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1.  Increased Frequency of Chromosome Translocations Associated with Diagnostic X-Ray Examinations 
Radiation research  2008;170(2):149-155.
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.
doi:10.1667/RR1422.1
PMCID: PMC2766815  PMID: 18666821
2.  ROUTINE DIAGNOSTIC X-RAY EXAMINATIONS AND INCREASED FREQUENCY OF CHROMOSOME TRANSLOCATIONS AMONG U. S. RADIOLOGIC TECHNOLOGISTS 
Cancer research  2008;68(21):8825-8831.
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.
doi:10.1158/0008-5472.CAN-08-1691
PMCID: PMC2586176  PMID: 18974125
Radiation exposure; diagnostic x-rays; chromosome translocations; FISH; risk factors
3.  Increased frequency of chromosome translocations in airline pilots with long-term flying experience 
Background
Chromosome translocations are an established biomarker of cumulative exposure to external ionising radiation. Airline pilots are exposed to cosmic ionising radiation, but few flight crew studies have examined translocations in relation to flight experience.
Methods
We determined the frequency of translocations in the peripheral blood lymphocytes of 83 airline pilots and 50 comparison subjects (mean age 47 and 46 years, respectively). Translocations were scored in an average of 1039 cell equivalents (CE) per subject using fluorescence in situ hybridisation (FISH) whole chromo-some painting and expressed per 100 CE. Negative binomial regression models were used to assess the relationship between translocation frequency and exposure status and flight years, adjusting for age, diagnostic x ray procedures, and military flying.
Results
There was no significant difference in the adjusted mean translocation frequency of pilots and comparison subjects (0.37 (SE 0.04) vs 0.38 (SE 0.06) translocations/100 CE, respectively). However, among pilots, the adjusted translocation frequency was significantly associated with flight years (p = 0.01) with rate ratios of 1.06 (95% CI 1.01 to 1.11) and 1.81 (95% CI 1.16 to 2.82) for a 1- and 10-year incremental increase in flight years, respectively. The adjusted rate ratio for pilots in the highest compared to the lowest quartile of flight years was 2.59 (95% CI 1.26 to 5.33).
Conclusions
This data suggests that pilots with long-term flying experience may be exposed to biologically significant doses of ionising radiation. Epidemiological studies with longer follow-up of larger cohorts of pilots with a wide range of radiation exposure levels are needed to clarify the relationship between cosmic radiation exposure and cancer risk.
doi:10.1136/oem.2008.038901
PMCID: PMC2608721  PMID: 19074211
4.  Novel breast cancer risk alleles and interaction with ionizing radiation among U.S. Radiologic Technologists 
Radiation research  2010;173(2):214-224.
As genome-wide association studies of breast cancer are replicating findings and refinement studies are narrowing the signal location, additional efforts are necessary to elucidate the underlying functional relationships. One approach is to evaluate variation in risk by genotype based on known breast carcinogens, such as ionizing radiation. Given the public health concerns associated with recent increases in medical radiation exposure, this approach may also identify potentially susceptible sub-populations. We examined interaction between 27 newly identified breast cancer risk alleles (identified within the NCI Cancer Genetic Markers of Susceptibility and the Breast Cancer Association Consortium genome-wide association studies) and occupational and medical diagnostic radiation exposure among 859 cases and 1083 controls nested within the United States Radiologic Technologists cohort. We did not find significant variation in the radiation-related breast cancer risk for the variant in RAD51L1 (rs10483813) on 14q24.1 as we had hypothesized. In exploratory analyses, we found that the radiation-associated breast cancer risk varied significantly by linked markers in 5p12 (rs930395, rs10941679, rs2067980, and rs4415084) in the mitochondrial ribosomal protein S30 (MRPS30) gene (pinteraction=0.04). Chance, however, may explain these findings, and as such, these results need to be confirmed in other populations with low to moderate levels of radiation exposure. Even though a complete understanding by which these variants may increase breast cancer risk remains elusive, this approach may yield clues for further investigation.
doi:10.1667/RR1985.1
PMCID: PMC2922870  PMID: 20095854
5.  POLYMORPHISMS IN ESTROGEN BIOSYNTHESIS AND METABOLISM-RELATED GENES, IONIZING RADIATION EXPOSURE, AND RISK OF BREAST CANCER AMONG U.S. RADIOLOGIC TECHNOLOGISTS 
Ionizing radiation-associated breast cancer risk appears to be modified by timing of reproductive events such as age at radiation exposure, parity, age at first live birth, and age at menopause. However, potential breast cancer risk modification of low- to moderate radiation dose by polymorphic estrogen metabolism-related gene variants has not been routinely investigated. We assessed breast cancer risk of 12 candidate variants in 12 genes involved in steroid metabolism, catabolism, binding, or receptor functions in a study of 859 cases and 1083 controls within the US Radiologic Technologists (USRT) cohort. Using cumulative breast dose estimates from a detailed assessment of occupational and personal diagnostic ionizing radiation exposure, we investigated the joint effects of genotype on the risk of breast cancer. In multivariate analyses, we observed a significantly decreased risk of breast cancer associated with the CYP3A4 M445T minor allele (rs4986910, OR=0.3; 95% CI 0.1–0.9). We found a borderline increased breast cancer risk with having both minor alleles of CYP1B1 V432L (rs1056836, CC vs. GG, OR=1.2; 95% CI 0.9–1.6). Assuming a recessive model, the minor allele of CYP1B1 V432L significantly increased the dose-response relationship between personal diagnostic x-ray exposure and breast cancer risk, adjusted for cumulative occupational radiation dose (pinteraction=0.03) and had a similar joint effect for cumulative occupational radiation dose adjusted for personal diagnostic x-ray exposure (pinteraction=0.06). We found suggestive evidence that common variants in selected estrogen metabolizing genes may modify the association between ionizing radiation exposure and breast cancer risk.
doi:10.1007/s10549-009-0307-3
PMCID: PMC2860373  PMID: 19214745
6.  Airline Pilot Cosmic Radiation and Circadian Disruption Exposure Assessment from Logbooks and Company Records 
Annals of Occupational Hygiene  2011;55(5):465-475.
Objectives: US commercial airline pilots, like all flight crew, are at increased risk for specific cancers, but the relation of these outcomes to specific air cabin exposures is unclear. Flight time or block (airborne plus taxi) time often substitutes for assessment of exposure to cosmic radiation. Our objectives were to develop methods to estimate exposures to cosmic radiation and circadian disruption for a study of chromosome aberrations in pilots and to describe workplace exposures for these pilots.
Methods: Exposures were estimated for cosmic ionizing radiation and circadian disruption between August 1963 and March 2003 for 83 male pilots from a major US airline. Estimates were based on 523 387 individual flight segments in company records and pilot logbooks as well as summary records of hours flown from other sources. Exposure was estimated by calculation or imputation for all but 0.02% of the individual flight segments’ block time. Exposures were estimated from questionnaire data for a comparison group of 51 male university faculty.
Results: Pilots flew a median of 7126 flight segments and 14 959 block hours for 27.8 years. In the final study year, a hypothetical pilot incurred an estimated median effective dose of 1.92 mSv (absorbed dose, 0.85 mGy) from cosmic radiation and crossed 362 time zones. This study pilot was possibly exposed to a moderate or large solar particle event a median of 6 times or once every 3.7 years of work. Work at the study airline and military flying were the two highest sources of pilot exposure for all metrics. An index of work during the standard sleep interval (SSI travel) also suggested potential chronic sleep disturbance in some pilots. For study airline flights, median segment radiation doses, time zones crossed, and SSI travel increased markedly from the 1990s to 2003 (Ptrend < 0.0001). Dose metrics were moderately correlated with records-based duration metrics (Spearman’s r = 0.61–0.69).
Conclusions: The methods developed provided an exposure profile of this group of US airline pilots, many of whom have been exposed to increasing cosmic radiation and circadian disruption from the 1990s through 2003. This assessment is likely to decrease exposure misclassification in health studies.
doi:10.1093/annhyg/mer024
PMCID: PMC3113148  PMID: 21610083
circadian disruption; cosmic radiation; exposure assessment; flight crew; pilots
7.  Risk of Cataract after Exposure to Low Doses of Ionizing Radiation: A 20-Year Prospective Cohort Study among US Radiologic Technologists 
American Journal of Epidemiology  2008;168(6):620-631.
The study aim was to determine the risk of cataract among radiologic technologists with respect to occupational and nonoccupational exposures to ionizing radiation and to personal characteristics. A prospective cohort of 35,705 cataract-free US radiologic technologists aged 24–44 years was followed for nearly 20 years (1983–2004) by using two follow-up questionnaires. During the study period, 2,382 cataracts and 647 cataract extractions were reported. Cigarette smoking for ≥5 pack-years; body mass index of ≥25 kg/m2; and history of diabetes, hypertension, hypercholesterolemia, or arthritis at baseline were significantly (p ≤ 0.05) associated with increased risk of cataract. In multivariate models, self-report of ≥3 x-rays to the face/neck was associated with a hazard ratio of cataract of 1.25 (95% confidence interval: 1.06, 1.47). For workers in the highest category (mean, 60 mGy) versus lowest category (mean, 5 mGy) of occupational dose to the lens of the eye, the adjusted hazard ratio of cataract was 1.18 (95% confidence interval: 0.99, 1.40). Findings challenge the National Council on Radiation Protection and International Commission on Radiological Protection assumptions that the lowest cumulative ionizing radiation dose to the lens of the eye that can produce a progressive cataract is approximately 2 Gy, and they support the hypothesis that the lowest cataractogenic dose in humans is substantially less than previously thought.
doi:10.1093/aje/kwn171
PMCID: PMC2727195  PMID: 18664497
cataract; radiation; technology, radiologic; x-rays
8.  ORGAN-SPECIFIC EXTERNAL DOSE COEFFICIENTS AND PROTECTIVE APRON TRANSMISSION FACTORS FOR HISTORICAL DOSE RECONSTRUCTION FOR MEDICAL PERSONNEL 
Health physics  2011;101(1):13-27.
While radiation absorbed dose (Gy) to the skin or other organs is sometimes estimated for patients from diagnostic radiologic examinations or therapeutic procedures, rarely is occupationally-received radiation absorbed dose to individual organs/tissues estimated for medical personnel, e.g., radiologic technologists or radiologists. Generally, for medical personnel, equivalent or effective radiation doses are estimated for compliance purposes. In the very few cases when organ doses to medical personnel are reconstructed, the data is usually for the purpose of epidemiologic studies, e.g., a study of historical doses and risks to a cohort of about 110,000 radiologic technologists presently underway at the U.S. National Cancer Institute. While ICRP and ICRU have published organ-specific external dose conversion coefficients (DCCs), i.e., absorbed dose to organs and tissues per unit air kerma and dose equivalent per unit air kerma, those factors have been primarily published for mono-energetic photons at selected energies. This presents two related problems for historical dose reconstruction, both of which are addressed here. It is necessary to derive conversion factors values for (i) continuous distributions of energy typical of diagnostic medical x rays (bremsstrahlung radiation), and (ii) for energies of particular radioisotopes used in medical procedures, neither of which are presented in published tables. For derivation of DCCs for bremsstrahlung radiation, combinations of x-ray tube potentials and filtrations were derived for different time periods based on a review of relevant literature. Three peak tube potentials (70 kV, 80 kV, and 90 kV) with four different amounts of beam filtration were determined to be applicable for historic dose reconstruction. The probability of these machine settings were assigned to each of the four time periods (earlier than 1949, 1949-1954, 1955-1968, and after 1968). Continuous functions were fit to each set of discrete values of the ICRP/ICRU mono-energetic DCCs and the functions integrated over the air-kerma weighted photon fluence of the 12 defined x-ray spectra. The air kerma-weighted DCCs in this work were developed specifically for an irradiation geometry of anterior to posterior (AP) and for the following tissues: thyroid, breast, ovary, lens of eye, lung, colon, testes, heart, skin (anterior side only), red bone marrow (RBM), heart, and brain. In addition, a series of functional relationships to predict DT per Ka values for RBM dependent on body mass index [BMI (kg m−2) ≡ weight per height2] and average photon energy were derived from a published analysis. Factors to account for attenuation of radiation by protective lead aprons were also developed. Because lead protective aprons often worn by radiology personnel not only reduce the intensity of x-ray exposure but also appreciably harden the transmitted fluence of bremsstrahlung x rays, DCCs were separately calculated for organs possibly protected by lead aprons by considering three cases: no apron, 0.25 mm Pb apron, and 0.5 mm Pb apron. For estimation of organ doses from conducting procedures with radioisotopes, continuous functions of the reported mono-energetic values were developed and DCCs were derived by estimation of the function at relevant energies. By considering the temporal changes in primary exposure-related parameters, e.g., energy distribution, the derived DCCs and transmission factors presented here allow for more realistic historical dose reconstructions for medical personnel when monitoring badge readings are the primary data on which estimation of an individual's organ doses are based.
doi:10.1097/HP.0b013e318204a60a
PMCID: PMC3964780  PMID: 21617389
9.  Predictors of skin cancer in commercial airline pilots 
Background Skin cancers among commercial airline pilots have been reported to occur at increased rates in pilot populations worldwide. The reasons for these increases are unclear, but postulated factors include ionizing radiation, circadian disruption and leisure sun exposure.
Aims To investigate the potential association of these occupational and lifestyle factors, as well as medical history and skin type, with non-melanoma skin cancer in pilots.
Methods Data were collected using a confidential Internet survey administered in collaboration with the Air Line Pilots Association International to all active pilots in four US commercial airlines. Pilots with non-melanoma skin cancer were compared to those without using multivariable analysis.
Results The response rate was 19%. Among pilots flying <20 years prior to diagnosis, factors associated with increased odds of non-melanoma skin cancer were at-risk skin type, childhood sunburns and family history of non-melanoma skin cancer. Off-duty sunscreen use and family history of melanoma were protective. Among pilots with ≥20 years flight time prior to diagnosis, childhood sunburns and family history of non-melanoma skin cancer persisted as risk factors, with the addition of flight time at high latitude.
Conclusions Further investigation regarding the potential health impact of long-term flying at high latitudes is recommended. Additionally, occupational health programmes for pilots should stress awareness of and protection against established risk factors for non-melanoma skin cancer.
doi:10.1093/occmed/kqp058
PMCID: PMC2729324  PMID: 19465434
Aviation; epidemiological studies; skin cancer
10.  Associations of Ionizing Radiation and Breast Cancer-Related Serum Hormone and Growth Factor Levels in Cancer-Free Female A-Bomb Survivors 
Radiation research  2011;176(5):678-687.
Levels of exposure to ionizing radiation are increasing for women worldwide due to the widespread use of CT and other radiologic diagnostic modalities. Exposure to ionizing radiation as well as increased levels of estradiol and other sex hormones are acknowledged breast cancer risk factors, but the effects of whole-body radiation on serum hormone levels in cancer-free women are unknown. This study examined whether ionizing radiation exposure is associated with levels of serum hormones and other markers that may mediate radiation-associated breast cancer risk. Serum samples were measured from cancer-free women who attended biennial health examinations with a wide range of past radiation exposure levels (N = 412, ages 26–79). The women were selected as controls for separate case-control studies from a cohort of A-bomb survivors. Outcome measures included serum levels of total estradiol, bioavailable estradiol, testosterone, progesterone, prolactin, insulin-like growth factor-1 (IGF1), insulin-like growth factor-binding protein 3 (IGFBP-3), and ferritin. Relationships were assessed using repeated-measures regression models fitted with generalized estimating equations. Geometric mean serum levels of total estradiol and bioavailable estradiol increased with 1 Gy of radiation dose among samples collected from postmenopausal women (17%1Gy, 95% CI: 1%–36% and 21%1Gy, 95% CI: 4%–40%, respectively), while they decreased in samples collected from premenopausal women (−11%1Gy, 95% CI: −20%–1% and −12%1Gy, 95% CI: −20%– −2%, respectively). Interactions by menopausal status were significant (P = 0.003 and P < 0.001, respectively). Testosterone levels increased with radiation dose in postmenopausal samples (30.0%1Gy, 95% CI: 13%–49%) while they marginally decreased in premenopausal samples (−10%1Gy, 95% CI: −19%–0%) and the interaction by menopausal status was significant (P < 0.001). Serum levels of IGF1 increased linearly with radiation dose (11%1Gy, 95% CI: 2%–18%) and there was a significant interaction by menopausal status (P = 0.014). Radiation-associated changes in serum levels of estradiol, bioavailable estradiol, testosterone and IGF1 were modified by menopausal status at the time of collection. No associations with radiation were observed in serum levels of progesterone, prolactin, IGFBP-3 or ferritin.
PMCID: PMC3925891  PMID: 21718103
11.  Nucleotide excision repair polymorphisms may modify ionizing radiation-related breast cancer risk in US radiologic technologists 
Exposure to ionizing radiation has been consistently associated with increased risk of female breast cancer. Although the majority of DNA damage caused by ionizing radiation is corrected by the base-excision repair pathway, certain types of multiple-base damage can only be repaired through the nucleotide excision repair pathway. In a nested case–control study of breast cancer in US radiologic technologists exposed to low levels of ionizing radiation (858 cases, 1,083 controls), we examined whether risk of breast cancer conferred by radiation was modified by nucleotide excision gene polymorphisms ERCC2 (XPD) rs13181, ERCC4 (XPF) rs1800067 and rs1800124, ERCC5 (XPG) rs1047769 and rs17655; and ERCC6 rs2228526. Of the 6 ERCC variants examined, only ERCC5 rs17655 showed a borderline main effect association with breast cancer risk (ORGC = 1.1, ORCC = 1.3; p-trend = 0.08), with some indication that individuals carrying the C allele variant were more susceptible to the effects of occupational radiation (EOR/GyGG = 1.0, 95% CI = <0, 6.0; EOR/GyGC/CC = 5.9, 95% CI = 0.9, 14.4; phet = 0.10). ERCC2 rs13181, although not associated with breast cancer risk overall, statistically significantly modified the effect of occupational radiation dose on risk of breast cancer (EOR/GyAA = 9.1, 95% CI = 2.1–21.3; EOR/GyAC/CC = 0.6, 95% CI = <0, 4.6; phet = 0.01). These results suggest that common variants in nucleotide excision repair genes may modify the association between occupational radiation exposure and breast cancer risk.
doi:10.1002/ijc.23779
PMCID: PMC3984912  PMID: 18767034
12.  Polymorphisms in oxidative stress and inflammation pathway genes, low-dose ionizing radiation, and the risk of breast cancer among US radiologic technologists 
Cancer causes & control : CCC  2010;21(11):1857-1866.
Objective
Ionizing radiation, an established breast cancer risk factor, has been shown to induce oxidative damage and chronic inflammation. Polymorphic variation in oxidative stress and inflammatory-mediated pathway genes may modify radiation-related breast cancer risk.
Methods
We estimated breast cancer risk for 28 common variants in 16 candidate genes involved in these pathways among 859 breast cancer cases and 1,083 controls nested within the US Radiologic Technologists cohort. We estimated associations between occupational and personal diagnostic radiation exposures with breast cancer by modeling the odds ratio (OR) as a linear function in logistic regression models and assessed heterogeneity of the dose–response across genotypes.
Results
There was suggestive evidence of an interaction between the rs5277 variant in PTGS2 and radiation-related breast cancer risk. The excess OR (EOR)/Gy from occupational radiation exposure = 5.5 (95%CI 1.2–12.5) for the GG genotype versus EOR/Gy < 0 (95%CI < 0–3.8) and EOR/Gy < 0 (95%CI < 0–14.8) for the GC and CC genotypes, respectively, (pinteraction = 0.04). The association between radiation and breast cancer was not modified by other SNPs examined.
Conclusions
This study suggests that variation in PTGS2 may modify the breast cancer risk from occupational radiation exposure, but replication in other populations is needed to confirm this result.
doi:10.1007/s10552-010-9613-7
PMCID: PMC3076104  PMID: 20711808
PTGS2; COX-2; Inflammation; Breast cancer; Radiation
13.  RADIATION: MEDICAL DIAGNOSTIC USES 
California Medicine  1961;94(5):295-301.
Use of radiologic procedures in diagnosis now contributes a significant dose of ionizing radiation to our population. Whether this presents a real risk to the health of the present and future population cannot be determined with certainty from evidence available at this time. Hence, it appears proper to keep the dose to every patient as low as practical consistent with good medical practice. The average dose can be significantly reduced by having more physicians apply the known techniques for minimizing the exposure to the patient.
The medical profession has a direct professional concern for the actual or potential risk of damage resulting from the radiation that patients are exposed to during diagnostic x-ray procedures, since these procedures constitute the largest single man-made source of genetically significant radiation our population is now exposed to.
It is important to distinguish two distinctly different types of radiation effects—somatic effect, in which the damage affects the health of the person irradiated, and genetic effect that is capable of producing constitutional defects in future progeny over many generations.
PMCID: PMC1575891  PMID: 18732398
14.  Cancer Risks Associated with External Radiation From Diagnostic Imaging Procedures 
CA: a cancer journal for clinicians  2012;10.3322/caac.21132.
The 600% increase in medical radiation exposure to the US population since 1980 has provided immense benefit, but potential future cancer risks to patients. Most of the increase is from diagnostic radiologic procedures. The objectives of this review are to summarize epidemiologic data on cancer risks associated with diagnostic procedures, describe how exposures from recent diagnostic procedures relate to radiation levels linked with cancer occurrence, and propose a framework of strategies to reduce radiation from diagnostic imaging in patients. We briefly review radiation dose definitions, mechanisms of radiation carcinogenesis, key epidemiologic studies of medical and other radiation sources and cancer risks, and dose trends from diagnostic procedures. We describe cancer risks from experimental studies, future projected risks from current imaging procedures, and the potential for higher risks in genetically susceptible populations. To reduce future projected cancers from diagnostic procedures, we advocate widespread use of evidence-based appropriateness criteria for decisions about imaging procedures, oversight of equipment to deliver reliably the minimum radiation required to attain clinical objectives, development of electronic lifetime records of imaging procedures for patients and their physicians, and commitment by medical training programs, professional societies, and radiation protection organizations to educate all stakeholders in reducing radiation from diagnostic procedures.
doi:10.3322/caac.21132
PMCID: PMC3548988  PMID: 22307864
15.  Fetal radiation doses and subsequent risks from X-ray examinations: Should we be concerned? 
Background: Pregnant women are sometimes exposed to ionizing radiation in radiology examinations for various reasons. In such cases, the radiation dose to the conceptus and subsequent risks should be estimated.
Objective: The purpose of this study was the calculation and presentation of fetal dose and subsequent risks resulted from different X-ray examinations.
Materials and Methods: An analytical simulation study was conducted and six common radiographies in different views and three types of special examinations were evaluated. The entrance skin exposure (ESE) was measured using a solid-state dosimeter. A Monte Carlo program was used in order to simulate different views of X-ray examinations and calculate the radiation doses received by the conceptus for every view of each examination. Then the risk of childhood cancer and small head size were calculated for different radiographies.
Results: The fetal doses and consequence risks of the small head size and childhood cancer for the radiographs of chest, skull, and sinuses were negligible but the risks of childhood cancer and small head size due to radiographies of abdomen, lumbar spine, and pelvis areas were ponderable.
Conclusion: Results of this study can be used for the pregnant women radiographies management.
PMCID: PMC3941392  PMID: 24639714
Pregnant women; Radiography; Radiation Effects; Fetus; Monte Carlo method
16.  Radiology Residents' Awareness about Ionizing Radiation Doses in Imaging Studies and Their Cancer Risk during Radiological Examinations 
Korean Journal of Radiology  2012;13(2):202-209.
Objective
Imaging methods that use ionizing radiation have been more frequent in various medical fields with advances in imaging technology. The aim of our study was to make residents be aware of the radiation dose they are subjected to when they conduct radiological imaging methods, and of cancer risk.
Materials and Methods
A total of 364 residents participated in this descriptive study which was conducted during the period between October, 2008 and January, 2009. The questionnaires were completed under strict control on a one-to-one basis from each department. A χ2-test was used for the evaluation of data obtained.
Results
Only 7% of residents correctly answered to the question about the ionizing radiation dose of a posteroanterior (PA) chest X-ray. The question asking about the equivalent number of PA chest X-rays to the ionizing dose of a brain CT was answered correctly by 24% of residents; the same question regarding abdominal CT was answered correctly by 16% of residents, thorax CT by 16%, thyroid scintigraphy by 15%, intravenous pyelography by 9%, and lumbar spine radiography by 2%. The risk of developing a cancer throughout lifetime by a brain and abdominal CT were 33% and 28%, respectively.
Conclusion
Radiologic residents should have updated knowledge about radiation dose content and attendant cancer risks of various radiological imaging methods during both basic medical training period and following practice period.
doi:10.3348/kjr.2012.13.2.202
PMCID: PMC3303904  PMID: 22438688
Residents; Radiological imaging methods; Ionizing radiation, Risk of cancer
17.  Minimization of Radiation Exposure due to Computed Tomography in Inflammatory Bowel Disease 
ISRN Gastroenterology  2012;2012:790279.
Patient awareness and concern regarding the potential health risks from ionizing radiation have peaked recently (Coakley et al., 2011) following widespread press and media coverage of the projected cancer risks from the increasing use of computed tomography (CT) (Berrington et al., 2007). The typical young and educated patient with inflammatory bowel disease (IBD) may in particular be conscious of his/her exposure to ionising radiation as a result of diagnostic imaging. Cumulative effective doses (CEDs) in patients with IBD have been reported as being high and are rising, primarily due to the more widespread and repeated use of CT (Desmond et al., 2008). Radiologists, technologists, and referring physicians have a responsibility to firstly counsel their patients accurately regarding the actual risks of ionizing radiation exposure; secondly to limit the use of those imaging modalities which involve ionising radiation to clinical situations where they are likely to change management; thirdly to ensure that a diagnostic quality imaging examination is acquired with lowest possible radiation exposure. In this paper, we synopsize available evidence related to radiation exposure and risk and we report advances in low-dose CT technology and examine the role for alternative imaging modalities such as ultrasonography or magnetic resonance imaging which avoid radiation exposure.
doi:10.5402/2012/790279
PMCID: PMC3332204  PMID: 22577571
18.  Status of radiation protection at different hospitals in Nepal 
Nepal has a long history of medical radiology since1923 but unfortunately, we still do not have any Radiation Protection Infrastructure to control the use of ionizing radiations in the various fields. The objective of this study was an assessment of the radiation protection in medical uses of ionizing radiation. Twenty-eight hospitals with diagnostic radiology facility were chosen for this study according to patient loads, equipment and working staffs. Radiation surveys were also done at five different radiotherapy centers. Questionnaire for radiation workers were used; radiation dose levels were measured and an inventory of availability of radiation equipment made. A corollary objective of the study was to create awareness in among workers on possible radiation health hazard and risk. It was also deemed important to know the level of understanding of the radiation workers in order to initiate steps towards the establishment of Nepalese laws, regulation and code of radiological practice in this field. Altogether, 203 Radiation workers entertained the questionnaire, out of which 41 are from the Radiotherapy and 162 are from diagnostic radiology. The radiation workers who have participated in the questionnaire represent more than 50% of the radiation workers working in this field in Nepal. Almost all X-ray, CT and Mammogram installations were built according to protection criteria and hence found safe. Radiation dose level at the reference points for all the five Radiotherapy centers are within safe limit. Around 65% of the radiation workers have never been monitored for radiation. There is no quality control program in any of the surveyed hospitals except radiotherapy facilities.
doi:10.4103/0971-6203.103611
PMCID: PMC3532754  PMID: 23293457
Dose limit; personnel monitoring; quality control; workload
19.  Paediatric CT scan usage and referrals of children to computed tomography in Germany-a cross-sectional survey of medical practice and awareness of radiation related health risks among physicians 
Background
Computed tomography (CT) is a major source of ionizing radiation exposure in medical diagnostic. Compared to adults, children are supposed to be more susceptible to health risks related to radiation. The purpose of a cross-sectional survey among office-based physicians in Germany was the assessment of medical practice in paediatric CT referrals and to investigate physicians' knowledge of radiation doses and potential health risks of radiation exposure from CT in children.
Methods
A standardized questionnaire was distributed to all paediatricians and surgeons in two defined study areas. Furthermore, the study population included a random sample of general practitioners in the two areas. The questionnaire covered the frequency of referrals for paediatric CT examinations, the medical diagnoses leading to paediatric CT referrals, physicians' knowledge of radiation doses and potential health risks of radiation exposure from CT in children.
Results
A total of 295 (36.4%) physicians responded. 59% of the doctors had not referred a child to CT in the past year, and approximately 30% referred only 1-5 children annually. The most frequent indications for a CT examination in children were trauma or a suspected cancer. 42% of the referrals were related to minor diagnoses or unspecific symptoms. The participants underestimated the radiation exposure due to CT and they overestimated the radiation exposure due to conventional X-ray examinations.
Conclusions
In Germany, the frequency of referrals of children to computed tomography is moderate. The knowledge on the risks from radiation exposure among office-based physicians in our sample varied, but there was a tendency to underestimate potential CT risks. Advanced radiological training might lead to considerable amendments in terms of knowledge and practice of CT referral.
doi:10.1186/1472-6963-12-47
PMCID: PMC3306200  PMID: 22364554
20.  The American College of Radiology white paper on radiation dose in medicine:deep impact on the practice of cardiovascular imaging 
In April 2007, the American College of Radiology released the "White Paper on Radiation Dose in Medicine". The Blue Ribbon panel members included private practice and academic diagnostic radiologists, medical physicists, representatives of industry and regulatory groups, and a patient advocate. The panel concluded that the expanding use of imaging modalities using ionizing radiations such as CT and nuclear medicine may result in an increased incidence of radiation-related cancer in the exposed population in the not-too-distant future, and this problem can likely be minimized by preventing the inappropriate use of such imaging and by optimizing studies that are performed to obtain the best image quality with the lowest radiation dose. The White Paper set forth practical suggestions to minimize radiation risk, including education for all stakeholders in the principles of radiation safety and preferential use of alternative (non-ionizing) imaging techniques, such as MRI and ultrasound. These recommendations are especially relevant for cardiologists, who prescribe and/or practice medical imaging examinations accounting for at least 50% of the total effective dose by radiation medicine, which amounts to an equivalent of about 160 chest x-rays per head per year in US. Were they be enacted, these simple recommendations would determine a revolution in the contemporary way of teaching, learning and practising cardiology.
doi:10.1186/1476-7120-5-37
PMCID: PMC2186301  PMID: 17974025
21.  Investigation of patient dose from common radiology examinations in Isfahan, Iran 
Background:
The aim of this study was measurement of the radiation doses received by patients for common radiology examinations in hospitals under control of Isfahan University of Medical Sciences, Iran.
Materials and Methods:
Thermoluminescence (lithium fluoride chips, LiF: Mg, Tl) dosimeter was used to measure patient dose for four (chest, posterior-anterior and lateral and skull anterior-posterior, or posterior-anterior and lateral) common radiographic views in six hospitals (seven X-ray machines). The entrance surface dose was measured on 20 randomly patients for each X-ray room.
Results:
The maximum (8.85 ± 0.62 mGy) and the minimum (0.62 ± 0.22 mGy) values of ESD was obtained for X-ray machines of Shimadzu and Varian located in Ashrafi-Khomeini-shahr and Kashani hospitals, respectively. As results shows, the values of ESD of skull were higher than that of chest examinations.
Conclusion:
The results of this study indicated that ESD measured doses were slightly greater than the ICRP and NRPB reference doses. Efforts should be made to further lower patient doses while securing image quality. In addition, the need to provide relevant education and training to staff in the radiology sections is of utmost importance.
doi:10.4103/2277-9175.96064
PMCID: PMC3507008  PMID: 23210070
Diagnostic radiology; patient dose; X-ray examinations
22.  Ionizing Radiation and Its Risks 
Western Journal of Medicine  1982;137(6):540-547.
Penetrating ionizing radiation fairly uniformly puts all exposed molecules and cells at approximately equal risk for deleterious consequences. Thus, the original deposition of radiation energy (that is, the dose) is unaltered by metabolic characteristics of cells and tissue, unlike the situation for chemical agents. Intensely ionizing radiations, such as neutrons and alpha particles, are up to ten times more damaging than sparsely ionizing sources such as x-rays or gamma rays for equivalent doses. Furthermore, repair in cells and tissues can ameliorate the consequences of radiation doses delivered at lower rates by up to a factor of ten compared with comparable doses acutely delivered, especially for somatic (carcinogenic) and genetic effects from x- and gamma-irradiation exposure. Studies on irradiated laboratory animals or on people following occupational, medical or accidental exposures point to an average lifetime fatal cancer risk of about 1 × 10-4 per rem of dose (100 per 106 person-rem). Leukemia and lung, breast and thyroid cancer seem more likely than other types of cancer to be produced by radiation. Radiation exposures from natural sources (cosmic rays and terrestrial radioactivity) of about 0.1 rem per year yield a lifetime cancer risk about 0.1 percent of the normally occurring 20 percent risk of cancer death. An increase of about 1 percent per rem in fatal cancer risk, or 200 rem to double the “background” risk rate, is compared with an estimate of about 100 rem to double the genetic risk. Newer data suggest that the risks for low-level radiation are lower than risks estimated from data from high exposures and that the present 5 rem per year limit for workers is adequate.
PMCID: PMC1274230  PMID: 6761969
23.  Extremely Low Doses of X-Radiation Can Induce Adaptive Responses in Mouse Prostate 
Dose-Response  2007;5(4):315-322.
The pKZ1 mouse chromosomal inversion assay is the only assay that has detected modulation of a mutagenic endpoint after single whole body X-irradiation with doses lower than 1 mGy. A non-linear dose response for chromosomal inversion has been observed in spleen and prostate between 0.001 mGy and 10 mGy, with doses between 0.005-0.01 mGy causing an increase in inversions and doses between 1–10 mGy causing a reduction below spontaneous inversion frequency. An adaptive response is a decreased biological effect induced by a low radiation dose. Adaptive responses contradict the linear-no-threshold model of risk estimation. We demonstrated that very low (0.001 mGy, 0.01 mGy, 1 mGy and 10 mGy) doses of X-radiation induced a chromosomal inversion adaptive response as measured by a reduction in the frequency of subsequent high dose (1000 mGy) induced inversions in prostate. These are the lowest X-radiation doses reported to induce an adaptive response for any endpoint. Adaptive response experiments were also performed where the high dose was administered four hours prior to a low dose of 0.01 mGy or 10 mGy In both cases an adaptive response was observed. Identification of the modifying factors involved in the adaptive response may provide candidates for radioprotection.
doi:10.2203/dose-response.07-019.Day
PMCID: PMC2477714  PMID: 18648563
low dose X-radiation; pKZ1 inversion assay; adaptive response; non-linear dose response
24.  Cancer risks following diagnostic and therapeutic radiation exposure in children 
Pediatric Radiology  2006;36(Suppl 2):121-125.
The growing use of interventional and fluoroscopic imaging in children represents a tremendous benefit for the diagnosis and treatment of benign conditions. Along with the increasing use and complexity of these procedures comes concern about the cancer risk associated with ionizing radiation exposure to children. Children are considerably more sensitive to the carcinogenic effects of ionizing radiation than adults, and children have a longer life expectancy in which to express risk. Numerous epidemiologic cohort studies of childhood exposure to radiation for treatment of benign diseases have demonstrated radiation-related risks of cancer of the thyroid, breast, brain and skin, as well as leukemia. Many fewer studies have evaluated cancer risk following diagnostic radiation exposure in children. Although radiation dose for a single procedure might be low, pediatric patients often receive repeated examinations over time to evaluate their conditions, which could result in relatively high cumulative doses. Several cohort studies of girls and young women subjected to multiple diagnostic radiation exposures have been informative about increased mortality from breast cancer with increasing radiation dose, and case-control studies of childhood leukemia and postnatal diagnostic radiation exposure have suggested increased risks with an increasing number of examinations. Only two long-term follow-up studies of cancer following cardiac catheterization in childhood have been conducted, and neither reported an overall increased risk of cancer. Most cancers can be induced by radiation, and a linear dose-response has been noted for most solid cancers. Risks of radiation-related cancer are greatest for those exposed early in life, and these risks appear to persist throughout life.
doi:10.1007/s00247-006-0191-5
PMCID: PMC2663653  PMID: 16862418
Radiation risks; Carcinogenesis; Diagnostic radiation; Therapeutic radiation
25.  The biological effects of diagnostic cardiac imaging on chronically exposed physicians: the importance of being non-ionizing 
Ultrasounds and ionizing radiation are extensively used for diagnostic applications in the cardiology clinical practice. This paper reviewed the available information on occupational risk of the cardiologists who perform, every day, cardiac imaging procedures. At the moment, there are no consistent evidence that exposure to medical ultrasound is capable of inducing genetic effects, and representing a serious health hazard for clinical staff. In contrast, exposure to ionizing radiation may result in adverse health effect on clinical cardiologists. Although the current risk estimates are clouded by approximations and extrapolations, most data from cytogenetic studies have reported a detrimental effect on somatic DNA of professionally exposed personnel to chronic low doses of ionizing radiation. Since interventional cardiologists and electro-physiologists have the highest radiation exposure among health professionals, a major awareness is crucial for improving occupational protection. Furthermore, the use of a biological dosimeter could be a reliable tool for the risk quantification on an individual basis.
doi:10.1186/1476-7120-2-25
PMCID: PMC538257  PMID: 15555078

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