Descripción de elementos de radioprotección y dosimetría en unidades de cardiología intervencionista sudamericanas: un estudio piloto / Radioprotection and dosimetry in Interventional cardiology units in South America. a pilot study

ANTECEDENTES: Las unidades de Cardiología intervencional han evidenciado un número creciente de procedimientos, cada vez más variados y complejos, lo cual podría eventualmente generar daños a los profesionales ocupacionalmente expuestos a radiaciones ionizantes (POEs) de no contar con los adecuados elementos de radioprotección y un uso correcto de ellos. OBJETIVO: Caracterizar la disponibilidad y utilización de los elementos de radioprotección y dosimetría de unidades de cardiología intervencionista de centros Sudamericanos. MATERIAL Y MÉTODOS: Se realizó una encuesta autoaplicada a 139 POEs, de ambos sexos de 7 países, a través de una plataforma on-line, se les consultó sobre características demográficas, dosimétricas y de radioprotección. RESULTADOS: Los elementos de radioprotección más tradicionales; delantales y cuellos plomados se utilizaron un 99,5 % y 98,4 % respectivamente, aquellos elementos más recientes como gafas, gorros y paños plomados solo alcanzaron un 36,8 %, 6,8 % y 34,2%, de utilización respectivamente, en cuanto a la utilización de los dosímetros, solo un 7,9 % lo hace apegado a las normas de la Organización Internacional de Energía Atómica (OIEA). CONCLUSIÓN: Se constató en la muestra analizada una falta de elementos de radioprotección y un uso inadecuado de ellos, urge realizar intervenciones educativas y técnicas para mejorar estos datos.

BACKGROUND: Due to the increasing number of interventional cardiology procedures currently performed, health professionals (POE) are exposed to ionizing radiation unless adequate protective elements are used. AIM: to describe the use of radioprotection elements and dosimetry in interventional cardiology laboratories in South America. METHODS: A self-administered survey was performed on 139 POE of both sexes and 7 countries using an online platform. Demographic data, dosimetry and characteristics of radioprotection analyzed. RESULTS: Commonly used radioprotective elements (lead aprons and collars) were used in 99.5% and 98% respectively. Recently introduced protection elements like lead goggles, caps and drapery were used in 36.8, 6.8 and 34.2% , respectively. Dosimetry according to the International Atomic Energy Commission (OIAE) was performed in only 7.9% of the procedures. CONCLUSION: there is a severe lack of adequate radioprotection during interventional cardiology procedures. Urgent measures, including technical implementation and educational interventions are needed to improve radioprotection in interventional cardiology.

Prehospital and en route analgesic use in the combat setting: a prospectively designed, multicenter, observational study.

BACKGROUND: Combat injuries result in acute, severe pain. Early use of analgesia after injury is known to be beneficial. Studies on prehospital analgesia in combat are limited and no prospectively designed study has reported the use of analgesics in the prehospital and en route care setting. Our objective was to describe the current use of prehospital analgesia in the combat setting. METHODS: This prospectively designed, multicenter, observational, prehospital combat study was undertaken at medical treatment facilities (MTF) in Afghanistan between October 2012 and September 2013. It formed part of a larger study aimed at describing the use of lifesaving interventions in combat. On arrival at the MTF, trained on-site investigators enrolled eligible patients and completed standardized data capture forms, which included the name, dose, and route of administration of all prehospital analgesics, and the type of provider who administered the drug. Physiological data were retrospectively ascribed as soon as practicable. The study was prospectively approved by the Brooke Army Medical Center institutional review board. RESULTS: Data were collected on 228 patients, with 305 analgesia administrations recorded. The predominant mechanism of injury was blast (50%), followed by penetrating (41%), and blunt (9%). The most common analgesic used was ketamine, followed by morphine. A combination of analgesics was given to 29% of patients; the most common combination was ketamine and morphine. Intravenous delivery was the most commonly used route (55%). Patients transported by the UK Medical Emergency Response Team (MERT) or U.S. Air Medical Evacuation (Dust-off) team were more likely to receive ketamine than those evacuated by U.S. Pararescue Jumpers (Pedro). Patients transported by Medical Emergency Response Team or Pedro were more likely to receive more than 1 drug. Patients who received only ketamine had a higher pulse rate (p<0.005) and lower systolic blood pressure (p=0.01) than other groups, and patients that received hydromorphone had a lower respiratory rate (p=0.04). CONCLUSIONS: In our prospectively designed, multicenter, observational, prehospital combat study, ketamine was the most commonly used analgesic drug. The most frequently observed combination of drugs was ketamine and morphine. The intravenous route was used for 55% of drug administrations.

[Protection against ionizing radiation by leaded glass googles during interventional cardiology]. / ¿Es suficiente la protección otorgada por gafas plomadas en cardiología intervencionista?

BACKGROUND: It is not known whether leaded glass goggles with 0.25 mm Pb equivalency, used in interventional cardiology procedures, attenuate radiation below the levels established by the latest recommendation of the International Commission on Radiological Protection (ICRP). AIM: To assess if the degree of attenuation of the secondary ionizing radiation achieved by the use of 0.25 mm Pb leaded glass goggles, in occupationally exposed workers in interventional cardiology procedures, meets the latest ICRP recommendations. MATERIAL AND METHODS: A prospective investigation was carried out to compare the eye exposure to secondary ionizing radiation received by occupationally exposed personnel in a 9 months period. A set of two thermo luminescent dosimeters was arranged in the front and back of leaded glass goggles in a cohort of seven members of an interventional cardiology service, exposed to 1057 consecutive procedures. RESULTS: The monthly dose equivalent measurement performed in front of the goggles ranged between 1.1 and 6.5 mSv, for paramedics and interventional cardiologists. The radiation measured in the back of the glass varied between 0.66 and 2.75 mSv, respectively. The degree of attenuation of the dose at eye level ranged from 40% to 57.7%, respectively. The projected annual exposure would reach 33 mSv for the interventional cardiologist. CONCLUSIONS: With a similar load of work and wearing 0.25 mm Pb equivalent glass goggles, interventional cardiologists will exceed the crystalline equivalent dose limit recommended by the ICRP (20 mSv/year averaged over the past 5 years).

Primary hemostatic capacity of whole blood: a comprehensive analysis of pathogen reduction and refrigeration effects over time.

BACKGROUND: Whole blood (WB) has been used in combat since World War I as it is readily available and replaces every element of shed blood. Component therapy has become standard; however, recent military successes with WB resuscitation have revived the debate regarding wider WB use. Characterization of optimal WB storage is needed. We hypothesized that refrigeration preserves WB function and that a pathogen reduction technology (PRT) based on riboflavin and ultraviolet light has no deleterious effect over 21 days of storage. STUDY DESIGN AND METHODS: WB units were stored for 21 days either at 4°C or 22°C. Half of each temperature group underwent PRT, yielding four final treatment groups (n = 8 each): CON 4 (WB at 4°C); CON 22 (WB at 22°C); PRT 4 (PRT WB at 4°C); and PRT 22 (PRT WB at 22°C). Testing was at baseline, Days 1-7, 10, 14, and 21. Assays included coagulation factors; platelet activation, aggregation, and adhesion; and thromboelastography (TEG). RESULTS: Prothrombin time (PT) and partial thromboplastin time increased over time; refrigeration attenuated the effects on PT (p ≤ 0.009). Aggregation decreased over time (p ≤ 0.001); losses were attenuated by refrigeration (p ≤ 0.001). Refrigeration preserved TEG parameters (p ≤ 0.001) and PRT 4 samples remained within normal limits throughout the study. Refrigeration in combination with PRT inhibited fibrinolysis (p ≤ 0.001) and microparticle formation (p ≤ 0.031). Cold storage increased shear-induced platelet aggregation and ristocetin-induced platelet agglutination (p ≥ 0.032), as well as GPIb-expressing platelets (p ≤ 0.009). CONCLUSION: The in vitro hemostatic function of WB is largely unaffected by PRT treatment and better preserved by cold storage over 21 days. Refrigerated PRT WB may be suitable for trauma resuscitation. Clinical studies are warranted.

¿Es suficiente la protección otorgada por gafas plomadas en cardiología intervencionista? / Protection against ionizing radiation by leaded glass googles during interventional cardiology

Background: It is not known whether leaded glass goggles with 0.25 mm Pb equivalency, used in interventional cardiology procedures, attenuate radiation below the levels established by the latest recommendation of the International Commission on Radiological Protection (ICRP). Aim: To assess ifthe degree of attenuation of the secondary ionizing radiation achieved by the use of 0.25 mm Pb leaded glass goggles, in occupationally exposed workers in interventional cardiology procedures, meets the latest ICRP recommendations. Material and Methods: A prospective investigation was carried out to compare the eye exposure to secondary ionizing radiation received by occupationally exposed personnel in a 9 months period. A set of two thermo luminescent dosimeters was arranged in the front and back of leaded glass goggles in a cohort ofseven members of an interventional cardiology service, exposed to 1057 consecutive procedures. Results: The monthly dose equivalent measurement performed in front ofthe goggles ranged between 1.1 and 6.5 mSv, for paramedics and interventional cardiologists. The radiation measured in the back of the glass varied between 0.66 and 2.75 mSv, respectively. The degree of attenuation of the dose at eye level ranged from 40% to 57.7%, respectively. The projected annual exposure would reach 33 mSvfor the interventional cardiologist. Conclusions: With a similar load ofwork and wearing 0.25 mm Pb equivalent glass goggles, interventional cardiologists will exceed the crystalline equivalent dose limit recommended by the ICRP (20 mSv/year averaged over the past 5 years).

Intervenciones coronarias percutáneas guiadas con medición de flujo de reserva coronario / Percutaneous coronary intervention guided by measurement of coronary flow reserve

Introducción: La revascularización de una estenosis coronaria que induce isquemia mejora el estatus funcional del paciente y su pronóstico. Por el contrario, la angioplastía de una lesión que no provoca isquemia puede implicar complicaciones sin beneficios. La medición de flujo de reserva coronario (FFR) es un índice del significado fisiopatológico de las estenosis coronarias. Objetivos: Comparar los eventos cardiovasculares adversos mayores (MACE) en pacientes en quienes la FFR permitió excluir una o más lesiones de angioplastia (Grupo FFR >0,75) con aquellos en que ésta obligó a la revascularización (grupo FFR < 0,75). Métodos: Estudio observacional en 74 pacientes derivados para angioplastía entre agosto de 2006 y julio de 2010. Se realizó medición de FFR con ade-nosina a lesiones de severidad intermedia (60-70 por ciento). Una FFR translesional <0,75 se consideró significativa para isquemia y subsidiaria de angioplastía. Se hizo un seguimiento de los MACE definidos como: muerte, infarto, necesidad de revascularización y/o presencia de angor. Resultados: 35 pacientes (47,3 por ciento) constituyeron el Grupo FFR >0,75, y en ellos disminuyó el porcentaje de lesiones múltiples angiográficamente significativas (dos o más vasos), desde un 51,4 por ciento (previo a la realización de FFR), a un 25,7 por ciento. En este grupo se utilizó un promedio de 0.7 stents por paciente, mientras que en el grupo FFR <0,75 (39 pacientes), este fue de 1.5 stents. Se efectuó un seguimiento promedio de 21,5 meses. Diecinueve pacientes (25,6 por ciento) desarrollaron MACE (28 eventos). No hubo fallecidos ni diferencias significativas en el análisis multifactorial en cuanto a infartos o angor, pero sí en la necesidad de nueva revascularización, siendo ésta significativamente mayor en el grupo FFR <0,75 (12,8 por ciento versus 2,9 por ciento, p=0,047). Conclusiones: La medición del FFR permite, en caso de descartar isquemia, disminuir la necesidad de angioplastías...

The treatment of coronary stenosis causing myocardial ischemia improves functional capacity and prognosis. Treatment of non-ischemia inducing coronary stenosis may lead to complications with no benefit to the patient Measurement of coronary flow reserve (CFR) may be used to assess the significance of coronary artery stenosis. Aim: To compare major adverse cardiovascular events (MACE) in patients with significant stenosis (CFR < 0.75), with those in which one or more stenosis was not significant (CFR > 0.75) and thus were not subjected to PTCA in the corresponding artery. Methods: 74 patients were included from August 2006 to July 2010. CFR was measured in lesions exhibiting 6070 percent stenosis, using adenosine. A value <0.75 was considered significant and led to PTCA. Patients were followed for death, myocardial infarction, revascularization and/or angina. Results: 35 patients (47 percent) constituted the >0.75 CFR group. After evaluation of CFR the number of significant coronary stenosis decreased from 51.4 percent to 25.7 percent. They received a mean of 0.7 stents per patient. On the other hand, in the group with CFR <0.75 (39 patients) the mean number of stents was 1.5. Patients were followed for a mean of 21.5 months. 28 MACE events were observed in 19 patients (25.6 percent). No deaths were observed. Multivariable analysis revealed no significant difference between groups regarding myocardial infarction or angina. The need for myocardial revascularization was greater in the CFR <0.75 group compared to the CFR >0.75 group (12.8 percent vs 2.9 percent, respectively, p=0.047). Conclusion: The exclusion of myocardial ischemia as inferred by a CFR >0.75 allowed a significantly lower number of PTCAs without increase in MACE at a medium term follow up. A greater number of revascularization procedures was required in patients with CFR <0.75, which is expected from the greater number of lesions subjected to PTCA.

Comparación de angiografía coronaria con el ultrasonido intracoronario como patrón de referencia en el diagnóstico de vasculopatía post trasplante cardíaco / Comparison of coronary angiography and intra-coronary ultrasound as gold standard in the diagnosis of post cardiac transplantation vasculopathy

Antecedentes: La Vasculopatía del injerto (VDI) es la principal causa de muerte tardía del trasplante cardiaco (TX). Un diagnóstico precoz de esta complicación tendría un impacto en la terapia y pronóstico de esta afección. El ultrasonido intracoronario (IVUS), permite un diagnóstico precoz y certero de VDI, pero en la mayoría de los centros aún se utiliza la coronariografía. Objetivo: Evaluar la validez de la coronariografía en el diagnostico de VDI en pacientes trasplantados cardiacos, comparado con el IVUS. Metodología: Estudio transversal, en el cual se analizó una muestra de 36 pacientes con un tiempo promedio de trasplante de 3,7 +/- 3,7 años, a quienes se realizó simultáneamente un examen de coronario-grafía y un IVUS. Se evaluó la reproducibilidad contrastando los resultados de la interpretación visual de la coronariografía versus la coronariografía con análisis cuantitativo. Se calculó la Sensibilidad, Especificidad, Valores predictivos (VPP, VPN), Likelihoods y el coeficiente de equivalencia de Spearman-Brown. Resultados: La coronariografía cualitativa mostró ser más exacta que la cuantitativa, con una sensibilidad 30,4 por ciento [95 por ciento IC= 11,6 - 49,2], una especificidad 92,3 por ciento [95 por ciento IC= 77,8 - 106,7], VPP 87,5 por ciento [95 por ciento IC= 64,5 - 110,4], VPN 42,8 por ciento [95 por ciento IC= 24,5 - 61,1], LR (+) 3,9 [95 por ciento IC 0,55 - 28,7] y un LR (-) 0,75 [95 por ciento IC= 0,55 - 1,03]. La coronariografía cualitativa y cuantitativa son moderadamente equivalentes con un coeficiente de equivalencia Spearman Brown de 0,65. Conclusión: La validez y la reproducibilidad de la coronariografía en el paciente con TX es moderada y debería ser complementada con IVUS para el diagnóstico de VDI.

Background: Graft vasculopathy (GV) is the main cause of late death following cardiac transplantation (TX). Early diagnosis of this condition may have an impact upon treatment and prognosis of this complication. Intravascular ultrasound (IVUS) allows an early and accurate diagnosis of GV. However, most centers continue to use coronary angiography for this purpose. Aim: to evaluate coronary angiography for the diagnosis of GV in relation to IVUS in post TX patients. Methods: In a cross-sectional study the results of coronary angiography and IVUS, used as gold standard, were compared in 36 patients with a mean post TX follow up of 3.7 +/- 3.7 years. Results were compared between visual and quantitative coronary angiography. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), likelihood ratios and the equivalence Spearman-Brown coefficient were calculated. Results: Visual evaluation of coronary angiography was more accurate than quantitative coronary angiography. The sensitivity for GV was 30.4 percent (95 percent C.I. 11.6 - 49.2), specificity 92.3 percent (95 percent C.I. 77.8 - 106.7), PPV 87.5 percent (95 percent C.I. 64.5 - 110.4, NPP 42.8 percent (95 percent C.I. 24.5 - 61.1), likelihood ratio (+) 3.9 (95 percent C.I. 0.55 - 28.7), likelihood ratio (-) 0.75 (95 percent C.I. 0.55 -1.03). The Spearman Brown coefficient between visual and quantitative coronary angiography evaluation was 0.65. Conclusion: Accuracy and reproducibility of coronary angiography in the evaluation of GV is limited. IVUS should be used for better identification of GV.

Challenges to improving chronic disease care and training in residencies.

PURPOSE: To improve quality of care for chronic disease, professional organizations and medical providers are adopting new care models. The transition to better delivery systems is not easy and there are many barriers under the best of circumstances. This study investigated residency-based experiences with changes in teaching and delivery of chronic disease care. METHOD: In 2004-05 at the University of Southern California, the authors conducted qualitative cross-sectional in-depth interviews with directors of grant-funded residency-based chronic care projects. Open- and closed-ended questions explored the intent of and the challenges encountered by primary care residencies implementing improvements in chronic disease care and training. RESULTS: Six out of 14 program director responded, reporting that rotation-based and longitudinal experiences were used to teach and deliver improved chronic disease care. Common challenges were identified across residency sites, as well as challenges unique to particular residency settings. Among these challenges were engaging faculty and residents who spend limited time in the practice center, as well as institutional barriers related to authority, competing priorities, process, and resources. CONCLUSIONS: Successful innovations for chronic disease care and training are possible in residencies, but their implementation cannot be taken lightly. There are predictable barriers that can be dealt with locally, but also others that would benefit from coordinated national attention.