Early cryoprecipitate transfusion versus standard care in severe postpartum haemorrhage: a pilot cluster-randomised trial.

There is a lack of evidence evaluating cryoprecipitate transfusion in severe postpartum haemorrhage. We performed a pilot cluster-randomised controlled trial to evaluate the feasibility of a trial on early cryoprecipitate delivery in severe postpartum haemorrhage. Pregnant women (>24 weeks gestation), actively bleeding within 24 h of delivery and who required at least one unit of red blood cells were eligible. Women declining transfusion in advance or with inherited clotting deficiencies were not eligible. Four UK hospitals were randomly allocated to deliver either the intervention (administration of two pools of cryoprecipitate within 90 min of first red blood cell unit requested plus standard care), or the control group treatment (standard care, where cryoprecipitate is administered later or not at all). The primary outcome was the proportion of women who received early cryoprecipitate (intervention) vs. standard care (control). Secondary outcomes included consent rates, acceptability of the intervention, safety outcomes and preliminary clinical outcome data to inform a definitive trial. Between March 2019 and January 2020, 199 participants were recruited; 19 refused consent, leaving 180 for analysis (110 in the intervention and 70 in the control group). Adherence to assigned treatment was 32% (95%CI 23-41%) in the intervention group vs. 81% (95%CI 70-90%) in the control group. The proportion of women receiving cryoprecipitate at any time-point was higher in the intervention (60%) vs. control (31%) groups; the former had fewer red blood cell transfusions at 24 h (mean difference -0.6 units, 95%CI -1.2 to 0); overall surgical procedures (odds ratio 0.6, 95%CI 0.3-1.1); and intensive care admissions (odds ratio 0.4, 95%CI 0.1-1.1). There was no increase in serious adverse or thrombotic events in the intervention group. Staff interviews showed that lack of awareness and uncertainty about study responsibilities contributed to lower adherence in the intervention group. We conclude that a full-scale trial may be feasible, provided that protocol revisions are put in place to establish clear lines of communication for ordering early cryoprecipitate in order to improve adherence. Preliminary clinical outcomes associated with cryoprecipitate administration are encouraging and merit further investigation.

Virtual reality for acute pain in outpatient hysteroscopy: a randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness of virtual reality as a distraction technique in the management of acute pain and anxiety during outpatient hysteroscopy. DESIGN: Parallel group, prospective randomised controlled trial. SETTING: UK University Hospital. METHODS: Forty consenting, eligible women were randomised to virtual reality intervention (immersive video content as a distraction method) or standard care during outpatient hysteroscopy from August to October 2018. MAIN OUTCOME MEASURES: Pain and anxiety outcomes were measured as a numeric rating score (scale 0-10). RESULTS: Compared with standard care, women with virtual reality intervention experienced less average pain (score 6.0 versus 3.7, mean difference 2.3, 95% CI 0.61-3.99, P = 0.009) and anxiety (score 5.45 versus 3.3, mean difference 2.15, 95% CI 0.38-3.92, P = 0.02). CONCLUSION: Virtual reality was effective in reducing pain and anxiety during outpatient hysteroscopy in a mixed-methods randomised control trial. Its wide potential role in ambulatory gynaecological procedures needs further evaluation. TWEETABLE ABSTRACT: Virtual reality can be used as a part of a multimodal strategy to reduce acute pain and anxiety in patients undergoing outpatient hysteroscopy.

Expression of glucose transporters in the prelaminar region of the optic-nerve head of the pig as determined by immunolabeling and tissue culture.

BACKGROUND: To develop the use of cultured tissue of the prelaminar optic nerve of the pig to explore possible alterations of the astrocyte-axon metabolic pathways in glaucoma, we map the distribution of the glucose transporters GLUT1 and GLUT3 in fresh and cultured tissue. METHODS: We monitor cell survival in cultures of the prelaminar optic-nerve tissue, measuring necrosis and apoptosis markers biochemically as well as morphologically, and establish the presence of the glucose transporters GLUT1 and GLUT3. We map the distribution of these transporters with immunolabeling in histological sections of the optic nerve using confocal and electronic transmission microscopy. RESULTS: We find that the main death type in prelaminar culture is apoptosis. Caspase 7 staining reveals an increment in apoptosis from day 1 to day 4 and a reduction from day 4 to day 8. Western blotting for GLUT1 shows stability with increased culture time. CLSM micrographs locate GLUT1 in the columnar astrocytes and in the area of axonal bundles. Anti-GLUT3 predominantly labels axonal bundles. TEM immunolabeling with colloidal gold displays a very specific distribution of GLUT-1 in the membranes of vascular endothelial cells and in periaxonal astrocyte expansions. The GLUT-3 isoform is observed with TEM only in axons in the axonal bundles. CONCLUSIONS: Tissue culture is suitable for apoptosis-induction experiments. The results suggest that glucose is transported to the axonal cleft intracytoplasmically and delivered to the cleft by GLUT1 transporters. As monocarboxylate transporters have been reported in the prelaminar region of the optic-nerve head, this area is likely to use both lactate and glucose as energy sources.

Utilidad del calcio arterial coronario para detectar enfermedad arterial coronaria significativa en sujetos asintomáticos / Usefulness of coronary artery calcium for detecting significant coronary artery disease in asymptomatic individuals

Objetivos: Confirmar el valor de la puntuación o score del calcio arterial coronario (CAC) como indicador de enfermedad arterial coronaria (EAC) significativa en población española asintomática, mediante coronariografía no invasiva por tomografía computarizada multidetector (TCMD). Métodos: Estudio retrospectivo de 232 individuos asintomáticos, remitidos para un chequeo de salud cardiovascular que incluyó CAC y TCMD. Resultados: La edad media de los sujetos estudiados fue de 54,6 años (DE: 12,8; 73,3% varones). El valor medio del CAC fue de 117,8 (DE: 277). Los individuos con hipertensión arterial, diabetes mellitus, tabaquismo y con ≥3 factores de riesgo mostraron un CAC significativamente mayor. Un 16,4% de los sujetos se encontraban en el percentil poblacional ≥75 de CAC. La TCMD identificó a 148 individuos (63,8%) con EAC, siendo las lesiones coronarias no significativas en 116 individuos (50%) y significativas (estenosis>50%) en 32 (13,8%). Los sujetos con diabetes, tabaquismo y ≥3 factores de riesgo vascular mostraron una mayor prevalencia de estenosis significativa. Los individuos con estenosis>50% presentaron valores de CAC superiores (352,5 vs. 1; p<0,0001) y los de percentil ≥75 presentaron un alto porcentaje de lesiones (57,9 vs. 5,2%; p<0,0001). Como variables predictoras de EAC significativa destacaron el CAC >300 (OR=10,9; IC95%: 3,35-35,8; p=0,0001), ocupar un percentil ≥75 (OR=5,65; IC95%: 1,78-17,93; p=0,03) y la agrupación de ≥3 factores de riesgo vascular (OR=4,19; IC95%: 1,44-12,14; p=0,008). Conclusión: La cuantificación del CAC es un método eficaz para determinar la extensión y magnitud de la EAC y delimitar la capacidad predictiva de los factores de riesgo tradicionales (AU)

Objectives: To confirm the value of the coronary artery calcium (CAC) score as an indicator of significant coronary artery disease (CAD) in the asymptomatic Spanish population, using noninvasive coronary angiography by multidetector computed tomography (MDCT). Methods: This was a retrospective study of 232 asymptomatic individuals, referred for a cardiovascular health checkup that included CAC and MDCT. Results: Participants’ mean age was 54.6 years (SD±12.8); 73.3% of them were men. The mean CAC value was 117.8 (SD±277). The individuals with arterial hypertension, diabetes mellitus, smoking and 3 or more risk factors had significantly greater CAC scores. Some 16.4% of the participants were in the ≥75 percentile population for CAC. The MDCT identified 148 individuals (63.8%) with CAD; the coronary lesions were not significant in 116 individuals (50%) and were significant (>50% stenosis) in 32 (13.8%). The participants with diabetes, smoking and ≥3 risk vascular factors had a greater prevalence of significant stenosis. The individuals with >50% stenosis had higher CAC values (352.5 vs. 1; P<.0001), and those in the ≥75 percentile had a high percentage of significant lesions (57.9% vs. 5.2%; P<.0001). The predictors of significant CAD were a CAC score >300 (OR=10.9; 95% CI 3.35-35.8; P=.0001), belonging to the ≥75 percentile (OR=5.65; 95% CI 1.78-17.93; P=.03) and having 3 or more vascular risk factors (OR=4.19; 95% CI 1.44-12.14; P=.008). Conclusion: CAC quantification is an effective method for determining the extent and magnitude of CAD and delimiting the predictive capacity of traditional risk factor (AU)

Usefulness of coronary artery calcium for detecting significant coronary artery disease in asymptomatic individuals.

OBJECTIVES: To confirm the value of the coronary artery calcium (CAC) score as an indicator of significant coronary artery disease (CAD) in the asymptomatic Spanish population, using noninvasive coronary angiography by multidetector computed tomography (MDCT). METHODS: This was a retrospective study of 232 asymptomatic individuals, referred for a cardiovascular health checkup that included CAC and MDCT. RESULTS: Participants' mean age was 54.6 years (SD ± 12.8); 73.3% of them were men. The mean CAC value was 117.8 (SD ± 277). The individuals with arterial hypertension, diabetes mellitus, smoking and 3 or more risk factors had significantly greater CAC scores. Some 16.4% of the participants were in the ≥75 percentile population for CAC. The MDCT identified 148 individuals (63.8%) with CAD; the coronary lesions were not significant in 116 individuals (50%) and were significant (>50% stenosis) in 32 (13.8%). The participants with diabetes, smoking and ≥3 risk vascular factors had a greater prevalence of significant stenosis. The individuals with >50% stenosis had higher CAC values (352.5 vs. 1; P<.0001), and those in the ≥75 percentile had a high percentage of significant lesions (57.9% vs. 5.2%; P<.0001). The predictors of significant CAD were a CAC score >300 (OR=10.9; 95% CI 3.35-35.8; P=.0001), belonging to the ≥75 percentile (OR=5.65; 95% CI 1.78-17.93; P=.03) and having 3 or more vascular risk factors (OR=4.19; 95% CI 1.44-12.14; P=.008). CONCLUSION: CAC quantification is an effective method for determining the extent and magnitude of CAD and delimiting the predictive capacity of traditional risk factors.

Computational modeling of electromechanical propagation in the helical ventricular anatomy of the heart.

The classical interpretation of myocardial activation assumes that the myocardium is homogeneous and that the electrical propagation is radial. However, anatomical studies have described a layered anatomical structure resulting from a continuous anatomical helical disposition of the myocardial fibers. To further investigate the sequence of electromechanical propagation based on the helical architecture of the heart, a simplified computational model was designed. This model was then used to test four activation patterns, which were generated by propagating the action potential along the myocardial band from different activation sites.

Evaluación del ventrículo izquierdo por ecocardiografia tridimensional. Comparación con la Cardio-RM / Evaluation of the left ventricle with three-dimensional echocardiography: comparison with cardiac magnetic resonance

Objetivo. La implantación de la ecocardiografia tridimensional (E3D) en el ámbito clínico está experimentando importantes avances. Sin embargo, la calidad de imagen depende de la ventana acústica, y puede ser difícil la identificación de los bordes endocárdicos. El objetivo de este estudio fue comparar la E3D en la determinación de los volúmenes y la fracción de eyección del ventrículo izquierdo en pacientes no seleccionados, usando la resonancia magnética cardiaca (RMC) como patrón de referencia. Material y métodos. A 47 pacientes no seleccionados sometidos a un estudio de RMC, se les practicó también una E3D mediante la técnica de adquisición en tiempo real y análisis con detección semiautomática de los bordes. Resultados. Se excluyeron 4 pacientes (8,5%) por tener una ventana acústica extremadamente deficiente. En el resto (43 pacientes), incluyendo aquellos con una ventana subóptima, se obtuvo una correlación aceptable entre la E3D y la RMC: volumen telediastólico: 0,71; volumen telesistólico: 0,77; fracción de eyección: 0,74. Aunque hubo una infraestimación sistemática del volumen telediastólico, no se observaron diferencias significativas en la determinación de la fracción de eyección. Al excluir los 11 pacientes con ventana subóptima, se observó una infraestimación sistemática de los volúmenes telediastólico y telesistólico, lo que dio lugar paradójicamente a una mejoría de los coeficientes de correlación (0,79, 0,92, 0,84), resultando más exacta la fracción de eyección. Conclusiones. En comparación con la RMC, la E3D infraestima sistemáticamente los volúmenes ventriculares, pero permite la determinación adecuada de la fracción de eyección ventricular izquierda independientemente de la ventana acústica (AU)

Objective. Three-dimensional echocardiography (3DE) is becoming increasingly common in clinical environments. However, the quality of the images depends on the acoustic window, and it can be difficult to identify the endocardial borders. The objective of this study was to evaluate the performance of 3DE in determining the volumes and left ventricular ejection fraction in unselected patients against the gold standard, cardiac magnetic resonance (CMR). Material and methods. In 47 unselected patients who underwent CMR, we performed 3DE using a real-time acquisition technique and semiautomatic border detection. Results. We excluded 4 patients (8.5%) because they had an extremely deficient acoustic window. In the remaining 43 patients, including those with a suboptimal acoustic window, we obtained the following correlations between 3DE and CMR: end-diastolic volume, 0.71; end-systolic volume, 0.77; ejection fraction, 0.74. Although the end-diastolic volume was systematically underestimated, no significant differences were observed in the ejection fraction. When the 11 patients with suboptimal acoustic windows were excluded, we observed a systematic underestimation of the end-diastolic and end-systolic volumes, which paradoxically gave rise to improved correlation coefficients (0.79, 0.92, and 0.84, respectively) and a more accurate ejection fraction. Conclusions. Compared to CMR, 3DE systematically underestimates the ventricular volumes but enables adequate determination of the left ventricular ejection fraction regardless of the quality of the acoustic window (AU)

Optimización en la técnica de medida de la presión arterial pulmonar por ecocardiografía Doppler con el uso de contraste en pacientes con enfermedad pulmonar obstructiva crónica / Improvement in the measurement technique of pulmonary artery pressure by Doppler echocardiography with contrast in chronic obstructive pulmonary disease

Objetivo Evaluar el beneficio del contraste en la ecocardiografía para medir la presión de arteria pulmonar sistólica (PAPs). Diseño Estándar de referencia (ecocardiografía) comparada con contraste. Ambito Gabinete de ecocardiografia. Pacientes Ambulatorio con enfermedad pulmonar obstructiva crónica (EPOC). Intervención La señal de la regurgitación tricuspidea (RT) por Doppler fue evaluada antes y después de administrar contraste intravenoso (Levovist(R)). Se definió una escala de 4 patrones de señal de RT: 0=ausencia de regurgitación; 1=señal protosistólica que no permite la medida de la velocidad pico; 2=señal de intensidad no homogénea pero que permite la medida de la velocidad pico y 3=señal uniforme y pansistólica. El valor de la PAPs fue estimado añadiendo 10mmHg al gradiente transtricuspideo. Resultados La PAPs fue calculada solo en 20 (49%) pacientes antes del contraste. Diecisiete pacientes fueron clasificados en el patrón 2 y 3 en el patrón 3 de la señal de la RT. Tras la administración de contraste 41 (95%) pacientes mostraron señal de RT. Dos fueron clasificados en el patrón 1, 11 con el patrón 2 y 28 con el 3. En los 20 pacientes en los que la PAPs fue estimada antes del contraste se observó aumento de su valor, 44±10mmHg vs. 56±15mmHg (p<0,01). Conclusión El uso de un agente de contraste intravenoso en la ecocardiografía Doppler aumenta el número de pacientes EPOC en los que la PAPs puede ser estimada de manera no invasiva y podría evitar una infraestimación del valor de la PAPs (AU)

Objective To evaluate the benefit of contrast echocardiography in the assessment of systolic pulmonary artery pressure (PAPs). Design Compare standard reference (Doppler-echocardiography) with contrast. Location Echocardiography department. Patients Ambulatory chronic obstructive patient disease (COPD). Intervention Continuous wave Doppler spectral signal of tricuspid regurgitation (TR) was evaluated before and after intravenous injection of a galactose-based intravenous echo-enhancing agent. A four patterns scale classified the quality of the TR signal: 0=absent regurgitation; 1=protosystolic signal not allowing the recognition of peak velocity; 2=non-homogenous signal intensity, albeit allowing the measurement of maximal velocity; and 3=uniform pansystolic velocity signal. PAPs was estimated adding 10mmHg to the transtricuspid gradient, calculated from the TR peak velocity. Results PAPs was only calculated reliably in 20 (49%) patients before the administration of contrast. Seventeen patients were classified as pattern 2, and three as pattern 3 on the scale of the TR quality signal. After contrast 41 (95%) patients showed a reliable TR signal. Two were classified as pattern 1, 11 as pattern 2 and 28 as pattern 3 on the scale of the TR quality signal. In the 20 patients in whom PAPs was estimated before contrast, a significant increase in PAPs values occurred after contrast, 44±10mmHg vs. 56±15mmHg (p<0.01). ConclusionThe use of an echocardiography contrast agent increases the number of COPD patients in whom PAPs can be estimated non-invasively and may avoid underestimation of the PAP value (AU)

[Evaluation of the left ventricle with three-dimensional echocardiography: comparison with cardiac magnetic resonance]. / Evaluación del ventrículo izquierdo por ecocardiografia tridimensional. Comparación con la Cardio-RM.

OBJECTIVE: Three-dimensional echocardiography (3DE) is becoming increasingly common in clinical environments. However, the quality of the images depends on the acoustic window, and it can be difficult to identify the endocardial borders. The objective of this study was to evaluate the performance of 3DE in determining the volumes and left ventricular ejection fraction in unselected patients against the gold standard, cardiac magnetic resonance (CMR). MATERIAL AND METHODS: In 47 unselected patients who underwent CMR, we performed 3DE using a real-time acquisition technique and semiautomatic border detection. RESULTS: We excluded 4 patients (8.5%) because they had an extremely deficient acoustic window. In the remaining 43 patients, including those with a suboptimal acoustic window, we obtained the following correlations between 3DE and CMR: end-diastolic volume, 0.71; end-systolic volume, 0.77; ejection fraction, 0.74. Although the end-diastolic volume was systematically underestimated, no significant differences were observed in the ejection fraction. When the 11 patients with suboptimal acoustic windows were excluded, we observed a systematic underestimation of the end-diastolic and end-systolic volumes, which paradoxically gave rise to improved correlation coefficients (0.79, 0.92, and 0.84, respectively) and a more accurate ejection fraction. CONCLUSIONS: Compared to CMR, 3DE systematically underestimates the ventricular volumes but enables adequate determination of the left ventricular ejection fraction regardless of the quality of the acoustic window.

[Improvement in the measurement technique of pulmonary artery pressure by Doppler echocardiography with contrast in chronic obstructive pulmonary disease]. / Optimización en la técnica de medida de la presión arterial pulmonar por ecocardiografía Doppler con el uso de contraste en pacientes con enfermedad pulmonar obstructiva crónica.

OBJECTIVE: To evaluate the benefit of contrast echocardiography in the assessment of systolic pulmonary artery pressure (PAPs). DESIGN: Compare standard reference (Doppler-echocardiography) with contrast. LOCATION: Echocardiography department. PATIENTS: Ambulatory chronic obstructive patient disease (COPD). INTERVENTION: Continuous wave Doppler spectral signal of tricuspid regurgitation (TR) was evaluated before and after intravenous injection of a galactose-based intravenous echo-enhancing agent. A four patterns scale classified the quality of the TR signal: 0=absent regurgitation; 1=protosystolic signal not allowing the recognition of peak velocity; 2=non-homogenous signal intensity, albeit allowing the measurement of maximal velocity; and 3=uniform pansystolic velocity signal. PAPs was estimated adding 10 mm Hg to the transtricuspid gradient, calculated from the TR peak velocity. RESULTS: PAPs was only calculated reliably in 20 (49%) patients before the administration of contrast. Seventeen patients were classified as pattern 2, and three as pattern 3 on the scale of the TR quality signal. After contrast 41 (95%) patients showed a reliable TR signal. Two were classified as pattern 1, 11 as pattern 2 and 28 as pattern 3 on the scale of the TR quality signal. In the 20 patients in whom PAPs was estimated before contrast, a significant increase in PAPs values occurred after contrast, 44±10 mm Hg vs. 56±15 mm Hg (p<0.01). CONCLUSION: The use of an echocardiography contrast agent increases the number of COPD patients in whom PAPs can be estimated non-invasively and may avoid underestimation of the PAP value.

Fenestrations and preferential flow routes in the prelaminar optic nerve through wet scanning electron microscope and perfusion of tracers.

PURPOSE: We study the vitreous interface of the optic disc to delimit the passages for the flow of fluids through the prelaminar tissue of porcine eyes. METHODS: Wet scanning electron microscope (SEM), conventional SEM and transmission electron microscope (TEM) were used to explore the surface of the optic nerve of the pig. The vitreous cavity was perfused with a fluorescent marker and colloidal gold at controlled pressure. Samples of perfused optic nerve head were cryosectioned and observed with the confocal laser microscope (lectin) or resin embedded and observed under TEM (gold). RESULTS: Fenestrations were present under the SEM in all three regions of the vitreous interface. SEM results were confirmed at the TEM level and under the wet-SEM. Perfusion experiments traced the flow of a fluorescent molecule delineating routes of preferential flow with origin in the fenestrations. Colloidal gold marked the site of entrance in the prelaminar tissue identifying major fenestrations in the basal membrane. CONCLUSIONS: Interchange of fluid between the optic nerve and the vitreous cavity in the pig is facilitated by fenestrations of varied sizes in the basal membrane and preferential flow routes through the prelaminar tissue. Preferential flow routes exist in the extracellular spaces of Elschnig and Kuhn' astrocytes and give a sharply distinct image when compared with flow through zones in which astrocytes envelope axons. Escape routes may be instrumental in preventing oedemas of the optic nerve head, but they could also serve as entrance doors for fluids from the vitreous and aqueous and play a pathogenic role in ageing and glaucoma.

A normalized framework for the design of feature spaces assessing the left ventricular function.

A through description of the left ventricle functionality requires combining complementary regional scores. A main limitation is the lack of multiparametric normality models oriented to the assessment of regional wall motion abnormalities (RWMA). This paper covers two main topics involved in RWMA assessment. We propose a general framework allowing the fusion and comparison across subjects of different regional scores. Our framework is used to explore which combination of regional scores (including 2-D motion and strains) is better suited for RWMA detection. Our statistical analysis indicates that for a proper (within interobserver variability) identification of RWMA, models should consider motion and extreme strains.

Correlation between myocardial fibrosis and the occurrence of atrial fibrillation in hypertrophic cardiomyopathy: a cardiac magnetic resonance imaging study.

Cardiac magnetic resonance imaging (CMR) in hypertrophic cardiomyopathy (HCM) often shows delayed contrast enhancement (DE) representing regions of focal myocardial fibrosis. Atrial fibrillation (AF) is a commonly reported complication of HCM. We determined the relationship between the presence of left ventricular myocardial fibrosis (LVMF) detected by DE-CMR and the occurrence AF in a series of patients with HCM. 67 patients with HCM (47 males; mean age 50.1+/-18.5 years) were studied by CMR measuring mass of LVMF, left ventricular mass, volume and function, and left atrial (LA) area. AF was present in 17 (25%) patients. LVMF was observed in 57% of patients. AF was significantly more frequent in patients who also showed LVMF, compared with the group without LVMF (42.1% vs. 3.4%, respectively; p<0.0001). LA size was larger in patients showing DE (LA area: 37.4+/-11.1 vs. 25.9+/-6.8 cm(2); respectively, p=0.0001). AF in HCM is related with myocardial fibrosis detected by DE-CMR and dilatation of the LA. This fact adds to the proven adverse prognostic value of myocardial fibrosis in HCM, thus, reinforcing the usefulness of this technique in the assessment of these patients.

Cementless cups do not increase osteolysis risk in metal-on-metal total hip arthroplasty. Apropos of 106 cases.

BACKGROUND: Metal-on-metal bearings in total hip arthroplasty (THA) were introduced to reduce the production of wear debris and debris-induced periprosthetic osteolysis. Analysis of various series according to the type of selected acetabular fixation highlights different evolutions: favourable results with uncemented cups contrasting with loosening and radiolucent lines (RLL) evolution for cemented cups. HYPOTHESIS: Combining metal-on-metal bearings to uncemented cups does not increase the osteolysis risk at a minimum 5 years' follow-up. MATERIALS AND METHODS: From January 1999 to December 2002, 106 Metasul THAs were implanted in 95 patients using a Hardinge anterolateral approach (40 women and 55 men with an average age of 59.2 years). The cups were of cementless, hydroxyapatite-coated Cedior type (Zimmer) housing a Metasul insert in a polyethylene sandwich. The femoral stem used was the cemented Acora, then the Exafit (Zimmer) type with Metasul 28-mm head mounted on a 8/10 Morse taper. Patients were evaluated clinically using the Postel-Merle-d'Aubigné (PMA) scoring system and radiologically using various markers: cup inclination angle, eventual RLL presence, appearance of osteolysis images, ectopic ossifications and finally, eventual implant migration. In the eventuality of suspected RLL evolution or osteolysis, advanced imaging was performed; joint aspiration liquid and cobalt serum level were studied. RESULTS: We reviewed 94 prostheses (85 patients) with an average follow-up of 6.4 years (4.3 to 9.3 years, median of 6.3 years). The rate of patient loss from follow-up and death was 12.1%. The PMA score of non-revised patients increased from 11.4+/-1.5 to 17.6+/-0.2 at follow-up. We numbered ten re-operations not attributable to the type of bearings used. Three revisions were directly related to the metal-on-metal bearing: two metallosis due to impingement and one case of hypersensitivity. Cup inclination angle was 45.7+/-5.49 degrees . No implant migration was noted during the follow-up duration. Only one cup undergoing revision presented a substantial osteolysis. On the femoral side, with non-revised implants, we observed 13 cement/bone RLL images around nine femoral stems and six calcar resorptions. The survival rate at more than 6 years was 95.8% (91.8-99.8) for the cups and 94.8% (90.3-99.2) for the femoral stems (95% confidence interval). DISCUSSION: The present study confirms our hypothesis: with Metasul bearings equipped cementless cups, the rates of aseptic loosening, RLL or acetabular osteolysis are low and remain stable over time, unlike the results observed for Metasul series with polyethylene directly cemented on bone. Specific complications, such as metallosis due to impingement and hypersensitivity, can rarely be encountered. These results encourage us to continue employing metal-on-metal bearings with non-cemented cups in active patients. LEVEL OF EVIDENCE: Level IV: Therapeutic study.

A pilot experience launching a national dose protocol for vascular and interventional radiology.

The design of a national dose protocol for interventional radiology has been one of the tasks during the European SENTINEL Coordination Action. The present paper describes the pilot experience carried out in cooperation with the Spanish Society on Vascular and Interventional Radiology (SERVEI). A prospective sample of procedures was initially agreed. A common quality control of the X-ray systems was carried out, including calibration of the air kerma area product (KAP) meters. Occupational doses of the radiologists involved in the survey were also included in the survey. A total of 10 Spanish hospitals with interventional X-ray units were involved. Six hundred and sixty-four patient dose data were collected from 397 diagnostic and 267 therapeutic procedures. Occupational doses were evaluated in a sample of 635 values. The obtained KAP median/mean values (Gy.cm2) for the gathered procedures were: biliary drainage (30.6/68.9), fistulography (4.5/9.8), lower limb arteriography (52.2/60.7), hepatic chemoembolisation (175.8/218.3), iliac stent (45.9/73.2) and renal arteriography (39.1/59.8). Occupational doses (mean monthly values, in mSv) were 1.9 (over apron); 0.3 (under apron) and 4.5 (on hands). With this National experience, a protocol was agreed among the SENTINEL partners to conduct future similar surveys in other European countries.

[Transthoracic echocardiography in stroke performed by neurologist: pilot study]. / Ecocardiografía transtorácica realizada por neurólogos en patología vascular: estudio piloto.

INTRODUCTION: The aim of this study is to assess concordance between transthoracic echocardiography (TTE) performed by neurologists and cardiologists for the screening of cardioembolic sources in patients with ischemic stroke. METHODS: We examined prospectively 27 consecutive patients with ischemic stroke. A potential source of embolism in all of the patients was sought by means of a TTE study. This study was performed by one neurologist after one-month full-time training on the technique and independently by one cardiologist whose results were considered as the reference standard. Regarding the risk of cardioembolism, findings from TTE studies were considered as normal, or indicative of either moderate or high risk, according to the TOAST criteria. Agreement between the two observers on the diagnosis of cardioembolic source was analyzed with the Cohen's Kappa Test (K). A K > 0,6 was considered as good agreement. RESULTS: The 27 patients studied had a mean age of 68,7 +/- 10,2 years and 70 % were men. A cardioembolic source was detected in 9 patients by the cardiologist and 8 of these were also identified by the neurologist: in 1 patient a mitral annulus calcification was not detected in the examination performed by the neurologist. In 2 patients with poor echocardiographic window, the neurologist underestimated the left ventricular function. Diagnostic agreement between both examinations was 88,9 % (K: 0,77; p = 0,001). CONCLUSION: Compared with cardiologists, trained neurologists show a fairly high degree of accuracy in the TTE screening of patients with stroke. Those cases with poor echocardiographic window or with abnormal findings should be confirmed by the cardiologists.

Ecocardiografía transtorácica realizada por neurólogos en patología vascular: estudio piloto / Transthoracic echocardiopraphy in stroke performed by neurologist: pilot study

El objetivo de nuestro estudio es comparar la concordancia entre la ecocardiografía transtorácica (ETT) realizada por neurólogos y cardiólogos en el cribado de fuentes cardioembólicas en pacientes con isquemia cerebral. Métodos. Evaluamos de forma prospectiva y consecutiva 27 pacientes con isquemia cerebral. A todos se les realizó una ETT por un neurólogo que había sido entrenado previamente durante un mes en la técnica, e independientemente, por un cardiólogo cuyos resultados fueron considerados como la referencia estándar. Según el riesgo de cardioembolismo, los hallazgos en la ETT fueron clasificados como normales, de moderado o alto riesgo según los criterios TOAST. La concordancia en el diagnóstico de fuente cardioembólica entre ambos exploradores fue evaluado con el test Kappa de Cohen (K). Una K>0,6 se consideró como buena concordancia. Resultados. De 27 pacientes con isquemia cerebral, la edad media fue de 68,7 ± 10,2 años y 70 % fueron hombres. En 9 pacientes el cardiólogo detectó una fuente cardioembólica, y de ellos, 8 pacientes también por el neurólogo (1 paciente con calcificación del anillo mitral no fue detectado). En 2 pacientes con mala ventana ecocardiográfica, el neurólogo infraestimó la función ventricular. El diagnóstico fue concordante entre ambas exploraciones en un 88,9 % de los pacientes (K: 0,77; p = 0,001). Conclusiones. Comparado con el cardiólogo, un neurólogo entrenado realiza la ETT con una buena fiabilidad. En los casos con mala ventana ecocardiográfica o con hallazgos patológicos, éstos deberían ser confirmados por el cardiólogo (AU)

Introduction. The aim of this study is to assess concordance between transthoracic echocardiography (TTE) performed by neurologists and cardiologists for the screening of cardioembolic sources in patients with ischemic stroke. Methods. We examined prospectively 27 consecutive patients with ischemic stroke. A potential source of embolism in all of the patients was sought by means of a TTE study. This study was performed by one neurologist after one-month full-time training on the technique and independently by one cardiologist whose results were considered as the reference standard. Regarding the risk of cardioembolism, findings from TTE studies were considered as normal, or indicative of either moderate or high risk, according to the TOAST criteria. Agreement between the two observers on the diagnosis of cardioembolic source was analyzed with the Cohen's Kappa Test (K). A K > 0,6 was considered as good agreement. Results. The 27 patients studied had a mean age of 68,7 ± 10,2 years and 70 % were men. A cardioembolic source was detected in 9 patients by the cardiologist and 8 of these were also identified by the neurologist: in 1 patient a mitral annulus calcification was not detected in the examination performed by the neurologist. In 2 patients with poor echocardiographic window, the neurologist underestimated the left ventricular function. Diagnostic agreement between both examinations was 88,9 % (K: 0,77; p = 0,001). Conclusion. Compared with cardiologists, trained neurologists show a fairly high degree of accuracy in the TTE screening of patients with stroke. Those cases with poor echocardiographic window or with abnormal findings should be confirmed by the cardiologists (AU)