Pacemaker Lead Placement via Transmural Approach in an Adult With Palliated Single Ventricle Heart Disease

Given the lack of systemic venous return to the heart, palliated single ventricle patients frequently require epicardial pacemaker implantation for management of dysrhythmias including sinus node dysfunction, atrial arrhythmias, and heart block. Repeated device hardware replacement, frequently required due to high lead thresholds or other device failure, is a challenging and significant problem for this population. 3-dimensional imaging can assist in delineating the cardiac anatomy allowing for novel approaches to intervention. We review a patient with extracardiac Fontan circulation who underwent placement of an endocardial atrial pacemaker lead via a transmural approach with a 3D-printed model used for procedural guidance.

The Experiences and Self-Efficacy of Faculty Members Using Distance Learning for the First Time

The purpose of this study was to understand faculty members' experience, self-efficacy, and sense-making processes after teaching via online distance learning for the first time in the Spring, Summer, and Fall 2020 academic terms (i.e., during the COVID-19 pandemic). The research also sought to understand how participants described their teaching and learning methods and approaches after having completed the three academic terms and received students' feedback. This study aimed to use the findings to develop and refine the preparation and procedural guidance offered to first-time distance learning teachers to improve their methods, approaches, and experiences. Using a phenomenological analysis, the researcher collected data from 70 interviews and seven focus groups. The results recommended school leadership to reform their current distance learning-based programs, and to first-time users of distance learning in teaching faculties to help them reflect on their teaching and learning methods and approaches based on a self-efficacy perspective.

On the Effectiveness of the Prosecutors Role in Pre-Trial Proceedings: the Position of the Legislator and the Opinion of the Law Enforcer

The author examines the problems connected with the position of the prosecutor in a criminal process from the standpoint of the effectiveness of the prosecutor’s work. Specifically, using statistical data on the situation with the legality and the quality of preliminary investigations and the results obtained by other Russian scholars who researched this issue, the author shows that the transfer of investigators from the jurisdiction of the prosecutor’s office to a newly created independent Investigation Committee of the Russian Federation, the transfer of the right to the procedural guidance of the investigation from the prosecutor to the head of the investigation body, revoking the prosecutor’s right to coordinate the decision of the investigator, inquirer, or an inquiry body to initiate a criminal case, and in general the right to do it — all of these, in fact, improved the effectiveness of the supervisory function and, consequently, improved the legality and quality of preliminary investigations. At the same time, the author presents his own view on the directions of improving the effectiveness of the role of the prosecutor in the pre-trial proceeding, which should ensure a general sustainable development of Russian criminal procedure legislation.

Reduction in Right Atrial Pressures Is Associated With Hemodynamic Improvements After Transcatheter Edge-to-Edge Repair of the Tricuspid Valve

Background: Investigational transcatheter edge-to-edge repair (TEER) for severe tricuspid regurgitation (TR) has shown promise as an alternative to surgery, but factors influencing outcomes, optimal patient selection, and procedural timing remain incompletely defined. Given the limitations of determining TR severity by conventional echocardiography, our objectives were to determine whether invasive right atrial (RA) pressures performed during the procedure are related to patient outcomes. Methods: This study was a retrospective review of patients who underwent off-label tricuspid TEER using MitraClip (Abbott Vascular, Menlo Park, CA) for significant TR at a single institution. Intraprocedural mean RA pressure, RA peak V-wave, RA pressure nadir, and systolic increase in RA pressure (XV height) were recorded. Results: Thirty-eight patients underwent tricuspid TEER; 33 underwent concomitant mitral TEER for mitral regurgitation. The study cohort was 39% female with a mean age of 78.6±14.3 years. Median follow-up was 339 days (interquartile range, 100–601). Any reduction in mean RA pressure, RA peak V-wave, RA nadir, and XV height occurred in 74%, 82%, 45%, and 87% of patients, respectively. At 1 year, event-free survival was 47%. Postprocedure XV height correlated with TR severity as determined by echocardiography ( P <0.0001). The highest quartile of postprocedure XV height (>8 mm Hg) had worse event-free survival compared with those who had concluding XV height ≤8 mm Hg ( P =0.02). Attainment of a concluding XV height less than or equal to median value was associated with a lower creatinine the next day (1.27±0.47 versus 1.64±0.47 mg/dL, P= 0.04). Conclusions: Intraprocedural XV height correlates with TR severity after tricuspid TEER, and lower concluding pressures are associated with improved outcomes. Analysis of RA pressures may serve as a complementary tool for the evaluation of disease severity and procedural guidance.

The invasive intracoronary imaging assessment of left main coronary artery disease

Left main coronary artery disease is associated with an unfavorable prognosis. Evidence-based decision making regarding the optimal revascularization strategy in patients with left main disease has become a challenge, in view of the recently published data. An improvement in outcomes following left main percutaneous interventions could be achieved by reducing the rate of repeat target lesion revascularization through stent optimization techniques. In the setting of left main disease, procedural guidance by intravascular ultrasound or optical coherence tomography is essential for good long-term results, in such a way that intravascular imaging has gained more of a therapeutic connotation. Besides stent optimization, intracoronary imaging quantifies lesion severity, guides lesion preparation through morphological data, facilitates stent selection through accurate vessel sizing, identifies the landing zones, diagnoses acute vessel wall complications such as stent-related edge dissection or intramural hematoma, and defines procedural success.This review focuses on the two main intracoronary imaging techniques used for diagnostic evaluation and procedural guidance in left main coronary artery disease: intravascular ultrasound and optical coherence tomography. Based on the most recently published data, the review discusses each technique’s advantages and pitfalls, and summarizes their indications.

Applying the Global Change App in Different Instruction Settings to Foster Climate Change Knowledge among Student Teachers

This study focuses on learning with the Global Change app, an interactive tool for fostering climate change knowledge. Numerous studies have contributed to the question on what type of instruction is best to achieve learning gains. The findings are mixed. We applied the app in university courses and investigated which instructional setting a discovery learning approach (no supplementary guidance) or an approach that leans more toward direct instruction is more effective (+ supplementary guidance). Thus, we distinguished between conceptual and procedural guidance within our direct instruction approach. Our study was implemented in a digital learning environment with 110 students participating in the study. We applied a 2 × 2 experimental design with different types of guidance as treatment (conceptual and procedural). An online questionnaire was administered in pretest and posttest to measure climate change knowledge as well as different variables. Our results show that the app provided gains in climate change knowledge in a short period of time regardless of treatment. Further, students who received no supplementary guidance acquired more knowledge about climate change than the groups that received supplemental guidance (either conceptual, procedural, or both). Learning gain correlated significantly negatively with cognitive load across the whole sample, but there were no significant differences between groups. This finding might be interpreted in terms of the renowned expertise reversal effect.

A Blueprint for an Integrated Point-of-Care Ultrasound Curriculum for Nephrology Trainees

Point-of-care ultrasonography (POCUS) is a limited ultrasound study performed by the clinician at bedside as a component or an adjunct to physical examination. POCUS has multiple applications in nephrology practice including evaluation of obstructive uropathy, objective assessment of volume status, arteriovenous access assessment, and procedural guidance. However, unlike specialties such as emergency medicine, POCUS training is not yet integrated into most nephrology fellowship curricula, and the sonographic applications taught vary widely among fellowship programs. In this article, we have used our institutional experience to provide a roadmap or blueprint for nephrology programs looking to create a POCUS program. We provide an overview of the curriculum including the basic organization, applications taught, online resources, milestone development, and quality assessment. We also discuss the nuances of POCUS workflow and perspectives on billing for these limited studies. In addition, we share the evaluation forms and sample documentation we use in our program. Future support, in the form of endorsed nephrology society guidelines, are needed before POCUS training is universally incorporated across nephrology fellowship programs.