or platinum range from about 500 to 800 A, the maximum occurring between 620 and 660 A. The average period in fibrils from infant skin does not differ significantly from that of adult and aged skin. 4. Depending on conditions of preparation, intraperiod fine structure, in the form of cross-bands, was observed in varying detail. The most detailed pattern commonly observed contains six bands of characteristic density and position. 5. Shadowed plastic replicas of dried collagen fibrils reproduce much of the structure commonly seen in shadowed fibrils. Replicas of moist fibrils show considerably less surface contouring than do dried fibrils. Replicas from smears of connective tissue fragments on glass show detailed structure, indicating the feasibility of applying this technique to biopsy material. 6. Infant skin differs from adult skin in having considerably greater amounts of amorphous material, little of which is strongly adherent to the collagen fibrils.     

Anti-neutrophil cytoplasmic antibodies (ANCA) directed against bactericidal/permeability increasing protein (BPI): a new seromarker for inflammatory bowel disease and associated disorders

It was our purpose to determine the immunodiagnostic value of ANCA directed against BPI in diseases known to be associated with ANCA, such as ANCA-associated vasculitides, inflammatory bowel disease (IBD) and the associated condition primary sclerosing cholangitis. The immunoreactivity of recombinant BPI (rBPI) was established in order to develop an ELISA specific for rBPI. By means of this assay, BPI-ANCA were assessed in sera of 178 patients with IBD or the associated disorder primary sclerosing cholangitis, 112 patients with ANCA-associated vasculitides, and in sera of 182 disease and 140 healthy controls. BPI-ANCA were found to be closely associated with IBD and primary sclerosing cholangitis (34% and 44% of ANCA-positive sera, respectively). By contrast, BPI-ANCA positivity was low (<10%) in the double-negative sera of patients with ANCA-associated vasculitides and in disease and healthy controls. BPI-ANCA appear to constitute an important marker for IBD and primary sclerosing cholangitis, but not for the ANCA-associated vasculitides.     

The Effect of Saline Iontophoresis on Skin Integrity in Human Volunteers: I. Methodology and Reproducibility

This study, conducted in 36 human volunteers, was an evaluationof the effects of saline iontophoresis on skin temperature,irritation, and barrier function. The major objectives wereto assess the effects of low-level ionic currents, to validatethe proposed methodology of assessment, and to establish reproducibilityin repeated saline iontophoresis applications. This was thefirst of a multistage study designed to assess the safety of24-hr saline iontophoresis episodes at selected currents andcurrent densities. Since an iontophoresis patch challenges theskin harrier both by occluding the skin surface and by passingionic current through the skin, the experimental protocol wasdesigned to permit measurement of the contribution of each ofthese processes to the overall response. In this first stagewe investigated the effect of 10 min of current delivery, at0.1 mA/cm² on a 1-cm² area patch and 0.2 mA/cm² on a 6.5-cm²area patch compared to unpowered control patches. Twelve subjectswere tested under each condition on two separate occasions toexamine reproducibility of the response variable measurements.A further 12 subjects were tested once under the 0.2 mA/cm 6.5-cm2condition. Skin irritation was evaluated via repeated measurementsof transepidermal water loss, capacitance, skin temperature,skin color, and a visual scoring system, before the iontophoresisepisode and after patch removal. No damage to skin harrier functionin terms of skin-water loss or skin-water content was detected.Slight, subclinical, short-lasting erythema was observed forboth conditions. Assessment of correlation coefficients showedhighly statistically significant indications of reproducibilityfor all five response variables measured. The experimental design,in combination with a repeated measures analysis, provided clearseparation of the occlusion and ionic current components ofthe iontophoretic patch challenge. Further, the repeated measuresanalysis gave a highly sensitive assessment of skin irritationand resolution after patch removal. We conclude that the experimentalmethodology is appropriate for assessing possible changes inskin integrity resulting from saline iontophoresis under similaroperating conditions for longer durations and for other skinchallenges from which a subclinical response is expected.     

Just How Stable Are Escape Rhythms after Atrioventricular Junction Ablation?

Background: Atrioventricular (AV) node ablation with implantation of a permanent pacemaker is an established mode of therapy in the treatment of atrial fibrillation. However, concern exists regarding subsequent dependency on an entirely paced rhythm and the possible sequela of unheralded pacemaker failure. Data regarding escape rhythm lability, an important feature of pacemaker dependency, are limited. Aims and Methods: The purpose of this study was twofold: (1) to determine the characteristics of escape rhythms at predefined serial time intervals following AV node ablation and pacemaker implantation, and (2) to identify risk factors predictive of unstable escape rhythms. Patients undergoing AV node ablation and pacemaker implantation were assessed for the presence or absence of an escape rhythm during pacemaker interrogation at five predetermined serial time points. Baseline demographics and comorbid conditions were evaluated as potential predictors of those with labile escape rhythms. Results : Seventy‐nine percent of the 96 patients studied had an underlying escape rhythm (≥30 beats per minute) immediately postablation. Although the percentage of patients with an escape rhythm increased at each follow‐up interval, the number of patients who consistently demonstrated an escape rhythm declined with each follow‐up, with 28% of patients lacking an escape rhythm at some time point, i.e., labile escape rhythm. There were no significant predictors of a labile escape rhythm. Conclusion: Among patients who have undergone AV node ablation and pacemaker implantation, 72% have a stable escape rhythm over time, but others are at risk for pacemaker dependency, as predicted by an underlying absent or labile escape rhythm. (PACE 2010; 939–944)