Left bundle branch area pacing as a first line pacing strategy, which patients should we consider?

Background

A higher right ventricular (RV) pacing burden in those with permanent pacemakers results in accelerated pacing induced cardiomyopathy, in addition to increased incidence of heart failure and mortality [1–3]. This process may necessitate upgrade to a biventricular system in time, as the cardiomyopathy progresses. Physiological conduction system pacing targets such as His-bundle pacing (HBP) or Left Bundle Branch Area Pacing (LBBAP) have been shown to generate comparatively narrower QRS complexes and thus mitigate this cardiomyopathy development [4,5].

The 2021 ESC guidelines have a class 2b indication for consideration of HBP as an alternative to RV pacing in those with AV block and left ventricular ejection fraction >40%, who are anticipated to have >20% ventricular pacing burden [6].

Purpose

To retrospectively identify ECG, echocardiographic, permanent pacemaker (PPM) setting and patient factors associated with high RV pacing burden that may aid selection of those who may benefit from conduction system pacing (CSP).

Methods

We retrospectively identified 300 consecutive patients who underwent cardiac implantable electronic device insertion in our Electrophysiology Lab from the years 2017–2018. We excluded patients who underwent generator replacements, in addition to those who had biventricular devices or implantable cardioverter defibrillators inserted. We collated ECG, echo, past medical history and pacing data for each patient over a three-year follow up period.

Data were analysed using SPSS v.26.

Results

160 patients met inclusion criteria. Those with an RV pacing burden >20% were categorised group one (n=85) and those with <20% in group two (n=75). Baseline characteristics of these two groups are compared in Table 1 and Table 2.

Our analysis showed that significant differences between these groups included a lower mean HR (Table 1) (55.1±17.8 vs 57.63±17.4) with a more prolonged PR interval (225.7ms ± 8.34 vs. 188.6ms ± 6.62) or atrial fibrillation/flutter (AF/AFL) on admission ECG. There were more males with a greater mean age (High Ventricular Paced (VP) = 76.6 years ± 8.4 vs Low VP = 71.23 years ± 12.3) in the higher VP group, and they demonstrated more incidence of dilated RA/RV on echo (Enlarged RA = 30.5%; Enlarged RV = 23.6% vs 10% and 8.4% respectively).

There were significant differences in PPM indications and setting between groups (Table 2), with the higher VP groups having PPM inserted for persistent high-grade AV block (CHB = 31.5% vs 4.9% and Mobitz 2 = 9.6% vs 0%) and had less MVP mode activated (Mode switch algorithm = 13.3% vs 71%).

Conclusion

Our data suggests that those with persistent high grade AV block such as Mobitz 2 or CHB should be considered for CSP. Other considerations include older age, male sex, dilated RV/RA, prolonged PR, lower intrinsic HR or AF/AFL on admission ECG. PPM mode switching settings to reduce RV pacing burden should be utilised where possible.

Funding Acknowledgement

Type of funding sources: None.

Clinical characteristics and natural history of pre-adolescent non-syndromic hypertrophic cardiomyopathy

Background

The clinical presentation and natural history of pre-adolescent sarcomeric hypertrophic cardiomyopathy (HCM) has not been systematically characterised. The aim of this study was to describe the clinical characteristics and outcomes of a large, international, multicentre cohort of children diagnosed with non-syndromic HCM below the age of 12.

Methods

Data from the International Paediatric Hypertrophic Cardiomyopathy Consortium on 639 children meeting diagnostic criteria for HCM below 12 years of age (pre-adolescent) were collected and compared with 568 diagnosed aged 12–16 years. Patients with syndromic and metabolic HCM were excluded.

Results

Of 639 (male n=417, 65.3%) children with pre-adolescent HCM, 339 (53.1%) had a family history of HCM and 57 (8.9%) a family history of sudden cardiac death (SCD). At the time of baseline assessment; 132 (20.7%) had heart failure symptoms and 39 (6.1%) reported unexplained syncope. Median maximal left ventricular wall thickness on echocardiogram was 13.6mm (IQR 10–19) with a corresponding median z-score of 8.7 (5.3–14.4). 145 (22.7%) had left ventricular outflow tract obstruction (LVOTO) (maximal LVOT gradient≥30mmHg) and 35 (5.5%) had severe LVOTO (gradient≥90mmHg). Over a median follow up 5.6 years (IQR 2.3–10), 10.5% underwent a myectomy and 23.2% implantable cardiac defibrillator (ICD) implantation for primary (81.8%) or secondary (14.2%) prevention. 42 (6.7%) patients died [SCD 4.9%, heart failure death 0.8%, other 1%] and 21 (3.3%) underwent cardiac transplantation. 69 (10.8%) patients had an arrhythmic event (SCD n=31, resuscitated cardiac arrest n=17, appropriate ICD therapy n=14, sustained VT with haemodynamic compromise n=7). Compared to those presenting after 12 years, those under 12 were less likely to have a family history of SCD (8.9% vs 13%, p:0.047) or report unexplained syncope (6.1% vs 12.3%, p<0.00). The degree of hypertrophy did not differ but a higher proportion of pre-adolescent patients had LVOTO (22.7% vs 14.4%, p<0.00). A higher proportion of pre-adolescent underwent a myectomy (10.5% vs 7.2%, p:0.045) but a lower proportion received a primary prevention ICD (18.9% vs 30.1%, p:0.041). The overall proportion of patients reaching the mortality or arrhythmic end-points did not differ, but SCD and resuscitated cardiac arrest events were more frequent in pre-adolescent patients (4.9% vs 3.9% and 2.7 vs 1.6% respectively).

Conclusion

Pre-adolescent HCM is associated with a high symptom burden and variable cardiac phenotype, comparable to those presenting later in childhood. Despite baseline similarities and equal overall survival, younger patients were less likely to receive a primary prevention ICD despite being more likely to experience a SCD or resuscitated cardiac arrest. This study suggests that younger patients should not be considered a distinct entity for risk stratification and that similar management strategies to older HCM patients should be employed.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): BHF (British Heart Foudnation) MRC (Medical Research Council)

Psychosocial, psychiatric and work-related risk factors associated with suicide in Ireland: optimised methodological approach of a case-control psychological autopsy study

BACKGROUND

Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls.

METHODS

The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners' registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners' records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources.

CONCLUSIONS

The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

Environmental, health, wellbeing, social and equity effects of urban green space interventions: A meta-narrative evidence synthesis

BACKGROUND

As populations become increasingly urbanised, the preservation of urban green space (UGS) becomes paramount. UGS is not just dedicated recreational space such as public parks, but other types of informal green space are important, for example, street trees and roof gardens. Despite the potential from cross-sectional evidence, we know little about how to design new, or improve or promote existing UGS for health, wellbeing, social and environmental benefits, or known influencing factors such as physical activity.

OBJECTIVES

To perform a meta-narrative review of the evidence regarding the health, wellbeing, social, environmental and equity effects, or known influencing factors of these outcomes, of UGS interventions.

DATA SOURCES

Eight electronic databases were searched ((Medline, PsycINFO, Web of Science (Science and Social Science Citation Indices), PADDI (Planning Architecture Design Database Ireland), Zetoc, Scopus, Greenfiles, SIGLE (System for Information on Grey Literature in Europe)), and reference lists of included studies and relevant reviews were hand searched for further relevant studies.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Eligibility criteria included: (i) evaluation of an UGS intervention; and (ii) health, wellbeing, social or environmental outcome(s), or known influencing factors of these outcomes, measured. Interventions involving any age group were included. Interventions must have involved: (a) physical change to green space in an urban-context including improvements to existing UGS or development of new UGS, or (b) combination of physical change to UGS supplemented by a specific UGS awareness, marketing or promotion programme to encourage use of UGS.

STUDY APPRAISAL AND SYNTHESIS METHODS

Following a meta-narrative approach, evidence was synthesised by main intervention approach, including: (i) park-based; (ii) greenways/trails; (iii) urban greening; (iv) large green built projects for environmental purposes. Outcomes such as economic (e.g. cost effectiveness and cost-benefit analyses), adverse effects and unintended consequences were also extracted. Evidence was synthesised following the RAMESES guidelines and publication standards, the PROGRESS-plus tool was used to explore equity impact, and risk of bias/study quality was assessed. The findings from the evidence review were presented at an expert panel representing various disciplines in a workshop and these discussions framed the findings of the review and provide recommendations that are relevant to policy, practice and research.

RESULTS

Of the 6997 studies identified, 38 were included. There was strong evidence to support park-based (7/7 studies) and greenway/trail (3/3 studies) interventions employing a dual-approach (i.e. a physical change to the UGS and promotion/marketing programmes) particularly for park use and physical activity; strong evidence for the greening of vacant lots (4/4 studies) for health, wellbeing (e.g. reduction in stress) and social (e.g. reduction in crime, increased perceptions of safety) outcomes; strong evidence for the provision of urban street trees (3/4 studies) and green built interventions for storm water management (6/7 studies) for environmental outcomes (e.g. increased biodiversity, reduction in illegal dumping). Park-based or greenway/trail interventions that did not employ a dual-approach were largely ineffective (7/12 studies showed no significant intervention effect). Overall, the included studies have inherent biases owing to the largely non-randomized study designs employed. There was too little evidence to draw firm conclusions regarding the impact of UGS interventions on a range of equity indicators. LIMITATIONS; CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: UGS has an important role to play in creating a culture of health and wellbeing. Results from this study provide supportive evidence regarding the use of certain UGS interventions for health, social and environmental benefits. These findings should be interpreted in light of the heterogeneous nature of the evidence base, including diverging methods, target populations, settings and outcomes. We could draw little conclusions regarding the equity impact of UGS interventions. However, the true potential of UGS has not been realised as studies have typically under-evaluated UGS interventions by not taking account of the multifunctional nature of UGS. The findings have implications for policymakers, practitioners and researchers. For example, for policymakers the trajectory of evidence is generally towards a positive association between UGS and health, wellbeing, social and environmental outcomes, but any intervention must ensure that negative consequences of gentrification and unequal access are minimised.

Monitoring and documentation of side effects from depot antipsychotic medication: an interdisciplinary audit of practice in a regional mental health service

This audit reviewed current practice within a rural mental health service area on the monitoring and documentation of side effects of antipsychotic depot medication. A sample of 60 case files, care plans and prescriptions were audited, which is 31% of the total number of service users receiving depot injections in the mental health service region (n= 181). The sample audited had a range of diagnoses, including: schizophrenia, schizoaffective disorder, bipolar affective disorder, depression, alcoholic hallucinosis and autism. The audit results revealed that most service users had an annual documented medical review and a documented prescription. However, only five (8%) case notes examined had documentation recorded describing the condition of the injection site, and alternation of the injection site was recorded in only 28 (47%) case notes. No case notes examined had written consent to commence treatment recorded. In 57 (95%) of case notes, no documentation of recorded information on the depot and on side effects was given. The failure to monitor and record some blood tests was partly attributed to a lack of clarity regarding whose responsibility it was. A standardized checklist has been developed as a result of the audit and this will be introduced by all teams across the service.

A touch-detecting teaching machine with auditory reinforcement

This teaching machine has been designed and used to train reading and other visual discrimination skills with normal and retarded children. On each frame the subject responds by touching one of three response panels on which are projected the multiple-choice alternatives. The response panels are coated with a transparent conducting film which allows electronic detection of this simple and direct response. Correct responses are reinforced by the machine naming the stimulus, while auditory reinforcement is absent for an incorrect response. The subject's performance level is continuously computed as an exponentially weighted moving average. The measure is weighted so that it rapidly follows recent changes in performance.

Knowledge and attitudes of mental health professionals in Ireland to the concept of recovery in mental health: a questionnaire survey

Recovery is the model of care presently advocated for mental health services internationally. The aim of this study was to examine the knowledge and attitudes of mental health professionals to the concept of recovery in mental health. A descriptive survey approach was adopted, and 153 health care professionals (nurses, doctors, social workers, occupational therapists and psychologists) completed an adapted version of the Recovery Knowledge Inventory. The respondents indicated their positive approach to the adoption of recovery as an approach to care in the delivery of mental health services. However, respondents were less comfortable in encouraging healthy risk taking with service users. This finding is important because therapeutic risk taking and hope are essential aspects in the creation of a care environment that promotes recovery. Respondents were also less familiar with the non-linearity of the recovery process and placed greater emphasis on symptom management and compliance with treatment. Multidisciplinary mental health care teams need to examine their attitudes and approach to a recovery model of care. The challenge for the present and into the future is to strive to equip professionals with the necessary skills in the form of information and training.

Amplification of AML1 in childhood acute lymphoblastic leukemias

Amplification of AML1 has been confirmed by fluorescence in situ hybridization analysis in two cases of childhood acute lymphoblastic leukemia. It remains to be elucidated whether this amplification results in up-regulation of the normal AML1 gene product or a potentially mutant AML1 transcript.

Reducing nosocomial pressure ulcers in an acute care facility

In 1996, a nursing committee at an acute care facility organized the first pressure ulcer point prevalence survey for that hospital. In 1996, hospital-acquired pressure ulcers were 90 percent of the predicted prevalence rate; in 1997, the rate dropped to 59 percent of the predicted prevalence and in 1998, to 53 percent of the predicted prevalence. The severity index decreased markedly from 291 (1996) to 98 (1997) then to 62 (1998). These improvements are attributed to the purposeful addition of multidimensional interventions, including best practices and research-based protocols, to prevent and treat nosocomial pressure ulcers.

Profiles in service (1986-1995). The Foster G. McGaw Prize winners. Copley Hospital, Morrisville, VT and Mount Sinai Hospital, Hartford, CT

For Carolyn Roberts of Copley Hospital, Morristown, VT, the 1987 Foster G. McGaw co-winning hospital, staying ahead of the curve means strengthening a commitment to community service. Meanwhile, after riding out a wave of financial troubles, Mt. Sinai Hospital, Hartford, CT, the other 1987 co-winner, affiliated with its competitor, potentially opening up even greater opportunities for reaching the community.

Cloning and partial characterization of the cDNA encoding the fox sperm protein FSA-Acr.1 with similarities to the SP-10 antigen

We have isolated and characterized a cDNA, cFSA-Acr.1, encoding a testis-specific fox sperm antigen. The antigen is located on the inner acrosomal compartment, and is expressed during spermatogenesis on the developing acrosome of round and elongating spermatids. Database searches with the deduced amino acid sequence of cFSA-Acr.1 revealed that the clone has high homology to both human and baboon sperm protein SP-10, and the mouse sperm protein, MSA-63. The region of highest homology is within the carboxyl terminus. In the middle of the open reading frame, the fox sequence shows unique sequences absent from both the human, baboon SP-10, and mouse MSA-63 sequences. In addition to cFSA-Acr.1, two other clones were also isolated from the same fox testis cDNA library, and sequence analysis shows that they may represent alternatively spliced mRNAs coding for other FSA-Acr proteins.

Cloning and characterization of a fox sperm protein FSA-1

A monoclonal antibody was raised to a fox sperm protein (FSA-1) which was found to be localized to the inner acrosomal compartment of sperm fixed in methanol. Western blots of testicular germ cell membrane extracts probed with this antibody identified a major protein band with a molecular weight of 36,000. Immunofluorescent studies on fox testis sections showed that the antigen is expressed on round and elongating spermatids on a crescent-shaped structure, which probably represents the developing acrosome. An antibody specific for FSA-1 was used to screen a fox testis cDNA library for its cognate gene. An 875-bp cDNA clone was isolated and sequenced revealing an open reading frame. Searches of the GenBank and EMBL databases with the nucleic acid sequence revealed significant homology (86%) of FSA-1 with 406 bases of an unidentified RNA transcript from human fetal brain (EST02625). Northern blot analysis of fox testis RNA samples identified an RNA transcript of approximately 0.9 kb during the months when spermatogenesis is active. Zoo Northern blots (at high stringency) reveal an RNA transcript of a similar size present in testis RNA from dogs and mice. Zoo Southern analysis (high stringency) reveal genomic sequences present in dogs, mice, cattle and sheep. At present, the function of the FSA-1 gene product remains unknown, but it may play a role as a structural protein component of the acrosome.

Cellular events in the lymph node and lung of mice with influenza. Consequences of depleting CD4+ T cells

The cellularity of the mediastinal lymph nodes of mice infected intranasally with a high dose of an H3N2 influenza A virus increases massively within 5 days. All classes of lymphocytes are involved. A similar, but much smaller, expansion in cell numbers occurs after exposure to a comparable dilution of normal chick allantoic fluid. In the control group, this increase in lymph node size is totally prevented by the in vivo depletion of CD4+ T cells whereas there is only a 50% reduction in the virus-infected mice. The lymphocyte component of the cellular exudate in the lungs of infected mice is dominated by activated, CD8+ T cells, which are also prevalent in the mediastinal lymph nodes. Elimination of the CD4+ subset does not greatly diminish the severity of this inflammatory process. The CD4-depleted mice clear the virus from the lung, and there is little effect on the frequency of virus-specific, cytotoxic T lymphocyte precursors in either the lymph node or the lung. Substantial involvement of CD4+ T cells is not essential for the development of effective cell-mediated immunity in mice with influenza.

Cellular events in the lymph node and lung of mice with influenza. Consequences of depleting CD4+ T cells

The cellularity of the mediastinal lymph nodes of mice infected intranasally with a high dose of an H3N2 influenza A virus increases massively within 5 days. All classes of lymphocytes are involved. A similar, but much smaller, expansion in cell numbers occurs after exposure to a comparable dilution of normal chick allantoic fluid. In the control group, this increase in lymph node size is totally prevented by the in vivo depletion of CD4+ T cells whereas there is only a 50% reduction in the virus-infected mice. The lymphocyte component of the cellular exudate in the lungs of infected mice is dominated by activated, CD8+ T cells, which are also prevalent in the mediastinal lymph nodes. Elimination of the CD4+ subset does not greatly diminish the severity of this inflammatory process. The CD4-depleted mice clear the virus from the lung, and there is little effect on the frequency of virus-specific, cytotoxic T lymphocyte precursors in either the lymph node or the lung. Substantial involvement of CD4+ T cells is not essential for the development of effective cell-mediated immunity in mice with influenza.