An Investigation of Procedural Radiation Dose Level Awareness and Personal Training Experience in Communicating Ionizing Radiation Examinations Benefits and Risks to Patients in Two European Cardiac Centers

PURPOSE

Cardiac interventional practitioners need to be appropriately informed regarding radiation dose quantities and risks. Communicating benefit-risk information to patients requires attention as specified in Basic Safety Standards Directive 2013/59/Eurotom. This study investigated the awareness of procedural radiation dose levels and the impact of personal training experience in communicating ionizing radiation benefit-risks to patients.

METHODOLOGY

A questionnaire, consisting of 28 questions, was distributed directly to adult and pediatric interventional cardiology specialists at specialized cardiovascular imaging centers in Dublin, Ireland and Milan, Italy.

RESULTS

A total of 18 interventional cardiologists (senior registrar to consultant grades with between 2 y to over 21 y experience in cardiac imaging) participated. The majority of participants (n = 17) stated that parents of pediatric and adult patients should be informed of the potential benefits and risk. All participants indicated they had radiation safety training; however, 50% had not received training in radiation examination benefit-risk communication. Despite this, 77.8% (n = 14) participants indicated a high confidence level in successfully explaining risks and/or benefits of cardiac imaging procedures. When asked to estimate effective dose (ED) values for common cardiac imaging procedures less than 50% identified appropriate dose ranges. All participants underestimated procedural dose values based on recent European data. 50% (n = 9) participants answered all questions correctly for a number of true or false radiation risk statements.

CONCLUSION

Benefit-risk communication training deficits and inaccurate understanding of radiation dose levels was identified. Further research and training to support clinicians using radiation on a daily basis is required.

Outcomes from penetrating ballistic cervical injury

AIMS

Ballistic cervical injury has become a significant source of both morbidity and mortality for the deployed UK soldier. The aim of this paper was to document a case series of ballistic cervical wounds to describe the pattern of these injuries and relate them to outcome.

METHODS

The records of all UK service personnel sustaining wounds to the neck in Iraq or Afghanistan between 01 August 2004 and 01 January 2008 were analysed following identification by the Joint Theatre Trauma Registry. Blunt or thermal injuries were excluded.

RESULTS

The records of 75/76 service personnel sustaining penetrating cervical injury during this period were available for analysis. 56/75 (75%) were due to explosive fragmentation and the remainder due to gunshot wounds (GSW). 33/75 (44%) of soldiers sustained vascular injury, 32/75 (43%) injury to the spine or spinal cord, 29/75 (39%) injury to the larynx or trachea and 11/75 (15%) injury to the pharynx or oesophagus. 14/75 (19%) patients in this series underwent surgery in a hospital facility for treatment of potentially life threatening cervical injuries, with a survival rate after surgery of 12/14 (86%). The overall mortality from this series of battlefield penetrating neck injury was 63%.

CONCLUSIONS

Penetrating cervical ballistic injury is a significant source of injury to deployed UK service personnel, predominantly due to neurovascular damage. Neck collars if worn would likely prevent many of the injuries in this case series but such protection is uncomfortable and may interfere with common military tasks. Newer methods of protecting the neck should be investigated that will be acceptable to the deployed UK soldier.

Self assessment questions in ear, nose & throat surgery

Ear, nose and throat conditions make up a large amount of a Medical Officer's clinical workload. The examples given here illustrate some principles that should be employed when dealing with such problems.

Follicular phase hypothalamic-pituitary-gonadal axis function in women with fibromyalgia and chronic fatigue syndrome

OBJECTIVE

Fibromyalgia (FM) and chronic fatigue syndrome (CFS) are clinically overlapping stress associated disorders. Neuroendocrine perturbations have been noted in both syndromes, and they are more common in women, suggesting abnormalities of gonadal steroid hormones. We tested the hypothesis that women with FM and CFS manifest abnormalities of the hypothalamic-pituitary-gonadal (HPG) hormonal axis.

METHODS

We examined the secretory characteristics of estradiol, progesterone, follicle stimulating hormone (FSH), and luteinizing hormone (LH), including a detailed analysis of LH in premenopausal women with FM (n = 9) or CFS (n = 8) during the follicular phase of the menstrual cycle compared to matched healthy controls. Blood was collected from an indwelling intravenous catheter every 10 min. over a 12 h period. LH was assayed from every sample; pulses of LH were identified by a pulse-detection program. FSH and progesterone were assayed from a pool of hourly samples for the 12 h period and estradiol from samples pooled over four 3 h time periods.

RESULTS

There were no significant differences in FSH, progesterone, or estradiol levels in patients versus controls. There were no significant differences in pulsatile secretion of LH.

CONCLUSION

There is no indication of abnormal gonadotropin secretion or gonadal steroid levels in this small, but systematic, study of HPG axis function in patients with FM and CFS.

Melatonin levels in women with fibromyalgia and chronic fatigue syndrome

OBJECTIVE

Fibromyalgia (FM) and chronic fatigue syndrome (CFS) are stress associated disorders mainly affecting women. FM is characterized primarily by widespread musculoskeletal pain, and CFS by profound debilitating fatigue, but there is considerable overlap of clinical symptoms between these 2 syndromes. Neuroendocrine abnormalities have been noted in both FM and CFS and desynchronization of circadian systems has been postulated in their etiology. The pineal hormone melatonin is involved in synchronizing circadian systems and the use of exogenous melatonin has become widespread in patients with FM and CFS.

METHODS

We examined the characteristics and relationship of melatonin and cortisol levels in premenopausal women with FM (n = 9) or CFS (n = 8), compared to age and menstrual cycle phase matched controls. Blood was collected from an indwelling intravenous catheter every 10 min over 24 h, and plasma melatonin and cortisol were determined by radioimmunoassay at 60 and 10 min intervals, respectively.

RESULTS

Night time (23:00-06:50) plasma melatonin levels were significantly higher in FM patients compared to controls (p<0.05), but there was no significant difference in melatonin levels between CFS patients and controls. No differences in the timing of cortisol and melatonin secretory patterns and no internal desynchronization of the 2 rhythms were found in either patient group, compared to controls.

CONCLUSION

Raised plasma melatonin concentrations have been documented in several other conditions that are associated with dysregulation of neuroendocrine axes. Increased melatonin levels may represent a marker of increased susceptibility to stress induced hypothalamic disruptions. These data indicate that there is no rationale for melatonin replacement therapy in patients with FM and CFS.

Structure-activity relationships for a class of inhibitors of purine nucleoside phosphorylase

Values of inhibition constants, Ki, for a family of structurally related, competitive inhibitors of calf spleen purine nucleoside phosphorylase (PNP) have been determined employing both inosine as substrate and a manual assay and 2-amino-6-mercapto-7-methylpurine ribonucleoside (MESG) as substrate and a robot-based enzyme kinetics facility. Several of the values determined robotically were confirmed employing the same substrate and a manual assay. Surprisingly, for many of the inhibitors examined, values of Ki determined with MESG as substrate are smaller than those obtained employing inosine as substrate by a factor that varies from less than 2 to 10. Values of concentrations required for 50% inhibition of PNP, IC50, have also been determined for the same family of inhibitors employing inosine as substrate. Values of IC50ino and those for Kiino and Kimesg for subsets of the inhibitors have been employed as training sets to create quantitative structure-activity relationships (QSAR) which have substantial power to predict values of IC50 and Ki for inhibitors outside the training set. These QSAR models should be useful in guiding future medicinal chemistry efforts designed to discover inhibitors of PNP having increased potency.

Parasitic infections in a pediatric population

We studied the frequency of parasitic infection and associated clinical symptoms in children who attended general pediatric and dental clinics at UCLA. Parasites were detected in stool specimens of 40 (38%) of the 1-4 children completing the study. Protozoan parasites were recovered in 39 (38%); one child had whipworm eggs. Parasites included Dientamoeba fragilis in 22 (21%) children and Giardia lamblia in 18 (17%) children; commensals were observed in 15 (14%) children. Parasitic infection was more frequent in younger children, those with a history of immigration or foreign travel and those attending a day care center. A significant proportion of children with parasites had vague gastrointestinal complaints; however, parasites had not been considered as the etiologic agent by the parent or child's physician. Anorexia, irritability and gas were frequent in children with G. lamblia; abdominal pain was more frequent in those with D fragilis. Intestinal parasitic infection should be considered in children with vague gastrointestional complaints, particularly those in endemic areas, with a history of foreign travel or immigration or attending a day care center. Siblings of infected children should have stool examination even if asymptomatic.