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The Intergovernmental Panel on Climate Change (IPCC) has been criticized for having a limited impact on policy decisions and actions. To enhance the IPCC’s impact, it has been argued that the organ...

Welfare service experiences are known to shape citizens' trust in public institutions and their support of the welfare state. But, there is poor understanding of how this relationship is shaped in systems of mixed provision, that is, welfare states that use public in-house as well as contracted private providers for publically funded services. Drawing on the notion of system trust this article provides a theoretical account of how mixed-provision welfare systems condition the relationship between service experience and trust, affecting the legitimacy of the state. Utilizing a randomized vignette experiment with participants in a general citizen survey in Sweden, we investigate whether it matters for the formation of institutional trust if the welfare service is provided by a public or third-party private provider. The main result show that the spillover of trust from positive service experiences with the provider to trust in public institutions is higher in cases of public service provision. Thus, the possibility of using welfare services to build trust in the welfare system seems to be greater when public provision is used.

Welfare services are an important channel for building institutional trust. But does it matter if the service is publicly or privately provided? Using SEM on individual data from public and private...

Trust is a crucial asset for any society, and the quest to generate and uphold trust is as crucial as ever. Several contemporary societal developments are proposed as being particularly challenging ...

Continued unsustainability and surpassed planetary boundaries require not only scientific and technological advances, but deep and enduring social and cultural changes. The purpose of this article is to contribute a theoretical approach to understand conditions and constraints for societal change towards sustainable development. In order to break with unsustainable norms, habits, practices, and structures, there is a need for learning for transformation, not only adaption. Based on a critical literature review within the field of learning for sustainable development, our approach is a development of the concept of transformative learning, by integrating three additional dimensions—Institutional Structures, Social Practices, and Conflict Perspectives. This approach acknowledges conflicts on macro, meso, and micro levels, as well as structural and cultural constraints. It contends that transformative learning is processual, interactional, long-term, and cumbersome. It takes place within existing institutions and social practices, while also transcending them. The article adopts an interdisciplinary social science perspective that acknowledges the importance of transformative learning in order for communities, organizations, and individuals to be able to deal with global sustainability problems, acknowledging the societal and personal conflicts involved in such transformation.

The aim of this study was to test the validity of battery depletion indicators to forecast end of service (EOS) in dual chamber pulse generators (PG). Two additional approaches for prediction of EOS were evaluated as well: the real-time telemetry of cell impedance and a battery stress test (BST) that used a transitory increase in pacing rate. The study population consisted of 119 patients with Intermedics dual chamber PG models Cosmos II and Relay, in which cell impedance had exceeded 2.5 k omega. The patients were followed in 6-month intervals. If the interrogation of the PG or the BST prompted the appearance of the intensified follow-up indicator (IFI), the next follow-up was scheduled within 2 months. PG replacement was performed on physician's discretion or immediately on appearance of the elective replacement indicator (ERI), regardless of the method of ERI provocation. During a period of 2 years/and 9 months, 33 patients underwent PG replacement. Out of 21 patients with positive ERI indicators, only 5 had positive warning indicators of approaching battery depletion in the preceding follow-up (IFI during BST, n = 4; ERI during BST n = 1). The majority of patients (n = 16, 76%) revealed ERI without prior activation of IFI, neither spontaneous nor during the BST. Four of these 16 ERI-positive patients had cell impedance values far below the ERI limits of the manufacturer. Based on battery depletion indicators, an exact prediction of EOS of dual chamber pacemakers is not possible. Measuring battery impedance allows for a statistical estimation of remaining service life but it may be misleading in the individual case. A BST that is based on a temporary increase of pacing rate is invalid in forecasting battery depletion. As activation of the ERI can trigger an abrupt change to the VVI backup mode, pacemaker dependent patients with low programmed basic pacing rates may be hemodynamically compromised by an unexpected activation of ERI. Close monitoring intervals and PG replacement before appearance of the ERI is recommended in those patients.

UNLABELLED Right atrial septal pacing yields shorter interatrial conduction delays than conventional right atrial pacing at the free wall or the right atrial appendage. However, the hemodynamic effects of right atrial septal pacing are less well known. This study measured the delay between right and left atrial contractions during right atrial septal pacing (n = 21), conventional right atrial pacing (n = 32) and atrial multisite pacing (n = 6) by pulse Doppler echocardiography of transtricuspidal and transmitral blood flow. The effects of right atrial septal pacing (n = 14) versus conventional right atrial pacing (n = 22) on the optimal AV delay during dual chamber pacing was examined in patients with high degree atrioventricular (AV) block. Compared to sinus rhythm, conventional right atrial pacing increased P wave duration from 119 +/- 21 ms to 137 +/- 24 ms (P < 0.001), whereas both right atrial septal pacing (119 +/- 10 ms before, 106 +/- 13 ms during pacing, P = 0.002) and atrial multisite pacing (123 +/- 20 ms before, 112 +/- 11 ms during pacing, P = 0.5) shortened P wave duration. Atrial pacing caused a significant (P < 0.002) prolongation of atrial contraction [corrected] delays from 24 +/- 21 ms to 41 +/- 26 ms during conventional right atrial pacing, and reversed the right-to-left into a left-to-right contraction sequence in 20 of 21 patients during right atrial septal pacing (atrial conduction delay during sinus rhythm: 34 +/- 23 ms vs -37 [corrected] +/- 26 ms during atrial pacing, P < 0.0001). Atrial multisite pacing caused a nonsignificant shortening of the usual right-to-left contraction delay from 22 +/- 34 ms to 11 +/- 18 ms. The optimal left heart AV delay during AV sequential pacing was significantly (P = 0.002) shorter during right atrial septal pacing (108 +/- 38 ms) than during conventional right atrial pacing (152 +/- 33 ms). During conventional right atrial pacing the optimal right heart AV delay was significantly (P = 0.029) shorter than the optimal left heart AV delay. The opposite relation was observed for right atrial septal pacing (P = 0.033). CONCLUSIONS Interatrial septal pacing does not synchronize right and left atrial contractions. It reverses the atrial mechanical timing from a right-to-left to a left-to-right contraction sequence, and requires the setting of shorter AV delays during dual chamber pacing if based on the optimization of left heart timing. Interatrial septal pacing is a technique which allows pacing of the left atrium from a right atrial site, rather than a single site approach to biatrial pacing.

In a prospective study, a low threshold screw-in electrode (Medtronic 5078, group I, n = 9) was compared to a conventional active fixation lead (Biotronik Y60BP, group II, n = 9) to investigate whether lower pacing thresholds really translate into longer projected service life of the pacemaker. The leads were implanted in the atrium and were connected to a dual chamber pacing system which included the same ventricular lead (Medtronic 5024) and the same pulse generator model (Intermedics 294-03) in both groups. Eighteen months after implantation, atrial and ventricular pacing thresholds were measured as the charge delivered per pulse [microC] at 0.5, 1.0, 1.5, 2.0, and 3.5 V, respectively. For chronic output programming in both channels, patients capturing at 0.5 V were set to 1.0 V, those capturing at 1.5 V were permanently programmed to 2.0 V with the double of the charge threshold as the safety margin for pacing ("safety charge"). A combination of atrial and ventricular output settings was optimal, if it resulted in minimum battery current drain (microA] as measured by pacemaker telemetry. In both groups, current consumption [microA] decreased significantly as output amplitude was decreased, exhibiting its lowest value at 1.0 V in either channel. All ventricular leads could be programmed to the optimum output amplitude of 1.0 V in groups 1 and 2. As the 2:1 "safety charge" values were almost identical, the ventricular channel essential contributes the same amount to the battery drain of the pacing system in both groups. In the atrium, all patients of group 1 could be programmed to the optimum output amplitude of 1.0 V with an average pulse duration of 0.42 +/- 0.15 ms. In group 2, however, all patients had to be programmed to 2.0 V with a mean pulse width of 0.52 +/- 0.15 ms. With the atrial and ventricular output being optimized, the average battery drain of the whole pacing system was 12.19 +/- 0.63 microA in group 1 versus 14.42 +/- 0.32 microA in group 2 (P < 0.001). As patients were chronically programmed to these output settings, this difference translates into a clinically relevant gain in projected pacemaker longevity of 17 months or 18.3% (121 +/- 4 vs. 104 +/- 2 months; P < 0.001). Thus, programming a 2:1 safety margin in terms of charge and optimizing the output parameters by real-time telemetry of the battery current is a useful approach to reduce battery current drain. Making the most of modern lead technology with a different performance in only one channel of an otherwise identical DDD pacing system translates into a significant prolongation of projected pacemaker service life which is of great importance with the increasing awareness of health care expenditures. The gain in projected longevity is mainly due to the option of reducing the output amplitude which is still significantly beneficial well below the nominal voltage of the power source.

In patients with sinoatrial disease, unexpected atrial flutter (Af) or fibrillation (AF) is a common problem during implantation of atrial-based pacing systems. As an alternative approach to blind atrial lead placement, lead positioning could be optimized by atrial electrogram mapping. It was the object of this study to evaluate if atrial lead implantation according to this approach and during ongoing arrhythmia is reasonable or if it should be postponed until restoration of sinus rhythm (SR). Twenty-nine consecutive patients (group I) with sick sinus syndrome received a dual-chamber pacemaker during an episode of Af (n = 11) or AF (n = 18). All but two atrial leads were of the screw-in type and had bipolar sensing. Atrial lead position was optimized by mapping the electrogram under fluoroscopy to find locations with high potential amplitudes. The patients were followed for 15.1 +/- 9.8 months, and atrial sensing threshold (AST), atrial pulse width threshold (PWT) at 2.0 V, the pacing mode programmed, and the clinical outcome (OUT) were recorded. The control group consisted of 30 patients (group II) who equally had a history of AF or Af, but were in SR during implantation. The atrial peak-to-peak potential (APEAK) after final lead placement was lower for AF (median value 2.5 mV, lower-upper quartile: 1.7-3.1 mV) as compared to Af (3.8 mV, 2.7-4.9 mV, P < 0.05) and SR (4.1 mV, 3.3-6.2 mV, P < 0.001). There was a correlation (P < 0.01) between APEAK during Af/AF and the postoperative AST immediately after restoration of SR. No lead in any group had to be corrected due to improper sensing in the postoperative course. Median chronic AST was 2.8 mV (2.0-4.0 mV) in group I and 4.0 mV (2.8-4.0 mV) in group II. Median chronic PWT at 2.0 V was 0.15 ms (0.12-0.26 ms) in group I and 0.15 ms (0.09-0.20 ms) in group II. There was no significant difference in chronic AST and PWT between both groups. All but two patients in group I preserved SR as the basic rhythm. A stable SR was observed in 10 of 29 patients, intermittent Af/AF was documented in 17 of 29 patients, seven of whom were asymptomatic. There was no significant difference in OUT between group I and II. Hence, sinus rhythm is not a prerequisite of atrial lead implantation. Mapping the Af or AF waves appears to be useful to guide lead placement and to achieve sufficient sensing and pacing conditions after conversion to sinus rhythm.

Malignant pericardial effusion (MPE) presents as a clinical spectrum that ranges from totally asymptomatic to acute cardiac tamponade. Primary malignancies with a propensity for cardiac involvement include lung cancer, breast cancer, and lymphomas. Echocardiography is one of the most specific and sensitive non-invasive tests in the evaluation of MPE. Pericardiocentesis is both a diagnostic and therapeutic tool in the management of MPE. Several non-specific sclerosing agents are available for instillation into the pericardium to prevent a recurrence of pericardial effusion. Mechanical interventions including different surgical approaches are also highly effective. Ultimately, therapy of MPE must be individualized according to the patient's clinical condition and underlying malignancy. The main goal of therapy is to achieve lasting relief from effusion recurrence as quickly and as safely as possible.

□ Amiodaron ist ein sehr wirksames Antiarrhythmikum zur Unterdruckung ventrikularer und supraventrikularer Tachyarrhythmien. Die wichtigste unerwunschte Wirkung ist die pulmonale Toxizitat. Die den pulmonalen Veranderungen zugrundeliegenden molekularen Mechanismen sind nicht eindeutig geklart. Die Lungenveranderungen konnen sich in verschiedenen Formen prasentieren, beispielsweise als interstitielle Pneumonitis, Fibrose oder organisierende Pneumonie. Die Inzidenz ist bei niedriger Erhaltungsdosis (≤ 300 mg/d) geringer. Es existieren keine eindeutigen Pradiktoren der pulmonalen Toxizitat. Die Diagnose der amiodaroninduzierten Lungenveranderungen ist in der Regel eine Absschlusdiagnose. Die wichtigste Therapiemasnahme besteht im Absetzen des Antiarrhythmikums. Bei schweren Verlaufsformen oder falls das Antiarrhythmikum unverzichtbar ist, wird eine Therapie mit Glukokortikoiden durchgefuhrt.

A logic error in the software of Cosmos II results in apparent malsensing of atrial signals at high rather than low sensitivity settings. The paradoxical function was found in 54 out of 87 units tested (= 62%) if the atrial sensitivity was increased and in 54 out of 87 units tested (= 62%) if the atrial sensitivity was increased and the ventricular refractory period was lengthened beyond critical limits that could be defined individually. The problem inherent in both unipolar (66%) and bipolar systems (54%) is attributed to a summation of a physiological signal and internal noise, which has to be detected at the atrial level within a specific timing window to disable atrial sensing for the next pacing cycle. The malfunction virtually disappears if the ventricular refractory period does not exceed 210 msec. It is recommended, therefore, that Cosmos II pacemakers be left at their nominal ventricular refractory value (200 msec).

SCHWABB, B., et al.: AAIR Versus DDDR Pacing in the Bradycardia Tachycardia Syndrome: A Prospective, Randomized, Double-blind, Crossover Trial. In 19 patients paced and medicated for bradycardia tachycardia syndrome (BTS), AAIR and DDDR pacing were compared with regard to quality of life (QoL), atrial tachyarrhythmia (AFib), exercise tolerance, and left ventricular (LV) function. Patients had a PQ interval ≤ 240 ms during sinus rhythm, no second or third degree AV block, no bundle branch block, or bifascicular block. In DDDR mode, AV delay was optimized using the aortic time velocity integral. After 3 months, QoL was assessed by questionnaires, patients were investigated by 24-hour Holter, cardiopulmonary exercise testing (CPX) was performed, and LV function was determined by echocardiography. QoL was similar in all dimensions, except dizziness, showing a significantly lower prevalence in AAIR mode. The incidence of AFib was 12 episodes in 2 patients with AAIR versus 22 episodes in 7 patients with DDDR pacing (P = 0.072). In AAIR mode, 164 events of second and third degree AV block were detected in 7 patients (37%) with pauses between 1 and 4 seconds. During CPX, exercise duration and work load were higher in AAIR than in DDDR mode (423 ± 127 vs 402 ± 102 s and 103 ± 31 vs 96 ± 27 Watt, P < 0.05). Oxygen consumption (VO2), was similar in both modes. During echocardiography, only deceleration of early diastolic flow velocity and early diastolic closure rate of the anterior mitral valve leaflet were higher in DDD than in AAI pacing (5.16 ± 1.35 vs 3.56 ± 0.95 m/s2 and 69.2 ± 23 vs 54.1 ± 26 mm/s, P < 0.05). As preferred pacing mode, 11 patients chose DDDR, 8 patients chose AAIR. Hence, AAIR and DDDR pacing seem to be equally effective in BTS patients. In view of a considerable rate of high degree AV block during AAIR pacing, DDDR mode should be preferred for safety reasons.

In 120 consecutive patients with standard pacing indications, we tested the feasibility of RV septal lead implantation technique guided by surface ECG and the degree to which this technique reduces paced QRS duration compared to RV apical stimulation when passive-fixation leads are used. During implantation, an ECG was recorded with a paper speed of 100 mm/s using the orthogonal Frank leads, and QRS was measured from the earliest to the latest deflection in any of the Frank leads. Pace-mapping of the septum was performed until QRS was minimal. The lead was attached, where QRS, pacing threshold, lead impedance, and EGM amplitude provided the best compromise. An average of 3.7 +/- 2.5 attempts (range 1-18, median 7) was needed until a final implantation site was found. There were no technical problems during implantation. QRS could be reduced by 5-55 ms (mean delta QRS 19 +/- 11 ms) in 83 (69%) of 120 patients. In 22 (18%) patients, QRS was identical with apical and septal pacing, and in 15 (13%) patients, QRS was 5-20 ms (10 +/- 4) longer despite septal stimulation. Average QRS was significantly shorter during septal pacing compared with apical pacing (151 +/- 20 vs 162 +/- 23 ms, P0.001). There was a tendency towards greatest QRS reduction when the high septum was stimulated (22 +/- 11 ms reduction) as compared with mid- (18 +/- 11 ms) or apical parts of the RV septum (16 +/- 10 ms). QRS reduction was most likely if apical QRS width was170 ms (P = 0.0002), and there was an inverse correlation between apical QRS and delta QRS (r = 0.53, P10(-7)). During a mean follow-up of 14 months, there was no pacing or sensing problem and no lead dislodgment occurred.

In an attempt to evaluate the prevalence and predisposing factors of bipolar ventricular far-field oversensing, 57 patients were studied who had a Medtronic dual chamber pacemaker implanted (models 7940: n = 6; 7960i: n = 41; 401: n = 3; 8968i: n = 7) and bipolar atrial leads with a dipole spacing from 8.6 to 60 mm attached to various parts of the atrial wall (lateral/anterior: n = 30; appendage: n = 10; atrial septum: n = 10; floating: n = 7). Median bipolar sensing threshold for P waves was 4.0 mV (2.8-4.0 mV, lower and upper quartile) with standard leads and 0.35 (0.25-1.4) mV with single pass (VDD) devices. At the highest sensitivity available, 43 of 50 DDD pacemakers but only two of seven VDD systems detected intrinsic R waves in the atrium (P < 0.01). Ventricular far-field oversensing occurred at 0.5 mV in 28 (56%) and at 1.0 mV in 16 of 50 DDD units (32%), respectively, and there was one observation in a septal implant at a sensitivity of even 2.8 mV. With ventricular pacing, VDD systems were as susceptible to far-field signals as DDD pacemakers. Outside the postventricular blanking period (100 ms), evoked R waves were detected by 27 of 57 systems (47%) at maximum atrial sensitivity, by 10 (18%) at 0.5 mV, and by 2 (4%) at a setting of 1.0 up to 1.4 mV, respectively. There was no definite superiority of any lead position, there was a trend in favor of the atrial free wall for better intrinsic R wave rejection, but just the opposite was the case for paced ventricular beats. Bipolar signal discrimination tended to be higher with short tip-to-ring spacing (1 7.8 mm) but the difference to larger dipole lengths (30-60 mm) was not significant in terms of the R to P wave ratio and the overall far-field susceptibility. In summary, bipolar ventricular far-field oversensing in the atrium is common with short postventricular blanking times and high atrial sensitivity settings that may be warranted for tachyarrhythmia detection and mode switching. A potentially more discriminant effect of shorter dipole lengths (< or = 10 mm) remains to be tested.

Steroid-eluting pacing leads are known to attenuate the threshold peaking early after implantation. Long-term performance, however, is not yet settled. The lead design tested in this prospective study combines a 5.8-mm2 tip of microporous platinum-iridium with elution of 1.0 mg of dexamethasone sodium phosphate and tines for passive fixation (model 5024, Medtronic Inc.). In 50 patients (mean age 69 +/- 10 years), the electrode was implanted in the right ventricular apex. Follow-up was performed on days 0, 2, 5, 10, 28, 90, 180 and every 6 months thereafter for 5-years postimplant. At each visit, pacing thresholds were determined as pulse duration (ms) at 1.0 V and as the minimum charge (microC) delivered for capture. Lead impedance (omega) was telemetered at 2.5 V-0.50 ms, and sensing thresholds (mV) were measured in triplicate using the automatic sensing threshold algorithm of the pacemaker implanted (model 294-03, Intermedics Inc.). On the day of implantation, mean values were 0.10 +/- 0.03 ms, 0.12 +/- 0.03 microC, 758 +/- 131 omega, and 13.1 +/- 1.8 mV, respectively. Beyond 1-year postimplant, pacing thresholds did not vary significantly. Sensing thresholds and lead impedance values were stable during long-term follow-up. Five years after implantation, mean values were 0.23 +/- 0.11 ms, 0.24 +/- 0.07 microC, 670 +/- 139 omega, and 11.6 +/- 3.1 mV for pulse width and charge threshold, lead impedance, and sensing threshold, respectively, and all leads captured at 1.0 V with the longest pulse duration available (1.50 ms). It is concluded that the bipolar steroid-eluting tined ventricular lead showed stable stimulation thresholds, lead impedance values, and sensing thresholds for 5 years after implantation.

Paclitaxel is a new antineoplastic agent with activity in lung cancer. This phase I clinical trial was designed to determine the maximum tolerated dose (MTD) of paclitaxel in combination with etoposide in previously untreated patients with non-small cell lung cancer (NSCLC). Doses of paclitaxel were in the range of 150-225 mg/m2 (d1) and of etoposide in the range of 100-120 mg/m2 (d2-4). The drugs were administered by i.v. infusion over 3 h (paclitaxel) and 2 h (etoposide). The patients received four courses at 21-day intervals. Twenty-four patients (six female, 18 male) entered the trial. The characteristics of the patients were as follows: median age 64 (55-73) years; Karnofsky index 80% (70-90%); stage IIIB n = 7, IV n = 17; histology, 14 adenocarcinoma, 10 squamous carcinoma. Hypersensitivity reactions after paclitaxel were not observed. The most relevant toxic effect observed was neutropenia (WHO grade 3-4). Three episodes of febrile neutropenia, two episodes of absolute neutropenia (100/microliter for3 days), and one case of mucositis (WHO gradeor = 3 for7 days) occurred. It can be concluded that the MTD of paclitaxel in combination with etoposide was reached at doses of 200 mg/m2 paclitaxel (d1) and 100 mg/m2 etoposide (d2-4).

Die Resultate der Studien zum Reizschwellenverhalten von Hochohmelektroden, die der Literatur entnommen werden konnen, sind nicht einheitlich und basieren auf kleinen Patientenzahlen (2, 3). Unsere Ergebnisse zeigen, das bei den hier verwendeten Elektrodenmodellen die Stimulationsreizschwellen, die Impedanz und die Wahrnehmungsschwellen uber einen Beobachtungszeitraum von 3 Jahren stabil waren. Lediglich bei einem Patienten mit dem bipolaren Elektrodenmodell kam es bei stabiler Wahrnehmung zu einem sprunghaften Anstieg der Impedanz und der Stimulationsreizschwelle 2 Jahre nach der Implantation.

Eine zuverlassige Planung des Betriebszeitendes von Zweikammer-Schrittmachern auf der Basis von Austauschindikatoren ist nicht moglich. Auch der vorgestellte Batteriestresstest erwies sich als invalide in der Prognose des Austauschzeitpunktes. Die Batterieimpedanz erlaubt eine grobe Abschatzung der verbliebenen Betriebszeit. Ihre grose Schwankungsbreite zum ERI-Zeitpunkt erschwert jedoch die Interpretation im Einzelfall. Um hamodynamische Probleme bei Umschaltung in den VVI-backup-Modus zu vermeiden, empfiehlt sich am Betriebszeitende vor allem bei schrittmacherabhangigen Patienten eine engmaschige Kontrolle der Batteriekenndaten und in Abhangigkeit davon ein Austausch noch vor Erreichen eines Indikators.

Mit Hilfe der VO2, die wahrend einer Spiroergometrie einfach gemessen werden kann, ist es moglich, das Verhalten des HMV wahrend korperlicher Belastung zu beurteilen. Wenn bei ansteigender Belastungsintensitat und zunehmender Stimulationsfrequenz VO2 in ein Plateau ubergeht, dann spricht diese Kinetik fur ein stagnierendes HMV.

Durch eine patientenindividuelle Programmierung, bei der die Anzahl der stimulierten Herzzyklen und die abgegebene Stimulationsenergie niedrig gehalten wird, kann die Betriebszeit von Schrittmachern erheblich uber die Nominalbetriebszeit hinaus verlangert werden. Mit den Intermedics-Zweikammer-Aggregaten Cosmos I, II und Relay wird unter Praxisbedingungen eine mediane Batterielebensdauer von 8,0 Jahren erzielt. Mindestens 21% der Patienten versterben, bevor der Schrittmacher seine Laufzeitgrenze erreicht. Auch unter Berucksichtigung der Patientenmortalitat und vorzeitiger Aggregatwechsel (7,7%) infolge von Komplikationen oder Defekten nutzt die Mehrzahl der Patienten die Batteriekapazitat des Schrittmachers aus und profitiert damit von einer Reduktion erforderlicher Reoperationen. Sind Aggregatwechsel erforderlich, besteht nur in einem marginalen Anteil (7%) die Indikation zum Downgrading auf ein VVI-System.