Forty-two years of neurophysiology in Aragon in relation to other neurological specialties

INTRODUCTION: Forty two years after the first EEG had been done in our community we decided (encouraged by the Sociedad Aragonesa de Neurofisiología Clínica) to write a biographical synopsis of the specialty of neurophysiology in Aragón, since knowledge of the past usually makes for a better future. DEVELOPMENT: Initially, seven specialists, many others with their smaller contributions, the proceedings of the Sociedad Aragonesa de Neurofisiología Clínica, the proceedings of Serrate and the archives of the chair of Psychiatry of Zaragoza University have all provided information about the history of neurophysiology in Aragón. We studied the activities of public hospitals, private centres as well as academic neurophysiology activities. We also evaluated influences from outside our community in training different specialists, finding information about training in France and Germany an, in our country, in Barcelona and Pamplona. CONCLUSIONS: We observed that the specialty has now become fully developed in our community. However, it had done so in close relationship with the specialties of Neurology and Psychiatry, with which it is perfectly integrated. The university has been successfully involved in development of the specialty and, in recent years, so has the Sociedad Aragonesa de Neurofisiología Clínica.     

Anticoagulation in cardiology

The various applications of anticoagulation in cardiology concern primary prevention, treatment of angina and infarction, revascularization either by angioplasty or by bypass grafts, treatment after artificial valve replacement, treatment of atrial fibrillation and, finally, as a precaution in the case of impaired ventricular function. Several methods of anticoagulation can be used in each of these indications: thrombin antagonists, vitamin K antagonists, antiaggregants and thrombolytics, although this last group is not discussed in this article.     

Radiocardiography in clinical cardiology

Quantitative radiocardiography provides a variety of noninvasive measurements of value in cardiology. A gamma camera and computer processing are required for most of these measurements. The advantages of ease, economy, and safety of these procedures are, in part, offset by the complexity of as yet unstandaridized methods and incomplete validation of results. The expansion of these techniques will inevitably be rapid. Their careful performance requires, for the moment, a major and perhaps dedicated effort by at least one member of the professional team, if the pitfalls that lead to unrecognized error are to be avoided. We may anticipate more automated and reliable results with increased experience and validation.     

Interventional hemodynamics in pediatric cardiology

A new color Doppler myocardial imaging (CDMI) system with high spatial and temporal resolution and novel postprocessing modalities has been developed that could allow quantifiable stress echocardiography. The purpose of this study was to determine whether regional myocardial systolic velocities could be accurately and reproducibly measured both at rest and during bicycle ergometry by using CDMI. Thirty normal subjects were examined with CDMI at rest, and peak mean systolic myocardial velocities (MSV) were measured for 34 predetermined left ventricular myocardial segments. Interobserver variability and intraobserver variability were established for all segments. Submaximal bicycle ergometry was performed in 20 normal subjects by using standardized weight-related increases in workload. MSV were measured at each step of exercise for 16 left ventricular stress echo segments. At rest, a base-apex gradient in regional MSV was recorded with highest longitudinal shortening velocities at the base. A similar pattern was noted for circumferential shortening MSV. Measurements were predictable and highly reproducible with low interobserver and intraobserver variability for 26 of 34 segments. Reproducibility was poor for basal anteroseptal segments in all views and mid anterior, anteroseptal, and septal segments in the short-axis views. During exercise, mid and basal segments of all walls showed a significant increase of MSV between each workload step and for apical segments between alternate steps. The resting base-apex velocity gradient observed at rest remained in all walls throughout ergometry. Thus a CDMI system with improved spatial and temporal resolution and postprocessing analysis modalities provided reproducible and accurate quantification of segmental left ventricular circumferential and longitudinal contraction both at rest and during exercise.     

Postgraduate cardiology training

Some indices of cell-mediated and humoral immunity were studied in 35 patients with insulin-dependent diabetes mellitus before and 7, 14 days, 3, 6, and 12 months after transplantation of pancreatic islet cell culture obtained from newborn pigs into m. rectus abdominis. It was established that the transplantation does not affect number of T- and B-lymphocytes, T-helpers, T-suppressors and level of antibodies to insulin. Clinical effect depended on the base level of transplantation immunity. Favourable results, such as liquidation of hypoglycaemia and reduction of exogenic insulin at the background of improved general condition may be expected in cases with high of heterophilic haemagglutinins low cytotoxicity index and increased number of sensibilized leukocytes.     

Pre-ECT cardiology consultation

A case of multiple primary Carcinomas of the gastrointestinal tract is reported in a man presenting with Carcinomas of the rectum and oesophagus.     

Preliminary reference levels in interventional cardiology

This article describes the European DIMOND approach to defining reference levels (RLs) for radiation doses delivered to patients during two types of invasive cardiology procedures, namely coronary angiography (CA) and percutaneous transluminal coronary angioplasty (PTCA). Representative centres of six European countries recorded patients' doses in terms of dose-area product (DAP), fluoroscopy time and number of radiographic exposures, using X-ray equipment that has been subject to constancy testing. In addition, a DAP trigger level for cardiac procedures which should alert the operator to possible skin injury, was set to 300 Gyxcm2. The estimation of maximum skin dose was recommended in the event that a DAP trigger level was likely to be exceeded. The proposed RLs for CA and PTCA were for DAP 45 Gyxcm2 and 75 Gyxcm2, for fluoroscopy time 7.5 min and 17 min and for number of frames 1250 and 1300, respectively. The proposed RLs should be considered as a first approach to help in the optimisation of these procedures. More studies are required to establish certain "tolerances" from the proposed levels taking into account the complexity of the procedure and the patient's size.     

Decision making in cardiology: methodology

This article reviews the methods employed in usual clinical thinking for making decisions, the problems and limitations inherent in them and claims that a more frequent utilization of the so called "Evidence Based Medicine" methods is a more valid and efficient alternative for medical decision making. We also describe the theoretical basis and strategies used in the medical decision process; the specific concepts and basic components for building decision trees are also shown. Finally, a real case is presented and approached step by step: the statement of the decision problem, its possible alternatives, the allocation of probabilities to each outcome based on the best available evidence, and the calculations of the expected values (projected usefulness, cost-effectiveness) and sensitivity analysis by means of specific software for making decisions.     

Methods of investigation in clinical cardiology. X. Studies on the evaluation of diagnostic tests in cardiology

Diagnosis is a complex cognitive process which is characterised by uncertainty. This uncertainty can be managed through specific knowledge in conjunction with probability theory. Studies evaluating diagnostic tests are the best way of building this knowledge. Studies evaluating diagnostic tests have two essential components: the gold standard and the new test. Both components, gold standard and test, are independent measurement process that can be influenced by diverse sources of variability. The comparison between diagnostic and test is essentially a hierarchical procedure. Diagnostic tests are evaluated by their sensitivity, specificity compared to a definitive gold standard. The predictive values and the likelihood ratio test are also used. Sensitivity (the proportion of true positives) and specificity (the proportion of true negatives) are values obtained from a sample and thereby can be considered as the conditional agreement between gold standard and the new test. Kappa coefficients for sensitivity and specificity are useful tools for adjusting both indices. Sensitivity and specificity are non-poblational values, they are estimates of the true values of the study population and can be affected by random error and systematic errors (bias). Confidence intervals are useful for giving an indication of the precision of the point estimates of sensitivity and specificity. A suitable sound design is required to avoiding a biased estimate of sensitivity, likelihood ratio, and predictive values. Finally a list of potential biases is given with methods for minimising these.