Patient exposure dose in interventional cardiology per clinical and technical complexity levels. Part 1: results of the VERIDIC project

Background Patients can be exposed to high skin doses during complex interventional cardiology (IC) procedures. Purpose To identify which clinical and technical parameters affect patient exposure and peak skin dose (PSD) and to establish dose reference levels (DRL) per clinical complexity level in IC procedures. Material and Methods Validation and Estimation of Radiation skin Dose in Interventional Cardiology (VERIDIC) project analyzed prospectively collected patient data from eight European countries and 12 hospitals where percutaneous coronary intervention (PCI), chronic total occlusion PCI (CTO), and transcatheter aortic valve implantation (TAVI) procedures were performed. A total of 62 clinical complexity parameters and 31 technical parameters were collected, univariate regressions were performed to identify those parameters affecting patient exposure and define DRL accordingly. Results Patient exposure as well as clinical and technical parameters were collected for a total of 534 PCI, 219 CTO, and 209 TAVI. For PCI procedures, body mass index (BMI), number of stents ≥2, and total stent length >28 mm were the most prominent clinical parameters, which increased the PSD value. For CTO, these were total stent length >57 mm, BMI, and previous anterograde or retrograde technique that failed in the same session. For TAVI, these were male sex, BMI, and number of diseased vessels. DRL values for Kerma-area product ( PKA), air kerma at patient entrance reference point ( Ka,r), fluoroscopy time (FT), and PSD were stratified, respectively, for 14 clinical parameters in PCI, 10 in CTO, and four in TAVI. Conclusion Prior knowledge of the key factors influencing the PSD will help optimize patient radiation protection in IC.

INFECTION AS A RISK FACTOR FOR GALLBLADDER CANCERLITERATURE REVIEW.

Gallbladder cancer (GBC) is the 6th most common gastrointestinal malignancy and most common hepatobiliary malignancy representing 85-90% worldwide with an annual incident of 2/1,00,000 and marked 1 geographical and ethnic variability and known for late diagnosis and poor outcome. High rates of gallbladder carcinoma are seen in different parts of the world like South America (Chilli, Bolivia, and 2 Ecuador) as well as in some parts of India (specically in north IndiaUP, Bihar, Delhi, West Bengal, Assam, and Madhya Pradesh, mostly in Gangetic belt), Pakistan, Japan, and Korea. In north India, gallbladder cancer is 10 times more common in comparison to south India. R 3 Kanthan et al . (2015) divides the risk factor for GBC into four broad groups: i)Patient demography, ii) GB abnormalities, iii)patient exposure to a specic chemical, genetic and molecular factors, iv) Infection. This study says that not only gallbladder stones but also infection by some microbial agents like salmonella and helicobacter also having contributory risk factors

The Impact of Standard in-Patients Exposure on Clinical Judgement among Undergraduate Nursing Students at SNC Lahore

Background: Clinical judgment skills development of nursing professional is essential and vital during clinical education. This quasi experimental study hasevaluated the impact of standardizedIn-patient’s exposure on clinical judgment among under graduate nursing students using observational measures. Method: A single group of undergraduate students was recruited with purposive sampling at College of Nursing, Shalamar Hospital Lahore, Pakistan and Tanner’s clinical rubric model was used. A total 78 under graduate nursing students accomplished in five In-patients exposure within 45 clinical hours. Two Clinical Nursing Instructors were hired to evaluate the outcome of nursing students; clinical judgment at the end of each standardized in-patient exposure session. The inter-rater reliability ranged 0.830 to 0.90 for the session. Results: Clinical judgment outcome were improved from first in-patient exposure to last patient exposure compared with pre and post data of clinical judgement of patient second, third, fourth and fifth. The debriefing method was helpful for the undergraduate nursing students to improve their critical thinking. The undergraduate nursing students confessed that in-patient exposure has not only uplifted their clinical experience but also strengthened the critical thinking in emergency situation and improve the ability to notice, interpret, and respond suitably. The clinical nursing faculty also highlighted and valued the newly learned knowledge and commented that exposure of In-patients to under graduate nursing students is essential for clinical skills preparation. Conclusion: Standardized In-patient exposure has potential to support the undergraduate nursing student for the development of clinical judgement. No doubt, the clinical instructor has enhanced nursing professional’s intrinsic motivation but standardized in-patient presented a true picture, while learning to complete assessment skills.A difference may exist between high fidelity simulator and standardized in-patient exposure among undergraduate nursing students, so further research can explore this phenomenology. Key words:Nursing students, Clinical Judgment, Standardized in-patients, Nursing professionals.

An Approach for Online Determining the Entrance Surface Air Kerma (ESAK) in Digital Radiology

An online method is proposed to determine the entrance surface air kerma (ESAK) in digital radiology from console-displayed kerma area product (PKA) data. ESAK values were calculated from X-ray tube outputs and patient exposure factors across five X-ray examinations. The corresponding PKAvalues were taken from the Digital Imaging and Communications in Medicine (DICOM) header. Using linear regression between ESAK and values, the slope and intercept coefficients for each type of X-ray equipment and procedure were determined. The coefficient to determine ESAK from ranged from 59% for a posteroanterior chest to 88% for anteroposterior lumbar spine view X-ray procedures. The results demonstrated the possibility of online estimates of ESAK from a console that displayed using readily available digital information in radiology. The results may have important implications in interventional radiology, where ESAK values are crucial for preventing skin injuries due to prolonged fluoroscopy times.

995 Bedside Teaching from A Distance; Surgical Education in The COVID Era

Introduction The COVID pandemic resulted in a shutdown of facilities and resources globally. With drastic changes in the provision of services available in the health sector, so too were medical students’ provision of learning. With the onslaught of COVID and the need for ongoing learning resources for students, novel methods to maintain adequate surgical patient exposure and student interaction on a platform amenable to the interactive format required was devised using a virtual platform to compliment current pedagogical approaches. Method This was a randomised control trial to evaluate the perceived use of remote learning in place of surgical bedside teaching in the COVID-19 era. Medical students in a regional hospital were recruited and randomised to undergo the bedside teaching in person or receive the teaching virtually through a Xpert eye, smart glasses to facilitate connections remotely. Feedback questionnaires and exit interviews carried out following each session. Content analysis of transcripts was performed to evaluate the presence and quality of perceived learning, benefits, and limitations. Results Feedback demonstrated greater engagement, satisfaction, involvement, and learning (p < 0.01) in the bedside teaching group. Content analysis yielded three main themes: Interpersonal content, technological features, and provision of content. Students reported the virtual teaching was an acceptable alternative in the current climate of social distancing and reduced patient access. Conclusions The current pandemic poses a risk to adequate patient exposure to patient centred learning. Teaching sessions received remotely are an acceptable alternative in the current climate of reduced clinical access, however bedside teaching remains the preferred method of learning.

An Update on COVID-19 Vaccine Induced Thrombotic Thrombocytopenia Syndrome and Some Management Recommendations

The thrombotic thrombocytopenia syndrome (TTS), a complication of COVID-19 vaccines, involves thrombosis (often cerebral venous sinus thrombosis) and thrombocytopenia with occasional pulmonary embolism and arterial ischemia. TTS appears to mostly affect females aged between 20 and 50 years old, with no predisposing risk factors conclusively identified so far. Cases are characterized by thrombocytopenia, higher levels of D-dimers than commonly observed in venous thromboembolic events, inexplicably low fibrinogen levels and worsening thrombosis. Hyper fibrinolysis associated with bleeding can also occur. Antibodies that bind platelet factor 4, similar to those associated with heparin-induced thrombocytopenia, have also been identified but in the absence of patient exposure to heparin treatment. A number of countries have now suspended the use of adenovirus-vectored vaccines for younger individuals. The prevailing opinion of most experts is that the risk of developing COVID-19 disease, including thrombosis, far exceeds the extremely low risk of TTS associated with highly efficacious vaccines. Mass vaccination should continue but with caution. Vaccines that are more likely to cause TTS (e.g., Vaxzevria manufactured by AstraZeneca) should be avoided in younger patients for whom an alternative vaccine is available.

Time trends of drug-specific actionable adverse events among patients on androgen receptor antagonists: Implications for remote monitoring

Introduction: In light of COVID-19, reducing patient exposure via remote monitoring is desirable. Patients prescribed abiraterone/enzalutamide are scheduled for monthly in-person appointments to screen for adverse events (AEs). We determined time trends of drug-specific actionable AEs among users of abiraterone/enzalutamide to assess the safety of remote monitoring. Methods: A chart review was conducted on 828 prostate cancer patients prescribed abiraterone and/or enzalutamide. Data were collected to determine time to actionable first AEs, including hypertension, elevated liver enzymes (aspartate transaminase [AST], alanine transaminase [ALT]), hyperbilirubinemia, and hypokalemia. Survival analysis was used to determine time to AEs. Results: In this study, 425 and 403 patients received enzalutamide and abiraterone, respectively. In total, 25.6% of those who took enzalutamide experienced an AE, compared to 28.8% of patients on abiraterone. For patients using abiraterone and experiencing an AE, cumulative incidence of AEs at three, six, nine, and 12 months were: 67.2%, 81.9%, 90.5%, and 93.9%, respectively. Among enzalutamide users experiencing an AE, cumulative incidence of AEs at three, six, nine, and 12 months were 51.4%, 70.7%, 82.6%, and 88.1%, respectively. The AEs associated with enzalutamide were hypertension and liver dysfunction (77.1% and 22.9%, respectively). In the abiraterone group, associated AEs were liver dysfunction (47.4%), hypertension (47.4%), and hypokalemia (5.2%). Conclusions: Attaining AEs secondary to abiraterone/enzalutamide decreases over time and tends to occur within the first six months of therapy. Most actionable AEs can be remotely monitored. Given COVID-19, remote monitoring after six months of initiating abiraterone or enzalutamide appears appropriate.

Assessment of SARS-CoV-2 Infection among Healthcare Workers of a German COVID-19 Treatment Center

To date, more than 160 million people have been infected with COVID-19 worldwide. In the present study, we investigated the history of SARS-CoV-2 infection among 3067 healthcare workers (HCW) in a German COVID-19 treatment center during the early phase of the pandemic (July 2020) based on the seroprevalence of SARS-CoV-2 antibodies and self-reported previous PCR results. The results demonstrate a low prevalence of SARS-CoV-2 infection (n = 107 [3.5%]) with no increased risk for employees with a high level of patient exposure in general or working in COVID-19-confined areas in particular. This suggests that the local hygiene standards implemented in our hospital during the first wave of COVID-19 pandemic were effective in preventing patient-to-HCW transmission. No evidence for highly mobile staff serving as a vector for SARS-CoV-2 transmission could be found. In addition, impairment of smell and/or taste was strongly associated with SARS-CoV-2 history.