Ventricular pacing or dual-chamber pacing for sinus-node dysfunction

BACKGROUND Dual-chamber (atrioventricular) and single-chamber (ventricular) pacing are alternative treatment approaches for sinus-node dysfunction that causes clinically significant bradycardia. However, it is unknown which type of pacing results in the better outcome. METHODS We randomly assigned a total of 2010 patients with sinus-node dysfunction to dual-chamber pacing (1014 patients) or ventricular pacing (996 patients) and followed them for a median of 33.1 months. The primary end point was death from any cause or nonfatal stroke. Secondary end points included the composite of death, stroke, or hospitalization for heart failure; atrial fibrillation; heart-failure score; the pacemaker syndrome; and the quality of life. RESULTS The incidence of the primary end point did not differ significantly between the dual-chamber group (21.5 percent) and the ventricular-paced group (23.0 percent, P=0.48). In patients assigned to dual-chamber pacing, the risk of atrial fibrillation was lower (hazard ratio, 0.79; 95 percent confidence interval, 0.66 to 0.94; P=0.008), and heart-failure scores were better (P CONCLUSIONS In sinus-node dysfunction, dual-chamber pacing does not improve stroke-free survival, as compared with ventricular pacing. However, dual-chamber pacing reduces the risk of atrial fibrillation, reduces signs and symptoms of heart failure, and slightly improves the quality of life. Overall, dual-chamber pacing offers significant improvement as compared with ventricular pacing

Quality of Life and Clinical Outcomes in Elderly Patients Treated with Ventricular Pacing as Compared with Dual-Chamber Pacing

ABSTRACT Background Standard clinical practice permits the use of either single-chamber ventricular pacemakers or dual-chamber pacemakers for most patients who require cardiac pacing. Ventricular pacemakers are less expensive, but dual-chamber pacemakers are believed to be more physiologic. However, it is not known whether either type of pacemaker results in superior clinical outcomes. Methods The Pacemaker Selection in the Elderly study was a 30-month, single-blind, randomized, controlled comparison of ventricular pacing and dualchamber pacing in 407 patients 65 years of age or older in 29 centers. Patients received a dual-chamber pacemaker that had been randomly programmed to either ventricular pacing or dual-chamber pacing. The primary end point was health-related quality of life as measured by the 36-item Medical Outcomes Study Short-Form General Health Survey. Results The average age of the patients was 76 years (range, 65 to 96), and 60 percent were men. Quality of life improved significantly after pacemaker implantation (P0.001), but there were no differences between the two pacing modes in either the quality of life or prespecified clinical outcomes (including cardiovascular events or death). However, 53 patients assigned to ventricular pacing (26 percent) were crossed over to dual-chamber pacing because of symptoms related to the pacemaker syndrome. Patients with sinus-node dysfunction, but not those with atrioventricular block, had moderately better quality of life and cardiovascular functional status with dual-chamber pacing than with ventricular pacing. Trends of borderline statistical significance in clinical end points favoring dual-chamber pacing were observed in patients with sinus-node dysfunction, but not in those with atrioventricular block. Conclusions The implantation of a permanent pacemaker improves health-related quality of life. The quality-of-life benefits associated with dualchamber pacing as compared with ventricular pacing are observed principally in the subgroup of patients with sinus-node dysfunction. (N Engl J Med 1998;338:1097-104.

Deliberate perioperative systems design improves operating room throughput

Background: New operating room (OR) design focuses more on the surgical environment than on the process of care. The authors sought to improve OR throughput and reduce time per case by goal-directed design of a demonstration OR and the perioperative processes occurring within and around it. Methods: The authors constructed a three-room suite including an OR, an induction room, and an early recovery area. Traditionally sequential activities were run in parallel, and nonsurgical activities were moved from the OR to the supporting spaces. The new workflow was supported by additional anesthesia and nursing personnel. The authors used a retrospective, case-and surgeon-matched design to compare the throughput, cost, and revenue performance of the new OR to traditional ORs. Results: For surgeons performing the same case mix in both environments, the new OR processed more cases per day than traditional ORs and used less time per case. Throughput improvement came from superior nonoperative performance. Nonoperative Time was reduced from 67 min (95% confidence interval, 64 -70 min) to 38 min (95% confidence interval, 35-40 min) in the new OR. All components of Nonoperative Time were meaningfully reduced. Operative Time decreased by approximately 5%. Hospital and anesthesia costs per case increased, but the increased throughput offset costs and the global net margin was unchanged. Conclusions: Deliberate OR and perioperative process redesign improved throughput. Performance improvement derived from relocating and reorganizing nonoperative activities. Better OR throughput entailed additional costs but allowed additiona

Edge reconstruction in the fractional quantum Hall regime

The interplay of electron-electron interaction and confining potential can lead to the reconstruction of fractional quantum Hall edges. We have performed exact diagonalization studies on microscopic models of fractional quantum Hall liquids, in finite size systems with disk geometry, and found numerical evidence of edge reconstruction under rather general conditions. In the present work we have taken into account effects like layer thickness and Landau level mixing, which are found to be of quantitative importance in edge physics. Due to edge reconstruction, additional nonchiral edge modes arise for both incompressible and compressible states. These additional modes couple to electromagnetic fields and thus can be detected in microwave conductivity measurements. They are also expected to affect the exponent of electron Green's function, which has been measured in tunneling experiments. We have studied in this work the electric dipole spectral function that is directly related to the microwave conductivity measurement. Our results are consistent with the enhanced microwave conductivity observed in experiments performed on samples with an array of antidots at low temperatures, and its suppression at higher temperatures. We also discuss the effects of the edge reconstruction on the single electron spectral function at the edge.Comment: 19 pages, 12 figure

Bifurcations of a driven granular system under gravity

Molecular dynamics study on the granular bifurcation in a simple model is presented. The model consists of hard disks, which undergo inelastic collisions; the system is under the uniform external gravity and is driven by the heat bath. The competition between the two effects, namely, the gravitational force and the heat bath, is carefully studied. We found that the system shows three phases, namely, the condensed phase, locally fluidized phase, and granular turbulent phase, upon increasing the external control parameter. We conclude that the transition from the condensed phase to the locally fluidized phase is distinguished by the existence of fluidized holes, and the transition from the locally fluidized phase to the granular turbulent phase is understood by the destabilization transition of the fluidized holes due to mutual interference.Comment: 35 pages, 17 figures, to be published in PR

Large enhancement of deuteron polarization with frequency modulated microwaves

We report a large enhancement of 1.7 in deuteron polarization up to values of 0.6 due to frequency modulation of the polarizing microwaves in a two liters polarized target using the method of dynamic nuclear polarization. This target was used during a deep inelastic polarized muon-deuteron scattering experiment at CERN. Measurements of the electron paramagnetic resonance absorption spectra show that frequency modulation gives rise to additional microwave absorption in the spectral wings. Although these results are not understood theoretically, they may provide a useful testing ground for the deeper understanding of dynamic nuclear polarization.Comment: 10 pages, including the figures coming in uuencoded compressed tar files in poltar.uu, which also brings cernart.sty and crna12.sty files neede

Vanishing wildlife corridors and options for restoration: a case study from Tanzania

Conserving wildlife corridors is increasingly important for maintaining ecological and genetic connectivity in times of unprecedented habitat fragmentation. Documenting connectivity loss, assessing root causes, and exploring restoration options are therefore priority conservation goals. A 2009 nationwide assessment in Tanzania documented 31 major remaining corridors, the majority of which were described as threatened. The corridor between the Udzungwa Mountains and the Selous Game Reserve in south-central Tanzania, a major link between western and southern wildlife communities, especially for the African elephant Loxodonta africana, provides an illuminating case study. A preliminary assessment in 2005 found that connectivity was barely persisting via two remaining routes. Here we present assessments of these two corridors conducted from 2007-2010, using a combination of dung surveys, habitat mapping and questionnaires. We found that both corridor routes have become closed over the last five years. Increased farming and livestock keeping, associated with both local immigration and population growth, were the main reasons for corridor blockage. However, continued attempts by elephants to cross by both routes suggest that connectivity can be restored. This entails a process of harmonizing differing land owners and uses towards a common goal. We provide recommendations for restoring lost connectivity and discuss the prospects for preventing further loss of corridors across the country

The parent?infant dyad and the construction of the subjective self

Developmental psychology and psychopathology has in the past been more concerned with the quality of self-representation than with the development of the subjective agency which underpins our experience of feeling, thought and action, a key function of mentalisation. This review begins by contrasting a Cartesian view of pre-wired introspective subjectivity with a constructionist model based on the assumption of an innate contingency detector which orients the infant towards aspects of the social world that react congruently and in a specifically cued informative manner that expresses and facilitates the assimilation of cultural knowledge. Research on the neural mechanisms associated with mentalisation and social influences on its development are reviewed. It is suggested that the infant focuses on the attachment figure as a source of reliable information about the world. The construction of the sense of a subjective self is then an aspect of acquiring knowledge about the world through the caregiver's pedagogical communicative displays which in this context focuses on the child's thoughts and feelings. We argue that a number of possible mechanisms, including complementary activation of attachment and mentalisation, the disruptive effect of maltreatment on parent-child communication, the biobehavioural overlap of cues for learning and cues for attachment, may have a role in ensuring that the quality of relationship with the caregiver influences the development of the child's experience of thoughts and feelings

The Scientific Foundations of Forecasting Magnetospheric Space Weather

The magnetosphere is the lens through which solar space weather phenomena are focused and directed towards the Earth. In particular, the non-linear interaction of the solar wind with the Earth's magnetic field leads to the formation of highly inhomogenous electrical currents in the ionosphere which can ultimately result in damage to and problems with the operation of power distribution networks. Since electric power is the fundamental cornerstone of modern life, the interruption of power is the primary pathway by which space weather has impact on human activity and technology. Consequently, in the context of space weather, it is the ability to predict geomagnetic activity that is of key importance. This is usually stated in terms of geomagnetic storms, but we argue that in fact it is the substorm phenomenon which contains the crucial physics, and therefore prediction of substorm occurrence, severity and duration, either within the context of a longer-lasting geomagnetic storm, but potentially also as an isolated event, is of critical importance. Here we review the physics of the magnetosphere in the frame of space weather forecasting, focusing on recent results, current understanding, and an assessment of probable future developments.Peer reviewe