Background: There are limited data on risks of haematopoietic malignancies associated with protracted low-to-moderate dose radiation.
Aims: To contribute the first incidence risk estimates for haematopoietic malignancies in relation to work history, procedures, practices, and protective measures in a large population of mostly female medical radiation workers.
Methods: The investigators followed up 71 894 (77.9% female) US radiologic technologists, first certified during 1926–80, from completion of a baseline questionnaire (1983–89) to return of a second questionnaire (1994–98), diagnosis of a first cancer, death, or 31 August 1998 (731 306 person-years), whichever occurred first. Cox proportional hazards regression was used to compute risks.
Results: Relative risks (RR) for leukaemias other than chronic lymphocytic leukaemia (non-CLL, 41 cases) were increased among technologists working five or more years before 1950 (RR = 6.6, 95% CI 1.0 to 41.9, based on seven cases) or holding patients 50 or more times for x ray examination (RR = 2.6, 95% CI 1.3 to 5.4). Risks of non-CLL leukaemias were not significantly related to the number of years subjects worked in more recent periods, the year or age first worked, the total years worked, specific procedures or equipment used, or personal radiotherapy. Working as a radiologic technologist was not significantly linked with risk of multiple myeloma (28 cases), non-Hodgkin's lymphoma (118 cases), Hodgkin's lymphoma (31 cases), or chronic lymphocytic leukaemia (23 cases).
Conclusion: Similar to results for single acute dose and fractionated high dose radiation exposures, there was increased risk for non-CLL leukaemias decades after initial protracted radiation exposure that likely cumulated to low-to-moderate doses.
During the last 15 years, developments in X-ray technologies have substantially improved the ability of practitioners to treat patients using fluoroscopically guided interventional techniques. Many of these procedures require a greater use of fluoroscopy and more recording of images. This increases the potential for radiation-induced dermatitis and epilation, as well as severe radiation-induced burns to patients. Many fluoroscope operators are untrained in radiation management and do not realize that these procedures increase the risk of radiation injury and radiation-induced cancer in personnel as well as patients. The hands of long-time fluoroscope operators in some cases exhibit radiation damage—especially when sound radiation protection practices have not been followed. In response, the Center for Devices and Radiological Health of the United States Food and Drug Administration has issued an Advisory calling for proper training of operators. Hospitals and administrators need to support and enforce the need for this training by requiring documentation of credentials in radiation management as a prerequisite for obtaining fluoroscopy privileges. A concerted effort on the part of professional medical organizations and regulatory agencies will be required to train fluoroscopy users to prevent physicians from unwittingly imparting serious radiation injuries to their patients.
Credentialing fluoroscopist; Fluoroscopist radiation dose
Orthopedic surgeons depend on the intraoperative use of fluoroscopy to facilitate procedures across all subspecialties. The versatility of the C-arm fluoroscope allows acquisition of nearly any radiographic view. This versatility, however, creates the opportunity for difficulty in communication between surgeon and radiation technologist. Poor communication leads to delays, frustration and increased exposure to ionizing radiation. There is currently no standard terminology employed by surgeons and technologists with regards to direction of the fluoroscope.
The investigation consisted of a web-based survey in 2 parts. Part 1 was administered to the membership of the Canadian Orthopedic Association, part 2 to the membership of the Canadian Association of Medical Radiation Technologists. The survey consisted of open-ended or multiple-choice questions examining experience with the C-arm fluoroscope and the terminology preferred by both orthopedic surgeons and radiation technologists.
The survey revealed tremendous inconsistency in language used by orthopedic surgeons and radiation technologists. It also revealed that many radiation technologists were inexperienced in operating the fluoroscope.
Adoption of a common language has been demonstrated to increase efficiency in performing defined tasks with the fluoroscope. We offer a potential system to facilitate communication based on current terminology used among Canadian orthopedic surgeons and radiation technologists.
Non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with reduced risk of colorectal and other cancers, but the association with basal cell carcinoma (BCC) is unclear. Previous epidemiological studies have been small in size, conducted in especially vulnerable populations, or have not accounted for solar UV exposure, a major risk factor for BCC. In the United States Radiologic Technologists cohort, we followed subjects to assess NSAID use on risk of first incident BCC. We included Caucasian participants who responded to both second and third questionnaires (administered from 1994–1998 and 2003–2005, respectively) and who reported no cancer at the time of the second questionnaire, N=58,213. BCC, constituent risk factors (e.g., eye color, complexion, hair color) and sun exposure history were assessed through self-administered survey. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards models. Of the 58,213 people in the study population, 2,291 went on to develop BCC. Any NSAID use was not associated with subsequent incidence of BCC (HR = 1.04, 95% CI: 0.92–1.16) after adjusting for age, sex, and estimated lifetime summer sun exposure. No association was observed when stratified by NSAID type (aspirin and other NSAIDs), nor did dose-response patterns emerge by frequency of use (average days per month). Further analyses did not reveal interaction with sex, birth cohort, smoking, alcohol consumption, sun exposure, occupational radiation exposure, or personal risk factors for BCC. In this large nationwide study, we observed no association between NSAID use and subsequent BCC risk.
non-steroidal anti-inflammatory drugs; basal cell carcinoma; ultraviolet radiation Article category: Epidemiology
Recent epidemiologic studies have suggested that ultraviolet radiation (UV) may protect against non-Hodgkin lymphoma (NHL), but few, if any, have assessed multiple indicators of ambient and personal UV exposure. Using the U.S. Radiologic Technologists study, we examined the association between NHL and self-reported time outdoors in summer, as well as average year-round and seasonal ambient exposures based on satellite estimates for different age periods, and sun susceptibility in participants who had responded to two questionnaires (1994-1998, 2003-2005) and who were cancer-free as of the earlier questionnaire. Using unconditional logistic regression, we estimated the odds ratio (OR) and 95% confidence intervals for 64,103 participants with 137 NHL cases. Self-reported time outdoors in summer was unrelated to risk. Lower risk was somewhat related to higher average year-round and winter ambient exposure for the period closest in time, and prior to, diagnosis (ages 20-39). Relative to 1.0 for the lowest quartile of average year-round ambient UV, the estimated OR for successively higher quartiles was 0.68 (0.42-1.10); 0.82 (0.52-1.29); and 0.64(0.40-1.03), p-trend = 0.06), for this age period. The lower NHL risk associated with higher year-round average and winter ambient UV provides modest additional support for a protective relationship between UV and NHL.
As medical reimbursements continue to decline, increasing financial pressures are placed upon medical imaging providers. This burden is exacerbated by the existing radiologic technologist (RT) crisis, which has caused RT salaries to trend upward. One strategy to address these trends is employing technology to improve technologist productivity. While industry-wide RT productivity benchmarks have been established for film-based operation, little to date has been published in the medical literature regarding similar productivity measures for filmless operation using PACS. This study was undertaken to document the complex relationship between technologist productivity and implementation of digital radiography and digital information technologies, including PACS and hospital/radiology information systems (HIS/RIS). A nationwide survey was conducted with 112 participating institutions, in varying degrees of digital technology implementation. Technologist productivity was defined as the number of annual exams performed per technologist full-time equivalent (FTE). Productivity analyses were performed among the different demographic and technology profile groups, with a focus on general radiography, which accounts for 65-70% of imaging department volumes. When evaluating the relationship between technologist productivity and digital technology implementation, improved productivity measures were observed for institutions implementing HIS/RIS, modality worklist, and PACS. The timing of PACS implementation was found to have a significant effect on technologist productivity measures, with an initial 10.8% drop in productivity during the first year of PACS implementation, followed by a 27.8% increase in productivity beyond year one. This suggests there is a "PACS learning curve" phenomenon, which should be considered when institutions are planning for PACS implementation.
Geographic gradients in breast cancer incidence and mortality suggest that vitamin D may reduce risk. The enzyme 25-hydroxyvitamin D 24-hydroxylase (CYP24A1), which degrades the active form of vitamin D, and the vitamin D receptor (VDR) are both found in breast tissue. We investigated six polymorphisms in CYP24A1 and two in the VDR gene in association with breast cancer risk.
Materials and Methods
We conducted a case--control study within the nationwide U.S. Radiologic Technologists cohort, including 845 controls and 484 incident breast cancer cases. Associations of polymorphic variants and ecologic and personal measures of sun exposure with breast cancer risk were assessed using unconditional logistic regression.
Two polymorphisms in CYP24A1 were associated with increased breast cancer risk (rs34043203, Ptrend = 0.03; rs2762934, Ptrend = 0.005) and one with reduced breast cancer risk (rs1570669, Ptrend=0.048). Risk was inversely associated with minor alleles for the VDR Bsm1 polymorphism (rs1544410, Ptrend = 0.05) but not Fok1 (rs2228570). Sunlight measures were not associated with breast cancer risk, however significant interactions between time outdoors in the teen years and three unlinked genotypes were found for VDR (rs1544410, rs2228570) and CYP24A1 (rs1570669).
In this nation-wide breast cancer case--control study, we found the vitamin D pathway was involved in disease etiology and further suggest that reduced cancer risk in association with sunlight may depend on timing of exposure and genetic background. These findings merit further investigation.
Vitamin D; sunlight; polymorphisms; breast cancer; gene; case—control
The U.S. population has nearly one radiographic examination per person per year and concern about cancer risks associated with medical radiation has increased. Radiologic technologists were surveyed to determine whether their personal cumulative exposure to diagnostic x-rays was associated with increased frequencies of chromosome translocations, an established radiation biomarker and possible intermediary suggesting increased cancer risk. Within a large cohort of U. S. radiologic technologists, 150 provided a blood sample for whole chromosome painting and were interviewed about past x-ray examinations. The number and types of examinations reported were converted to a red bone marrow (RBM) dose score with units that approximated 1 mGy. The relationship between dose score and chromosome translocation frequency was assessed using Poisson regression. The estimated mean cumulative RBM radiation dose score was 49 (range 0 – 303). After adjustment for age, translocation frequencies significantly increased with increasing RBM dose score with an estimate of 0.004 translocations per 100 cell equivalents per score unit (95% confidence interval 0.002 to 0.007; P < 0.001). Removing extreme values or adjustment for gender, cigarette smoking, occupational radiation dose, allowing practice x-rays while training, work with radioisotopes, and radiotherapy for benign conditions did not affect the estimate. Cumulative radiation exposure from routine x-ray examinations was associated independently with increased chromosome damage, suggesting the possibility of elevated long-term health risks, including cancer. The slope estimate was consistent with expectation based on cytogenetic experience and atomic bomb survivor data.
Radiation exposure; diagnostic x-rays; chromosome translocations; FISH; risk factors
Gastrostomy allows enteral nutrition to continue in patients who are unable to meet their caloric requirements orally. Though the indications for gastrostomy placement are varied, dysphagia secondary to a neurological condition is the most common. These catheters were initially placed surgically, but percutaneous endoscopic placement is now the routine in most centers. Interventional radiologists have been performing this procedure under fluoroscopic guidance for several years with encouraging results. Percutaneous radiological gastrostomy is reported to have a success rate comparable to that of the endoscopic method, with lower morbidity and mortality rates. A further benefit is that it may be performed in patients for whom the endoscopic method would be difficult or dangerous, such as those with head and neck malignancies. One of the main factors currently limiting the use of this procedure is the shortage of interventional radiology facilities and specialists.
This article describes a technique for routine percutaneous radiological gastrostomy catheter placement and procedural variations for difficult cases. Indications and contraindications will be discussed, as will complication rates and how these compare with the traditional methods of gastrostomy tube placement.
Gastrostomy; gastrojejunostomy; interventional radiology
In 2000, the REACH Boston 2010 Breast and Cervical Cancer Coalition conducted a community needs assessment and found several factors that may have contributed to disproportionately high breast and cervical cancer mortality among black women: (a) Focus group participants reported that many women in their communities had limited awareness about risk factors for cancer as well as about screening. (b) Black women experienced barriers to care related to the cultural competence of providers and of institutions. (c) Black women were not receiving adequate follow-up for abnormal mammograms and Pap smears. The Coalition's Community Action Plan to address disparities includes a model primary care service for black women; scholarships to increase the number of black mammogram technologists; primary care provider and radiology technologist training about disparities and cultural competence; and education to increase awareness among black women and to increase leadership and advocacy skills.
To clarify aspects of the association between physical activity and breast cancer, such as activity intensity required, and possible effect modification by factors such as menopausal hormone therapy (MHT) use.
We prospectively examined physical activity in relation to breast cancer risk among 45,631 women participating in the U.S. Radiologic Technologists cohort. Participants provided information at baseline regarding hours spent per week engaging in strenuous activity, walking/hiking for exercise, and walking at home or work. We estimated multivariable relative risks (RR) and 95% confidence intervals (CI) of breast cancer using Cox regression.
We identified 864 incident invasive breast cancers. Greatest risk reduction was observed among women who reported walking/hiking for exercise 10 or more hours per week (RR, 0.57;95%CI, 0.34-0.95) compared with those reporting no walking/hiking. The association between walking/hiking for exercise and breast cancer was modified by MHT use (p for interaction=0.039). Postmenopausal women who never used MHT had reduced risks of breast cancer associated with physical activity whereas no relation was observed among ever users of MHT.
Our study suggests moderate intensity physical activity, such as walking, may protect against breast cancer. Further, the relation between physical activity and breast cancer may be modified by MHT use.
breast cancer; physical activity; cohort studies; hormones
One of the greatest dilemmas facing medical imaging departments today is the worsening personnel crisis in the radiologic technologist (RT) workforce. As the volume and complexity of medical imaging studies continues to increase, an unprecedented imbalance exists between RT supply and demand. A number of etiologic factors have been postulated to contribute to this RT shortage including decreasing morale, perceived inadequacies in compensation, decreasing number of training programs, and limitations in the career ladder. Previous studies have cited improved technologist productivity as imaging departments successfully transition from film-based to filmless operation. This study was undertaken to address the impact of digital technologies (information systems, PACS, digital radiography) on technologist productivity, in an attempt to determine whether these technologies can be used to positively affect the existing RT workforce imbalance. A total of 112 facilities participated in this nationwide study, with representation of imaging providers that paralleled the demographic profile of the marketplace as a whole. Survey results indicate the existing RT staffing shortage is greatest within academic and rural-based hospitals and is most severe in the area of general radiography, which accounts for 65-70% of imaging department volumes. For general radiography alone, respondents report an average shortage of 2 RT full-time equivalents (FTE's) per institution, when comparing the number of budgeted RT FTE's versus the actual number of RT FTE's. Preliminary results indicate that at this time, RT staffing shortages are not affected by the presence or absence of digital information technologies. Additional research is planned through a five-year longitudinal data collection, to better delineate the complex relationship that exists between implementation of digital technologies and RT staffing.
We wanted to report on our experience with modified radiology-guided percutaneous gastrostomy (MRPG) without endoscopic or nasogastric access for treating patients with complete obstruction of the upper digestive tract.
Materials and Methods
Fourteen oncology patients (13 had hypopharyngeal cancer and 1 had upper esophageal cancer) with complete obstruction of the upper digestive tract were recruited. Conventional percutaneous endoscopic gastrostomy (PEG) and radiologic (fluoroscopy-guided) percutaneous gastrostomy (RPG) were not feasible in all the patients. An MRPG technique (with a combination of ultrasound, an air enema and fluoroscopic guidance) was performed in these patients.
We achieved successfully percutaneous gastrostomy using the modified technique in all patients without any major or minor complications after the procedure.
A modified radiology-guided percutaneous gastrostomy technique can be safely performed in patients who failed to receive conventional PEG or RPG due to the absence of nasogastric access in the completely obstructed upper digestive tract.
Percutaneous gastrostomy; Complete obstruction; Upper digestive tract
Three hundred and twenty-two Canadian animal health technologists (AHTs) were surveyed to determine their attitudes toward postoperative pain management in dogs and cats following 6 surgical procedures, their concerns regarding the use of opioid analgesics, and their role within veterinary practices with respect to postoperative pain control. Two hundred and sixty-four (82%) returned the questionnaire. Pain perception was defined as the average of pain rankings for dogs and cats (on a scale of 1 to 10) following abdominal surgery, or the value for dogs or cats if the AHT worked with only 1 of the 2 species. Maximum concern about the risks associated with the postoperative use of morphine or oxymorphone was defined as the highest rating assigned to any of the 6 risks evaluated in either dogs or cats. Animal health technologists reported significantly higher pain perception scores than did veterinarians who completed a similar survey 2 years previously. Higher pain perception scores were associated with decreased satisfaction with the adequacy of analgesic therapy in their practice, higher pain control goals, and attendance at continuing education within the previous 12 months. The majority of AHTs (55%) agreed that one or more risks associated with the use of morphine or oxymorphone outweighed the benefits. The 3 issues that were perceived to pose the greatest risk were respiratory depression, bradycardia, and sedation and excitement, for dogs and cats, respectively. Most AHTs (68%) considered their knowledge related to the recognition and control of pain to be adequate, compared with 24% of veterinarians who responded to a similar previous survey. As for veterinarians, experience gained while in practice was ranked as the most important source of knowledge, while the technical program attended was ranked as least important. Over 88% of the AHTs provided nursing care during the postoperative period, monitored animals for side effects of postoperative analgesic therapy, informed veterinarians when animals were in pain, recommended analgesic therapy when they believed it was warranted, reported that animals received analgesics when they believed it was warranted, administered analgesics under the instruction of a veterinarian, and believed they were part of a team working to provide adequate postoperative pain control.
The purpose of this study was to evaluate the effect of a switch to a filmless image management system on the time required for technologists to produce radiographic images in the emergency department (ED) after controlling for exam difficulty and a variable workload. Time and motion data were collected on patients who had radiographic images taken while being treated in the emergency department over the 3½-year period from April 1997 to November 2000. Event times and demographic data were obtained from the radiology information system, from the hospital information system, from emergency department records, or by observation by research coordinators. Multiple least squares regression analysis identified several independent predictors of the time required for technologists to produce radiographic images. These variables included the level of technologist experience, the number of trauma-alert patient arrivals, and whether a filmless image management system was used (all P <.05). Our regression model explained 22% of the variability in technologist time (R2 Adjusted, 0.22; F = 24.01; P <.0001). The regression model predicted a time saving of 2 to 3 minutes per patient in the elapsed time from notification of a needed examination until image availability because of the implementation of PACS, a delay of 4 to 6 minutes per patient who were imaged by technologists who spent less than 10% of their work assignments within the ED, and a delay of 18 to 27 minutes in radiology workflow because of the arrival of a trauma alert patient. A filmless system decreased the amount of time required to produce radiographs. The arrival of a trauma alert patient delayed radiology workflow in the ED. Inexperienced technologists require 4 to 6 minutes of additional time per patient to complete the same amount of work accomplished by an experienced technologist.
Controversy regarding potential health risks from increased use of medical diagnostic radiologic examinations has come to public attention. We evaluated whether chromosome damage, specifically translocations, which are a potentially intermediate biomarker for cancer risk, was increased after exposure to diagnostic X-rays, with particular interest in the ionizing radiation dose–response below the level of approximately 50 mGy. Chromosome translocation frequency data from three separately conducted occupational studies of ionizing radiation were pooled together. Studies 1 and 2 included 79 and 150 medical radiologic technologists, respectively, and study 3 included 83 airline pilots and 50 university faculty members (total = 155 women and 207 men; mean age = 62 years, range 34–90). Information on personal history of radiographic examinations was collected from a detailed questionnaire. We computed a cumulative red bone marrow (RBM) dose score based on the numbers and types of X-ray examinations reported with 1 unit approximating 1 mGy. Poisson regression analyses were adjusted for age and laboratory method. Mean RBM dose scores were 49, 42, and 11 for Studies 1–3, respectively (overall mean = 33.5, range 0–303). Translocation frequencies significantly increased with increasing dose score (P < 0.001). Restricting the analysis to the lowest dose scores of under 50 did not materially change these results. We conclude that chromosome damage is associated with low levels of radiation exposure from diagnostic X-ray examinations, including dose scores of approximately 50 and lower, suggesting the possibility of long-term adverse health effects.
AIM: To evaluate the efficacy of percutaneous imaging-guided biliary interventions in the management of acute biliary disorders in high surgical risk patients.
METHODS: One hundred and twenty two patients underwent 139 percutaneous imaging-guided biliary interventions during the period between January 2007 to December 2009. The patients included 73 women and 49 men with a mean age of 61 years (range 35-90 years).
Fifty nine patients had acute biliary obstruction, 26 patients had acute biliary infection and 37 patients had abnormal collections. The procedures were performed under computed tomography (CT)- (73 patients), sonographic- (41 patients), and fluoroscopic-guidance (25 patients). Success rates and complications were determined. The χ2 test with Yates’ correction for continuity was applied to compare between these procedures. A P value < 0.05 was considered significant.
RESULTS: The success rates for draining acute biliary obstruction under CT- , fluoroscopy- or ultrasound-guidance were 93.3%, 62.5% and 46.1%, respectively with significant P values (P = 0.026 and 0.002, respectively). In acute biliary infection, successful drainage was achieved in 22 patients (84.6%). The success rates in patients drained under ultrasound- and CT-guidance were 46.1% and 88.8%, respectively and drainage under CT-guidance was significantly higher (P = 0.0293). In 13 patients with bilomas, percutaneous drainage was successful in 11 patients (84.6%). Ten out of 12 cases with hepatic abscesses were drained with a success rate of 83.3%. In addition, the success rate of drainage in 12 cases with pancreatic pseudocysts was 83.3%. The reported complications were two deaths, four major and seven minor complications.
CONCLUSION: Percutaneous imaging-guided biliary interventions help to promptly diagnose and effectively treat acute biliary disorders. They either cure the disorders or relieve sepsis and jaundice before operations.
Biliary drainage; Biliary obstruction; Biliary sepsis; Cholecystostomy; Interventional radiology
Individual exposure to ultraviolet radiation (UVR) is challenging to measure, particularly for diseases with substantial latency periods between first exposure and diagnosis of outcome, such as cancer. To guide the choice of surrogates for long-term UVR exposure in epidemiologic studies, we assessed how well stable sun-related individual characteristics and environmental/meteorological factors predicted daily personal UVR exposure measurements.
We evaluated 123 United States Radiologic Technologists subjects who wore personal UVR dosimeters for 8 hours daily for up to 7 days (N = 837 days). Potential predictors of personal UVR derived from a self-administered questionnaire, and public databases that provided daily estimates of ambient UVR and weather conditions. Factors potentially related to personal UVR exposure were tested individually and in a model including all significant variables.
The strongest predictors of daily personal UVR exposure in the full model were ambient UVR, latitude, daily rainfall, and skin reaction to prolonged sunlight (R2 = 0.30). In a model containing only environmental and meteorological variables, ambient UVR, latitude, and daily rainfall were the strongest predictors of daily personal UVR exposure (R2 = 0.25).
In the absence of feasible measures of individual longitudinal sun exposure history, stable personal characteristics, ambient UVR, and weather parameters may help estimate long-term personal UVR exposure.
We examined the risk of childhood cancer (<20 years) among 105 950 offspring born in 1921–1984 to US radiologic technologist (USRT) cohort members. Parental occupational in utero and preconception ionising radiation (IR) testis or ovary doses were estimated from work history data, badge dose data, and literature doses (the latter doses before 1960). Female and male RTs reported a total of 111 and 34 haematopoietic malignancies and 115 and 34 solid tumours, respectively, in their offspring. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression. Leukaemia (n=63) and solid tumours (n=115) in offspring were not associated with maternal in utero or preconception radiation exposure. Risks for lymphoma (n=44) in those with estimated doses of <0.2, 0.2–1.0, and >1.0 mGy vs no exposure were non-significantly elevated with HRs of 2.3, 1.8, and 2.7. Paternal preconception exposure to estimated cumulative doses above the 95th percentile (⩾82 mGy, n=6 cases) was associated with a non-significant risk of childhood cancer of 1.8 (95% CI 0.7–4.6). In conclusion, we found no convincing evidence of an increased risk of childhood cancer in the offspring of RTs in association with parental occupational radiation exposure.
radiation; in utero; preconception; malignancy; aetiology; risk factors
Informative studies of cancer risks associated with medical radiation are difficult to conduct owing to low radiation doses, poor recall of diagnostic X rays, and long intervals before cancers occur. Chromosome aberrations have been associated with increased cancer risk and translocations are a known radiation biomarker. Seventy-nine U.S. radiologic technologists were selected for blood collection, and translocations were enumerated by whole chromosome painting. We developed a dose score to the red bone marrow for medical radiation exposure from X-ray examinations reported by the technologists that they received as patients. Using Poisson regression, we analyzed translocations in relation to the dose scores. Each dose score unit approximated 1 mGy. The estimated mean cumulative red bone marrow radiation dose score was 42 (range 1–265). After adjustment for age, occupational radiation, and radiotherapy for benign conditions, translocation frequencies significantly increased with increasing red bone marrow dose score with an estimate of 0.007 translocations per 100 CEs per score unit (95% CI, 0.002 to 0.013; P = 0.01). Chromosome damage has been linked with elevated cancer risk, and we found that cumulative radiation exposure from medical X-ray examinations was associated with increased numbers of chromosome translocations.
The introduction of the National Health Service (NHS) Breast Screening Programme has led to a considerable increase in the detection of impalpable breast cancer. Patients with impalpable breast cancer typically undergo oncological resection facilitated either by the insertion of guide wires placed stereo-tactically or through ultra-sound guided skin markings to delineate the extent of a lesion. The need for radiological interventions on the day of surgery adds complexity and introduces the risk that a patient may accidentally transferred to the operating room directly without the image guidance procedure.
A case is described of a patient who required a pre-operative ultrasound scan in order to localise an impalpable breast cancer but who was accidentally taken directly to the operating theatre (OR) and anaesthetised without pre-operative intervention. The radiologist was called to the OR and an on-table ultrasound was performed without further consequence.
It is evident that breast cancer patients undergoing image-guided resection are exposed to an additional layer of clinical risks. These risks are not offset by the World Health Organisation surgical safety checklist in its present guise. Here, we review a number of simple and inexpensive changes to the system that may improve the safety of the breast cancer patient undergoing surgery.
Breast; Cancer; Ultrasound; Mammography; Wire
While blind or fluoroscopically guided infiltration works well for intra-articular injections, injections into the tendon sheath are much more difficult. Ultrasound guidance with high-frequency transducers now allows visualization and infiltration of tendon sheaths. The interventional phase should be preceded by a diagnostic scan. Patients should be questioned to identify possible contraindications to the procedure and informed of the potential risks. Strict asepsis must be maintained for both patient and operator. This review includes separate discussions of the tendons in different areas of the body that are most commonly treated with ultrasound-guided injections, with descriptions of the lesions that are treated and the approach used for each. Interventional sonography is currently the only technique that allows visualization of the tendon being infiltrated. It requires training and experience as well as good knowledge of the indications and equipment used for the procedures, and the anatomy of the areas being treated.
Sonography; Tendons; Interventional procedures
Basal cell carcinoma (BCC) is the most common cancer in Caucasian populations. Although several risk factors are well-established, including ultraviolet radiation (UVR) sensitivity and exposure, few studies have examined anthropometric measures and BCC. Using Cox proportional hazards regression analysis, we prospectively investigated the relationship between height, weight, and body mass index (BMI) and BCC in 58,213 Caucasian participants (11,631 men and 46,582 women) from the United States Radiological Technologists cohort. This analysis was limited to participants who were cancer-free at baseline. The baseline questionnaire provided self-reported anthropometric factors and the subsequent questionnaire collected skin cancer susceptibility factors, lifetime UVR exposure derived from residential and personal UVR exposure (time outdoors), and health outcomes. During 509,465 person-years of follow-up, we identified 2,291 BCC cases (486 men; 1,805 women). BCC risk increased with increasing height, and decreased with increasing weight and BMI in both sexes, even after adjusting for UVR susceptibility factors and exposures. For BMI categories: <25 (reference); 25–<30; 30–<35; and ≥ 35 kg/m2, multivariate hazard ratios (HR) in women were: 1.00; 0.74 (95% CI=0.66–0.83); 0.67 (0.56–0.81); and 0.57 (0.44–0.74) respectively, p-trend ≤0.0001. Risks were similar in men. The inverse association between BMI and BCC was unaffected by controlling for sun-related exposures. Nevertheless, it may at least partly reflect residual UVR confounding. Further research with more detailed sun exposure data, including clothing patterns, would help clarify the relationship between BMI and BCC.
Basal cell carcinoma; weight; height; body mass index
Although the risk of radiation-induced spontaneous malignancy and genetic anomalies from occupational radiological procedures is relatively low – and perhaps slightly lower still for the general population – patients and endoscopists in particular, should be aware of the cumulative risk associated with all exposure. Radiation dose has a direct linear relationship with fluoroscopy duration; therefore, limiting fluoroscopy time is one of the most modifiable methods of reducing exposure during fluoroscopic procedures. This retrospective study analyzed more than 1000 endoscopic retrograde cholangiopancreatography procedures and aimed to determine the specific patient, physician and procedural factors that affect fluoroscopy duration.
Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) has a logarithmic relationship with radiation exposure, and carries a known risk of radiation exposure to patients and staff. Factors associated with prolonged fluoroscopy duration have not been well delineated.
To determine the specific patient, physician and procedural factors that affect fluoroscopy duration.
A retrospective analysis of 1071 ERCPs performed at two tertiary care referral hospitals over an 18-month period was conducted. Patient, physician and procedural variables were recorded at the time of the procedure.
The mean duration of 969 fluoroscopy procedures was 4.66 min (95% CI 4.38 to 4.93). Multivariable analysis showed that the specific patient factors associated with prolonged fluoroscopy duration included age and diagnosis (both P<0.0001). The endoscopist was found to play an important role in the duration of fluoroscopy (ie, all endoscopists studied had a mean fluoroscopy duration significantly different from the reference endoscopist). In addition, the following procedural variables were found to be significant: number of procedures, basket use, biopsies, papillotomy (all P<0.0001) and use of a tritome (P=0.004). Mean fluoroscopy duration (in minutes) with 95% CIs for different diagnoses were as follows: common bile duct stones (n=443) 5.12 (3.05 to 4.07); benign biliary strictures (n=135) 3.94 (3.26 to 4.63); malignant biliary strictures (n=124) 5.82 (4.80 to 6.85); chronic pancreatitis (n=49) 4.53 (3.44 to 5.63); bile leak (n=26) 3.67 (2.23 to 5.09); and ampullary mass (n=11) 3.88 (1.28 to 6.48). When no pathology was found (n=195), the mean fluoroscopy time was 3.56 min (95% CI 3.05 to 4.07). Comparison using t tests determined that the only two diagnoses for which fluoroscopy duration was significantly different from the reference diagnosis of ‘no pathology found’ were common bile duct stones (P<0.0001) and malignant strictures (P<0.0001).
Factors that significantly affected fluoroscopy duration included age, diagnosis, endoscopist, and the number and nature of procedures performed. Elderly patients with biliary stones or a malignant stricture were likely to require the longest duration of fluoroscopy. These identified variables may help endoscopists predict which procedures are associated with prolonged fluoroscopy duration so that appropriate precautions can be undertaken.
ERCP; Fluoroscopy time; Radiation
Although many clinicians know about the reducing effects of the pulsed and low-dose modes for fluoroscopic radiation when performing interventional procedures, few studies have quantified the reduction of radiation-absorbed doses (RADs). The aim of this study is to compare how much the RADs from a fluoroscopy are reduced according to the C-arm fluoroscopic modes used.
We measured the RADs in the C-arm fluoroscopic modes including 'conventional mode', 'pulsed mode', 'low-dose mode', and 'pulsed + low-dose mode'. Clinical imaging conditions were simulated using a lead apron instead of a patient. According to each mode, one experimenter radiographed the lead apron, which was on the table, consecutively 5 times on the AP views. We regarded this as one set and a total of 10 sets were done according to each mode. Cumulative exposure time, RADs, peak X-ray energy, and current, which were viewed on the monitor, were recorded.
Pulsed, low-dose, and pulsed + low-dose modes showed significantly decreased RADs by 32%, 57%, and 83% compared to the conventional mode. The mean cumulative exposure time was significantly lower in the pulsed and pulsed + low-dose modes than in the conventional mode. All modes had pretty much the same peak X-ray energy. The mean current was significantly lower in the low-dose and pulsed + low-dose modes than in the conventional mode.
The use of the pulsed and low-dose modes together significantly reduced the RADs compared to the conventional mode. Therefore, the proper use of the fluoroscopy and its C-arm modes will reduce the radiation exposure of patients and clinicians.
fluoroscopy; radiation; radiation dosage; radiographic image enhancement