Radiation dose optimisation for conventional imaging in infants and newborns using automatic dose management software: an application of the new 2013/59 EURATOM directive.

Objective: The new 2013/59 EURATOM Directive (ED) demands dosimetric optimisation procedures without undue delay. The aim of this study was to optimise paediatric conventional radiology examinations applying the ED without compromising the clinical diagnosis. METHODS: Automatic dose management software (ADMS) was used to analyse 2678 studies of children from birth to 5 years of age, obtaining local diagnostic reference levels (DRLs) in terms of entrance surface air kerma. Given local DRL for infants and chest examinations exceeded the European Commission (EC) DRL, an optimisation was performed decreasing the kVp and applying the automatic control exposure. To assess the image quality, an analysis of high-contrast resolution (HCSR), signal-to-noise ratio (SNR) and figure of merit (FOM) was performed, as well as a blind test based on the generalised estimating equations method. RESULTS: For newborns and chest examinations, the local DRL exceeded the EC DRL by 113%. After the optimisation, a reduction of 54% was obtained. No significant differences were found in the image quality blind test. A decrease in SNR (-37%) and HCSR (-68%), and an increase in FOM (42%), was observed. CONCLUSION: ADMS allows the fast calculation of local DRLs and the performance of optimisation procedures in babies without delay. However, physical and clinical analyses of image quality remain to be needed to ensure the diagnostic integrity after the optimisation process. Advances in knowledge: ADMS are useful to detect radiation protection problems and to perform optimisation procedures in paediatric conventional imaging without undue delay, as ED requires.

[The role of fetal magnetic resonance imaging in the study of congenital diaphragmatic hernia]. / El papel de la resonancia magnética fetal en el estudio de la hernia diafragmática congénita.

INTRODUCTION AND OBJECTIVES: Different echographic and fetal magnetic resonance (MRI) measurements have been described in the diagnosis of associated malformations and the prognosis of congenital diaphragmatic hernia (CDH). We have reviewed our experience searching for useful isolated or combined parameters and how MRI can complement ultrasound. MATERIAL AND METHODS: We evaluated 29 fetuses with CDH. We examined ultrasonography: Lung to Head (LHR o/e) and in MRI: ipsilateral lung volume (IPV) and total expressed as percentage of observed / expected lung volume (VPT o/e) and percentage of herniated liver (PHH). We studied: survival, ECMO and associated malformations. RESULTS: LHR o/e was the measure that best predicted survival (p< 0.05). VPT o/e did not predict survival or the need of ECMO (p> 0.05). PHH ≥19% was related to the need of ECMO. IPV < 2 cc required ECMO more frequently (p< 0.018) and when it was 0 cc in all cases. No combination of MR measurements was superior to LHR o/e in prediction of survival. MRI complemented the ultrasound in 4 cases: diaphragmatic eventration diagnosed with HDC, right HDC with fluid in the sac that suggested thoracic cyst, differentiation between spleen and lung that measured together overestimated the LHR and/or suspicion of Cornelia de Lange due to facial malformations. CONCLUSIONS: Not a single or combined MRI measurement exceeds LHR o/e in survival prediction. MRI is related to prognosis and can be used to support ultrasound in making decisions. MRI occasionally provides complementary morphological information.

INTRODUCCION Y OBJETIVOS: Distintas medidas ecográficas y de resonancia magnética fetal (RM) han sido descritas en el diagnóstico de malformaciones asociadas y el pronóstico de la hernia diafragmática congénita (HDC). Hemos revisado nuestra experiencia buscando parámetros aislados o combinados útiles y cómo la RM puede complementar a la ecografía. MATERIAL Y METODOS: Evaluamos 29 fetos con HDC. Revisamos en ecografía: Lung to Head Ratio observado/esperado (LHR o/e) y en RM: volumen pulmonar ipsilateral (VPI) y total expresado como porcentaje del volumen pulmonar observado/esperado (VPT o/e) y porcentaje de hígado herniado (PHH). Estudiamos: supervivencia, oxigenación con membrana extracorpórea (ECMO) y malformaciones asociadas. RESULTADOS: El LHR o/e fue la medida que mejor predijo supervivencia (p< 0,05). El VPT o/e no predijo supervivencia ni la necesidad de ECMO (p> 0,05). El PHH ≥19% se relacionó con necesidad de ECMO. El VPI menor de 2 cc requirió ECMO más frecuentemente (p< 0,018) y cuando fue de 0 cc en todos los casos. Ninguna combinación de medidas de RM fue superior al LHR o/e en predicción de supervivencia. La RM complementó a la ecografía en 4 casos: eventración diafragmática diagnosticada como HDC, HDC derecha con líquido en el saco que sugería quiste torácico, diferenciación entre bazo y pulmón que medidos juntos sobreestimaba el LHR o/e y sospecha de síndrome de Cornelia de Lange por malformaciones faciales. CONCLUSIONES: Ninguna medida aislada o combinada de RM supera al LHR o/e en la predicción de supervivencia. La RM se relaciona con el pronóstico y puede usarse como apoyo de la ecografía en la toma de decisiones. La RM aporta ocasionalmente información morfológica complementaria.

Toxic concentrations in fish early life stages peak at a critical moment.

During the development of an embryo into a juvenile, the physiology and behavior of a fish change greatly, affecting exposure to and uptake of environmental pollutants. Based on experimental data with sole (Solea solea), an existing bioaccumulation model was adapted and validated to calculate the development of concentrations of persistent organic pollutants in the tissue of developing fish. Simulation revealed that toxic tissue concentrations of pollutants with log octanol-water partition ratio (K(OW)) > 5 peak at the moment when the larvae become free-feeding, when the lipid reserves are depleted. This may explain the delayed effects observed in fish early-life-stage experiments with exposed eggs. In the field, eggs can be exposed through maternal transfer to adult pollutant tissue concentrations, which will increase in the larva to peak tissue concentrations, exceeding those of the adult fish. The results demonstrate the risk of underestimating the effects of lipophilic persistent organic pollutants with log K(OW) > 5 in short-term, early-life-stage fish tests and underscore the importance of maternal transfer as an exposure route in the field situation.

Utilidad de la terapia intracoronaria con células progenitoras en pacientes con miocardiopatía dilatada: ¿puente o alternativa al trasplante cardiaco? / Usefulness of intracoronary therapy with progenitor cells in patients with dilated cardiomyopathy: Bridge or alternative to heart transplantation?

Introducción y objetivos: Recientemente, algunas publicaciones pediátricas han planteado la utilidad de la terapia intracoronaria con células progenitoras autólogas (CPA) derivadas de la médula ósea en niños con miocardiopatía dilatada (MCD) e insuficiencia cardiaca. Describimos la utilidad de este tratamiento en dos lactantes con MCD e insuficiencia cardiaca grave, que habían sido trasladados a nuestro centro para valoración de trasplante cardiaco. Pacientes y métodos: El primer paciente es un varón de 3 meses de edad y 4 kg de peso. El segundo es un varón de 4 meses de edad y 5 kg de peso. En el momento del ingreso, ambos presentan mala situación clínica (NYHA IV), dilatación y disfunción sistólica grave (fracción de eyección [FE] <30%) del ventrículo izquierdo y marcada elevación de NT-pro BNP, precisando tratamiento con ventilación mecánica e inotrópicos en perfusión IV. Tras movilización con G-CSF durante 4 días, las CPA se obtienen desde la sangre periférica mediante leucocitoaféresis. Se administran por vía intracoronaria, con catéter-balón y técnica de stop-flow, 6,15 x 106 célulasCD34-positivas/kg en el primer paciente, y 10,55 x 106 células CD34-positivas/kg en el segundo. Resultados: Ya en la primera semana tras el procedimiento, la situación clínica de los pacientes mejora significativamente y en la ecocardiografía se objetiva una disminución importante de la dilatación del ventrículo izquierdo. Un mes después, también se evidencia mejoría importante en la FE (>40%) y de los niveles de NT-pro BNP, que se mantiene en el tiempo posteriormente. No obstante, en el primer paciente, a los cuatro meses del tratamiento, el ventrículo izquierdo se dilata de nuevo y empeora discretamente su función, aunque sin existir repercusión clínica significativa. Conclusiones: La terapia intracoronaria con CPA puede suponer una alternativa terapéutica en niños, especialmente de corta edad, con MCD y fallo cardiaco, pudiendo disminuir la mortalidad en lista, mejorar su situación clínica y ofrecer mayor tiempo de espera para recibir un órgano idóneo o, incluso, hacer innecesario el trasplante(AU)

Introduction and objectives: Some paediatric publications have recently raised the value of intracoronary therapy with autologous bone marrow-derived progenitor cells (APCs) in children with dilated cardiomyopathy (DCM) and heart failure. We describe the usefulness of this treatmen tin two infants with severe DCM and heart failure, who had been transferred to our hospital for cardiac transplant evaluation. Patients and methods: The first patient was a 3 months old male weighing 4 kg. The second was a 4 months old male weighing 5 kg. At the time of admission, both were in poor clinical condition (NYHA IV), with severe dilation and systolic dysfunction (ejection fraction [EF] <30%)of the left ventricle and marked elevation of NT-pro BNP, requiring treatment with mechanical ventilation and inotropic iv infusion. After mobilization with G-CSF for 4 days, APCs were obtained from peripheral blood by leukocytapheresis, administering them by a slow intracoronary bolus injection using a stop-flow technique (6.15x106 CD34-positive cells/Kg in the first patient, and 10.55x106 CD34-positive cells/Kg in the second). Results: Since the first week after the procedure, clinical status of patients improved and echocardiography showed a decrease in left ventricular dilation. A month later, there was a significant improvement in EF (> 40%) and NT-pro BNP levels, subsequently maintained throughout the follow-up. However, four months later in the first patient, the left ventricle dilated again and its function slightly worsened, but without any significant impact in his clinical status. Conclusions: Intracoronary therapy with APCs can be an alternative in children, especially infants, with DCM and heart failure. It can reduce the waiting list mortality, improve clinical status and provide more time on the waiting list to receive a suitable organ, or even to make transplantation unnecessary (AU)

[Usefulness of intracoronary therapy with progenitor cells in patients with dilated cardiomyopathy: Bridge or alternative to heart transplantation?]. / Utilidad de la terapia intracoronaria con células progenitoras en pacientes con miocardiopatía dilatada: ¿puente o alternativa al trasplante cardiaco?

INTRODUCTION AND OBJECTIVES: Some paediatric publications have recently raised the value of intracoronary therapy with autologous bone marrow-derived progenitor cells (APCs) in children with dilated cardiomyopathy (DCM) and heart failure. We describe the usefulness of this treatment in two infants with severe DCM and heart failure, who had been transferred to our hospital for cardiac transplant evaluation. PATIENTS AND METHODS: The first patient was a 3 months old male weighing 4 kg. The second was a 4 months old male weighing 5 kg. At the time of admission, both were in poor clinical condition (NYHA IV), with severe dilation and systolic dysfunction (ejection fraction [EF]<30%) of the left ventricle and marked elevation of NT-proBNP, requiring treatment with mechanical ventilation and inotropic iv infusion. After mobilization with G-CSF for 4 days, APCs were obtained from peripheral blood by leukocytapheresis, administering them by a slow intracoronary bolus injection using a stop-flow technique (6.15x106 CD34-positive cells/Kg in the first patient, and 10.55x106 CD34-positive cells/Kg in the second). RESULTS: Since the first week after the procedure, clinical status of patients improved and echocardiography showed a decrease in left ventricular dilation. A month later, there was a significant improvement in EF (> 40%) and NT-proBNP levels, subsequently maintained throughout the follow-up. However, four months later in the first patient, the left ventricle dilated again and its function slightly worsened, but without any significant impact in his clinical status. CONCLUSIONS: Intracoronary therapy with APCs can be an alternative in children, especially infants, with DCM and heart failure. It can reduce the waiting list mortality, improve clinical status and provide more time on the waiting list to receive a suitable organ, or even to make transplantation unnecessary.

Respuesta de los servicios de radiodiagnóstico ante ataques terroristas con múltiples víctimas / Diagnostic imaging departments responses to terrorist attempts with multiple victims

Objetivos Analizar si el manejo radiológico de las víctimas graves del 11M estuvo condicionado por su elevado número en 2 hospitales de Madrid. Valorar la organización, detectar fallos y proponer un protocolo de actuación desde los servicios de radiodiagnóstico. Material y métodosal hospital A llegaron 251 pacientes y al B 36. Ambos cuentan con áreas de radiología de urgencias y con protocolos para la atención a politraumatizados. Se comparan: aspectos organizativos (clasificación, identificación), recursos materiales, humanos, asistenciales (número y tipo de exploraciones) así como el manejo radiológico inicial, con el protocolo habitual y con las recomendaciones para incidentes con múltiples victimas. Resultadoslos pacientes fueron clasificados en graves (175) y leves (76) en el hospital A y en muy graves (13), graves (4) y leves (19) en el B. En ambos se reforzó el personal de radiología de urgencias. En el hospital A se practicaron 62 radiografías portátiles, 39 ecografías, 25 tomografías computarizadas (TC) craneales, 6 cervicales, 2 torácicas y 2 abdominopélvicas. En el hospital B se efectuaron 19 radiografías portátiles (74 en total), 9 ecografías y 17 TC cráneo-toraco-abdomino-pélvicas, 2 cervicales, 2 orbitarias y 2 de senos. Conclusiónen ambos hospitales cada víctima se manejó como si hubiera sido única. Las discrepancias entre ambos (porcentaje de TC) se debieron a diferencias en el protocolo habitual para politraumatizados. Reconocidos los errores organizativos se propone un plan de actuación sustentado en la correcta identificación y activación progresiva de recursos materiales y humanos hasta alcanzar los efectivos suficientes (AU)

Objectives To analyze whether the radiological management of seriously injured victims from the March 11 terrorist attempt was affected by the large number of victims treated at two hospitals in Madrid. To evaluate the organization for providing imaging services, detect failings, and propose a protocol for diagnostic imaging departments. Material and methodsTwo hundred and fifty one patients arrived at hospital A and 36 at hospital B. Both centers have emergency imaging areas and protocols for the treatment of patients with multiple trauma. We compared organizational aspects (classification, identification), material resources, human resources, healthcare resources (number and type of examinations), as well as the initial radiological management with the usual protocol and with the recommendations for incidents with multiple victims. ResultsIn hospital A, patients injuries were classified as severe (175) or minor (76); in hospital B, injuries were classified as extremely severe (13), severe (4), or minor (19). Additional staff were assigned to the emergency imaging areas in both hospitals. In hospital A, 62 portable plain-film radiographs, 39 ultrasonographic examinations, 25 cranial CT examinations, 6 cervical CT examinations, 2 chest CT examinations, and 2 abdominopelvic CT examinations were performed. In hospital B, 19 portable plain-film radiographs (74 in total), 9 ultrasonographic examinations, 17 cranial-chest-abdominopelvic CT examinations, 2 cervical CT examinations, 2 orbital CT examinations, and 2 CT examinations of the sinuses were performed. Conclusion: In both hospitals, each victim was managed as if he or she were the only patient. The discrepancies between the two hospitals were due to differences in the usual protocol for multiple trauma patients. In light of the organizational errors discovered, we propose a plan of action based on the identification and progressive activation of material and human resources until sufficient levels are achieved (AU)

[Diagnostic imaging departments' responses to terrorist attempts with multiple victims.]. / Respuesta de los servicios de radiodiagnóstico ante ataques terroristas con múltiples víctimas.

OBJECTIVES: To analyze whether the radiological management of seriously injured victims from the March 11 terrorist attempt was affected by the large number of victims treated at two hospitals in Madrid. To evaluate the organization for providing imaging services, detect failings, and propose a protocol for diagnostic imaging departments. MATERIAL AND METHODS: Two hundred and fifty one patients arrived at hospital A and 36 at hospital B. Both centers have emergency imaging areas and protocols for the treatment of patients with multiple trauma. We compared organizational aspects (classification, identification), material resources, human resources, healthcare resources (number and type of examinations), as well as the initial radiological management with the usual protocol and with the recommendations for incidents with multiple victims. RESULTS: In hospital A, patients' injuries were classified as severe (175) or minor (76); in hospital B, injuries were classified as extremely severe (13), severe (4), or minor (19). Additional staff were assigned to the emergency imaging areas in both hospitals. In hospital A, 62 portable plain-film radiographs, 39 ultrasonographic examinations, 25 cranial CT examinations, 6 cervical CT examinations, 2 chest CT examinations, and 2 abdominopelvic CT examinations were performed. In hospital B, 19 portable plain-film radiographs (74 in total), 9 ultrasonographic examinations, 17 cranial-chest-abdominopelvic CT examinations, 2 cervical CT examinations, 2 orbital CT examinations, and 2 CT examinations of the sinuses were performed. CONCLUSION: In both hospitals, each victim was managed as if he or she were the only patient. The discrepancies between the two hospitals were due to differences in the usual protocol for multiple trauma patients. In light of the organizational errors discovered, we propose a plan of action based on the identification and progressive activation of material and human resources until sufficient levels are achieved.

Imagen radiológica de las anomalías congénitas de las costillas. Parte I. Anomalías de número y fusión.Costillas finas / Radiologic imaging of congenital anomalies of the ribs: number and fusion anomalies thin ribs

Las anomalías congénitas del tórax son una causa significativa de morbilidad en neonatos, lactantes, niños e incluso en la edad adulta. La evaluación de los pacientes afectados requiere frecuentemente múltiples modalidades de imagen para diagnosticarlas y, en su caso, planear la corrección quirúrgica. Este artículo analiza e ilustra aspectos prácticos de ciertas anomalías congénitas comunes e infrecuentes que afectan a las costillas, con énfasis particular en las manifestaciones radiológicas. Se evalúa, asimismo, la utilidad de las diferentes modalidades de imagen en el diagnóstico y manejo de estas alteraciones. Las alteraciones descritas incluyen anomalías de número y fusión (ausencia e hipoplasia de costillas y costillas supernumerarias) y costillas finas (neurofibromatosis, síndrome de la trisomía 13, síndrome de la trisomía 18 y osteogénesis imperfecta congénita). Las bases embriológicas y patológicas de los distintos hallazgos radiológicos se discuten en los casos apropiados. Se incluye también el diagnóstico diferencial de algunos de estos procesos (AU)

[Application of a geriatric evaluation protocol in primary care: comparison with data from the clinical history]. / Aplicación de un protocolo de valoración geriátrica en atención primaria: comparación con los datos de la historia clínica.

OBJECTIVES: To determine the prevalence of the health problems included in a multidimensional geriatric assessment (MGA) protocol and to compare them with the problems detected in the clinical histories (CH) of the population consulting at a primary care centre (PCC). DESIGN: Cross-sectional observational. SETTING: Urban PCC (metropolitan area of Barcelona). PATIENTS: Users > or = 65 of a PCC between 01/11/97 and 31/01/98. MEASUREMENTS AND MAIN RESULTS: A random sample of 114 people was chosen. The MGA protocol was used to screen disorders in: hearing, vision, mobility, affective state, cognitive state, social support, functionalism of the instrumental activities of daily life. The clinical histories provided age, sex and information previously recorded on these disorders. 102 people were surveyed (participation: 89.5%). The MGA enabled more problems to be detected, with the difference very marked in some cases such as visual disorders: 55.9% (46.2-65.5) with MGA and 23.5% (15.3-31.8) with CH. There was poor concordance between MGA and CH. For example, neither the 73.3% (54.1-87.7) of the hearing disorders detected with the MGA, nor 94.1% (71.3-99.8) of the cognitive deterioration detected with the MGA had been previously recorded in the CH. CONCLUSIONS: MGA detects more health problems than are normally recorded in primary care clinical histories, which makes this technique relevant to PC consultations with the elderly. However, it would be advisable to identify the population for whom there was better diagnostic performance.

Aplicación de un protocolo de valoración geriátrica en atención primaria: comparación con los datos de la historia clínica / Application of a protocol of geriatric assessment in primary care: comparison with the data in the clinical history

Objetivo. Determinar la prevalencia de los problemas de salud incluidos en un protocolo de valoración geriátrica multidimensional (VGM) y compararlos con los detectados en la historia clínica (HCAP) en población consultante de un centro de atención primaria (CAP). Diseño. Observacional transversal. Emplazamiento: CAP urbano (área metropolitana de Barcelona). Pacientes. Usuarios >= 65 años de un CAP entre 01-XI-1997 y el 31-I-1998. Mediciones y resultados principales. Se seleccionó una muestra aleatoria de 114 individuos. Se cribó con el protocolo VGM las alteraciones en: audición; visión; movilidad; estado afectivo; estado cognitivo; soporte social; funcionalismo de las actividades instrumentales de la vida diaria (AIVD). De la HCAP se recogió: edad, sexo e información previamente registrada sobre estas alteraciones. Se encuestaron 102 sujetos (participación, 89,5 por ciento). La VGM aporta más capacidad de detección de problemas, siendo la diferencia muy acentuada en algún caso, como en las alteraciones visuales, 55,9 por ciento (46,2-65,5) con VGM y 23,5 por ciento (15,3-31,8) con HCAP. La concordancia entre la VGM y la HCAP es baja. Así, por ejemplo, ni el 73,3 por ciento (54,1-87,7) de las alteraciones auditivas detectadas con la VGM ni el 94,1 por ciento (71,3-99,8) de los deterioros cognitivos habían sido registrados previamente en la HCAP. Conclusiones. La VGM detecta prevalencias de problemas de salud superiores al registro habitual de la HCAP, por lo que parece interesante utilizar esta técnica en las consultas de atención primaria a la población anciana. Sin embargo, sería recomendable identificar la población en la que el rendimiento diagnóstico fuera superior (AU)