Trends in percutaneous coronary intervention and angiography in Ireland, 2004-2011: Implications for Ireland and Europe

Radiation shielding calculation for interventional radiology: An updated workload survey using a dose monitoring software

Shielding design is an essential aspect of radiation protection. It is necessary to ensure that barriers safeguard workers, patients, the general public, and the environment from the harmful radiation emitted by X-ray machines. The National Council on Radiation Protection and Measurements (NCRP) 147 method is widely accepted within the radiation protection experts' (RPEs) community for structural shielding design for medical X-ray imaging facilities. However, these indications are based on data collected in 1996. In recent years, interventional radiology procedures have seen significant developments. Therefore, it is important to evaluate whether updating the data on workload in the different specialities is necessary. We extracted all interventional radiology exposure data parameters from three angiographs from two vendors using dose monitoring software for 3066 procedures and 214,697 individual exposures. The workload distribution as a function of the kVp for five interventional rooms was calculated by summing all exposures and then normalising them by the number of patients. Analysing this data, we obtained new transmission curves through lead, concrete and gypsum wallboard, finding the parameters (α, β, and γ) in the Archer equation for the secondary radiation. Finally, our aim was to share an example of shielding calculations for haemodynamics and neuroangiography rooms to illustrate the impact of updated transmission data.

Prevention of contrast-associated acute kidney injury in an era of increasingly complex interventional procedures

Radiological and interventional cardiology procedures are in continuous expansion, leading to an important increase in the incidence of contrast-associated acute kidney injury (CA-AKI). Although numerous methods of CA-AKI prevention have been studied, at present, there is no consensus on the definition of this entity or on its prevention. In this paper, we aim to provide a critical analysis of the existing data on the epidemiology, pathophysiology, and clinical significance of CA-AKI. Existing and emergent approaches for CA-AKI prevention are also discussed, with a focus on parenteral fluid administration and on the most recent clinical and experimental data. We also emphasize a number of questions that remain to be answered, and we identify hotspots for future research.

Geographical variation of emergency hospital admissions for ambulatory care sensitive conditions in older adults in Ireland 2012-2016

OBJECTIVE

Ambulatory care sensitive (ACS) conditions are those for which intensified primary care management could potentially prevent emergency admissions. This study aimed to quantify geographical variation in emergency admissions with ACS conditions in older adults and explore factors influencing variation.

DESIGN

Repeated cross-sectional study.

SETTING

34 public hospitals in the Ireland.

PARTICIPANTS

Adults aged ≥65 years hospitalised for seven ACS conditions between 2012 and 2016 (chronic obstructive pulmonary disease, congestive heart failure (CHF), diabetes, angina, pyelonephritis/urinary tract infections (UTIs), dehydration and pneumonia).

PRIMARY OUTCOME MEASURE

Age and sex standardised emergency admission rates (SARs) per 1000 older adults.

ANALYSIS

Age and sex SARs were calculated for 21 geographical areas. Extremal quotients and systematic components of variance (SCV) quantified variation. Spatial regression analyses was conducted for SARs with unemployment, urban population proportion, hospital turnover, supply of general practitioners (GPs), and supply of hospital-based specialists as explanatory variables.

RESULTS

Over time, an increase in UTI/pyelonephritis SARs was seen while SARs for angina and CHF decreased. Geographic variation was moderate overall and high for dehydration and angina (SCV=11.7-50.0). For all conditions combined, multivariable analysis showed lower urban population (adjusted coefficient: -2.2 (-3.4 to -0.9, p<0.01)), lower GP supply (adjusted coefficient: -5.5 (-8.2 to -2.9, p<0.01)) and higher geriatrician supply (adjusted coefficient: 3.7 (0.5 to 6.9, p=0.02)) were associated with higher SARs.

CONCLUSIONS

Future research should evaluate methods of preventing admissions for ACS conditions among older adults, including how resources are allocated at a local level.

Information Needs in Percutaneous Coronary Artery Intervention: Validation and Reliability Analysis of NPCI-10 Item Scale

Introduction: Percutaneous coronary intervention (PCI) is a nonsurgical procedure used in the treatment of coronary heart disease.

Purpose: The purpose of this study was to validate a scale created in order to assess the importance and fulfillment of information needs in patients after PCI.

Methods: A 10-item scale was created by the researchers to explore the level of information needs and the level of fulfillment of these needs. The total scores have a possible range of 10 to 40 with higher scores indicating higher importance and fulfillment. The validation of the questionnaire included face and content validity, construct validity, internal consistency, repeatability, and discriminant validity.

Results: Forty patients contributed to this validation. Mean and median scores for each question separately and also overall scores suggest that patients consider the need to be informed very important and that it was fulfilled to a very high degree (mean scores 39.5 and 39.3, respectively). All questions were found to be significantly correlated with the overall scores (rho > 0.3) meaning strong construct validity. Cronbach’s α coefficients were high (>0.7) indicating great consistency. Both total scores had great repeatability, which suggests a high degree of reliability of the participants' responses (ICCs > 0.8). Regarding discriminant validity, a statistically significant association was observed only between marital status and the degree of fulfillment of the need to be informed (p = 0.036). More specifically, divorced or widowed patients had a lower degree of fulfillment than married patients (mean 38.6 vs. 39.6).

Conclusion: It is a reliable instrument that will help clinicians who are at close contact with patients after PCI to gain a better understanding of their needs.

AN INTERVENTIONAL CARDIOLOGY INVESTIGATION: PATIENT EXPOSURE TO RADIATION AND INTER-OPERATOR VARIABILITY IN AN IRISH SETTING

AIM

To evaluate patient radiation exposure for Diagnostic Coronary Angiography (DCA) and Percutaneous Cardiac Intervention (PCI) performed by different operators.

METHODS AND RESULTS

Retrospective (n = 160) and prospective (n = 62) data for DCA (n = 179) and PCI (n = 43) examinations performed by interventional cardiologists (n = 3) using the same imaging equipment were reviewed. The operator with consistently low diagnostic reference levels (DRLs) was interviewed for their personal perceptions upon operator training. Retrospective Median [IQR] DAP was 18.8 [11.8-31.6] and 50.7 [35.3-85.6] Gy.cm2 for DCA and PCI, respectively. Prospective Median [IQR] DAP for DCA and PCI was 7.9 [5.2-10.6] and 15.9 [10.0-17.7] Gy.cm2, respectively. DRLs were within Irish and European DRLs; however, significant inter-operator variability (p < .001) was identified.

CONCLUSION

Radiation exposure in Interventional cardiology is highly operator dependent; further research is warranted in standardization of operator training with evolving technologies.

Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments

OBJECTIVE

To determine whether sex differences exist in the triage, management and outcomes associated with non-traumatic chest pain presentations in the emergency department (ED).

METHODS

All adults (≥18 years) with non-traumatic chest pain presentations to three EDs in Melbourne, Australia between 2009 and 2013 were retrospectively analysed. Data sources included routinely collected hospital databases. Triage scoring of the urgency of presentation, time to medical examination, cardiac troponin testing, admission to specialised care units, and in-ED and in-hospital mortality were each modelled using the generalised estimating equations approach.

RESULTS

Overall 54 138 patients (48.7% women) presented with chest pain, contributing to 76 216 presentations, of which 26 282 (34.5%) were cardiac. In multivariable analyses, compared with men, women were 18% less likely to be allocated an urgency of 'immediate review' or 'within 10 min review' (OR=0.82, 95% CI 0.79 to 0.85), 16% less likely to be examined within the first hour of arrival to the ED by an emergency physician (0.84, 0.81 to 0.87), 20% less likely to have a troponin test performed (0.80, 0.77 to 0.83), 36% less likely to be admitted to a specialised care unit (0.64, 0.61 to 0.68), and 35% (p=0.039) and 36% (p=0.002) more likely to die in the ED and in the hospital, respectively.

CONCLUSIONS

In the ED, systemic sex bias, to the detriment of women, exists in the early management and treatment of non-traumatic chest pain. Future studies that identify the drivers explaining why women presenting with chest pain are disadvantaged in terms of care, relative to men, are warranted.

Appropriate use of elective coronary angiography in patients with suspected stable coronary artery disease

INTRODUCTION

The American College of Cardiology Foundation (ACCF) with other professional societies developed appropriate use criteria (AUC) for diagnostic coronary angiography. This study aims to examine the appropriate use of elective coronary angiography for patients with suspected stable coronary artery disease in an Irish tertiary referral center.

METHODS

A retrospective chart review of all elective outpatient diagnostic coronary angiograms performed in Cork University Hospital in 2014 was carried out. Data on demographics, risk factors, clinical presentation, and prior non-invasive investigations were extracted. Each patient was evaluated according to the 2012 ACCF appropriate use criteria and classified as appropriate, uncertain, or inappropriate. Univariable and multivariable logistic regression analysis was performed to investigate the factors that predict patients undergoing appropriate diagnostic coronary angiography.

RESULTS

Of 417 elective outpatient diagnostic coronary angiograms, 259 (62%) were included in the analysis. Of these, 108 (42%) were classified as appropriate, 97 (37%) as uncertain, and 54 (21%) as inappropriate. In multivariable analysis, those with private health insurance were more likely to have an appropriate indication for coronary angiogram (OR 2.1, 95% CI 1.2-3.7) as were those with atrial fibrillation (OR 3.9, 95% CI 1.2-12.8). Ever smokers were less likely to have an appropriate indication for coronary angiogram than never smokers (OR 0.5, 95% CI 0.3-0.9).

CONCLUSION

This is the first Irish study to evaluate the appropriate use of elective coronary angiography. Rates were similar to those of studies in other jurisdictions; however, there remains significant potential for quality improvement.

Mechanical Criterion for the Rupture of a Cell Membrane under Compression

We investigate the mechanical conditions leading to the rupture of the plasma membrane of an endothelial cell subjected to a local, compressive force. Membrane rupture is induced by tilted microindentation, a technique used to perform mechanical measurements on adherent cells. In this technique, the applied force can be deduced from the measured horizontal displacement of a microindenter's tip, as imaged with an inverted microscope and without the need for optical sensors to measure the microindenter's deflection. We show that plasma membrane rupture of endothelial cells occurs at a well-defined value of the applied compressive stress. As a point of reference, we use numerical simulations to estimate the magnitude of the compressive stresses exerted on endothelial cells during the deployment of a stent.

Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications - a nationwide population-based study

Background

The volume and percentage of percutaneous coronary interventions (PCIs) performed for nonacute indications have declined in the United States since 2007. However, little is known if similar trends occurred in Taiwan.

Methods

We used data from Taiwan National Health Insurance inpatient claims to examine the regional and hospital variations in the extent of decline in the percentage of nonacute indication PCIs from 2007 to 2012.

Results

The volume of total PCIs persistently increased from 29,032 in 2007 to 35,811 in 2010 and 37,426 in 2012. However, the volume of nonacute indication PCIs first increased from 7916 in 2007 to 9143 in 2009 and then decreased to 8666 in 2012. The percentage of nonacute indication PCIs steadily decreased from 27% in 2007 to 26% in 2009 and then to 23% in 2012, a − 15% change. The extent of decline was largest in the North region (from 27% to 21%, a − 22% change) and least in Kaopin region (from 20% to 18%, a − 13% change). Of the 71 hospitals studied, 14 did not show a decreasing trend. Five of the 14 hospitals even showed an increasing trend, with a percentage change >10% between 2007 and 2012. In 2012, 6 hospitals had a nonacute indication PCI percentage >35%.

Conclusions

In Taiwan, four-fifths of the hospitals showed a decline in the percentage of nonacute indication PCIs from 2007 to 2012. It is plausible that Taiwanese cardiologists would have been influenced by the recommendations of crucial US trials and guidelines.

Denmark: coronary and structural heart interventions from 2010 to 2015

Interventional cardiology in Denmark has been carried out since the mid 1980s. Interventional cardiology is only performed at a few high-volume centres. Healthcare coverage is universal and is essentially free of charge. Hospitals are mostly publicly owned and financed by fixed budgets and, in part, an activity-based funding system. Approximately 30,000 coronary angiographies (CAG), 10,000 percutaneous coronary interventions (PCIs) of which approximately 25% are primary PCIs, and 500 transcatheter aortic valve implantations (TAVIs) are carried out each year. The numbers of CAG and PCI have reached a plateau in recent years, whereas structural heart interventions, in particular TAVI, are increasing. Around 90% of all patients treated with PCI have a stent implanted, with more than 95% of these being drug-eluting stents. There is a low but increasing use of bioabsorbable scaffolds and drug-eluting balloons.