Custo Direto do Tratamento do Acidente Vascular Cerebral Isquêmico na Perspectiva de um Hospital Público Terciário (Direct Cost of Treating Ischemic Stroke From the Perspective of a Tertiary Public Hospital).

OBJECTIVES: To measure the direct cost of treating acute ischemic stroke (IS) from the perspective of a public hospital in Brazil (HCFMB) and compare it with the reimbursement by the Unified Health System (SUS), through the Procedure Table Management System, Medicines, Orthoses/Prostheses and Special Materials of the Unified Health System (SIGTAP). METHODS: We performed a micro-costing study; four scenarios were evaluated: standard (1); alteplase (2); alteplase and mechanical thrombectomy (3); mechanical thrombectomy (4). Based on the number of patients hospitalized for ischemic stroke in 2019, hospital cost, and SUS billing were calculated for each scenario. Hospital costs were adjusted for inflation using CCEMG-EPPI-Centre Cost Converter. RESULTS: In 2019, 258 patients were hospitalized due to IS, 89.5% in scenario 1, 8% in scenario 2, 1.5% in scenario 3, 1% in scenario 4. From the hospital's perspective, the cost per patient was estimated at R$7780.13, R$15 741.23, R$28 988.49, R$25 739.79, for scenarios 1, 2, 3 and 4, respectively. The reimbursement by SIGTAP was estimated at R$3079.87, R$5417.21, R$10 901.92, R$10 286.28, respectively. If thrombectomy had been included in the SIGTAP, the last two values would be R$25 393.34 and R$24 248.89. CONCLUSIONS: The hospital cost of treating acute IS in 2019 was estimated at R$2 295 209, the SUS reimbursement at R$889 391.54. With the inclusion of thrombectomy at SIGTAP, this reimbursement would be R$975 282.44, and the loss in the cost of HCFMB per patient in relation to reimbursement by the SUS is greater in scenarios without this procedure.

To what extent does frailty mediate the association between age and the outcomes of brain reperfusion following acute ischemic stroke?

Objective: We evaluated the extent to which frailty mediated the association between age, poor functional outcomes, and mortality after acute ischemic stroke when patients were treated with brain reperfusion (thrombolytic therapy and/or thrombectomy). Materials and methods: This retrospective cohort study included patients diagnosed with ischemic stroke who had undergone intravenous cerebral reperfusion therapy and/or mechanical thrombectomy. We created a mediation model by analyzing the direct natural effect of an mRS score > 2 and death on age-mediated frailty according to the Frailty Index. Results: We enrolled 292 patients with acute ischemic stroke who underwent brain reperfusion. Their mean age was 67.7 ± 13.1 years. Ninety days after the stroke ictus, 54 (18.5%) participants died, and 83 (28.4%) lived with moderate to severe disability (2 < mRS < 6). In the mediation analysis of the composite outcome of disability (mRS score > 2) or death, frailty accounted for 28% of the total effect of age. The models used to test for the interaction between age and frailty did not show statistically significant interactions for either outcome, and the addition of the interaction did not significantly change the direct or indirect effects, nor did it improve model fit. Conclusion: Frailty mediated almost one-third of the effect of age on the composite outcome of disability or death after acute ischemic stroke.

Challenges in adapting a stroke unit in a middle-income country: warning about costs and underfunding to achieve the Brazilian Ministry of Health's benchmark.

Background: Since the implementation of the stroke care line in Brazil, the relationship (adequacy) of costs spent during hospitalization with the Brazilian Ministry of Health indicators for a stroke unit have not yet been analyzed. Aims: This study aimed to assess the adequacy of a comprehensive stroke center for key performance indicators and analyze the costs involved in hospitalization. We verified the association between stroke severity at admission and care costs during hospitalization. Methods: A retrospective medical chart review of 451 patients was performed using semiautomatic electronic data from a single comprehensive stroke center in Brazil between July 2018 and January 2020. Clinical and resource utilization data were collected, and the mean acute treatment cost per person was calculated. The Kruskal-Wallis test with Dunn's post-test was used to compare the total costs between stroke types and reperfusion therapies. A robust linear regression test was used to verify the association between stroke severity at hospital admission and the total hospitalization costs. Good adequacy rates were observed for several indicators. Results: Data from 451 patients were analyzed. The stroke unit had good adaptation to key performance indicators, but some critical points needed revision and improvement to adapt to the requirements of the Ministry of Health. The average total cost of the patient's stay was the USD 2,637.3, with the daily hospitalization, procedure, operating room, and materials/medication costs equating to USD 2,011.1, USD 220.7, USD 234.1, and USD 98.8, respectively. There was a positive association between the total cost and length of hospital stay (p < 0.001). Conclusion: The stroke unit complied with most of the main performance indicators proposed by the Brazilian Ministry of Health. Underfunding of the costs involved in the hospitalization of patients was verified, and high costs were associated with the length of stay, stroke severity, and mechanical thrombectomy.

Neurofibromatosis type 1, fibromuscular dysplasia, and ischemic stroke: an association lost in time? A case report.

Neurofibromatosis Type 1 (NF1) is a rare cause of ischemic stroke (IS) in the general population. We report a case of a young patient with NF1 in whom IS was caused by fibromuscular dysplasia. An angiographic study demonstrated occlusion in the right internal carotid artery (ICA), just after its origin, and the left ICA, just before the intracranial portion, and brain magnetic resonance imaging showed the limits of an area of brain infarction in the right frontoparietal region. Despite these concomitant neuroimaging findings, this association is rare, and it is difficult to establish the contribution to the outcome made by each of these diseases, which treatment is the best to implement, or what prognosis is.

A neurofibromatose tipo 1 (NF1) é uma causa rara de acidente vascular cerebral isquêmico (AVCi) na população geral. Neste estudo, relatamos o caso de um paciente jovem com AVCi, com diagnóstico de NF1 associada a displasia fibromuscular. O estudo angiográfico demonstrou oclusão da carótida interna direita, logo após sua origem, e esquerda, antes da porção intracraniana. A ressonância magnética do encéfalo mostrou delimitação de um infarto na região frontoparietal direita. Apesar desses achados concomitantes na neuroimagem, essa associação é rara, sendo difícil de estabelecer a contribuição de cada uma dessas doenças no desfecho, tampouco qual o melhor tratamento a ser implementado e qual o prognóstico.

World federation of interventional and therapeutic neuroradiology (WFITN) federation assembly neurointerventional surgery safety checklist.

Over the last 10 years, there has been a rise in neurointerventional case complexity, device variety and physician distractions. Even among experienced physicians, this trend challenges our memory and concentration, making it more difficult to remember safety principles and their implications. Checklists are regarded by some as a redundant exercise that wastes time, or as an attack on physician autonomy. However, given the increasing case and disease complexity along with the number of distractions, it is even more important now to have a compelling reminder of safety principles that preserve habits that are susceptible to being overlooked because they seem mundane. Most hospitals have mandated a pre-procedure neurointerventional time-out checklist, but often it ends up being done in a cursory fashion for the primary purpose of 'checking off boxes'. There may be value in iterating the checklist to further emphasize safety and communication. The Federation Assembly of the World Federation of Interventional and Therapeutic Neuroradiology (WFITN) decided to construct a checklist for neurointerventional cases based on a review of the literature and insights from an expert panel.

Tracking excess of maternal deaths associated with COVID-19 in Brazil: a nationwide analysis.

BACKGROUND: The COVID-19 pandemic brought a new challenge to maternal mortality in Brazil. Throughout 2020, Brazil registered 549 maternal deaths, mainly in second and third-trimester pregnant women. The objective of this study was to estimate the excess maternal deaths in Brazil caused directly and indirectly by Covid-19 in the year 2020. In addition, we sought to identify clinical, social and health care factors associated with the direct maternal deaths caused by Covid-19. METHODS: We performed nationwide analyses based on data from the Mortality Information System (SIM) for general and maternal deaths and the Influenza Epidemiological Surveillance System (SIVEP-Influenza) for estimates of female and maternal deaths due to COVID-19. Two distinct techniques were adopted. First, we describe maternal deaths directly caused by covid-19 and compare them with the historical series of deaths from covid-19 among women of childbearing age (15 to 49 years). Next, we estimated the total excess maternal mortality. Then, we calculated odds ratios for symptoms, comorbidities, social determination proxies and hospital care aspects between COVID-19 maternal deaths and deaths of women of childbearing age who were not pregnant or no maternal deaths. We chose women of childbearing age (15 to 49 years) as a reference because sex and age introduce differentials in the risk of COVID-19 death. RESULTS: Most maternal deaths occurred during pregnancy compared to postpartum deaths month by month in 2020 (µ = 59.8%, SD = 14.3%). The excess maternal mortality in 2020 in Brazil was 1.40 (95% CI 1.35-1.46). Even considering excess mortality due to COVID-19 for the childbearing age female population (MMR 1.14; 95% CI 1.13-1.15), maternal mortality exceeded the expected number. The odds of being a black woman, living in a rural area and being hospitalized outside the residence municipality among maternal deaths were 44, 61 and 28% higher than the control group. Odds of hospitalization (OR 4.37; 95% CI 3.39-5.37), ICU admission (OR 1.73; 95% CI 1.50-1.98) and invasive ventilatory support use (OR 1.64; CI 95% 1.42-1.86) among maternal deaths were higher than in the control group. CONCLUSIONS: There was excess maternal mortality in 2020 in Brazil. Even with adjustment for the expected excess mortality from Covid-19 in women of childbearing age, the number of maternal deaths exceeds expectations, suggesting that there were deaths among pregnant and postpartum women indirectly caused by the pandemic, compromising access to prenatal care., adequate childbirth and puerperium.

Exploring chemical diversity in Glycine max cultivars: A multivariate approach in the search for bioactive compounds against Spodoptera cosmioides.

Soybean crop is regulated by abiotic and biotic stresses with great potential in reducing grain yield and quality. The selection of resistant cultivars is a promising approach for mitigating these damages. We evaluated the chemical profile of Glycine max leaves from different cultivars in order to explore their defense mechanisms against Spodoptera cosmioides caterpillars. We optimized solid-liquid extraction techniques using ultrasound bath and static headspace extraction. Additionally, we developed an approach based on liquid and gas chromatography for analyzing the chemical profile of G. max cultivars. The principal component analysis allowed the classification of transgenic cultivars, which are classified as susceptible to S. cosmioides, from those obtained by genetic improvement and resistant to the insect. Differences were observed in the abundance of phenolic glycosides, lipids, aldehydes, and alcohols. More specifically, S. cosmioides resistant cultivars presented molecules related to the jasmonic and salicylic acid pathways. Such data can contribute to a molecular understanding of phenotypic diversity in soybean cultivars, from plant quality to resistance mechanisms and adaptation, to environmental stress and herbivory.

Transcranial doppler as screening method for sickling crises in children with sickle cell anemia: a latin America cohort study.

BACKGROUND: Sickle cell anemia (SCA) is the leading cause of childhood stroke. We aimed to evaluate whether altered cerebral flow velocities, as measured by transcranial Doppler (TCD), are associated with vaso-occlusive complications in addition to stroke in pediatric SCA patients. METHODS: We evaluated 37 children aged between 2 and 16 years with SCA who underwent screening for TCD between January 2012 and October 2018. Genotypic profiles and demographic data were collected, TCD examinations were performed during follow-up, and the presence of sickling crises was compared. Survival analyses were performed using simple frailty models, in which each predictor variable was analyzed separately in relation to the occurrence of a sickling crisis. RESULTS: The variables related to sickle cell crises in the univariate analysis were peak systolic velocity (PSV) in the middle cerebral artery (MCA), hazard ratio (HR) 1.01 (1.00-1.02) p = 0.04; end-diastolic velocity (EDV) in the MCA, HR 1.02 (1.01-1.04) p = 0.01; time average mean maximum velocity (TAMMV) in the basilar artery (BA), HR 1.02 (1.00-1.04) p = 0.04; hemoglobin, HR 0.49 (0.38-0.65) p < 0.001; hematocrit, HR 0.78 (0.71-0.85) p < 0.001; leukocyte counts, HR 1.1 (1.05-1.15) p < 0.001; platelets counts, HR 0.997 (0.994-0.999) p = 0.02; and reticulocyte numbers, HR 1.14 (1.06-1.23) p < 0.001. CONCLUSIONS: Our results indicate PSV and EDV in the MCA and TAMMV in the BA as markers of risk for the occurrence of sickling crises in SCA.

Clinical and Functional Outcomes of Patients Receiving Cerebral Reperfusion Therapy: A Stroke Databank Study in Brazil.

Objectives: Cerebral reperfusion therapy is recommended for the treatment of acute ischemic stroke. However, the outcomes of patients receiving this therapy in middle- and low-income countries should be better defined. This study aimed to evaluate the clinical and functional outcomes of cerebral reperfusion therapy in patients with ischemic stroke. Materials and Methods: This retrospective study included patients with ischemic stroke treated with cerebral reperfusion therapy, including intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and IVT with MT. The primary outcomes were death and disability, assessed using the modified Rankin scale (mRS), and stroke severity, assessed using the National Institutes of Health Stroke Scale (NIHSS), after intervention and 90 days after ictus. The association between the type of treatment and the primary outcome was assessed using binary logistic regression after adjusting for confounding variables. Furthermore, receiver operating characteristic (ROC) curves were generated to identify the cutoff point of the NIHSS score that could best discriminate the mRS score in all types of treatments. Results: Patients (n = 291) underwent IVT only (n = 241), MT (n = 21), or IVT with MT (n = 29). In the IVT with MT group, the incidence of death within 90 days increased by five times (OR, 5.192; 95% CI, 2.069-13.027; p = 0.000), prevalence of disability increased by three times (OR, 3.530; 95% CI, 1.376-9.055; p = 0.009) and NIHSS score increased after IVT (from 14.4 ± 6.85 to 17.8 ± 6.36; p = 0.045). There was no significant difference between the initial NIHSS score and that after MT (p = 0.989). Patients' NIHSS score that increased or decreased by 2.5 points had a sensitivity of 0.74 and specificity of 0.65, indicating severe disability or death in these patients. Conclusion: Altogether, a 2.5-point variation in NIHSS score after reperfusion is an indicator of worse outcomes. In our particular context, patients receiving the combination of IVT and MT had inferior results, which probably reflects challenges to optimize MT in LMIC.

Presentation of cerebral and cervical arterial dissections in Botucatu, Brazil: case series.

Spontaneous dissection of the cervical and cerebral arteries is an important cause of stroke and disability in young patients. In this report, the authors present a case series of patients with spontaneous carotid, vertebral, or cerebral artery dissection who underwent digital angiography. A review of the published literature on this subject is also presented.

A dissecção espontânea das artérias cervicais e cerebrais é uma causa importante de acidente vascular cerebral e incapacidade em pacientes jovens. Neste relato, é apresentada uma série de casos de pacientes com dissecção espontânea da artéria carótida, vertebral ou cerebral submetidos à angiografia digital. Além disso, é fornecida uma revisão da literatura sobre esse assunto.

The Impact of Age on Mortality and Disability in Patients With Ischemic Stroke Who Underwent Cerebral Reperfusion Therapy: A Brazilian Cohort Study.

Introduction: The main driver for increased stroke prevalence is the aging of the population; however, the best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Therefore, the aim was studying the association of age with clinical outcomes (mortality and functional disability) in stroke patients who underwent cerebral reperfusion therapy at hospital discharge and 90 days after ictus. Methods: This was a retrospective (stroke databank analysis) cohort study of participants who had been diagnosed with ischemic stroke and undergone intravenous cerebral reperfusion therapy or mechanical thrombectomy. The variable of interest was patient age, which was categorized into four groups: (1) up to 59 years; (2) 60 to 69 years; (3) 70 to 79 years old; and (4) above 79 years. The primary outcome was mortality at hospital discharge and 90 days after stroke, and the secondary outcome was functional capacity at hospital discharge and 90 days after stroke. Results: A total of 281 patients was included in the study (235 treated by thrombolysis alone, and 46 treated with mechanical thrombectomy). The mean age of the total sample was 67 ± 13.1 years. The oldest patients had the most unfavorable outcomes, except for mortality rate, at hospital discharge (mRS > 2; OR: 1.028; 95% CI 1.005 to 1.051; p = 0.017; mRS > 3; OR: 1.043, 95% CI 1.018 to 1.069; p = 0.001) and 90 days after stroke (mRS > 2; OR: 1.028; 95% CI 1.005 to 1.051; p = 0.017; mRS > 3; OR: 1.043, 95% CI 1.018 to 1.069; p = 0.001). Conclusion: Cerebral reperfusion was a viable treatment for ischemic stroke in both elderly and very elderly patients, as it did not increase mortality. However, it was observed that older individuals had worse functional outcomes at hospital discharge and 90 days after stroke.

Relation of Nonrecurrent Laryngeal Nerve with Zuckerkandl's Tubercle.

The nonrecurrent laryngeal nerve (NRLN) is a rare anatomical variation of the recurrent laryngeal nerve (RLN) that may hinder the identification and preservation of this nerve during surgery and is associated with increased iatrogenic risks. Zuckerkandl's tubercle (ZT) is considered a useful reference for locating the RLN during thyroid surgery. We report the case of an asymptomatic patient with a 23 mm uninodular goitre suspicious for cancer. Ultrasound examination showed a hypoechoic nodule with regular contours and microcalcifications. The patient had normal thyroid-stimulating hormone and thyroxine levels, and aspiration biopsy was suspicious for follicular cancer. She was treated with total thyroidectomy after the intraoperative examination confirmed the presence of a papillary thyroid carcinoma. The standard approach to the RLN below the inferior thyroid artery was used on both sides. The nerve displayed anatomical variation in the nonrecurrent form (NRLN) on the right side and was associated with another variation that was not found in the consulted literature. It was completely surrounded by thyroid tissue in the region of ZT, and the surgeon was forced to remove it from within the thyroid tissue. This combination of anatomical variations seems to be quite rare. Knowledge of the anatomy of the RLN and its variations, as well as its identification and careful dissection, is essential to avoid injury to the nerve during surgical procedures.

Relationship of spontaneous microembolic signals to risk stratification, recurrence, severity, and mortality of ischemic stroke: a prospective study.

INTRODUCTION: The presence of microembolic signals (MES) during the acute phase of stroke is poorly understood, and its role and clinical application in relation to risk stratification and prognosis in patients remain uncertain. We assessed the prevalence of spontaneous MES in acute stroke and their relationship with risk stratification, stroke recurrence, morbidity, and mortality. PATIENTS AND METHODS: This was a prospective cohort study conducted in the Stroke Unit. The MES presence was evaluated by transcranial Doppler (TCD) in patients with ischemic stroke within 48 h. The outcomes (risk stratification, morbidity, mortality, and recurrence of a stroke) were followed up for 6 months. The relationship between risk stratification and MES was obtained by odds ratios and that between MES and stroke recurrence, morbidity, and mortality using multiple logistic regression; considering statistical significance at P < 0.05. RESULTS: Of the 111 patients studied, 70 were men (63.1%) and 90 were white (81.1%), with a median age of 68 years. The MES frequency was 7%. There was a significant relationship between MES and symptomatic carotid disease (OR = 22.7; 95% CI 4.1-125.7; P < 0.001), a shorter time to monitoring (OR = 12.4; 95% CI 1.4-105.4; P = 0.02), and stroke recurrence (OR = 16.83; 95% CI 2.01-141; P = .009). DISCUSSION: It was observed that the stroke recurrence adjusted for prior stroke was higher and earlier among patients with MES detection. In conclusion, MES demonstrated a significant correlation with symptomatic carotid disease and a shorter DELAY until monitoring, and could be a predictor for the early recurrence of stroke in the long term.

Nonmelanoma Skin Cancer at Critical Facial Sites: Results and Strategies of the Surgical Treatment of 102 Patients.

BACKGROUND: To evaluate the surgical treatment results of a consecutive series of patients with nonmelanoma skin cancer in critical facial regions such as the nose, lip, eyelid, ear, forehead, cheek, and chin. METHODS: This was a prospective observational cohort study evaluating the surgical treatment results of 102 patients with nonmelanoma skin cancer who underwent surgical excision and required some type of reconstruction. The reconstruction strategy used, histological type and margins, aesthetic result, and complications were evaluated. RESULTS: The most common facial site was the nose (48.01%), followed by the eyelid, ear, cheek, forehead, and lip. The most frequently used type of reconstruction was the advancement flap (30.39%), followed by transposition flap (27,45%), rotation flap (14.70%), and grafts (10.78%). Basal cell carcinoma was the most frequent histological type, accounting for 90.19% of the sample, with 54.90% of these cases being of the nodular subtype. Disease-free margins were obtained in 94.11% of the patients, and only one patient presented compromised margins and underwent marginal extension. A good cosmetic result was found in 93.13% of the participants. CONCLUSION: Surgical treatment can provide excellent oncological, functional, and cosmetic results in the treatment of patients with nonmelanoma skin cancer at critical facial sites.

Ischemic stroke enhancement using a variational model and the expectation maximization method.

OBJECTIVES: In order to enable less experienced physicians to reliably detect early signs of stroke, A novel approach was proposed to enhance the visual perception of ischemic stroke in non-enhanced CT. METHODS: A set of 39 retrospective CT scans were used, divided into 23 cases of acute ischemic stroke and 16 normal patients. Stroke cases were obtained within 4.5 h of symptom onset and with a mean NIHSS of 12.9±7.4. After selection of adjunct slices from the CT exam, image averaging was performed to reduce the noise and redundant information. This was followed by a variational decomposition model to keep the relevant component of the image. The expectation maximization method was applied to generate enhanced images. RESULTS: We determined a test to evaluate the performance of observers in a clinical environment with and without the aid of enhanced images. The overall sensitivity of the observer's analysis was 64.5 % and increased to 89.6 % and specificity was 83.3 % and increased to 91.7 %. CONCLUSION: These results show the importance of a computational tool to assist neuroradiology decisions, especially in critical situations such as the diagnosis of ischemic stroke. KEY POINTS: • Diagnosing patients with stroke requires high efficiency to avoid irreversible cerebral damage. • A computational algorithm was proposed to enhance the visual perception of stroke. • Observers' performance was increased with the aid of enhanced images.

High final energy of gallium arsenide laser increases MyoD gene expression during the intermediate phase of muscle regeneration after cryoinjury in rats.

The aim of this study was to determine the effects of gallium arsenide (GaAs) laser on IGF-I, MyoD, MAFbx, and TNF-α gene expression during the intermediate phase of muscle regeneration after cryoinjury 21 Wistar rats were divided into three groups (n = 7 per group): untreated with no injury (control group), cryoinjury without GaAs (injured group), and cryoinjury with GaAs (GaAs-injured group). The cryoinjury was induced in the central region of the tibialis anterior muscle (TA). The region injured was irradiated once a day during 14 days using GaAs laser (904 nm; spot size 0.035 cm2, output power 50 mW; energy density 69 J cm-2; exposure time 4 s per point; final energy 4.8 J). Twenty-four hours after the last application, the right and left TA muscles were collected for histological (collagen content) and molecular (gene expression of IGF-I, MyoD, MAFbx, and TNF-α) analyses, respectively. Data were analyzed using one-way ANOVA at P < 0.05. There were no significant (P > 0.05) differences in collagen density and IGF-I gene expression in all experimental groups. There were similar (P < 0.05) decreases in MAFbx and TNF-α gene expression in the injured and GaAs-injured groups, compared to control group. The MyoD gene expression increased (P = 0.008) in the GaAs-injured group, but not in the injured group (P = 0.338), compared to control group. GaAs laser therapy had a positive effect on MyoD gene expression, but not IGF-I, MAFbx, and TNF-α, during intermediary phases (14 days post-injury) of muscle repair.

Efficiency of personal dosimetry methods in vascular interventional radiology.

PURPOSE: The aim of the present study was to determine the efficiency of six methods for calculate the effective dose (E) that is received by health professionals during vascular interventional procedures. METHODS: We evaluated the efficiency of six methods that are currently used to estimate professionals' E, based on national and international recommendations for interventional radiology. Equivalent doses on the head, neck, chest, abdomen, feet, and hands of seven professionals were monitored during 50 vascular interventional radiology procedures. Professionals' E was calculated for each procedure according to six methods that are commonly employed internationally. To determine the best method, a more efficient E calculation method was used to determine the reference value (reference E) for comparison. RESULTS: The highest equivalent dose were found for the hands (0.34±0.93mSv). The two methods that are described by Brazilian regulations overestimated E by approximately 100% and 200%. The more efficient method was the one that is recommended by the United States National Council on Radiological Protection and Measurements (NCRP). The mean and median differences of this method relative to reference E were close to 0%, and its standard deviation was the lowest among the six methods. CONCLUSIONS: The present study showed that the most precise method was the one that is recommended by the NCRP, which uses two dosimeters (one over and one under protective aprons). The use of methods that employ at least two dosimeters are more efficient and provide better information regarding estimates of E and doses for shielded and unshielded regions.