Optimal Site for Proximal Optimization Technique in Complex Coronary Bifurcation Stenting: A Computational Fluid Dynamics Study

Background/purpose: The optimal position of the balloon distal radio-opaque marker during the post optimization technique (POT) remains debated. We analyzed three potential different balloon positions for the final POT in two different two-stenting techniques, to compare the hemodynamic effects in terms of wall shear stress (WSS) in patients with complex left main (LM) coronary bifurcation. Methods/materials: We reconstructed the patient-specific coronary bifurcation anatomy using the coronary computed tomography angiography (CCTA) data of 8 consecutive patients (6 males, mean age 68.2± 18.6 years) affected by complex LM bifurcation disease. Subsequently a virtual bench test was performed in each patient using two different double stenting techniques represented by the DK and Nano crush using the reconstruction of Orsiro stents (Biotronik IC, Bulack, Switzerland). Results: A significant reduction in the mean WSS values in all the lesion's sites was observed when the final POT was performed 1 mm distally the carina cut plane in both techniques. Moreover, a significant improvement in the mean WSS values of the entire SB (e.g. LCX) was obtained performing the POT 1 mm distally to the carina cut plane. The proximal POT resulted in larger area of lower WSS values at the carina using both the Nano crush and the DK crush techniques. Conclusions: In patients with complex LM bifurcation disease the use of a final POT performed 1 mm distally to the carina cut plane might results in more favorable WSS patterns (i.e. higher WSS values) along all stented segments and, especially, along the entire LCX lesions

Biomechanical Evaluation of Different Balloon Positions for Proximal Optimization Technique in Left Main Bifurcation Stenting

Background: Proximal optimization technique (POT) is a key step during left main (LM) bifurcation stenting. However, after crossover stenting, the ideal position of POT balloon is unclear. We sought to evaluate the biomechanical impact of different POT balloon positions during LM cross-over stenting procedure. Methods: We reconstructed the patient-specific LM bifurcation anatomy, using coronary computed tomography angiography data of 5 consecutive patients (3 males, mean age 66.3 ± 21.6 years) with complex LM bifurcation disease, defined as Medina 1,1,1, evaluated between 1st January 2018 to 1st June 2018 at our center. Finite element analyses were carried out to virtually perform the stenting procedure. POT was virtually performed in a mid (marker just at the carina cut plane), proximal (distal marker 1 mm before the carina) and distal (distal marker 1 mm after the carina) position in each investigated case. Final left circumflex obstruction (SBO%), strut malapposition, elliptical ratio and stent malapposition were evaluated. Results: The use of both proximal and distal POT resulted in a smaller LM diameter compared to the mid POT. SBO was significantly higher in both proximal and distal configurations compared to mid POT: 38.3 ± 5.1 and 29.3 ± 3.1 versus 18.3 ± 3.6%, respectively. Similarly stent malapposition was higher in both proximal and distal configurations compared to mid POT: 1.3 ± 0.4 and 0.82 ± 1.8 versus 0.78 ± 1.2, respectively. Conclusions: Mid POT offers the best results in terms of LCx opening maintaining slightly smaller but still acceptable LM and LAD diameters compared to alternative POT configuration

YP10-03 Cross-cultural psychiatry, liaison psychiatry and other major challenges for modern psychiatrists

Beyond the awareness that psychiatry and contemporary medicine have undergone a dramatic change in recent years, walking the first steps as recently-qualified consultants in psychiatry is a major challenge. As a consequence of changes in society, technological progress and restricted funding availability, modern psychiatrists have to face problems that are new, and difficult to be faced, but also representing an opportunity to grow and contribute massively to medicine.This is particularly true in two specific fields, cross-cultural psychiatry and consultation-liaison psychiatry. The former is defined as psychiatry of disorders influenced by the cultural background; the latter is defined as the care of psychiatric disturbances in the medically ill. Though generic, these definitions highlight what is challenging in these branches of psychiatry: the disposition towards an inter-disciplinary approach to human illnesses. Both deepen their roots in the bio-psycho-social paradigm of George Engel and were in fact frequently mentioned in Engel's writings as the future of psychiatry. Training and clinical experience in cross-cultural and consultation-liaison psychiatry are to be major components of the curriculum of psychiatric trainees.Therefore, the role of psychiatrists and psychiatrists-to-be in the contemporary scientific community and society must be a strong one: on the side of scientific knowledge, by marking the complex, systemic nature of physiopathology and therapy; on the side of epistemology, by marking the paradoxes of bio-medicine; on the side of organization of health care, by promoting the need for a person-oriented approach to illness; and finally on the side of culture, society and ethics

Selectra 3D- guided conduction system pacing: single-center experience

Abstract Background Conduction system pacing (CSP)is becoming increasingly popular thanks to the ability to both maintain physiological electrical activation in patients with narrow QRS and restore ventricular synchrony in patients with bundle branch block (BBB). The Selectra3D introducer is a new tool able to support the correct positioning and screwing of the catheter on the bundle of His (HBP) or on the left branch (LBBP). It does exist in 3 different shapes: S, M, L (Fig. 1) based on the radius of main curvature. The internal diameter of 7.3 Fr allows it to support both the 3830 lumen-less catheter historically used for CSP, as well as standard 6Fr stylet-driven leads. Objective To evaluate the effectiveness of the Selectra3D introducer for CSP (including both HBP and LBBP), considering the procedural success rate and the lead stability (stability of electrical parameters or need for implant revision) in the medium-term follow-up. Methods and results The Selectra3D introducer was used in 56 patients' candidates for CSP (mean age 80±6 years). Pacing indications included A-V block in 21 patients, AF with slow ventricular response in 9 patients; SND in 8 patients and HF and severe ventricular dysfunction in 18 patients (of which 4 were PICM). The mean baseline EF was 40±15%. A PM was implanted in 40 patients and an ICD in 16. A standard stylet-driven lead was used in 48 cases, a fixed exposed screw lead was used in 8 patients. HBP was obtained in 21 cases and LBBP in 30 cases, while in 5 cases (8.9%) neither HBP nor LBBP could be obtained. Implants were performed via a left-sided approach in 55 cases and a right-sided approach in 1 case. The baseline QRS duration was 144±38 ms and the paced QRS duration was 118±21 ms. The electrical parameters were optimal with sensing 8.7±8 mV; impedance 625±276 ohm; threshold 1±0.5 V. During follow-up, 2 lead dislodgement (3.9%) (1 HBP and 1 LBBP) were recorded, both within 7 days after implantation. All the others showed stability of the electrical parameters at a mean follow-up of 8.4±4.2 months. Conclusions The new Selectra3D introducer supports effectively and safely the lead implant on conduction system catheters (HBP and LBBP), allowing the implant of both exposed fixed screw leads and standard stylet-driven leads, leading to procedural success>90%. The electrical parameters were optimal at implantation and remained stable during follow-up. Funding Acknowledgement Type of funding sources: None. Figure

Effectiveness and acceptability of psycho-education group intervention for people hospitalized in psychiatric wards and nurses

Objective: To assess effectiveness and acceptability of a Psycho-education Group Intervention (PGI) on a sample of patients admitted to a Psychiatric Inpatient Unit (PIU) and on ward nurses. Methods: Case-control study. PGI was delivered according to the model of Vendittelli and colleagues (2008). Male and female patients aged 18-70 were eligible. Cases attended the PGI, while controls did not. A 5-item ad hoc Likert-scale was used to record ward atmosphere. The Italian version of the Simple Feedback Question Form for people attending Cognitive Behaviour Therapy Group (SFQF-CBTG) was administered to each patient before discharge. The primary outcome was readmission rate after 6 months from discharge, secondary outcomes were ratings of ward atmosphere by nurses and feed-back from people hospitalized. All Statistics were performed with STATA 13.1. Results: Fifty-two patients were enrolled, 17 cases and 35 controls. No significant differences emerged in the primary outcome, though compulsory readmissions were noticeable only among controls. Ratings of ward atmosphere in relation to group activities did not differ. Seventeen SFQF-CBTG were filled in. Most cases reported at discharge to have found the group "helpful", stating that "they would attend it in the future again", and "group topics were not difficult". Conclusions: No evidence emerged in favour or against effectiveness of the PGI for patients and ward nurses, though the intervention was rated as acceptable and feasible

Migrant pathways to community mental health centres in Italy.

Background: Many studies indicate that migrants in western countries have limited access to and low utilization of community mental health centres (CMHCs) despite the high prevalence of mental disorders. Aims: We aimed to compare migrant pathways to care across four CMHCs located in different Italian provinces and to identify pathway to care predictors. Methods: Migrants attending the four CMHCs between 1 July 1999 and 31 December 2007 were included in the study. Data were gathered retrospectively from clinical data sets and chart review. Results: Five hundred and eleven (511) migrants attended the four CMHCs, 61% were referred by GPs or other health services and 39% followed non-medical pathways to care (self-referral or through social and voluntary organizations), with important site variations. Younger age and being married were predictors of medical pathways to care; lacking a residence permit and having a diagnosis of substance abuse were related to non-medical pathways. Conclusions: Pathways to CMHCs are complex and influenced by many factors. Non-medical pathways to care seem to be frequent among migrants in Italy. More attention should be paid to developing psychiatric consultation liaison models that also encompass the social services and voluntary organizations

Migrant pathways to community mental health centres in Italy.

Background: Many studies indicate that migrants in western countries have limited access to and low utilization of community mental health centres (CMHCs) despite the high prevalence of mental disorders. Aims: We aimed to compare migrant pathways to care across four CMHCs located in different Italian provinces and to identify pathway to care predictors. Methods: Migrants attending the four CMHCs between 1 July 1999 and 31 December 2007 were included in the study. Data were gathered retrospectively from clinical data sets and chart review. Results: Five hundred and eleven (511) migrants attended the four CMHCs, 61% were referred by GPs or other health services and 39% followed non-medical pathways to care (self-referral or through social and voluntary organizations), with important site variations. Younger age and being married were predictors of medical pathways to care; lacking a residence permit and having a diagnosis of substance abuse were related to non-medical pathways. Conclusions: Pathways to CMHCs are complex and influenced by many factors. Non-medical pathways to care seem to be frequent among migrants in Italy. More attention should be paid to developing psychiatric consultation liaison models that also encompass the social services and voluntary organizations

Mental disturbances and perceived complexity of nursing care in medical inpatients: results from a European study

AIMS AND OBJECTIVES: The relationship between mental disturbances - anxiety and depression, somatization and alcohol abuse - on admission to internal medicine units and perceived complexity of care as indicated by the nurse at discharge was studied. The goal was to study the utility of short screeners for mental disturbances to select patients for case-management on admission. DESIGN: The study had a cohort design: patients were included on admission and followed through their hospital stay until discharge. The study was conducted within the framework of the European Biomed 1 Risk Factor study. RESEARCH METHODS AND INSTRUMENTS: In the first 3 days of admission the patients were interviewed by a trained health care professional, who scored the SCL-8D, a somatization questionnaire based on the Whiteley-7 and the CAGE. At discharge, nurses rated the complexity of the patient's care. RESULTS: Patients with high scores on anxiety and depression (SCL-8D) and on somatization received higher ratings on perceived nursing complexity than those with low scores, with and without control for age, severity of illness and chronicity. The actual nursing intensity and medical care utilization, as measured daily by means of a checklist, could not explain these relations. No differences were found between patients with high or low scores on alcohol abuse. CONCLUSIONS: The study shows a potential use of screeners for mental disturbances to detect patients for whom nurses might need additional help. However, mental disturbance is not the sole criterion: functional status and other variables that predict medical and nursing care utilization should be included in a screening strategy for case-management programme

A brief diagnostic screening instrument for mental disturbances in general medical wards

OBJECTIVE: Mental illness is prevalent among general hospital ward patients but often goes unrecognised. The aim of this study was to validate the SCL-8d as a brief questionnaire for mental disturbances for use in general hospitals. METHODS: The study included 2040 patients, 18 years or older, consecutively admitted to 11 general internal medicine wards in seven European countries. All patients were screened on admission by means of the SCL-8d questionnaire. The psychometric performance (i.e., the internal validity) of the SCL-8d scale was tested using modern item response theory (IRT) in the form of the Rasch model. RESULTS: Differences between sample characteristics were considerable. Even so, the SCL-8d scale showed a remarkable, statistically significant fit in terms of internal homogeneity (P>.01) in all individual settings, except in Spain and Germany where the item "Everything is an effort" had to be excluded to obtain a fit. When pooling data from all centres, an excellent statistical significance of fit (P>.05) was obtained by exclusion of the "Effort" item. The scale was homogeneous as to gender (P>.05), but not age as it performed better among young patients than among patients older than 60 years (P<.01). In these two patient groups both internal and external homogeneity (gender, median age) was achieved. The SCL-8d sum score showed a marked correlation with current and previous treatment for mental illness. CONCLUSION: Apart from the "Effort" item ranking differently on the latent severity dimension as to age, the SCL-8d seems very robust from a psychometric point of view. Besides being short, the SCL-8d scale contains only emotional symptoms. It would therefore seem to be an excellent diagnostic tool for use in medical settings