Clinical radiation management for fluoroscopically guided interventional procedures

The primary goal of radiation management in interventional radiology is to minimize the unnecessary use of radiation. Clinical radiation management minimizes radiation risk to the patient without increasing other risks, such as procedural risks. A number of factors are considered when estimating the likelihood and severity of patient radiation effects. These include demographic factors, medical history factors, and procedure factors. Important aspects of the patient's medical history include coexisting diseases and genetic factors, medication use, radiation history, and pregnancy. As appropriate, these are evaluated as part of the preprocedure patient evaluation; radiation risk to the patient is considered along with other procedural risks. Dose optimization is possible through appropriate use of the basic features of interventional fluoroscopic equipment and intelligent use of dose-reducing technology. For all fluoroscopically guided interventional procedures, it is good practice to monitor radiation dose throughout the procedure and record it in the patient's medical record. Patients who have received a clinically significant radiation dose should be followed up after the procedure for possible deterministic effects. The authors recommend including radiation management as part of the departmental quality assurance program.     

Bone lead levels and blood pressure endpoints: a meta-analysis

BACKGROUND: Previous reviews have shown increases in blood pressure and hypertension associated with increases in lead levels in blood. We performed a meta-analysis of the association of bone lead levels with systolic blood pressure, diastolic blood pressure, and hypertension using published data. METHODS: We searched Medline, Embase, and Toxline for epidemiologic studies on bone lead levels and blood pressure endpoints. We used inverse-variance weighted random-effects models to summarize the association of tibia or patella lead levels with blood pressure endpoints. RESULTS: We summarized data from 3 prospective studies and 5 cross-sectional studies. All studies measured lead levels in tibia bone and 3 studies measured lead levels in patella. For a 10 microg/g increase in tibia lead, the cross-sectional summary increases in blood pressure were 0.26 mm Hg for systolic (95% confidence interval = 0.02 to 0.50) and 0.02 mm Hg for diastolic (-0.15 to 0.19). The summary odds ratio for hypertension was 1.04 (1.01 to 1.07). For a 10 microg/g increase in patella lead, the summary odds ratio for hypertension was 1.04 (0.96 to 1.12). CONCLUSION: Systolic blood pressure and hypertension risk were associated with lead levels in tibia bone, but the magnitude of the summary estimates was small. These summary estimates, however, were based on published data and we could not evaluate nonlinear dose-response relationships, the relative contribution of bone and blood lead levels, or the influence of differences in study populations. A more detailed characterization of the association of bone lead levels and blood pressure endpoints would require a pooled analysis of individual participant data from existing studies.     

Navigating Latinas with breast screen abnormalities to diagnosis

BACKGROUND.

Breast cancer is the leading cause of cancer‐related deaths in Latinas, chiefly because of later diagnosis. The time from screening to diagnosis is critical to optimizing cancer care, yet the efficacy of navigation in reducing it is insufficiently documented. Here, the authors evaluate a culturally sensitive patient navigation program to reduce the time to diagnosis and increase the proportions of women diagnosed within 30 days and 60 days.

METHODS.

The authors analyzed 425 Latinas who had Breast Imaging Reporting and Data System (BI‐RADS) radiologic abnormalities categorized as BI‐RADS‐3, BI‐RADS‐4, or BI‐RADS‐5 from July 2008 to January 2011. There were 217 women in the navigated group and 208 women in the control group. Women were navigated by locally trained navigators or were not navigated (data for this group were abstracted from charts). The Kaplan‐Meier method, Cox proportional hazards regression, and logistic regression were used to determine differences between groups.

RESULTS.

The time to diagnosis was shorter in the navigated group (mean, 32.5 days vs 44.6 days in the control group; hazard ratio, 1.32; P = .007). Stratified analysis revealed that navigation significantly shortened the time to diagnosis among women who had BI‐RADS‐3 radiologic abnormalities (mean, 21.3 days vs 63.0 days; hazard ratio, 2.42; P < .001) but not among those who had BI‐RADS‐4 or BI‐RADS‐5 radiologic abnormalities (mean, 37.6 days vs 36.9 days; hazard ratio, 0.98; P = .989). Timely diagnosis occurred more frequently among navigated Latinas (within 30 days: 67.3% vs 57.7%; P = .045; within 60 days: 86.2% vs 78.4%; P = .023). This was driven by the BI‐RADS‐3 strata (within 30 days: 83.6% vs 50%; P < .001; within 60 days: 94.5% vs 67.2%; P < .001). A lack of missed appointments was associated with timely diagnosis.

CONCLUSIONS.

Patient‐centered navigation to assist Latina women with abnormal screening mammograms appeared to reduced the time to diagnosis and increase rates of timely diagnosis overall. However, in stratified analyses, only navigated Latinas with an initial BI‐RADS‐3 screen benefited, probably because of a reduction in missed diagnostic appointments. Cancer 2013. © 2012 American Cancer Society.     

Metals in Urine and Diabetes in U.S. Adults

Our objective was to evaluate the relationship of urine metals including barium, cadmium, cobalt, cesium, molybdenum, lead, antimony, thallium, tungsten, and uranium with diabetes prevalence. Data were from a cross-sectional study of 9,447 participants of the 1999–2010 National Health and Nutrition Examination Survey, a representative sample of the U.S. civilian noninstitutionalized population. Metals were measured in a spot urine sample, and diabetes status was determined based on a previous diagnosis or an A1C ≥6.5% (48 mmol/mol). After multivariable adjustment, the odds ratios of diabetes associated with the highest quartile of metal, compared with the lowest quartile, were 0.86 (95% CI 0.66–1.12) for barium (P_trend = 0.13), 0.74 (0.51–1.09) for cadmium (P_trend = 0.35), 1.21 (0.85–1.72) for cobalt (P_trend = 0.59), 1.31 (0.90–1.91) for cesium (P_trend = 0.29), 1.76 (1.24–2.50) for molybdenum (P_trend = 0.01), 0.79 (0.56–1.13) for lead (P_trend = 0.10), 1.72 (1.27–2.33) for antimony (P_trend < 0.01), 0.76 (0.51–1.13) for thallium (P_trend = 0.13), 2.18 (1.51–3.15) for tungsten (P_trend < 0.01), and 1.46 (1.09–1.96) for uranium (P_trend = 0.02). Higher quartiles of barium, molybdenum, and antimony were associated with greater HOMA of insulin resistance after adjustment. Molybdenum, antimony, tungsten, and uranium were positively associated with diabetes, even at the relatively low levels seen in the U.S. population. Prospective studies should further evaluate metals as risk factors for diabetes.     

Nitroglycerin patch for the treatment of chondrodermatitis nodularis helicis: a new therapeutic option

Chondrodermatitis nodularis helicis (CNH) is an inflammatory process that affects the skin and cartilage of the ear. At present, there are many treatment options, although they are not always effective. Based on previous studies where nitroglycerin 2% gel was used, we propose the use of nitroglycerin patches. The purpose of this study was to evaluate the effectiveness of nitroglycerin patches in treating CNH. We performed a prospective study in 11 patients diagnosed with CNH treated with nitroglycerin patches 5 mg, 12 hours a day for 2 months. The therapeutic effectivity was determined by the improvement in the appearance and symptoms of the lesion. Seven of 11 patients (63.6%) had a complete response. One of 11 patients (9%) did not respond completely and surgical treatment was performed. Two of 11 patients (18.1%) stopped the treatment because of headache. One of 11 patients (9%) did not complete the treatment because the said patient forgot to apply the patch every night. Transdermal nitroglycerin has demonstrated efficacy in the treatment of the symptoms and lesional appearance of CNH noninvasive manner. The success rate is comparable with other published methods and the rate of adverse effects is acceptable.     

Latinos report less use of pharmaceutical aids when trying to quit smoking

BACKGROUND: Latino smokers are more likely than white non-Latino smokers to attempt cessation, but less likely to receive cessation advice from physicians or to use nicotine replacement therapy (NRT). Proposed underlying causes have included lighter smoking, lower financial status, and less healthcare access. This study assessed these factors as possible explanations for disparate rates of smoking-cessation support. METHODS: Data were analyzed from a random, population-level telephone survey of Colorado adults that interviewed 10,945 white non-Latino respondents and 1004 Latino respondents. For the current analysis, main outcome measures were receipt of physician advice to quit smoking, use of NRT, and use of bupropion or other anti-depressant for smoking cessation. RESULTS: Latino smokers reported higher prevalence of quit attempts (71.5% v 61.6%, p <0.01) but less physician advice to quit smoking (46.4% v 56.2%, p <0.05) and less use of NRT or an anti-depressant for cessation (10.6% v 24.8%, p <0.0001). Adjusted for potentially confounding factors, the odds ratio (OR) for less Latino use of cessation medications was substantial and significant (full model OR=0.31; 95% confidence interval, 0.17 to 0.57). The adjusted OR for physician cessation advice was not significant. CONCLUSIONS: Population-level differences in health status, smoking level, financial status, or healthcare access do not explain why Latino smokers less often use proven pharmaceutical aids to increase cessation. Further research is needed to understand these disparities, and greater effort is needed to deliver cessation support to Latino smokers seeking to quit.     

Structured management strategy based on the Gastro-oesophageal Reflux Disease (GERD) Questionnaire (GerdQ) vs. usual primary care for GERD: pooled analysis of five cluster-randomised European studies

Background: Response to treatment among primary care patients with gastro‐oesophageal disease (GERD) is variable. Aim: The GERD Management Project (GMP) evaluated the effectiveness of a structured management approach to GERD vs. standard treatment (usual care). Methods: Data from five cluster‐randomised clinical trials in adult primary care patients with symptoms of GERD were pooled. The structured pathway was based on the self‐administered GERD Questionnaire (GerdQ) and was compared with standard treatment. Results: 1734 patients were enrolled (structured treatment, n = 834; standard treatment, n = 900). The difference in the mean GerdQ score change from baseline favoured the structured pathway (?0.61; 95% CI: ?0.88, ?0.34; p < 0.001). The odds ratio for an indication for treatment revision at the end of follow‐up (structured vs. standard treatment) was 0.39 (95% CI: 0.29, 0.52; p = 0.001). Conclusions: Management of primary care patients with GERD can be improved by systematic stratification of patients using a patient management tool such as the GerdQ.