Diseño e implantación de un proyecto docente para la formación de la identidad médica en estudiantes de Medicina / Design and implementation of a teaching project for the formation of medical identity in medical students

Se describen el diseño y la puesta en marcha de un proyecto docente en la Facultad de Medicina de la Universidad de Navarra dirigido a promover una fuerte identidad médica centrada en el paciente que armonice el desarrollo personal y el profesional de los futuros médicos. La acción educativa se lleva a cabo en 3 fases consecutivas. La primera consiste en unos talleres previos a las rotaciones clínicas en los que se reflexiona, de manera participativa, sobre un aspecto de identidad profesional seleccionado. En un segundo momento, el alumno identificará manifestaciones concretas de ese contenido en la práctica clínica: esa experiencia se recoge por escrito en un portafolio, no solo de manera descriptiva, sino también con una reflexión personal sobre lo que se ha vivido. Se cierra el proceso educativo con la evaluación razonada del portafolio y el contraste de su contenido con el tutor clínico

We describe the process of designing and implementation of a new teaching project in the University of Navarra. The aim of the project is to promote a patient-centered professional and personal identity for the future doctors. The educational process has 3 consecutive phases. First, workshops that take place prior to clerkships, where students actively reflect on a selected professional identity quality. Then, the student will identify real clinical scenarios during their clerkships where this professional behavior takes place. They should reflect on this, and they should learn through their own reactions and emotions and write a self-reflection. The educational process finishes with the formative and personal feedback from the clinical tutor

Adenosine triphosphate (ATP) and adenosine cause similar vasodilator effect in patients undergoing stress perfusion cardiac magnetic resonance imaging.

To evaluate the vasodilator effect of adenosine triphosphate (ATP) compared with adenosine in stress perfusion cardiac magnetic resonance (CMR) examinations. A total of thirty-three patients underwent clinically indicated stress/rest perfusion CMR examination following intravenous injection of a total dose of 0.2 mmol/kg of gadobutrol. Individuals were randomly assigned to ATP (160 mcg/kg/min) or adenosine (140 mcg/kg/min). The vasodilator effect of both drugs was analyzed by comparing differences in heart rate, symptoms during stress, and semiquantitative myocardial and splenic perfusion parameters, including time, time to peak, upslope, myocardial perfusion reserve index, tissue perfusion values, splenic and myocardial signal intensity ratios, and splenic-to-myocardial signal intensity ratios. No significant difference was found in heart rate variation between the stressors (26.1 ± 19.1 bpm for ATP vs. 21.7 ± 17.3 bpm for adenosine, p = 0.52). Patients receiving ATP referred less pronounced clinical symptoms. Semiquantitative myocardial perfusion parameters were comparable, and patients in the adenosine and ATP groups showed similar myocardial perfusion reserve index values (2.34 [1.62-2.73] vs 1.63 [1.29-2.10], p = 0.07). Splenic switch off was visually confirmed in all patients and estimated spleen to myocardium ratio was similar (0.92 [0.53-1.09] vs 0.81 [0.53-0.86] with ATP and adenosine, respectively, p = 0.12). Both ATP and adenosine are potent coronary vasodilators that can be safely employed in stress-CMR. Both stressor cause similar hyperemic response. Splenic switch-off can be used to assess stress adequacy in patients undergoing stress-CMR with either adenosine or ATP.

Cribado de cáncer de pulmón: catorce años de experiencia del Programa Internacional de Detección Precoz de Cáncer de Pulmón con TBDR de Pamplona (P-IELCAP) / Lung Cancer Screening: Fourteen Year Experience of the Pamplona Early Detection Program (P-IELCAP)

Introducción y objetivos: La experiencia europea en relación con el cribado de cáncer de pulmón con tomografía de baja dosis de radiación (TBDR) es amplia. Sin embargo, la evidencia sobre la experiencia en España es limitada. Nuestro objetivo es presentar los resultados del programa de cribado de cáncer de pulmón más largo de España. Métodos: El Programa Internacional de Detección Precoz de Cáncer de Pulmón con TBDR de Pamplona (P-IELCAP) viene reclutando individuos de manera activa desde el año 2000 siguiendo el protocolo IELCAP. Se incluyen individuos ≥ 40 años de edad, fumadores o ex fumadores (consumo acumulado ≥ 10 paquetes-año). Los resultados se comparan con los de otros estudios europeos. Resultados: Un total de 2.989 participantes fueron reclutados hasta marzo de 2014 (73% varones), realizando una mediana de 2 (IQR 1-3) rondas de cribado por individuo. Se detectaron 60 cánceres de pulmón en 53 participantes (73% en estadio i). Adenocarcinoma fue el tipo histológico más frecuente. La proporción de prevalencia e incidencia de cáncer de pulmón fue del 1,0 y del 1,4%, respectivamente, con una tasa de detección anual de 0,41. La tasa de supervivencia a 10 años de los pacientes con cáncer de pulmón fue del 70%. La enfermedad pulmonar obstructiva crónica y el enfisema son importantes factores de riesgo para desarrollar cáncer de pulmón. Conclusiones: La experiencia del programa de cribado de cáncer de pulmón más largo de España es comparable con lo descrito en el resto de Europa y confirma la viabilidad y la eficacia del cribado mediante TBDR

Introduction and objectives: European experience regarding lung cancer screening using low-dose chest CT (LDCT) is available. However, there is limited data on the Spanish experience in this matter. Our aim is to present the results from the longest ongoing screening program in Spain. Methodology: The Pamplona International Early Lung Cancer Detection Program (P-IELCAP) is actively screening participants for lung cancer using LDCT since year 2000 following the IELCAP protocol, including spirometric assessments. Men and women, ≥ 40 years of age, current or former smokers with a tobacco history of ≥ 10 pack-years are included. Results are compared to those from other European trials. Results: A total of 2989 participants were screened until March 2014 (73% male). A median of 2 (IQR 1-3) annual screening rounds were performed. Sixty lung cancers were detected in 53 participants (73% in Stage I). Adenocarcinoma was the most frequent. The lung cancer prevalence and incidence proportion was 1.0% and 1.4%, respectively, with an annual detection rate of 0.41. The estimated 10-year survival rate among individuals with lung cancer was 70%. Chronic obstructive pulmonary disease and emphysema are important lung cancer predictors. Conclusions: The experience in Spain’s longest lung cancer screening program is comparable to what has been described in the rest of Europe, and confirms the feasibility and efficacy of lung cancer screening using LDCT

Lung cancer screening: fourteen year experience of the Pamplona early detection program (P-IELCAP).

INTRODUCTION AND OBJECTIVES: European experience regarding lung cancer screening using low-dose chest CT (LDCT) is available. However, there is limited data on the Spanish experience in this matter. Our aim is to present the results from the longest ongoing screening program in Spain. METHODOLOGY: The Pamplona International Early Lung Cancer Detection Program (P-IELCAP) is actively screening participants for lung cancer using LDCT since year 2000 following the IELCAP protocol, including spirometric assessments. Men and women, ≥40 years of age, current or former smokers with a tobacco history of ≥10 pack-years are included. Results are compared to those from other European trials. RESULTS: A total of 2989 participants were screened until March 2014 (73% male). A median of 2 (IQR 1-3) annual screening rounds were performed. Sixty lung cancers were detected in 53 participants (73% in StageI). Adenocarcinoma was the most frequent. The lung cancer prevalence and incidence proportion was 1.0% and 1.4%, respectively, with an annual detection rate of 0.41. The estimated 10-year survival rate among individuals with lung cancer was 70%. Chronic obstructive pulmonary disease and emphysema are important lung cancer predictors. CONCLUSIONS: The experience in Spain's longest lung cancer screening program is comparable to what has been described in the rest of Europe, and confirms the feasibility and efficacy of lung cancer screening using LDCT.

Systolic prospectively ECG-triggered dual-source CT angiography for evaluation of the coronary arteries in heart transplant recipients.

OBJECTIVES: To assess feasibility, image quality, and radiation dose of prospectively ECG-triggered coronary CT angiography (CTA) in orthotopic heart transplant (OHT) recipients. METHODS: 47 consecutive OHT recipients (40 men, mean age 62.1 ± 10.9 years, mean heart rate 86.3 ± 14.4 bpm) underwent dual-source CTA to rule out coronary allograft vasculopathy in a prospectively ECG-triggered mode with data acquisition during 35% to 45% of the cardiac cycle. Two independent observers blindly assessed image quality on a per-segment and per-vessel basis using a four-point scale (1-excellent, 4-not evaluable). Scores 1-3 were considered acceptable for diagnosis. Multivariate analysis was performed to evaluate differences between image quality scores obtained at different reconstruction intervals. Effective radiation doses were calculated. RESULTS: 671 coronary segments were evaluated. Interobserver agreement on the image quality was κ=0.75. Diagnostic image quality was observed in 93.9%, 95.5% and 93.3% of the segments at 35%, 40% and 45% reconstruction intervals. Mean image quality score was 1.5 ± 0.7 for the entire coronary tree, 1.4 ± 0.7 for the RCA, 1.6 ± 0.8 for the LCA and 1.6 ± 0.7 for the Cx at the best reconstruction interval. Estimated mean radiation dose was 4.5 ± 1.2 mSv. CONCLUSION: Systolic prospectively ECG-triggered CTA allows diagnostic image quality coronary angiograms in OHT recipients at low radiation doses.

Low-dose volumetric computed tomography for quantification of emphysema in asymptomatic smokers participating in an early lung cancer detection trial.

PURPOSE: High-resolution computed tomography (CT) is a validated method to quantify the extent of pulmonary emphysema. In this study, we assessed the reliability of low-dose volumetric CT (LDCT) for the quantification of emphysema and its correlation with spirometric indices of airway obstruction. MATERIALS AND METHODS: The study population consisted of 102 consecutive current and former smokers participating in a lung cancer screening trial. All subjects underwent spirometry testing and LDCT at entry and a LDCT after 12 months. The extent of emphysema was estimated by 2 techniques; by using the lung attenuation threshold analysis and by visual assessment of the 2 independent radiologists. The reproducibility of these determinations was assessed using test-retest reliability and kappa coefficient of agreement. The correlation of LDCT-based emphysema determinations with indices of airway obstruction on spirometry was also calculated. RESULTS: Eighty percent of the participants were male, with a mean (standard deviation) age of 54.5 (7.5) years, and median pack-years (interquartile range) of 20 (24). Test-retest reliability of all LDCT-based emphysema determinations was very good (intraclass correlation coefficient of 0.92 for the volume of emphysema, and 0.93 for the emphysema index or emphysema volume/total lung volume). Similarly, there was an excellent interrater agreement for visual assessment of emphysema (kappa coefficient=0.91). Higher volumes of emphysema measured quantitatively or visually significantly correlated with spirometric markers of airway obstruction. CONCLUSIONS: Volumetric LDCT is a reliable and valid technique for the quantification of emphysema in asymptomatic smokers.

Dual-source CT in heart transplant recipients: quantification of global left ventricular function and mass.

OBJECTIVE: To evaluate reliability of global left ventricular (LV) function and mass quantification in heart transplant recipients undergoing cardiac dual-source computed tomography examinations by means of manual contour tracing and using a region-growing-based semiautomatic segmentation analysis software tool. MATERIALS AND METHODS: Twenty-six consecutive heart transplant recipients undergoing cardiac dual-source computed tomography examinations with tube current modulation were included. Double-oblique short-axis 8-mm slice thickness multiphase image reconstructions were used for manual contouring and axial 0.75 mm slices were used for the semiautomated segmentation. LV ejection fraction, end-diastolic volume, end-systolic volume, stroke volume, cardiac output, and myocardial mass were assessed by both segmentation methods. Length of time needed for manual contour tracing and for the semiautomated software was recorded. Contrast-to-noise ratio was calculated in end-diastolic and end-systolic images. RESULTS: No statistically significant differences were observed in LV functional parameters derived from semiautomatic contour detection algorithm as compared with manual contouring, with excellent agreement (concordance-correlation coefficient >or=0.80). The semiautomated contour detection algorithm overestimated LV mass (mean difference 12.84+/-3.39) (P<0.001). The evaluated software allowed to quantify LV parameters in a significantly shorter period of time (mean difference 201.68+/-121.98 s, P<0.001). Contrast-to-noise ratio in end-systole and end-diastole statistically differed (mean difference 5.29+/-2.94 Hounsfield units; P<0.01) but did not significantly hamper the semiautomated segmentation. CONCLUSIONS: Objective quantification of LV volumes using the evaluated semiautomated segmentation software is precise, reproducible, and time effective.

Dual-source CT for visualization of the coronary arteries in heart transplant patients with high heart rates.

OBJECTIVE: The purpose of this study was to evaluate the quality of dual-source CT images of the coronary arteries in heart transplant recipients with high heart rates. SUBJECTS AND METHODS: Contrast-enhanced dual-source CT coronary angiography was performed on 23 heart transplant recipients (20 men, three women; mean age, 61.1 +/- 12.8 years). Data sets were reconstructed in 5% steps from 30% to 80% of the R-R interval. Two blinded independent readers using a 5-point scale (0, not evaluative; 4, excellent quality) assessed the quality of images of coronary segments. RESULTS: The mean heart rate during scanning was 89.2 +/- 10.4 beats/min. Interobserver agreement on the quality of images of the whole coronary tree was a kappa value of 0.78 and for selection of the optimal reconstruction interval was a kappa value of 0.82. The optimal reconstruction interval was systole in 17 (74%) of the 23 of heart transplant recipients. At the best reconstruction interval, diagnostic image quality (score >or= 2) was obtained in 92.1% (303 of 329) of the coronary artery segments. The mean image quality score for the whole coronary tree was 3.1 +/- 1.01. No significant correlation between mean heart rate (rho = 0.31) or heart rate variability (rho = 0.23) and overall image quality score was observed (p = not significant). CONCLUSION: Dual-source CT acquisition yields coronary angiograms of diagnostic quality in heart transplant recipients. Mean heart rate and heart rate variability during scanning do not have a negative effect on the overall quality of images of the coronary arteries.

Dual-source CT coronary imaging in heart transplant recipients: image quality and optimal reconstruction interval.

The image quality and optimal reconstruction interval for coronary arteries in heart transplant recipients undergoing non-invasive dual-source computed tomography (DSCT) coronary angiography was evaluated. Twenty consecutive heart transplant recipients who underwent DSCT coronary angiography were included (19 male, one female; mean age 63.1 +/- 10.7 years). Data sets were reconstructed in 5% steps from 30% to 80% of the R-R interval. Two blinded independent observers assessed the image quality of each coronary segments using a five-point scale (from 0 = not evaluative to 4 = excellent quality). A total of 289 coronary segments in 20 heart transplant recipients were evaluated. Mean heart rate during the scan was 89.1 +/- 10.4 bpm. At the best reconstruction interval, diagnostic image quality (score > or = 2) was obtained in 93.4% of the coronary segments (270/289) with a mean image quality score of 3.04 +/- 0.63. Systolic reconstruction intervals provided better image quality scores than diastolic reconstruction intervals (overall mean quality scores obtained with the systolic and diastolic reconstructions 3.03 +/- 1.06 and 2.73 +/- 1.11, respectively; P < 0.001). Different systolic reconstruction intervals (35%, 40%, 45% of RR interval) did not yield to significant differences in image quality scores for the coronary segments (P = 0.74). Reconstructions obtained at the systolic phase of the cardiac cycle allowed excellent diagnostic image quality coronary angiograms in heart transplant recipients undergoing DSCT coronary angiography.

Quantification of left ventricular function and mass in cardiac Dual-Source CT (DSCT) exams: comparison of manual and semiautomatic segmentation algorithms.

The purpose of our study was to evaluate reliability of left ventricular (LV) function and mass quantification in cardiac DSCT exams comparing manual contour tracing and a region-growing-based semiautomatic segmentation analysis software. Thirty-three consecutive patients who underwent cardiac DSCT exams were included. Axial 1-mm slices were used for the semiautomated technique, and short-axis 8-mm slice thickness multiphase image reconstructions were the basis for manual contour tracing. Left ventricular volumes, ejection fraction and myocardial mass were assessed by both segmentation methods. Length of time needed for both techniques was also recorded. Left ventricular functional parameters derived from semiautomatic contour detection algorithm were not statistically different from manual tracing and showed an excellent correlation (p<0.001). The semiautomatic contour detection algorithm overestimated LV mass (180.30+/-44.74 g) compared with manual contour tracing (156.07+/-46.29 g) (p<0.001). This software allowed a significant reduction of the time needed for global LV assessment (mean 174.16+/-71.53 s, p<0.001). Objective quantification of LV function using the evaluated region-growing-based semiautomatic segmentation analysis software is feasible, accurate, reliable and time-effective. However, further improvements are needed to equal results achieved by manual contour tracing, especially with regard to LV mass quantification.

Assessing the relationship between lung cancer risk and emphysema detected on low-dose CT of the chest.

RATIONALE: Identification of risk factors for lung cancer can help in selecting patients who may benefit the most from smoking cessation interventions, early detection, or chemoprevention. OBJECTIVE: To evaluate whether the presence of emphysema on low-radiation-dose CT (LDCT) of the chest is an independent risk factor for lung cancer. METHODS: The study used data from a prospective cohort of 1,166 former and current smokers participating in a lung cancer screening study. All individuals underwent a baseline LDCT and spirometry followed by yearly repeat LDCT studies. The incidence density of lung cancer among patients with and without emphysema on LDCT was estimated. Stratified and multiple regression analyses were used to assess whether emphysema is an independent risk factor for lung cancer after adjusting for age, gender, smoking history, and the presence of airway obstruction on spirometry. RESULTS: On univariate analysis, the incidence density of lung cancer among individuals with and without emphysema on LDCT was 25.0 per 1,000 person-years and 7.5 per 1,000 person-years, respectively (risk ratio [RR], 3.33; 95% confidence interval [CI], 1.41 to 7.85). Emphysema was also associated with increased risk of lung cancer when the analysis was limited to individuals without airway obstruction on spirometry (RR, 4.33; 95% CI, 1.04 to 18.16). Multivariate analysis showed that the presence of emphysema (RR, 2.51; 95% CI, 1.01 to 6.23) on LDCT but not airway obstruction (RR, 2.10; 95% CI, 0.79 to 5.58) was associated with increased risk of lung cancer after adjusting for potential cofounders. CONCLUSIONS: Results suggest that the presence of emphysema on LDCT is an independent risk factor for lung cancer.

Abdominal and iliac arterial stenoses: comparative double-blinded randomized study of diagnostic accuracy of 3D MR angiography with gadodiamide or gadopentetate dimeglumine.

PURPOSE: To prospectively evaluate accuracy of gadolinium-enhanced three-dimensional (3D) magnetic resonance (MR) angiography with gadodiamide and gadopentetate dimeglumine (0.1 mmol/kg), with intraarterial DSA as reference standard, for imaging abdominal and iliac arterial stenoses. MATERIALS AND METHODS: The study was approved by all institutional review boards; informed consent was obtained from each subject before procedures. Two hundred forty-seven subjects were included; 240 received either contrast agent and were available for safety analysis; 222 were available for accuracy analysis. Enhanced 3D MR angiography and DSA were performed; image data were evaluated in a double-blinded randomized study. Stenoses were classified as not relevant (<50% stenosis) or relevant (> or =50%). For detection of main stenosis, accuracy with enhanced 3D MR angiography compared with that with DSA was determined. RESULTS: The difference in accuracy for imaging with gadodiamide and gadopentetate was 3.6%. Noninferiority was inferred because the lower bound of the exact two-sided 95% confidence interval was -10.1 and was above the noninferiority margin (-15%). Accuracy for detection of the main stenosis was low, 56.4% for gadodiamide and 52.8% for gadopentetate group. Subgroup analysis with exclusion of inferior mesenteric artery and internal iliac arteries and the most false-positive stenosis classifications yielded better results: 76.6% and 71.6%, respectively. Sensitivity, specificity, and negative and positive predictive values did not differ substantially between study groups. In the main analysis, values were 44%, 96%, 35%, and 97% for gadodiamide and 44%, 83%, 30%, and 90% for gadopentetate, respectively. In the subgroup analysis, values were 66%, 95%, 61%, and 96% for gadodiamide and 63%, 86%, 58%, and 88% for gadopentetate, respectively. CONCLUSION: Noninferiority of gadodiamide versus gadopentetate was verified based on the primary end point, which was accuracy for detection of the main stenosis with enhanced 3D MR angiography compared with DSA.

[Screening for lung cancer with low-dose spiral CT: results in 150 asymptomatic subjects]. / Detección precoz del cáncer de pulmón por tomografía computarizada de baja dosis de radiación: resultados de una muestra de 150 individuos asintomáticos.

BACKGROUND AND OBJECTIVE: Our aim is to present initial baseline data from a screening trial on low-dose spiral computed tomography (CT). We describe enrollment criteria and a diagnostic algorithm based on initial low-dose CT findings. SUBJECTS AND METHOD: From September 2000 to May 2001, 150 asymptomatic smokers (age range 40-78 years; mean 55 years) were studied using non-enhanced low-dose spiral CT of the chest. Repeated short-term high resolution CT follow-up was performed for non-calcified pulmonary nodules smaller than 10 mm in diameter. Non-calcified pulmonary nodules 10 mm or larger were considered as potentially malignant and a complementary positron emission tomography (PET) exam was recommended. RESULTS: 54 non-calcified pulmonary nodules were found in 34 out of 141 (24.15%) symptom-free subjects. The diameter was 5 mm or shorter in 24 participants (70.6%), 6-10 mm in 7 (20.6%) and longer than 10 mm in 3 (8.8%) individuals. One patient with a non-calcified pulmonary nodule of at least 10 mm underwent a complementary PET exam, which was positive. Biopsy of this nodule demonstrated lung cancer (squamous cell carcinoma). CT follow-up over one year was decided in the other two subjects having non-calcified pulmonary nodules longer than 10 mm, as no radiographic signs indicative of malignancy were observed in the baseline scan. CONCLUSION: Following this low-dose CT based screening programme, detection of early-stage lung cancer in asymptomatic subjects at high risk of developing the disease is feasible. Further studies are however necessary to pursue more definitive results.

Detección precoz del cáncer de pulmón por tomografía computarizada de baja dosis deradiación: resultados de una muestra de 150 individuos asintomáticos / Screening for lung cancer with low-dose spiral CT: Results in 150 asymptomatic subjects

FUNDAMENTO Y OBJETIVO: Presentar los datos iniciales de un programa de detección precoz del cáncer de pulmón por tomografía computarizada de baja dosis de radiación, así como exponer los criterios de inclusión y el algoritmo de actuación inicial de este proyecto. SUJETOS Y MÉTODO: Desde septiembre de 2000 a mayo de 2001 se realizó una TC torácica con baja dosis de radiación a 150 fumadores asintomáticos (intervalo de edad, 40-78 años). El protocolo de estudio incluía: TC basal de baja dosis de radiación, control evolutivo por TC convencional de los nódulos pulmonares no calcificados de diámetro inferior a 10 mm y exploraciones complementarias (tomografía por emisión de positrones [PET]) de los nódulos mayores de 10 mm de diámetro, potencialmente malignos. RESULTADOS: Se detectaron 54 nódulos pulmonares no calcificados en 34 sujetos asintomáticos (24,15 por ciento). El diámetro mayor fue de 5 mm o menos en 24 individuos (70,6 por ciento), entre 6 y 10 mm en 7 (20,6 por ciento) y mayor de 10 mm en tres (8,8 por ciento). Se realizó una PET en un único caso, con resultado positivo y diagnóstico histológico de carcinoma escamoso. Los otros dos nódulos no calcificados mayores de 10 mm se consideraron probablemente benignos al presentar un aspecto radiológico de lesión cicatrizal residual. CONCLUSIÓN: Siguiendo el protocolo descrito, es posible detectar el cáncer de pulmón en estadios tempranos en sujetos asintomáticos con factores de riesgo para desarrollar esta enfermedad. Aunque los resultados preliminares son esperanzadores, es preciso incrementar el tamaño de la muestra antes de obtener conclusiones definitivas (AU)

Radiologic screening for lung cancer.

Lung cancer is the leading cause of cancer death. A number of screening trials have been carried out over the past two decades and have failed to demonstrate a reduction of lung cancer-related mortality. Recent advances in new forms of technology--spiral low-dose CT--have resuscitated interest in screening programs. Preliminary results are promising but the outstanding question is whether the magnitude of improvement is sufficient to affect a measurable reduction in lung cancer mortality?