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1.  White paper on radiation protection by the European Society of Radiology 
Insights into Imaging  2011;2(4):357-362.
In the past decade, the medical effective dose per caput has increased in most European countries because of CT; it now ranges between 0.4 and 2 mSv/year. The biological impact of diagnostic imaging exposure is dominated by stochastic effects: based on the linear-no-threshold hypothesis, the risk of cancer induction is estimated to increase proportionally to organ dose, reaching around 0.5% at an effective dose of 100 mSv. The risk is higher the younger the age at the time of exposure, it is different for different organs, and women are more susceptible than men. Fluoroscopy-based imaging, above all intervention, may reach the dose threshold for deterministic effects, observed most often at the skin above around 3 Gy, and it is also the major source of occupational exposure in radiology. This white paper discusses the role of justification, evidence-based referral guidelines, optimization, diagnostic reference levels, clinical audits and quality assurance programs. The ESR strongly supports education and training of the medical staff involved in imaging by ionizing radiation. It disseminates information regarding radiation protection, takes initiatives, cooperates with partners and supports projects in justification as well as optimization. To reach these aims, the ESR cooperates with other organizations involved in radiation protection.
doi:10.1007/s13244-011-0108-1
PMCID: PMC3259338  PMID: 22358387
Radiation protection; Cancer risk; Imaging
2.  White paper on radiation protection by the European Society of Radiology 
Insights into Imaging  2011;2(4):357-362.
In the past decade, the medical effective dose per caput has increased in most European countries because of CT; it now ranges between 0.4 and 2 mSv/year. The biological impact of diagnostic imaging exposure is dominated by stochastic effects: based on the linear-no-threshold hypothesis, the risk of cancer induction is estimated to increase proportionally to organ dose, reaching around 0.5% at an effective dose of 100 mSv. The risk is higher the younger the age at the time of exposure, it is different for different organs, and women are more susceptible than men. Fluoroscopy-based imaging, above all intervention, may reach the dose threshold for deterministic effects, observed most often at the skin above around 3 Gy, and it is also the major source of occupational exposure in radiology. This white paper discusses the role of justification, evidence-based referral guidelines, optimization, diagnostic reference levels, clinical audits and quality assurance programs. The ESR strongly supports education and training of the medical staff involved in imaging by ionizing radiation. It disseminates information regarding radiation protection, takes initiatives, cooperates with partners and supports projects in justification as well as optimization. To reach these aims, the ESR cooperates with other organizations involved in radiation protection.
doi:10.1007/s13244-011-0108-1
PMCID: PMC3259338  PMID: 22358387
Radiation protection; Cancer risk; Imaging
3.  Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery) 
Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients.
Hemodynamically Unstable Pelvic Trauma is a frequent death cause among people who sustain blunt trauma. We present the results of the First Italian Consensus Conference.
doi:10.1186/1749-7922-9-18
PMCID: PMC3975341  PMID: 24606950
Pelvic trauma; Angiography; Preperitoneal pelvic packing; External fixation; Pelvic binder
4.  2014 Korean Guidelines for Appropriate Utilization of Cardiovascular Magnetic Resonance Imaging: A Joint Report of the Korean Society of Cardiology and the Korean Society of Radiology 
Korean Circulation Journal  2014;44(6):359-385.
Cardiac magnetic resonance (CMR) imaging is now widely used in several fields of cardiovascular disease assessment due to recent technical developments. CMR can give physicians information that cannot be found with other imaging modalities. However, there is no guideline which is suitable for Korean people for the use of CMR. Therefore, we have prepared a Korean guideline for the appropriate utilization of CMR to guide Korean physicians, imaging specialists, medical associates and patients to improve the overall medical system performances. By addressing CMR usage and creating these guidelines we hope to contribute towards the promotion of public health. This guideline is a joint report of the Korean Society of Cardiology and the Korean Society of Radiology.
doi:10.4070/kcj.2014.44.6.359
PMCID: PMC4248609  PMID: 25469139
Guideline; Appropriateness criteria; Magnetic resonance imaging; Heart; Evidence-based medicine
5.  2014 Korean Guidelines for Appropriate Utilization of Cardiovascular Magnetic Resonance Imaging: A Joint Report of the Korean Society of Cardiology and the Korean Society of Radiology 
Korean Journal of Radiology  2014;15(6):659-688.
Cardiac magnetic resonance (CMR) imaging is now widely used in several fields of cardiovascular disease assessment due to recent technical developments. CMR can give physicians information that cannot be found with other imaging modalities. However, there is no guideline which is suitable for Korean people for the use of CMR. Therefore, we have prepared a Korean guideline for the appropriate utilization of CMR to guide Korean physicians, imaging specialists, medical associates and patients to improve the overall medical system performances. By addressing CMR usage and creating these guidelines we hope to contribute towards the promotion of public health. This guideline is a joint report of the Korean Society of Cardiology and the Korean Society of Radiology.
doi:10.3348/kjr.2014.15.6.659
PMCID: PMC4248622  PMID: 25469078
Guideline; Appropriateness criteria; Magnetic resonance imaging; Heart; Evidence-based medicine
6.  Interventional radiology at the meetings of the German Radiological Society from 1998 to 2008: evaluation of structural changes and radiation issues 
Insights into Imaging  2011;3(1):101-109.
Objectives
Evaluation of structural changes and the weight given to radiation exposure of interventional radiology (IR) contributions at the Congress of the German Radiological Association from 1998 to 2008.
Methods
All IR abstracts were evaluated for type of contribution, design, imaging modality, and anatomic region. Weight given to radiation exposure was recorded as general statement, main topic and/or dose reduction. Statistical analysis included calculation of absolute/relative proportions of subgroups and ANOVA regression analyses.
Results
Out of 9,436 abstracts, 1,728 (18%) were IR-related. IR abstracts significantly rose to a maximum of 200 (20%) in 2005 (P = 0.048). While absolute numbers of scientific contributions declined, educational contributions significantly increased (P = 0.003). Computed tomography (CT) and magnetic resonance imaging (MRI) were the main IR imaging modalities, with growing use of CT (P = 0.021). The main body regions were vessels (45%) and abdomen (31%). Radiation exposure was addressed as a general statement in 3% of abstracts, as a main topic in 2%, and for dose reduction in 1%, respectively. During the study interval a significant growth of dose reduction abstracts was observed (P = 0.016).
Conclusions
IR emerged as a growing specialty of radiology, with a significant increase in educational contributions. Radiation exposure was rarely in the focus of interest but contributions relating to dose reduction demonstrated a significant growth during the study period.
Main Messages
• Interventional radiology emerged as a growing specialty at the German radiological congress.
• Significant increments of educational and prospective research contributions could be observed.
• Despite a significant trend towards computed tomography, radiation exposure of IR was rarely in the focus of interest.
• Contributions related to dose reduction demonstrated a significant growth during the study period.
doi:10.1007/s13244-011-0138-8
PMCID: PMC3292639  PMID: 22696003
Interventional radiology; Radiation exposure; Dose reduction; CT; MRI
7.  Interventional radiology at the meetings of the German Radiological Society from 1998 to 2008: evaluation of structural changes and radiation issues 
Insights into Imaging  2011;3(1):101-109.
Objectives
Evaluation of structural changes and the weight given to radiation exposure of interventional radiology (IR) contributions at the Congress of the German Radiological Association from 1998 to 2008.
Methods
All IR abstracts were evaluated for type of contribution, design, imaging modality, and anatomic region. Weight given to radiation exposure was recorded as general statement, main topic and/or dose reduction. Statistical analysis included calculation of absolute/relative proportions of subgroups and ANOVA regression analyses.
Results
Out of 9,436 abstracts, 1,728 (18%) were IR-related. IR abstracts significantly rose to a maximum of 200 (20%) in 2005 (P = 0.048). While absolute numbers of scientific contributions declined, educational contributions significantly increased (P = 0.003). Computed tomography (CT) and magnetic resonance imaging (MRI) were the main IR imaging modalities, with growing use of CT (P = 0.021). The main body regions were vessels (45%) and abdomen (31%). Radiation exposure was addressed as a general statement in 3% of abstracts, as a main topic in 2%, and for dose reduction in 1%, respectively. During the study interval a significant growth of dose reduction abstracts was observed (P = 0.016).
Conclusions
IR emerged as a growing specialty of radiology, with a significant increase in educational contributions. Radiation exposure was rarely in the focus of interest but contributions relating to dose reduction demonstrated a significant growth during the study period.
Main Messages
• Interventional radiology emerged as a growing specialty at the German radiological congress.
• Significant increments of educational and prospective research contributions could be observed.
• Despite a significant trend towards computed tomography, radiation exposure of IR was rarely in the focus of interest.
• Contributions related to dose reduction demonstrated a significant growth during the study period.
doi:10.1007/s13244-011-0138-8
PMCID: PMC3292639  PMID: 22696003
Interventional radiology; Radiation exposure; Dose reduction; CT; MRI
8.  Cardiovascular and Interventional Radiological Society of Europe Commentary on the Treatment of Chronic Cerebrospinal Venous Insufficiency 
Chronic cerebrospinal venous insufficiency (CCSVI) is a putative new theory that has been suggested by some to have a direct causative relation with the symptomatology associated with multiple sclerosis (MS) [1]. The core foundation of this theory is that there is abnormal venous drainage from the brain due to outflow obstruction in the draining jugular vein and/or azygos veins. This abnormal venous drainage, which is characterised by special ultrasound criteria, called the “venous hemodynamic insufficiency severity score” (VHISS), is said to cause intracerebral flow disturbance or outflow problems that lead to periventricular deposits [2]. In the CCSVI theory, these deposits have a great similarity to the iron deposits seen around the veins in the legs in patients with chronic deep vein thrombosis. Zamboni, who first described this new theory, has promoted balloon dilatation to treat the outflow problems, thereby curing CCSVI and by the same token alleviating MS complaints. However, this theory does not fit into the existing bulk of scientific data concerning the pathophysiology of MS. In contrast, there is increasing worldwide acceptance of CCSVI and the associated balloon dilatation treatment, even though there is no supporting scientific evidence. Furthermore, most of the information we have comes from one source only. The treatment is called “liberation treatment,” and the results of the treatment can be watched on YouTube. There are well-documented testimonies by MS patients who have gained improvement in their personal quality of life (QOL) after treatment. However, there are no data available from patients who underwent unsuccessful treatments with which to obtain a more balanced view. The current forum for the reporting of success in treating CCSVI and thus MS seems to be the Internet. At the CIRCE office and the MS Centre in Amsterdam, we receive approximately 10 to 20 inquiries a month about this treatment. In addition, many interventional radiologists, who are directly approached by MS patients, contact the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) for advice. Worldwide, several centres are actively promoting and performing balloon dilatation, with or without stenting, for CCSVI. Thus far, no trial data are available, and there is currently no randomized controlled trial (RCT) in progress Therefore, the basis for this new treatment rests on anecdotal evidence and successful testimonies by patients on the Internet. CIRSE believes that this is not a sound basis on which to offer a new treatment, which could have possible procedure-related complications, to an often desperate patient population.
doi:10.1007/s00270-010-0050-5
PMCID: PMC2816826  PMID: 21136256
9.  American College of Radiology (ACR) and American Society for Radiation Oncology (ASTRO) Practice Guideline for the Performance of Stereotactic Radiosurgery (SRS) 
American College of Radiology and American Society for Radiation Oncology Practice Guideline for the Performance of Stereotactic Radiosurgery (SRS). SRS is a safe and efficacious treatment option of a variety of benign and malignant disorders involving intracranial structures and selected extracranial lesions. SRS involves a high dose of ionizing radiation with a high degree of precision and spatial accuracy. A quality SRS program requires a multidisciplinary team involved in the patient management. Organization, appropriate staffing, and careful adherence to detail and to established SRS standards is important to ensure operational efficiency and to improve the likelihood of procedural success. A collaborative effort of the American College of Radiology and American Society for Therapeutic Radiation Oncology has produced a practice guideline for SRS. The guideline defines the qualifications and responsibilities of all the involved personnel, including the radiation oncologist, neurosurgeon, and qualified medical physicist. Quality assurance is essential for safe and accurate delivery of treatment with SRS. Quality assurance issues for the treatment unit, stereotactic accessories, medical imaging, and treatment-planning system are presented and discussed. Adherence to these practice guidelines can be part of ensuring quality and patient safety in a successful SRS program.
doi:10.1097/COC.0b013e31826e053d
PMCID: PMC4285440  PMID: 23681017
stereotactic radiation therapy; stereotactic radiosurgery; quality assurance; safety; practice guidelines; radiation oncology
10.  Patient communication, confidentiality and consent: radiology policy and practice in Europe. A survey by the European Society of Radiology 
Insights into Imaging  2013;4(2):153-156.
The data collected in this article were gathered from various practising radiology departments around Europe. The focus is communication and confidentiality between patient and radiologist, specifically the ramifications of PACS and other electronic systems for the confidentiality of patient information. The differences and similarities in practice across Europe are explored.
Main Messages
• Monitoring of access to confidential patient imaging information does not appear to have kept pace with electronic image storage systems
• Europe lacks a unified approach to define clear guidelines for patient confidentiality and guidance on what constitutes invasion of patient privacy
• Specific training in communication is not routinely incorporated into radiology training schemes
doi:10.1007/s13244-013-0236-x
PMCID: PMC3609950  PMID: 23471633
Communication; Confidentiality; Consent; Radiology
11.  Joint UK societies’ 2014 consensus statement on renal denervation for resistant hypertension 
Heart  2014;101(1):10-16.
Resistant hypertension continues to pose a major challenge to clinicians worldwide and has serious implications for patients who are at increased risk of cardiovascular morbidity and mortality with this diagnosis. Pharmacological therapy for resistant hypertension follows guidelines-based regimens although there is surprisingly scant evidence for beneficial outcomes using additional drug treatment after three antihypertensives have failed to achieve target blood pressure. Recently there has been considerable interest in the use of endoluminal renal denervation as an interventional technique to achieve renal nerve ablation and lower blood pressure. Although initial clinical trials of renal denervation in patients with resistant hypertension demonstrated encouraging office blood pressure reduction, a large randomised control trial (Symplicity HTN-3) with a sham-control limb, failed to meet its primary efficacy end point. The trial however was subject to a number of flaws which must be taken into consideration in interpreting the final results. Moreover a substantial body of evidence from non-randomised smaller trials does suggest that renal denervation may have an important role in the management of hypertension and other disease states characterised by overactivation of the sympathetic nervous system. The Joint UK Societies does not recommend the use of renal denervation for treatment of resistant hypertension in routine clinical practice but remains committed to supporting research activity in this field. A number of research strategies are identified and much that can be improved upon to ensure better design and conduct of future randomised studies.
doi:10.1136/heartjnl-2014-307029
PMCID: PMC4283620  PMID: 25431461
12.  Historical Review of Cancer Risks in Medical Radiation Workers 
Radiation research  2010;174(6):793-808.
Epidemiologic studies of medical radiation workers have found excess risks of leukemia, skin and female breast cancer in those employed before 1950, but little consistent evidence of cancer risk increases subsequently. Occupational radiation-related dose-response, risk estimates for recent years, and lifetime cancer risk data are limited for radiologists and radiologic technologists and lacking for physicians and technologists performing or assisting with fluoroscopically-guided procedures. Based on data from 80 mostly small studies of cardiologists and substantially fewer studies of physicians in other specialties, estimated effective doses to physicians per interventional procedure vary by more than an order of magnitude. There is an urgent need to expand the limited base of information on average annual occupational radiation exposures and time-trends in doses received by medical radiation workers, to assess lifetime cancer risks of radiologists and radiologic technologists in the existing cohorts, and to initiate long-term follow-up studies of cancer and other radiation-associated disease risks in physicians and technologists performing or assisting with interventional procedures. Such studies will help to optimize standardized protocols for radiologic procedures, determine if current radiation protection measures are adequate, provide guidance on cancer screening needs, and yield valuable insights on cancer risks associated with chronic radiation exposure.
doi:10.1667/RR2014.1
PMCID: PMC4098897  PMID: 21128805
radiologists; interventional radiologists; radiologic technologists; interventional cardiologists; neoplasms; reviews
13.  European survey on imaging referral guidelines 
Insights into Imaging  2013;5(1):15-23.
Abstract
The objective of this study was to devise and implement a Europe-wide study on referral guidelines for radiological imaging in the EU Member States in order to identify potential major issues, important differences between Member States and good practices. A web-based survey was used to assess the availability of imaging referral guidelines, development methodology and preferences for future initiatives for European community action to facilitate justification and appropriate use of radiological diagnostic procedures. A questionnaire was distributed to representatives of national radiological and nuclear medicine societies as well as to competent authorities for radiation protection in 30 European countries, including all 28 EU Member States. Responses were collated and analysed to produce a series of conclusions and recommendations.
Main messages
• Survey respondents in 21/30 countries were aware of legal requirements for Guidelines
• Survey respondents in 18/30 countries were aware of the availability of Guidelines in their country.
• The majority of responders support the development of European Guidelines. These may either be from a combination of multiple national Guidelines with consensus or Pan-European Guidelines developed centrally.
• Guidelines developed in two countries included all of the following important features: radiation dose information; specific advice for imaging children; specific advice for the pregnant woman/unborn child; an evidence-based process; a formal consensus for recommendations.
• Suggestions for additional measures needed to reinforce the use of Guidelines include: educational initiatives; integrating Guidelines into clinical decision support systems; clinical audit for monitoring of the availability, use and implementation of Guidelines.
Electronic supplementary material
The online version of this article (doi:10.1007/s13244-013-0300-6) contains supplementary material, which is available to authorized users.
doi:10.1007/s13244-013-0300-6
PMCID: PMC3948911  PMID: 24338617
14.  Poul Erik Andersen's radiological work on Osteochondrodysplasias and interventional radiology 
World Journal of Radiology  2011;3(8):210-214.
Poul Erik Andersen is a Professor and Interventional Radiologist at the University of Southern Denmark, Odense and Odense University Hospital, Denmark. His innovative and expertise is primarily in vascular interventions where he has introduced and developed many procedures at Odense University Hospital. His significant experience and extensive scientific work has led to many posts in the Danish Society of Interventional Radiology, the European Society of Radiology and the Cardiovascular and Interventional Radiological Society of Europe, where he is a fellow and has passed the European Board of Interventional Radiology - The European qualification in Interventional Radiology.
doi:10.4329/wjr.v3.i8.210
PMCID: PMC3198263  PMID: 22022640
Biography; Clinical competence; Education; Interventional; Radiology
15.  Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: Executive summary 
With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease (CHD) has increased. In the current era, there are more adults with CHD than children. This population has many unique issues and needs. They have distinctive forms of heart failure, and their cardiac disease can be associated with pulmonary hypertension, thromboemboli, complex arrhythmias and sudden death. Medical aspects that need to be considered relate to the long-term and multisystemic effects of single-ventricle physiology, cyanosis, systemic right ventricles, complex intracardiac baffles and failing subpulmonary right ventricles. Since the 2001 Canadian Cardiovascular Society Consensus Conference report on the management of adults with CHD, there have been significant advances in the understanding of the late outcomes, genetics, medical therapy and interventional approaches in the field of adult CHD. Therefore, new clinical guidelines have been written by Canadian adult CHD physicians in collaboration with an international panel of experts in the field. The present executive summary is a brief overview of the new guidelines and includes the recommendations for interventions. The complete document consists of four manuscripts that are published online in the present issue of The Canadian Journal of Cardiology, including sections on genetics, clinical outcomes, recommended diagnostic workup, surgical and interventional options, treatment of arrhythmias, assessment of pregnancy and contraception risks, and follow-up requirements. The complete document and references can also be found at www.ccs.ca or www.cachnet.org.
PMCID: PMC2851468  PMID: 20352134
Adult congenital heart disease; Congenital heart disease; Consensus; Guidelines; Surgery
16.  Advancing radiology through informed leadership: summary of the proceedings of the Seventh Biannual Symposium of the International Society for Strategic Studies in Radiology (IS3R), 23–25 August 2007 
European Radiology  2009;19(8):1827-1836.
The International Society for Strategic Studies in Radiology (IS3R) brings together thought leaders from academia and industry from around the world to share ideas, points of view and new knowledge. This article summarizes the main concepts presented at the 2007 IS3R symposium, providing a window onto trends shaping the future of radiology. Topics addressed include new opportunities and challenges in the field of interventional radiology; emerging techniques for evaluating and improving quality and safety in radiology; and factors impeding progress in molecular imaging and nanotechnology and possible ways to overcome them. Regulatory hurdles to technical innovation and drug development are also discussed more broadly, along with proposals for addressing regulators’ concerns and streamlining the regulatory process.
doi:10.1007/s00330-009-1370-1
PMCID: PMC2705708  PMID: 19277668
Interventional radiology; Molecular imaging; Device approval processes; Drug approval processes; Health-care quality; Radiology; Leadership
17.  European society of intensive care medicine study of therapeutic hypothermia (32-35°C) for intracranial pressure reduction after traumatic brain injury (the Eurotherm3235Trial) 
Trials  2011;12:8.
Background
Traumatic brain injury is a major cause of death and severe disability worldwide with 1,000,000 hospital admissions per annum throughout the European Union.
Therapeutic hypothermia to reduce intracranial hypertension may improve patient outcome but key issues are length of hypothermia treatment and speed of re-warming. A recent meta-analysis showed improved outcome when hypothermia was continued for between 48 hours and 5 days and patients were re-warmed slowly (1°C/4 hours). Previous experience with cooling also appears to be important if complications, which may outweigh the benefits of hypothermia, are to be avoided.
Methods/design
This is a pragmatic, multi-centre randomised controlled trial examining the effects of hypothermia 32-35°C, titrated to reduce intracranial pressure <20 mmHg, on morbidity and mortality 6 months after traumatic brain injury. The study aims to recruit 1800 patients over 41 months. Enrolment started in April 2010.
Participants are randomised to either standard care or standard care with titrated therapeutic hypothermia. Hypothermia is initiated with 20-30 ml/kg of intravenous, refrigerated 0.9% saline and maintained using each centre's usual cooling technique. There is a guideline for detection and treatment of shivering in the intervention group. Hypothermia is maintained for at least 48 hours in the treatment group and continued for as long as is necessary to maintain intracranial pressure <20 mmHg. Intracranial hypertension is defined as an intracranial pressure >20 mmHg in accordance with the Brain Trauma Foundation Guidelines, 2007.
Discussion
The Eurotherm3235Trial is the most important clinical trial in critical care ever conceived by European intensive care medicine, because it was launched and funded by the European Society of Intensive Care Medicine and will be the largest non-commercial randomised controlled trial due to the substantial number of centres required to deliver the target number of patients. It represents a new and fundamental step for intensive care medicine in Europe. Recruitment will continue until January 2013 and interested clinicians from intensive care units worldwide can still join this important collaboration by contacting the Trial Coordinating Team via the trial website http://www.eurotherm3235trial.eu.
Trial registration
Current Controlled Trials ISRCTN34555414
doi:10.1186/1745-6215-12-8
PMCID: PMC3027122  PMID: 21226939
18.  Assessment of acute myocardial infarction: current status and recommendations from the North American society for cardiovascular imaging and the European society of cardiac radiology 
There are a number of imaging tests that are used in the setting of acute myocardial infarction and acute coronary syndrome. Each has their strengths and limitations. Experts from the European Society of Cardiac Radiology and the North American Society for Cardiovascular Imaging together with other prominent imagers reviewed the literature. It is clear that there is a definite role for imaging in these patients. While comparative accuracy, convenience and cost have largely guided test decisions in the past, the introduction of newer tests is being held to a higher standard which compares patient outcomes. Multicenter randomized comparative effectiveness trials with outcome measures are required.
doi:10.1007/s10554-010-9714-0
PMCID: PMC3035779  PMID: 20972835
Acute myocardial infarction; Acute coronary syndrome; Cardiac imaging
19.  Assessment of acute myocardial infarction: current status and recommendations from the North American society for cardiovascular imaging and the European society of cardiac radiology 
There are a number of imaging tests that are used in the setting of acute myocardial infarction and acute coronary syndrome. Each has their strengths and limitations. Experts from the European Society of Cardiac Radiology and the North American Society for Cardiovascular Imaging together with other prominent imagers reviewed the literature. It is clear that there is a definite role for imaging in these patients. While comparative accuracy, convenience and cost have largely guided test decisions in the past, the introduction of newer tests is being held to a higher standard which compares patient outcomes. Multicenter randomized comparative effectiveness trials with outcome measures are required.
doi:10.1007/s10554-010-9714-0
PMCID: PMC3035779  PMID: 20972835
Acute myocardial infarction; Acute coronary syndrome; Cardiac imaging
20.  Control and prevention of tuberculosis in the United Kingdom: Code of Practice 1994. Joint Tuberculosis Committee of the British Thoracic Society. 
Thorax  1994;49(12):1193-1200.
BACKGROUND--The guidelines on control and prevention of tuberculosis in the United Kingdom have been reviewed and updated. METHODS--A subcommittee was appointed by the Joint Tuberculosis Committee (JTC). Each member of this group drafted one or more sections of the guidelines, and drafts were made available to all members of the group. In the course of several meetings drafts were altered and incorporated into a final text. The guidelines were approved by the full JTC and by the Standards of Care Committee of the British Thoracic Society. In revising the guidelines the authors took account of new published evidence and recent concerns about drug resistance and possible effects of HIV on tuberculosis. CONCLUSIONS--(1) All cases of tuberculosis must be notified. (2) A few patients need hospital admission. (3) Patients with positive sputum smears and sensitive organisms should be considered infectious until they have received two weeks' chemotherapy. (4) Treatment of all tuberculosis patients should be supervised by a respiratory physician employing standard medication guidelines and monitoring compliance at least monthly. (5) Health care workers at risk should be protected by BCG vaccination and appropriate infection control measures, and evidence of infectious tuberculosis should be sought among prospective NHS staff, school teachers, and others. (6) Prison staff should be protected. (7) Tuberculosis should be considered in the elderly in long stay care with persistent chest symptoms. (8) Contact tracing should be vigorously pursued with chemoprophylaxis, BCG vaccination, or follow up where applicable. (9) Entrants to the UK from high risk countries (tuberculosis incidence more than 40/100,000 population per year) should be screened. (10) BCG vaccination should be offered where appropriate but not in subjects with known or suspected HIV infection. (11) The local organisation of tuberculosis services should be strengthened and should include adequate nursing and support staff. (12) Contracts between purchasers and providers should specify management of tuberculosis in line with this and other JTC guidelines.
PMCID: PMC475322  PMID: 7878551
21.  Growth Hormone Research Society Workshop Summary: Consensus Guidelines for Recombinant Human Growth Hormone Therapy in Prader-Willi Syndrome 
Context:
Recombinant human GH (rhGH) therapy in Prader-Willi syndrome (PWS) has been used by the medical community and advocated by parental support groups since its approval in the United States in 2000 and in Europe in 2001. Its use in PWS represents a unique therapeutic challenge that includes treating individuals with cognitive disability, varied therapeutic goals that are not focused exclusively on increased height, and concerns about potential life-threatening adverse events.
Objective:
The aim of the study was to formulate recommendations for the use of rhGH in children and adult patients with PWS.
Evidence:
We performed a systematic review of the clinical evidence in the pediatric population, including randomized controlled trials, comparative observational studies, and long-term studies (>3.5 y). Adult studies included randomized controlled trials of rhGH treatment for ≥ 6 months and uncontrolled trials. Safety data were obtained from case reports, clinical trials, and pharmaceutical registries.
Methodology:
Forty-three international experts and stakeholders followed clinical practice guideline development recommendations outlined by the AGREE Collaboration (www.agreetrust.org). Evidence was synthesized and graded using a comprehensive multicriteria methodology (EVIDEM) (http://bit.ly.PWGHIN).
Conclusions:
Following a multidisciplinary evaluation, preferably by experts, rhGH treatment should be considered for patients with genetically confirmed PWS in conjunction with dietary, environmental, and lifestyle interventions. Cognitive impairment should not be a barrier to treatment, and informed consent/assent should include benefit/risk information. Exclusion criteria should include severe obesity, uncontrolled diabetes mellitus, untreated severe obstructive sleep apnea, active cancer, or psychosis. Clinical outcome priorities should vary depending upon age and the presence of physical, mental, and social disability, and treatment should be continued for as long as demonstrated benefits outweigh the risks.
doi:10.1210/jc.2012-3888
PMCID: PMC3789886  PMID: 23543664
22.  Report of the Canadian Hypertension Society Consensus Conference: 1. Definitions, evaluation and classification of hypertensive disorders in pregnancy 
OBJECTIVES: To provide Canadian physicians with a standard definition of hypertension in pregnancy, recommendations for laboratory investigations and tests for the assessment and management of hypertensive disorders in pregnancy, and a classification of such disorders. OPTIONS: To improve or not improve Canadian uniformity and standardization in the investigation and classification of hypertensive disorders in pregnancy. OUTCOMES: 1) Accuracy, reliability and practicality of diagnostic clinical criteria for hypertensive disorders in pregnancy. 2) Laboratory tests useful to determine severity and prognosis of disorders as measured by maternal and neonatal adverse outcomes. 3) A classification of disorders for use by Canadian physicians to facilitate uniformity and diffusion of research through a common language. EVIDENCE: Articles on hypertensive disorders in pregnancy published from 1966 to 1996, retrieved through MEDLINE search, related to definitions, tests, diagnostic criteria and classification, as well as documents on diagnosis and classification from authorities in the United States, Europe and Australia and from special interest groups. VALUES: High priority was given to the principle of preventing adverse maternal and neonatal outcomes through the provision of diagnostic criteria for severity and prognosis and through dissemination of reliable and pertinent information and research results using a common language. BENEFITS, HARMS AND COST: Higher degree of vigilance in diagnosing hypertensive disorders in pregnancy, allowing for earlier assessment and intervention, and more efficient dissemination of comparative information through common language. No harm or added cost is perceived at this time. RECOMMENDATIONS: (1) A diastolic blood pressure of 90 mm Hg or more should be the criterion for a diagnosis of hypertension in pregnancy and should trigger investigation and management. Except for very high diastolic readings (110 mm Hg or more), all diastolic readings of 90 mm Hg or more should be confirmed after 4 hours. (2) A regularly calibrated mercury sphygmomanometer, with an appropriate-sized cuff, is the instrument of choice. A rest period of 10 minutes should be allowed before taking the blood pressure. The woman should be sitting upright and the cuff positioned at the level of the heart. (3) Both Korotkoff phase IV and V sounds should be recorded, but the phase IV sound should be used for initiating clinical investigation and management. (4) A urine protein level of more than 0.3 g/d should be the criterion for a diagnosis of proteinuria; 24-hour urine collection should be the standard method for determining proteinuria. (5) Edema and weight gain should not be used as diagnostic criteria. (6) Hypertensive disorders diagnosed during pregnancy should be classified as pre-existing hypertension; gestational hypertension with or without proteinuria; pre-existing hypertension with superimposed gestational hypertension with proteinuria; and unclassifiable antenatally but final classification 42 days after delivery. VALIDATION: Except for expert opinions and reviews solicited for this project, these recommendations need to be field tested and validated in Canada. Guidelines endorsed by the Canadian Hypertension Society and the Society of Obstetricians and Gynaecologists of Canada.
PMCID: PMC1228113  PMID: 9307560
23.  Outcomes of androgen replacement therapy in adult male hypogonadism: recommendations from the Italian society of endocrinology 
Objective
We developed clinical practice guidelines to assess the individual risk–benefit profile of androgen replacement therapy in adult male hypogonadism (HG), defined by the presence of specific signs and symptoms and serum testosterone (T) below 12 nmol/L.
Participants
The task force consisted of eight clinicians experienced in treating HG, selected by the Italian Society of Endocrinology (SIE). The authors received no corporate funding or remuneration.
Consensus process
Consensus was guided by a systematic review of controlled trials conducted on men with a mean T < 12 nmol/L and by interactive discussions. The guidelines were reviewed and sequentially approved by the SIE Guidelines Commission and Executive Committee.
Conclusions
We recommend T supplementation (TS) for adult men with severely reduced T levels (T < 8 nmol/L) to improve body composition and sexual function. We suggest that TS be offered to subjects with T < 12 nmol/L to improve glycaemic control, lipid profile, sexual function, bone mineral density, muscle mass and depressive symptoms, once major contraindications have been ruled out. We suggest that lifestyle changes and other available interventions (e.g. for erectile dysfunction) be suggested prior to TS. We suggest that TS should be combined with currently available treatments for individuals at high risk for complications, such as those with osteoporosis and/or metabolic disorders. We recommend against using TS to improve cardiac outcome and limited mobility. We recommend against using TS in men with prostate cancer, unstable cardiovascular conditions or elevated haematocrit. The task force places a high value on the timely treatment of younger and middle-aged subjects to prevent the long-term consequences of hypoandrogenism.
doi:10.1007/s40618-014-0155-9
PMCID: PMC4282686  PMID: 25384570
24.  Interventional radiography and mortality risks in U.S. radiologic technologists 
Pediatric Radiology  2006;36(Suppl 2):113-120.
With the exponential increase in minimally invasive fluoroscopically guided interventional radiologic procedures, concern has increased about the health effects on staff and patients of radiation exposure from these procedures. There has been no systematic epidemiologic investigation to quantify serious disease risks or mortality. To quantify all-cause, circulatory system disease and cancer mortality risks in U.S. radiologic technologists who work with interventional radiographic procedures, we evaluated mortality risks in a nationwide cohort of 88,766 U.S. radiologic technologists (77% female) who completed a self-administered questionnaire during 1994–998 and were followed through 31 December 2003. We obtained information on work experience, types of procedures (including fluoroscopically guided interventional procedures), and protective measures plus medical, family cancer history, lifestyle, and reproductive information. Cox proportional hazards regression models were used to compute relative risks (RRs) with 95% confidence intervals (CIs). Between completion of the questionnaire and the end of follow-up, there were 3,581 deaths, including 1,209 from malignancies and 979 from circulatory system diseases. Compared to radiologic technologists who never or rarely performed or assisted with fluoroscopically guided interventional procedures, all-cause mortality risks were not increased among those working on such procedures daily. Similarly, there was no increased risk of mortality resulting from all circulatory system diseases combined, all cancers combined, or female breast cancer among technologists who daily performed or assisted with fluoroscopically guided interventional procedures. Based on small numbers of deaths (n=151), there were non-significant excesses (40%–0%) in mortality from cerebrovascular disease among technologists ever working with these procedures. The absence of significantly elevated mortality risks in radiologic technologists reporting the highest frequency of interventional radiography procedures must be interpreted cautiously in light of the small number of deaths during the relatively short follow-up. The present study cannot rule out increased risks of cerebrovascular disease, specific cancers, and diseases with low case-fatality rates or a long latency period preceding death.
doi:10.1007/s00247-006-0224-0
PMCID: PMC2663634  PMID: 16862404
Radiologic technologists; Interventional radiography; Occupational radiation exposure; Mortality
25.  Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): An American Society for Radiation Oncology evidence-based guideline 
Practical Radiation Oncology  2012;2(3):210-225.
Purpose
To systematically review the evidence for the radiotherapeutic and surgical management of patients newly diagnosed with intraparenchymal brain metastases.
Methods and Materials
Key clinical questions to be addressed in this evidence-based Guideline were identified. Fully published randomized controlled trials dealing with the management of newly diagnosed intraparenchymal brain metastases were searched systematically and reviewed. The U.S. Preventative Services Task Force levels of evidence were used to classify various options of management.
Results
The choice of management in patients with newly diagnosed single or multiple brain metastases depends on estimated prognosis and the aims of treatment (survival, local treated lesion control, distant brain control, neurocognitive preservation).
Single brain metastasis and good prognosis (expected survival 3 months or more): For a single brain metastasis larger than 3 to 4 cm and amenable to safe complete resection, whole brain radiotherapy (WBRT) and surgery (level 1) should be considered. Another alternative is surgery and radiosurgery/radiation boost to the resection cavity (level 3). For single metastasis less than 3 to 4 cm, radiosurgery alone or WBRT and radiosurgery or WBRT and surgery (all based on level 1 evidence) should be considered. Another alternative is surgery and radiosurgery or radiation boost to the resection cavity (level 3). For single brain metastasis (less than 3 to 4 cm) that is not resectable or incompletely resected, WBRT and radiosurgery, or radiosurgery alone should be considered (level 1). For nonresectable single brain metastasis (larger than 3 to 4 cm), WBRT should be considered (level 3).
Multiple brain metastases and good prognosis (expected survival 3 months or more): For selected patients with multiple brain metastases (all less than 3 to 4 cm), radiosurgery alone, WBRT and radiosurgery, or WBRT alone should be considered, based on level 1 evidence. Safe resection of a brain metastasis or metastases causing significant mass effect and postoperative WBRT may also be considered (level 3).
Patients with poor prognosis (expected survival less than 3 months): Patients with either single or multiple brain metastases with poor prognosis should be considered for palliative care with or without WBRT (level 3).
It should be recognized, however, that there are limitations in the ability of physicians to accurately predict patient survival. Prognostic systems such as recursive partitioning analysis, and diagnosis-specific graded prognostic assessment may be helpful.
Conclusions
Radiotherapeutic intervention (WBRT or radiosurgery) is associated with improved brain control. In selected patients with single brain metastasis, radiosurgery or surgery has been found to improve survival and locally treated metastasis control (compared with WBRT alone).
doi:10.1016/j.prro.2011.12.004
PMCID: PMC3808749

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