NATIONAL DIAGNOSTIC REFERENCE LEVELS IN INTERVENTIONAL RADIOLOGY SUITES IN LEBANON: A MULTICENTER SURVEY.

Air kerma-area product (PKA), cumulative air kerma at patient entrance reference point, fluoroscopy time and number of images were retrospectively collected from 15 hospitals in Lebanon for 11282 fluoroscopically-guided interventional (FGI) procedures between March 2016 and November 2018. National diagnostic reference levels (NDRLs) were established based on the third quartile of the distribution of median values of exposure parameters per department for 27 types of FGI procedures. NDRLs were in line with international DRLs except for coronary angiography (CA), percutaneous coronary interventions (PCI) and transcatheter aortic valve implantation (TAVI) which require optimisation. Additionally, following the National Council on Radiation Protection and Measurements report 168, PCI, TAVI, triple chamber pacemaker implantation, endovascular aortic repair, nephrostomy, kyphoplasty and percutaneous transhepatic biliary drainage were classified as potentially high-dose procedures with >5% of the patients with PKA exceeding 300 Gycm2. The established NDRLs will promote dose optimisation and patient radiation protection.

MEASUREMENT OF PATIENT SKIN DOSE DISTRIBUTIONS IN THREE LEBANESE INTERVENTIONAL CARDIOLOGY SUITES.

Using a mesh of 30 thermoluminescent dosemeters, adults' patient skin doses were measured for 99 coronary angiography (CA) and 89 percutaneous coronary interventions (PCI) performed in three Lebanese hospitals. Average peak skin dose (Dskin,max) were 152 mGy (range: 16-1144) for CAs and 576 mGy (range: 7-3361) for PCIs. While only four patients had a Dskin,max value exceeding the 2 Gy threshold for skin injuries, several patients had skin dose values above 1 Gy at several distinct locations proving that Dskin,max alone is not sufficient for repetitive procedures; 2D dose maps are required instead. Dskin,max correlated well with total air kerma-area product (PKA,T) for PCI in Hospitals 1 and 2 (R = 0.91 and 0.76, respectively) enabling the setup of an alert level at PKA,T = 240 and 210 Gy cm2, respectively, corresponding to a Dskin,max of 2 Gy. This was not possible for Hospital 3 due to weak correlations between Dskin,max and PKA,T.

OCCUPATIONAL DOSES FOR THE FIRST AND SECOND OPERATORS IN LEBANESE INTERVENTIONAL CARDIOLOGY SUITES.

The study monitored occupational dose for 12 interventional cardiologists (first operators) and 10 technicians (second operators), from 10 different Lebanese hospitals performing coronary angiography and precutaneous coronary interventions exclusively on adult patients. Each individual wore dosemeters under and over the lead apron at chest and collar level, respectively, on the wrist and next to the left eye. The total follow-up period for each first/second operator varied between two to six bimonthly monitoring periods. For the first operator, the mean (range) effective, hand and eye lens doses were of 6 (1-41), 112 (10-356) and 15 (5-47) µSv/procedure, respectively. These were of 2.3 (0.1-8), 16 (2-109) and 7 (2-14) µSv/procedure for the second operator. Extrapolated annual eye lens doses revealed that both first and second operators may exceed 3/10th of the annual eye lens dose permissible limit thus supporting the need for dedicated eye lens monitoring.

Establishing the European diagnostic reference levels for interventional cardiology.

Interventional cardiac procedures may be associated with high patient doses and therefore require special attention to protect the patients from radiation injuries such as skin erythema, cardiovascular tissue reactions or radiation-induced cancer. In this study, patient exposure data is collected from 13 countries (37 clinics and nearly 50 interventional rooms) and for 10 different procedures. Dose data was collected from a total of 14,922 interventional cardiology procedures. Based on these data European diagnostic reference levels (DRL) for air kerma-area product are suggested for coronary angiography (CA, DRL = 35 Gy cm2), percutaneous coronary intervention (PCI, 85 Gy cm2), transcatheter aortic valve implantation (TAVI, 130 Gy cm2), electrophysiological procedures (12 Gy cm2) and pacemaker implantations. Pacemaker implantations were further divided into single-chamber (2.5 Gy cm2) and dual chamber (3.5 Gy cm2) procedures and implantations of cardiac resynchronization therapy pacemaker (18 Gy cm2). Results show that relatively new techniques such as TAVI and treatment of chronic total occlusion (CTO) often produce relatively high doses, and thus emphasises the need for use of an optimization tool such as DRL to assist in reducing patient exposure. The generic DRL presented here facilitate comparison of patient exposure in interventional cardiology.

A STUDY ON THE UNCERTAINTY FOR THE ROUTINE DOSIMETRY SERVICE AT THE LEBANESE ATOMIC ENERGY COMMISSION USING HARSHAW 8814 DOSEMETERS.

The personal dosimetry service at the Lebanese Atomic Energy Commission uses Harshaw 8814 cards with LiF:Mg,Ti detectors. The dosemeters are read in a Harshaw 6600 TLD reader. In the process of accreditation for the ISO 17025 standard((1)), different influence factors are investigated and the uncertainty has been determined. The Individual Monitoring Service Laboratory-LAEC reads the dosemeters once it receives them from the customer, and new cards are immediately given for the next wearing period. The wearing period is 2 months. The dosemeter results are reported to the customers without background subtraction. Both Hp(10) and Hp(0.07) are reported. For this paper, only the uncertainty on Hp(10) will be focussed. The following factors are taken into account for the uncertainty: calibration factor, dosemeter homogeneity and repeatability, energy and angular dependence, non-linearity, temperature dependence, etc. Also the detection limit was determined. One of the important factors is the correction for fading. This fading correction depends on the procedure used such as storage temperatures, the time-temperature profile of the read-out, pre-heat and annealing conditions. Pre- and post-irradiation fading curves were measured for a storage period up to 182 d at room temperature (15-25°C). The resulting final combined standard uncertainty on the reported doses is of the order of 24 % for doses of ∼1 mSv.

Placental transmogrification of the lung, a histologic variant of giant bullous emphysema. Clinicopathological study of three further cases.

Placental transmogrification of the lung was described by Chesney in 1978 as an unusual cystic lesion involving a single pulmonary lobe (3). We studied three additional cases with identical clinical and pathologic features. The patients were a 33-year-old woman and men aged 24 and 27 years. Each patient was first seen with respiratory distress; one had repeated pneumothoraces. Radiographically, an enlarging cystic lesion was present in a lower (two) or middle (one) lobe. The lesion had been present for 10 years in one patient. In two patients, mediastinal shift was noted. Lobectomy was curative in all instances. Grossly there was a uni- or paucilocular cyst lined by papillary structures. Microscopically, the papillae contained proliferating blood vessels, lymphoid nodules, smooth muscle, and fat. Sclerotic foci obliterated the vessels in some areas. The growth pattern and topography resembled those of placental villi. Systematic review of the histologic features in other lungs with marked emphysema revealed a spectrum of similar changes and suggested that the lesion in our patients may be a complication of bulla formation and is most likely the clinico-pathologic analog of the "vanishing lung" syndrome (idiopathic giant bullous emphysema).

Epididymal metastasis from prostatic adenocarcinoma mimicking adenomatoid tumor.

A case of epididymal metastasis from prostatic carcinoma is presented. The initial histologic findings were suggestive of adenomatoid tumor, but a diagnosis of metastatic adenocarcinoma of prostatic origin has been established by prostatic acid phosphatase and prostate-specific antigen immunoperoxidase staining.

[Long QTc interval complicating halofantrine therapy in 2 children with Plasmodium falciparum malaria]. / Allongement de l'espace QTc compliquant la prescription d'halofantrine chez deux enfants présentant un accès palustre à Plasmodium falciparum.

UNLABELLED: Halofantrine has been shown to be very effective against multiple drug resistant falciparum malaria. It is usually administered in children at 24 mg/kg at six-hour intervals for three doses, and a second therapeutic course one week following the initial treatment is recommended. It is usually well tolerated. However, prolongation of the QT interval has been reported in adults receiving this drug for malaria. CASES REPORTS: Two children experienced a prolongation of the QTc interval while receiving halofantrine. The first child, aged two years, had a prolonged QTc interval (490 ms) six hours after the third administration, at the usual therapeutic dose. The second child, aged six years, had a normal QT interval (360 ms) after the first 24 mg/kg dose and had a prolonged QTc (450 ms) during the second course seven days later, 15 h after the last dose. In both cases, the QTc interval returned to normal values (below 440 ms) rapidly after the end of treatment. CONCLUSION: Cardiotoxic effects are felt to be dose-dependant and young children may be particularly at risk due to pharmacological and cardiac immaturity. Therefore, guidelines for drug administration should be followed (administration in a child with an empty stomach, drug not recommended in combination with drugs known to prolong the QTc interval) and monitoring ECG in pediatric patients may be justified. The modalities of the second course in children, which is recommended by the manufacturer to travellers from non-endemic areas, should also be discussed.

[Severe lactic acidosis disease disclosing milk-protein intolerance to cows' milk]. / Malaise grave avec acidose lactique révélant une intolérance aux protéines du lait de vache.

UNLABELLED: The age of discovery and initial symptoms of cow milk allergy can vary. Lactic acidosis is exceptionally associated to this allergy. CASE REPORT: A 32-day-old girl was admitted for a severe malaise with metabolic acidosis and hyperlactacidemia. There were no neonatal or family problems; breastfeeding was stopped on the 25th day. Fever was noted on the 29th day and her mother reported behavior anomalies followed by a severe malaise with unconsciousness between the 29th and 32nd day. At admission, the infant showed a severe neurological distress, hypotonia and lethargy. Infection and neurological imaging were normal. A compensated metabolic acidosis with hyperlactacidemia (5.96 mmol/L) was noted. There was no argument for esophageal reflux nor vagal hypertony; mitochondrial cytopathy was also excluded. After a 24 hours fast, the clinical state gradually improved and normalized at h48. The infant was discharged with a milk protein hydrolysate formula. Her mother attempted to reintroduce cow milk on the 59th and 64th day, but this was immediately followed by allergic manifestations which supported the diagnosis of cow milk allergy. CONCLUSION: Neurological distress and hyperlactacidemia exceptionally reveal this type of intolerance. The mechanism of hyperlactacidemia remains unclear; it is possibly the consequence of severe changes of the intestinal mucosa, an exclusive glycolytic tissue.

Double-blind randomized evaluation of clinical and biological tolerance of polyethylene glycol 4000 versus lactulose in constipated children.

OBJECTIVES: To assess the safety of a polyethylene glycol (PEG) 4000 laxative without additional salts in pediatric patients. STUDY DESIGN: This was a 3-month multicenter, randomized, double-blind, double-dummy, lactulose-controlled, parallel study enrolling 96 ambulatory constipated children aged 6 months to 3 years, treated daily with 4-8 g PEG or 3.33 g-6.66 g lactulose. Total protein, albumin, iron, electrolytes, and vitamins B9 (folates), A and D (25OHD3) were measured in blood before and after treatment (day 84) in a central laboratory. RESULTS: The percentage of children with at least one value out of normal range at day 84 with respect to baseline status (with or without at least one value out of normal range), i.e. the primary endpoint, was 87% and 90% in the PEG and lactulose groups, respectively, without any difference between groups. The whole blood parameters showed no qualitative or quantitative treatment-related changes. Vitamin A values were above normal range in 56% and 41% of children at baseline versus 33% and 36% at day 84 in the PEG and lactulose groups, respectively. Iron values were similarly under normal range in 47% and 51% at baseline versus 42% and 51% at day 84. Clinical tolerance was similar for both treatments except for vomiting and flatulence, which were significantly higher with lactulose. Significantly higher improvements were evidenced with PEG regarding stool consistency, appetite, fecaloma and use of additional laxatives. CONCLUSION: This 3-month study in 96 constipated children aged 6 months to 3 years confirms the long-term tolerance of PEG 4000 in pediatrics and indicates a PEG efficacy similar to or greater than that of lactulose.

A diffuse infiltrative CD8 lymphocytosis syndrome in human immunodeficiency virus (HIV) infection: a host immune response associated with HLA-DR5.

STUDY OBJECTIVE: To describe the clinical, immunologic, and immunogenetic features of a diffuse infiltrative lymphocytic disorder resembling Sjögren syndrome in persons infected with human immunodeficiency virus (HIV). DESIGN: Clinical case study. SETTING: University-affiliated hospitals and outpatient clinics. PATIENTS: Consecutive sample of 17 patients. MEASUREMENTS AND MAIN RESULTS: All of the 17 patients had bilateral parotid gland enlargement; 14 had xerostomia and 6 had xerophthalmia. Of the 17 patients, 14 had generalized lymphadenopathy, 10 had histologically proved lymphocytic interstitial pneumonitis, 4 had neurologic involvement, and 3 had lymphocytic infiltration of the gastrointestinal tract. Gallium scanning in all of 11 tested patients showed abnormal salivary gland uptake. Minor salivary gland biopsies showed more than 2 lymphocytic foci per 4 mm2 tissue in all of 11 tested patients, the infiltrate consisting predominantly of CD8 cells. Fifteen patients had circulating CD8 lymphocytosis; the principal phenotype of these cells was CD8+ CD29+. Rheumatoid factor and antinuclear antibodies were infrequent, and none of the patients had anti-Ro/SS-A or anti-La/SS-B antibodies. HLA-DR5 was significantly more frequent in the black patients (10 of 12) compared with controls (13 of 45). Only one patient developed an opportunistic infection during 544 patient-months of study, and none has died of AIDS. CONCLUSIONS: A distinct syndrome primarily characterized by parotid gland enlargement, sicca symptoms, and pulmonary involvement occurs in HIV infection. This disorder is associated with CD8 lymphocytosis and the presence of HLA-DR5, and appears to be a genetically determined host immune response to HIV.

IgM monoclonal gammopathy/Waldenström's macroglobulinemia: a morphological and immunophenotypic study of the bone marrow.

The presence of a monoclonal paraprotein in the serum or urine raises the possibility of myeloma or lymphoma/leukemia. Yet, in a significant proportion of individuals with serum paraproteins, particularly those with low levels of paraprotein, clinical and routine bone marrow evaluation is not diagnostic of an underlying neoplasm. The purpose of this study was to define the pathologic basis for macroglobulinemia in patients whose routine bone marrow biopsies were not diagnostic of a lymphoplasmacytic neoplasm. We used immunofluorescence microscopy and flow cytometry of cell suspensions prepared from aspirated marrow, as well as immunohistochemistry of core biopsies, to perform immunopathologic evaluations of the bone marrow from 16 such patients. Seven individuals without a monoclonal serum paraprotein, who were similarly studied, served as controls. Our data indicate that 13 of the 16 patients with monoclonal serum IgM paraproteins whose routine bone marrow biopsies were normal or showed nondiagnostic changes morphologically had a dispersed monotypic B lineage population of concordant immunoglobulin heavy and light chain type in the bone marrow. The immunophenotype of these cells spanned the range from mature B cell to plasmacytoid B cell to plasma cell. In four of these 13 patients a diagnosis of lymphoplasmacytic lymphoma could be made on the basis of greater than or equal to 20% monoclonal B lineage cells among bone marrow mononuclear cells.