Proposing national diagnostic reference levels for electrophysiology studies and catheter ablation procedures in Bulgaria.

INTRODUCTION: The implementation of diagnostic reference levels (DRLs) is an essential tool for optimisation of the routine practice, better management of patient exposure while maintaining sufficient image quality. National DRLs for electrophysiology (EP) procedures are not available in our country. PURPOSE: The main purpose of the study was to propose, for first time in Bulgaria, national DRLs (NDRLs) for EP studies and ablation procedures of two different levels of complexity. The proposed DRLs can be later used to establish NDRLs by the national authority with regulatory functions related to medical exposure. METHOD: A retrospective study was done with the three highest volume Bulgarian EP centers, where over 95% of all cardiac ablations were performed. Data were extracted from the electronic registry for invasive electrophysiology BG-EPHY. Independently of the proposed NDRLs, we also compared the air kerma-area product (KAP) between the participating centers for procedures of the same level of complexity. RESULTS: The proposed NDRL in terms of KAP were: 5.2 Gy.cm2 for diagnostic EP studies, 25.5 Gy.cm2 for simple ablations, and 52.1 Gy.cm2 for complex ablations. There was a significant variation in KAP for procedures with the same degree of complexity within each center. CONCLUSION: This study is the first to propose NDLRs for EP studies and ablation procedures of two levels of complexity in Bulgaria. The results identified EP procedures requiring further optimization of patient protection and provided a basis for future comparisons and standardization with further investigations on the topic. The proposed NDRLs are recommended to be used for better management of radiation exposure during EP procedures of different levels of complexity.

Adult Attachment Representations and Body Image.

In modern literature, the body image is interpreted as a multidimensional construct, which is considered important for both individual development and quality of life. The body image is central to the self-concept and has important consequences for mental functioning. A negative body image can result in adverse psychosocial consequences for both sexes. For a long time in the professional literature the study of socio-cultural factors on the development of the body image has prevailed. This line of research creates social constructivism, in which the earliest attachment relations are eliminated, and instead the idea is suggested that external sources have a direct influence. The present text proposes an approach to the body image as a development construct, arising and developing in the attachment relations, related to the provision of security and protection. Attachment disturbances, as well as attachment disorganization, are defined as the inability to provide security and protection. Attachment relationships in connection with the development of body image develop through the mechanisms of reflection, sensitive responses to the child's signals and synchronous relationships. In the first months of human life, the attachment needs are first and foremost the needs of the body, which are satisfied by the responses of the primary caregiver. The topic of body image discusses attachment disorganization, the understanding of attachment trauma, and the "enactment" of the loss on the body's territory. Trauma always involves loss. Griefs that cannot be mourned and injuries that cannot be represented seem to be central to understanding the body's problematization.

Does cardiac pacing reduce syncopal recurrences in cardioinhibitory vasovagal syncope patients selected with head-up tilt test? Analysis of a 5-year follow-up database.

PURPOSE: Benefit of cardiac pacing in patients with vasovagal syncope (VVS) and cardioinhibitory response to head-up tilt test (HUTT) is still debated. We aimed at retrospectively assessing the long-term effect of cardiac pacing in a cohort routinely followed in our institutions. METHODS AND RESULTS: From a cohort of 1502 patients who performed HUTT between 2008 and 2014, 181 (12%) patients had VASIS 2A (40) or 2B (141) response (median age 43 [interquartile range, 25-56] years, 59% male). Fifty patients (28%) received a dual-chamber pacemaker and 131 (72%) received training on physical maneuvers and medical therapy. The so-called 'Closed Loop Stimulation' (CLS) function was activated for at least 18 months in the pacing group. The 5-year recurrence rate of syncope of paced patients was compared with non-paced patients and with a subgroup of 18 propensity-score matched patients selected among non-paced patients. The 5-year Kaplan-Meier syncope free-rate was 81% (CI, 67%-90%) in the pacing group, 57% (47%-67%; p = 0.004) in the unmatched control group, 53% (27%-74%; p = 0.005) in the 18 propensity-matched patients. The hazard ratio of pacing versus non-pacing was 0.34 (CI, 0.18-0.70) when comparing with the whole non-pacing control group, and 0.25 (CI, 0.09-0.65) including only the propensity-score matched subgroup. No deaths were observed during the follow-up. CONCLUSIONS: In the selected VVS population with HUTT-induced cardioinhibitory response, pacemaker therapy with CLS function was associated to 66% relative and 24% absolute risk reduction of 5-year syncopal recurrence rate. Benefit was confirmed after controlling variables affecting propensity for pacemaker therapy.