Extension Distance Mismatch—An Unrecognized Factor for Suboptimal Side Branch Ostial Coverage in Bifurcation Lesion Stenting

Background: The unsatisfactory side branch (SB) ostial strut coverage remains a problem in coronary bifurcation stenting. Both the surplus and lack of struts at SB ostium may be the causative mechanism. We propose that the inability of available stents to cover the “extension distance” of the bifurcation region is the cause of in‐stent restenosis. Methods: The extension distance (ED) is defined as the maximal distance at the carina tip, which must be covered by the stent struts to ensure optimal coverage of the main branch (MB) and SB openings. A mathematical model was created, representing the key factors that govern geometrical reconfigurations after stent implantation in bifurcations. There are two options—with and without bifurcation region deformation. The theoretical assumptions were tested on a bifurcation model (soft polyvinylchloride polymer tubes) permitting free wall deformations and the following parameters: Parent Vessel, MB, SB diameters of 3.5, 3.0, and 2.5 mm, respectively, with an angle of 45° between the MB and SB. After stenting, final KBI with 3.5 mm and 3.0 mm balloons was performed up to 20 atm. Results: After the carina displacement, the ED, which has to be covered, is considerably smaller if the suboptimal result (DS >50%) at the SB ostium is acceptable. The maximal EDs from the bench test measurements are: Vision, Abbott Vascular – 5.62 mm ± 0.04; Liberte, Boston Scientific Corp. – 5.2 mm ± 0.03; Chopin2, Balton – 4.58 mm ± 0.05; Volo, Invatec – 4.41 mm ± 0.04; Driver, Medtronics – 4.39 mm ± 0.04; BxSonic, Cordis, J&J – 4.48 mm ± 0.05. The theoretical maximal ED of the model is 6.91 mm—28–62% larger than actually observed with different stents. Conclusions: The achievement of perfect ostial coverage of the SB is unsatisfactory with most of the currently available stents, especially when poststenting excessive dilation of the ostium of the SB is performed. (J Interven Cardiol 2010;23:305–318)     

Long-Term Survival of Chosen Atrial-Based Pacing Modalities

Atrial-based cardiac pacing modalities were chosen in 341 of 684 (50%) patients selected for permanent cardiac pacing at the Grey Nuns Community Health Center between 1989 and 1995. There were 183 males and 158 females. Mean age was 70 years (range 8–97 years). The indications for atrial-based pacing were: advanced atri- oventricular (AV) block (n = 166) 49%; sick sinus syndrome (n = 153) 45%; hypersensitive carotid sinus syndrome (n = 11) 3%; neurocardiac syncope (n = 10) 2.9%; and hypertrophic cardiomyopathy (n = 1) 0.3%. Forty-eight patients had a known history of paroxysmal atrial arrhythmias. All patients had routine follow-up performed at 24 hours, 7 days, 6 weeks, 3 months, and then 6 biannuallv. Mean follow-up was 6.5 years (range 1 month to 12 years). Observed survival of the programmed atrial-based modality was compared to the original mode chosen at the time of implantation. Thirty-five of 37 (95%) chosen for AAIR modes remain programmed AAIR. Twenty-two of 24 (92%) chosen for VDDR modes remain programmed VDDR. Two hundred and fifty-five of 280 (91 %) chosen for DDD or DDDR modes remain programmed DDDR. Two of 37 (5%) patients originally implanted with AAI pacing systems were upgraded to DDDR mode due to new onset AV block. One of 24 (4%) patients originally implanted with a VDDR pacing system was upgraded to DDDR due to loss of atrial sensing of the single pass lead. Twenty-six of 304 (8.5%) patients originally implanted with DDD/DDDR (n - 25) and VDDR (n = 1) pacing systems were reprogrammed to VVI or WIR: 16 (62%) due to sustained refractory atrial arrhythmias; 5 (19%) due to atrial lead malfunction; and 5 (19%) due to reasons unrelated to the pacing system. With careful review of the patients' conduction disorder and appropriate selection of pacing modality, the observed survival of long-term atrial-based pacing remains at 92% when compared to the chosen modality at the time of implantation. Atrial-based pacing may be used to reduce the incidence of atrial dysrhythmia with careful programming of the base atrial pacing rates.     

Perspectives of spiritual care for nurse managers

battey b.w. (2012) Journal of Nursing Management  20, 1012–1020
Perspectives of spiritual care for nurse managers Aim The purpose of this article is to explore the current status, perspectives and attitudes of nurse managers, nurses and others toward spiritual care. Background The nursing profession has not defined what is expected of the nurses and some question the need for teaching it in nursing education. The leadership roles of chief executive officers, nursing leaders, chaplains and others are considered. Gallup polls indicate people consider religion very important in their lives, but studies show patients report receiving none or limited care. Evaluation While the spiritual dimension of holistic care is considered essential to healing, its practice has yet to be achieved. Key issues Requirements and criteria are in place through accreditation agencies and professional codes identifying spiritual care as part of the role of nursing, but guidelines for implementing spiritual care are vague and broadly stated. Conclusions If nurse managers implement agency-wide programmes of spiritual care then clear direction can be provided for the nursing staff. Implications for nursing management An agency-wide programme of spiritual care practice for nurses needs to be developed not only to provide evidence for accreditation but also to provide guidelines for nursing staff.