For the first time at the Charing Cross Symposium, physicians shared their product ideas with experienced physician-inventors, engineers and marketing experts in an event called “Speed Dating”. The event was held at the Innovation Showcase on Sunday 6 April. Physician-inventor David King (London, UK) won the “Dragons’ Den CX Innovation Showcase prize”.

Jean Bismuth, Elika Kashef and Stephen Greenhalgh, chairs of the session, designed the event to provide a platform for physicians who are seeking advice from experts on how to put their business and product ideas onto market.

Bismuth explained the rationale for the event: “Many young physicians and even senior physicians—as they gain experience through the years—have a desire to design their own medical tools and they start thinking and developing the idea. Unfortunately, sometimes they cannot get their innovations onto the market because they do not have the access to the experts to take the idea to the next level. With this “Speed Dating” event, we want to collaborate to bridge that gap.”

At the event, physicians had the opportunity to speak first to a group of physicians who have experience developing devices, then to engineers and finally to marketing experts. “Protect your idea” was the main advice that experts gave to the participants.

After the “Speed Dating” event, the Dragons’ Den CX Innovation session took place and awarded David King with £1,000 for his innovative idea. King designed a Doppler device called “Blue Dop” that works via a tablet device. He said that it uses a special algorithm that can measure blood pressure without the need to use a cuff or needles. He noted that the device is unique in the market and can be used in renal dialysis, arterial disease and sports medicine.

A session held yesterday at the Charing Cross International Symposium revealed that there is a widespread lack of physician awareness about the dangers of radiation in the interventional suite. The effect of exposure to radiation has become particularly important with the move from open to endovascular procedures, and delegates heard how no single specialty had a monopoly on bad practice when it came to radiation.

During the session it became apparent that the knowledge base about radiation had not been developed and incorporated into training and that appropriate behaviour in the interventional suite was often ignored, leading to operators receiving unnecessary doses of radiation. Surgeons, who have belatedly started using radiation, interventional cardiologists, interventional radiologists and radiologists are all guilty of bad practice, delegates heard.

“We are not aware of how badly affected we can be and this session turns the spotlight on how little we know. It is very important to become aware and realise the danger before you can start steps to reduce it. Perhaps as a profession we are not doing enough,” said Roger Greenhalgh, London, UK, chairman of the symposium.

Lindsay Machan, Vancouver, Canada, who was invited to comment on the Radiation Exposure session, told delegates that there were “two dirty little secrets” about radiation that he wanted delegates to pay attention to. “The first is that there is no safe dose of radiation; the idea that there is a threshold has now been debunked. The second is that every person in this room has a variant level of the radiation repair genes and there is no test as yet for the repair genes.”

Machan referred to the results of a long-term international study of thousands of workers exposed to radiation in the Chernobyl disaster in 1986, which found that the disaster clean-up crew, no matter where they were located, had the same incidence of cataracts, dispelling the idea of there being a threshold for cataract development. Referring to the outcomes from another 20-year study published by Chodick et al in the American Journal of Epidemiology in 2008 that found that there was no apparent threshold level for technologists to get cataracts, he said: “Everything that you hear about thresholds is absolutely not true. Treat radiation like iodinated contrast and use only as much as needed and no more.”

Machan also told delegates about the work of the late Basil V Worgul, New York, USA, which had shown that there was a possibility that the human population included genetically predisposed radiosensitive subsets.

“Everybody in this room has some degree of radiation damage and not everyone has complex innovations available to help them reduce the dosage. However, the distance from the tube and the importance of magnification cannot be overstated,” Machan said.

A member of the audience referred to currently available tools that enabled the visualisation of dosage in the form of a light or sound alarm. “Everybody wants to avoid radiation, they are just not aware of how their behaviour impacts dose. So if you stand unnecessarily close to the machine, there is an immediate warning and this can teach operators a lot,” 
he said.

Operator behaviour is driven by various factors

“You cannot overstate the importance of a real time reminder of the dose. Another important thing we have observed is that when our nurses and technologists became aware of their own risk, it changed the dynamic quite considerably. Operators are driven by a different dynamic; we want to get that procedure done, we want to show the photos and have a tendency to ignore [the radiation dose] and the consequences as they might be 20 years away. However, the nurses and technologists are not [driven by the same things]. They are there to do a job. As soon as they realise that they are at risk, it has an amazing impact. They start pointing out the fluoro time, question where they are asked to stand, and if you are doing a pedal puncture they might not stand behind the foot and hold the foot for you,” Machan said.

Another member of the audience made the point that they had measured and found that the radiation exposure was less in the hybrid suite as compared to their previous set-up. Their team had also found that the operator steps away just 6% of the time during digital subtraction angiography turns and have been working on educating the entire team. The awareness is lamentable, delegates heard.

Patients suffering burns

“One of the problems is that radiation burns can occur several months after the procedure and often the patient does not connect that to the procedure. Also, due to the fact that the image intensifier is above them, they think that the radiation dose is there. They do not realise why they have a burn on their back and often go to see a physician who does not have radiation in their mind as the cause, so there is a gross underreporting of the problem,” Machan said. The panel also commented that the biggest risks were for health professionals, as they are exposed repetitively during the course of their work. The maximum exposure resulted when branched devices were implanted, and the biggest risks are for health professionals as they are exposed every day.

Is regulation around the corner?

Machan made the point that while the health effects of radiation were one aspect, another issue was that of looming regulation for radiation workers. He pointed to the current practice in some US hospitals of radiation workers “sitting it out” if they had a high reading on their dosimeters. The sit-out period could range from anywhere between a week and a month. “Think of what this would do to your endovascular practice,” urged Machan. “If you have to sit out for a month every couple of months, you cannot actually practise.”

The panellists noted that while there was a wide variation in education and training requirements for personnel to be able to use radiation, there was need for special education for the whole team on to behave in an operating room. Machan also noted that while there were well laid out and appropriate guidelines in place, that the bigger problem was with adherence and enforcement.

Johannes Gahlen, Ludwigsburg, Germany, who spoke on the importance of radiation dosage exposure to patient and operator, said: “It is vital to adhere to the ALARA principle of keeping the dose as low as reasonably achievable. It is important to decrease the beam time, keep  your distance from the system, use protective shielding, instruct the team, collimate the field of view, reduce the frame rate use use low dose programmes,” he said.

Following Gahlen’s presentation, Koning spoke about the novel X-ray system and how it can reduce radiation doses for patient and staff during endovascular procedures. He presented the results of a study and said that initial findings indicate that a significant radiation dose reduction of up to 75% to staff and patient can be realised for specific procedures.

He continued saying that radiation reduction in complex procedures, such as fenestrated stent graft implantation, means that implementation of lower doses of radiation is sometimes not attainable. He said that reducing radiation dose during the procedure will typically result in lower image quality, which may be unacceptable for clinical success of the endovascular treatment.  

In the study, the investigators upgraded their existing C-arch to AlluraClarity (Philips Healthcare), which reportedly resulted in an ability to lower the required radiation exposure without losing image quality and without changing the workflow of the physician.

Koning reported that the results of the study are currently being processed for scientific publication. However, he said that initial findings indicate a significant dose reduction can be achieved. He said image quality was judged to be equal or superior compared to the image quality before installation and interventional work flows were uninterrupted.

Concluding, Koning said: “With the latest generation in imaging systems, we also see promise in increasing patient and staff safety without sacrificing the imaging quality required to provide optimal care.”

At CX 2014, a mini symposium on abdominal compartment syndrome shed light on how little is known about the condition. It became apparent that the syndrome still has not been clearly defined, many of its triggering factors have yet to be recognised, and its management is limited to surgical decompression. Therefore, preventing both intra-abdominal hypertension and preventing intra-abdominal aortic hypertension from developing into abdominal aortic compartment syndrome is key.

Jan de Waele (Ghent, Belgium) stated that abdominal compartment syndrome has gone from being a syndrome that many vascular surgeons thought is “imaginary” to one that was now “being taken seriously.” He added that, according to the definitions of the World Society of the Abdominal Compartment Syndrome (WASCS), the syndrome was now defined as sustained intra-abdominal pressure of 20mmHg and it is associated with new organ dysfunction. “It can be a combination of haemodynamic problems, respiratory dysfunction, metabolic acidosis, and acute kidney dysfunction,” de Waele commented. However, he reported that “organ dysfunction sets in if you just look for it” at the threshold for intra-abdominal hypertension (a sustained pressure of 12mmHg or more). Therefore, he said it “made sense” to take steps to prevent both intra-abdominal hypertension and abdominal compartment syndrome. De Waele added: “We know the patients who are at risk, so we can really target intervention and we a have an indicator available—the intra-abdominal pressure.”

Anders Wanhainen (Uppsala, Sweden) explained that the WASCS had identified that risk factors for intra-abdominal hypertension and abdominal compartment syndrome included diminished abdominal wall compliance, increased intra-abdominal contents, capillary leak/fluid resuscitation, and increased intra-luminal contents. He noted that many of these risk factors were “relevant for vascular surgeons, particularly those managing patients with ruptured abdominal aortic aneurysms.” For example, Wanhainen explained, ruptured aortic aneurysms are associated with major trauma, intra-abdominal fluid collection, acidosis, hypothermia, polytransfusion, and shock or hypotension. He added: “Repair of a ruptured abdominal aortic aneurysm is definitely a high-risk procedure for the development of abdominal compartment syndrome.” According to Wanhainen, a study found that about 50% of patients undergoing open repair develop intra-abdominal hypertension and about 20% develop abdominal compartment syndrome. He added that these figures were, respectively, about 20% and 10% in patients undergoing endovascular aortic aneurysm repair (EVAR) but commented: “The observed lower risk after EVAR for a ruptured abdominal aortic aneurysm will probably change when more patients in shock are treated with EVAR.”

Wanhainen stated that because of the risk of intra-abdominal hypertension and abdominal compartment syndrome, intra-abdominal pressure “can and should be measured, preferably at the bedside in the intensive care unit” in patients undergoing emergency surgery or EVAR for a ruptured abdominal aortic aneurysm. He added that it was “completely possible” to eliminate the problem of abdominal compartment syndrome by taking adequate preventative measures—these measured included early bleeding control (which he called “crucial”), judicious fluid resuscitation, and prophylactic open abdomen management in selected patients. He added that preoperative and intraoperative factors could help to determine which patients should be selected for open abdomen management.

Martin Björck (Uppsala, Sweden) also stated that prevention was important in the management of intra-abdominal hypertension/abdominal compartment syndrome. In the context of EVAR/open repair, he said that prevention “started at the operating table.” He noted that this involved “a massive transfusion protocol and avoiding crystalloids,” agreeing with de Waele that it was “crucial” to monitor intra-abdominal pressure in all patients after aortic aneurysm repair in the postoperative period.

Björck noted: “We prevent abdominal compartment syndrome with aggressive medical management [in patients with intra-abdominal hypertension] but sometimes abdominal decompression is necessary.” He added, in terms of medical management, early pain relief could be “remarkably effective” and neuromuscular blockade, if the patient needs mechanical ventilation, was also very effective.

Björck reported that the recently updated 2013 WASCS guidelines were able to give strong recommendations for the management of abdominal compartment syndrome. He said that the guidelines recommend decompression laparotomy if abdominal compartment syndrome was present, protocolled effort should be made to obtain an early abdominal closure as “severe complications” can occur if open abdomen therapy is prolonged, and strategies using negative pressure wound therapy should be used. Björck agreed with de Waele that open abdomen treatment as a preventative treatment was an option as it “made sense” not to close a tense abdomen [in patients undergoing open repair] even though there are no data to support this approach.

However, he added if delegates used the preventative open abdomen therapy, they should close the abdomen “quickly”.

De Waele also spoke about the management of intra-abdominal hypertension/abdominal compartment syndrome, focusing on critical care. He said that the introduction of medical management options to decrease intra-abdominal pressure had “significantly changed the management of patients with intra-abdominal hypertension” and expanded on the WASCS recommendations—“The WASCS medical management algorithm identified five targets for medical interventions such as nasogastric decompression, neuromuscular blocking agents and percutaneous drainage among others. It is estimated that medical management can avoid surgery in a large proportion of patients with impending abdominal compartment syndrome.” However, de Waele said that surgical decompression remained an important element in the armamentarium and “may still be required” in some patients with therapy resistant abdominal compartment syndrome and significant organ derangement.” Concluding, he said that the management of abdominal compartment syndrome had now become the management of intra-abdominal hypertension as monitoring intra-aortic pressure was the “first and essential step” and prevention should be used where possible.

Charing Cross chairman Roger Greenhalgh (London, UK) told CX Daily News: “If I were a young physician, looking for an area to elucidate, I would choose abdominal compartment syndrome.”