Knowledge of radiation exposure associated with common trauma imaging modalities among orthopaedic surgeons,emergency medicine physicians,and general surgeons in the United States

BACKGROUND:Few contemporary studies have assessed physicians’knowledge of radiation exposure associated with common imaging studies,especially in trauma care.The purpose of this study was to assess the knowledge of physicians involved in caring for trauma patients regarding the effective radiation doses of musculoskeletal(MSK)imaging studies routinely utilized in the trauma setting.METHODS:An electronic survey was distributed to United States orthopaedic surgery,general surgery,and emergency medicine(EM)residency programs.Participants were asked to estimate the radiation dose for common imaging modalities of the pelvis,lumbar spine,and lower extremity,in terms of chest X-ray(CXR)equivalents.Physician estimates were compared to the true effective radiation doses.Additionally,participants were asked to report the frequency of discussing radiation risk with patients.RESULTS:A total of 218 physicians completed the survey;102(46.8%)were EM physicians,88(40.4%)wereorthopaedicsurgeons,and28(12.8%)weregeneralsurgeons.Physicians underestimated the effective radiation doses of nearly all imaging modalities,most notably for pelvic computed tomaography(CT)(median 50 CXR estimation vs.162 CXR actual)and lumbar CT(median 50 CXR estimation vs.638 CXR actual).There was no difference between physician specialties regarding estimation accuracy(P=0.133).Physicians who regularly discussed radiation risks with patients more accurately estimated radiation exposure(P=0.007).CONCLUSION:The knowledge among orthopaedic and general surgeons and EM physicians regarding the radiation exposure associated with common MSK trauma imaging is lacking.Further investigation with larger scale studies is warranted,and additional education in this area may improve care.

Radiation Exposure during Dynamic Hip Screw Fixation: A Comparative Study

Background: The safe amount of radiation permissible during fixation of neck of femur fractures has long been studied. Factors including surgeons’ experience have been highlighted. We aimed in this study to compare different factors for quality and safety improvement. Methods: It was a retrospective study, including all patients who had undergone a standard DHS fixation between January 2018 and June 2019 for inter-trochanteric neck of femur fractures. Two groups were stratified;(Group A) had the procedure performed by a specialist non-consultant surgeon (NCG) and (Group B) by an established consultant (CG). The Dose Area Product (DAP) and the duration of radiation exposure were recorded. Results: Over a period of 18 months, 91 cases were included with a mean age of 82 years old. The mean weight was 62 kg. 42 patients had complex fractures, and 49 patients had simple fractures. 12% of patients were ASA II, 70% of cases were ASA III and 18% of the patients were ASA IV. The mean DAP for group A was 345.131 CGYCM2 (SD 273.65) and for group B 234.63 CGYCM2 (SD 165.30). The time of exposure was 8.6 sec and 13.16 sec in groups B and A respectively. Conclusion: The data collected from this study were comparable to others. The amount of radiation exposure was of difference related to the decision-making intra-operatively. Other factors were not statistically significant.

Medical Radiation Exposure and Human Carcinogenesis-Genetic and Epigenetic Mechanisms

Ionizing radiation （IR） is a potential carcinogen. Evidence for the carcinogenic effect of IR radiation has been shown after long-term animal investigations and observations on survivors of the atom bombs in Hiroshima and Nagasaki. However, IR has been widely used in a controlled manner in the medical imaging for diagnosis and monitoring of various diseases and also in cancer therapy. The collective radiation dose from medical imagings has increased six times in the last two decades, and grow continuously day to day. A large number of evidence has revealed the increased cancer risk in the people who had frequently exposed to x-rays, especially in childhood. It has also been shown that secondary malignancy may develop within the five years in cancer survivors who have received radiotherapv, because of IR-mediated damage to healthy cells. In this article, we review the current knowledge about the role of medical x-ray exposure in cancer development in humans, and recently recognized epigenetic mechanisms in IR-induced carcinogenesis.

Percutaneous kidney stone surgery and radiation exposure: A review

During the past 3 decades,radiation exposure(RE)has increased drastically among patients undergoing percutaneous nephrolithotomy(PCNL),thus potentially causing new cases of cancer each year.The effective dose received by patients comes from pre-and postoperative computed tomography(CT)and intraoperative fluoroscopy(FL).We reviewed literature to find novel techniques and approaches that help to decrease RE of patients and personnel.We performed PubMed search using keywords percutaneous nephrolithotomy,intraoperative fluoroscopy,radiation exposure,imaging,percutaneous access,ultrasound,computed tomography,endoscopy,reconstruction,innovations,and augmented reality.Forty-four relevant articles were included in this review.As much as 20%of patients with first diagnosed urolithiasis exceed background RE level almost 17-fold.For diagnosing purposes using low-dose and ultra-low-dose CT,as well as low-dose dual energy scan protocols can be efficient ways to decrease RE while maintaining decent accuracy.Patients with urinary stones can be effectively monitored with digital tomosynthesis,ultrasound alone or ultrasound combined with plain film of the abdomen.Percutaneous access(PCA)into the kidney can be performed with reduced or even no RE,using novel PCA methods.REs from conventional imaging techniques during diagnosis and treatment increase probability of non-stochastic radiation effects.Urologists should be aware of protocols that decrease RE from CT and FL in diagnosis and management of urinary stones.Consideration of recently developed imaging modalities and PCA techniques will also aid in adherence to the“as low as reasonably achievable”principle.

Effect of Radioactive Minerals Potentiality and Primordial Nuclei Distribution on Radiation Exposure Levels within Muscovite Granite, Wadi Nugrus, Southeastern Desert, Egypt

The studied area at Wadi Nugrus, Southeastern Desert, Egypt, is located between lat. 24°41'00'' and 24°41'35''N and long. 34°36'47'' and 34°37'09''E. The rock types are represented by layered metagabbros, biotite schists, gneisses, granodiorites, and Muscovite granites. The muscovite granite of Wadi Nugrus, is small exposure in size (~5.0 km2), emplaced along NW-SE trend, with about 0.5 - 4.5 Km in length and 100 - 250 m in width and intruding the biotite schists. The studied muscovite granite is composed mainly of plagioclases, potash feldspars, quartz, biotite and muscovite. The recorded minerals assemblage can be classified into secondary U-minerals (uranophane and meta-autunite), U-bearing minerals (uranothorite and columbite) and accessory minerals (zircon, flourite, allanite, zinnwaldite and hematite). The U/eU is more unity where, the measured chemical uranium is higher than the measured equivalent uranium in the most analyzed samples especially in trenches, which reflect disequilibrium state. The activity concentrations range from 251.72 to 1096.2 Bq·kg-1 for 232Th, from 494 to 2593.5 Bq·kg-1 for 226Ra, and from 1314.6 to 1846.7 Bq·kg-1 for 40K. The obtained radiological data show that the average internal and external hazard indices are 9.11 and 5.78, respectively which are more than unity and highly exceeding the permissible limits (International Commission on Radiation Protection, ICRP). The internal and external hazards are mainly due to 226Ra nuclei while the absorbed dose rate (nGy/h) is related to 232Th nuclei. The contributions of the three nuclei in the total absorbed dose rates and internal and external hazardous, for 226Ra, it contributes by 72% in Hin, 57% in Hex and 55% of DR, for 232Th it contributes by 24% in Hin, 37% in Hex and 36.9% of DR, while for 40K it contributes by 4.1% in Hin, 6.4% in Hex and 8.1% of DR.

Using ArcGIS to Measure the Rate Of Radiation Exposure in Marshes Environment in Southern Iraq

Both Arc GIS 9.2 and ERDAS 9.1 software were used to analyze the concentrations in radiation exposure of marshlands in southern Iraq during June 2009 and January 2010. It was measured radiation exposure rates above the soil and water surface, and also measured radioactivity in the environmental models （soil, plants, sediment and water） for all the selected sites of the study area. Furthermore, it has＂ been measuring the level of radioactive contamination concentration of the isotope Bi-214 and Ac-228 and K-40 as well as peer-Cs-137-resulting from the operations of nuclear fission and measured the background radiation compared with other regions. Environmental samples （soil-water-plant-deposits） were taken and measuring the concentration ratio of radioisotopes in using the system account gentle rays Kama multi-channel and using the counter--Nal-tinged element--thallium--Type-WIZARD-1470 as well as a LB 1200. The results showed the regions of the marshes of radioactive contamination now.

Three-Dimensional Rotational Angiography in Congenital Heart Disease:Estimation of Radiation Exposure

Objectives: There is an increasing use of three-dimensional rotational angiography (3D-RA) during catheterization of congenital heart disease. Dose-area-product (DAP) measured by the angiography system and computed-tomography dose index (CTDI) do not appear practical for dose assessment. Hence, we performed real dose measurements in anthropomorphic phantoms. Methods: Three different anthropomorphic phantoms (10 kg, 19 kg and 73 kg bodyweight) equipped with thermoluminescent dosimeters (TLD) were used. We used a typical standard diagnostic program and a low-dose program. The effective dose (ED) was calculated according to the International Commission on Radiological Protection (ICRP) 103. The 3D distribution of radiation in the body was assessed. Results: ED for the male 10 kg phantom was 0.192 mSv in the diagnostic program and 0.050 mSv (male) in the low-dose program. The 19 kg phantom received an ED of 0.205 mSv (male) in the diagnostic program. In the low-dose program the ED reached 0.058 mSv (male). The male adult 73 kg phantom was exposed with an ED of 0.730 mSv in the diagnostic program and 0.282 mSv in the low-dose program. ED for the female phantoms was slightly higher for both acquisition-programs. Dose distribution was inhomogeneous with a dose maximum in the esophageal region behind the heart, whereas in the brain, intestine and gonads we found nearly no radiation. Conclusions: 3D-RA imaging in the interventional catheter laboratory is possible with an effective dose lower than 1 mSv. With its potential to reduce fluoroscopic time and the number of control angiographies in catheterization and intervention in complex anatomy, it can decrease the radiation dose.

Expression levels of K_(ATP)channel subunits and morphological changes in the mouse liver after exposure to radiation

BACKGROUND ATP sensitive K+(K_(ATP))channels are ubiquitously distributed in various of cells and tissues,including the liver.They play a role in the pathogenesis of myocardial and liver ischemia.AIM To evaluate the radiation-induced changes in the expression of K_(ATP)channel subunits in the mouse liver to understand the potential role of K_(ATP)channels in radiation injury.METHODS Adult C57BL/6 mice were randomly exposed toγ-rays at 0 Gy(control,n=2),0.2 Gy(n=6),1 Gy(n=6),or 5 Gy(n=6).The livers were removed 3 and 24 h after radiation exposure.Hematoxylin and eosin staining was used for morphological observation;immunohistochemical staining was applied to determine the expression of K_(ATP)channel subunits in the liver tissue.RESULTS Compared with the control group,the livers exposed to 0.2 Gyγ-ray showed an initial increase in the expression of Kir6.1 at 3 h,followed by recovery at 24 h after exposure.Exposure to a high dose of 5.0 Gy resulted in decreased expression of Kir6.1 and increased expression of SUR2B at 24 h.However,the expression of Kir6.2,SUR1,or SUR2A had no remarkable changes at 3 and 24 h after exposure to any of these doses.CONCLUSION The expression levels of Kir6.1 and SUR2B in mouse liver changed differently in response to different radiation doses,suggesting a potential role for them in radiation-induced liver injury.

Monte Carlo calculation of the exposure of Chinese female astronauts to earth’s trapped radiation on board the Chinese Space Station

With the development of China’s crewed space mission,the space radiation risk for astronauts is increasingly prominent.This paper describes a simulation of the radiation doses experienced by a Chinese female voxel phantom on board the Chinese Space Station(CSS)performed using the Monte Carlo N-Particle(MCNP)software.The absorbed dose,equivalent dose,and effective dose experienced by the voxel phantom and its critical organs are discussed for different levels of shielding of the Tianhe core module.The risk of space-radiation exposure is then assessed by comparing these doses with the current risk limits in China(the skin dose limit for short-term low-earth-orbit missions)and the NASA figures(National Council on Radiation Protection and Measurements Report No.98)for female astronauts.The results obtained can be used to guide and optimize the radiation protection provided for manned space missions.

Effect of fluoroscopy frame rate on radiation exposure and in-hospital outcomes in cardiovascular implantable electronic device implantation procedures

Objective:To assess the radiation exposure in cardiovascular implantable electronic device(CIED)implantation procedures,the effect of fluoroscopy frame rate on various radiation exposure indices,and in-hospital outcomes.Methods:Data of CIED implantation procedures from September 2015 to December 2019 of all the CIED implantation procedures performed at our institute were retrospectively analyzed.The procedural data were divided into two groups:a)pre-group:procedures that were performed under fluoroscopy frame rate of 7.5 frames per second(fps);b)post-group:procedures that were performed under fluoroscopy frame rate of 3.75 fps.We compared procedure time,fluoroscopy time,Kerma air product,effective dose,and in-hospital outcomes between the two groups.Results:A total of 2,225 procedures were included in the analysis with mean age of(62±15)years.The procedures consisted of the implantation of single-chamber(n=1,436),double chamber(n=656),and biventricular devices(n=133).Procedure time and radiation indices showed a significant reduction over the study period(P<0.001).Reduction in the fluoroscopy frame rate was associated with a significant reduction in radiation exposure indices(P<0.001).In-hospital outcomes did not differ between the two groups.Conclusions:Reduction in the fluoroscopy frame rate from 7.5 to 3.75 fps significantly decreased the radiation exposure in CIED implantation procedures.A framerate lower than 3.75 fps should be the default setting during such procedures.

Radiation dose analysis of computed tomography coronary angiography in Children with Kawasaki disease

BACKGROUND There is evolving role of computed tomography coronary angiography(CTCA)in non-invasive evaluation of coronary artery abnormalities in children with Kawasaki disease(KD).Despite this,there is lack of data on radiation dose in this group of children undergoing CTCA.AIM To audit the radiation dose of CTCA in children with KD.METHODS Study(December 2013-February 2018)was performed on dual source CT scanner using adaptive prospective electrocardiography-triggering.The dose length product(DLP in milligray-centimeters-mGy.cm)was recorded.Effective radiation dose(millisieverts-mSv)was calculated by applying appropriate age adjusted conversion factors as per recommendations of International Commission on Radiological Protection.Radiation dose was compared across the groups(0-1,1-5,5-10,and>10 years).RESULTS Eighty-five children(71 boys,14 girls)with KD underwent CTCA.The median age was 5 years(range,2 mo-11 years).Median DLP and effective dose was 21 mGy.cm,interquartile ranges(IQR)=15(13,28)and 0.83 mSv,IQR=0.33(0.68,1.01)respectively.Mean DLP increased significantly across the age groups.Mean effective dose in infants(0.63 mSv)was significantly lower than the other age groups(1-5 years 0.85 mSv,5-10 years 1.04 mSv,and>10 years 1.38 mSv)(P<0.05).There was no significant difference in the effective dose between the other groups of children.All the CTCA studies were of diagnostic quality.No child required a repeat examination.CONCLUSION CTCA is feasible with submillisievert radiation dose in most children with KD.Thus,CTCA has the potential to be an important adjunctive imaging modality in children with KD.

Role of contrast-enhanced serial/spot abdominal X-rays in perioperative follow-up of patients undergoing abdominal surgery:An observational clinical study

BACKGROUND Many imaging methods such as ultrasonography,computed tomography(CT),magnetic resonance imaging,and endoscopy are used to identify the problems or complications that occur in the perioperative period and to determine the appropriate therapeutic approach.Specialists at surgical clinics and intensive care units sometimes need diagnostic procedures that can give quick results or reveal unexpected results.In particular,rapid on-site evaluation of patients followed under intensive care conditions has several advantages.AIM To determine the problems developing in patients in the perioperative period by contrast-enhanced abdominal X-ray(CE-AXR),revealing their current status or defining the effectiveness of CE-AXR.METHODS The files of the patients who underwent hepatopancreatobiliary or upper gastrointestinal surgery,whose CE-AXR film was taken,were reviewed retrospectively.Abdominal X-ray radiographs taken after ingestion of a watersoluble contrast agent(iohexol,300 mg,50 cc vial)and its application in a drain,nasogastric tube,or stent were evaluated.The contribution of the data obtained in patients who underwent CE-AXR to the diagnosis,follow-up,and treatment processes and the effectiveness of the application were investigated.RESULTS CE-AXR was applied to 131 patients in our clinic,most of whom underwent hepatopancreatobiliary or upper gastrointestinal surgery.It was determined that the data obtained from CE-AXR films taken in 98(74.8%)of the patients contributed to the diagnosis,treatment,and follow-up expectations and positively affected the clinical processes.CONCLUSION CE-AXR is a simple procedure that can be applied anywhere,especially in intensive care patients and at bedside,with a portable X-ray device.The simplicity of the procedure,less radiation exposure for the patients,less time wastage,reduction in the CT and endoscopy procedure burden and costs,quick results,rapid assessment of the situation,and enabling the monitoring of processes with repetitive procedures are important advantages.X-rays taken will be useful in terms of being a reference value during the follow-up period of the patient and determining the situation in medicolegal processes.

A new free-hand pedicle screw placement technique with reference to the supraspinal ligament

We sought to compare the safety and accuracy of a new free-hand pedicle screw placement technique to that of the conventional technique. One hundred fifty-three consecutive adult patients with simple fracture in the tho- racic or/and lumbar spine were alternately assigned to either the new free-hand or the conventional group. In the new free-hand technique group, preoperative computerized tomography （CT） images were used to calculate the targeted medial-lateral angle of each pedicle trajectory and the pedicle screw was inserted perpendicular to the corresponding supraspinal ligament. In the conventional technique group, the medial-lateral and cranial-caudal angle of each pedicle trajectory was determined by intraoperatively under fluoroscopic guidance. The accuracy rate of pedicle screw placement, the time of intraoperative fluoroscopy, the operating time and the amount of blood loss during operation were respectively compared. All screws were analyzed by using intraoperative ra- diographs, intraoperative triggered electromyography （EMG） monitoring data, postoperative CT data and clinical outcomes. The accuracy rate of pedicle screw placement in the new free-hand technique group and the conven- tional technique group was 96.3% and 94.2% （P 〈 0.05）, respectively. The intraoperative fluoroscopy time of the new technique group was less than that of the conventional technique group （5.37 seconds vs. 8.79 seconds, P 〈 0.05）. However, there was no statistical difference in the operating time and the amount of blood loss during op- eration （P 〉 0.05）. Pedicle screw placement with the free-hand technique which keeps the screw perpendicular to the supraspinal ligament is an accurate, reliable and safe technique to treat simple fracture in the thoracic or lum- bar spine.

Colorectal cancer screening:The role of CT colonography

Computed tomography colonography(CTC) in colorectal cancer(CRC) screening has two roles:one present and the other potential.The present role is,without any further discussion,the integration into established screening programs as a replacement for barium enema in the case of incomplete colonoscopy.The potential role is the use of CTC as a first-line screening method together with Fecal Occult Blood Test,sigmoidoscopy and colonoscopy.However,despite the fact that CTC has been officially endorsed for CRC screening of average-risk individuals by different scientif ic societies including the American Cancer Society,the American College of Radiology,and the US Multisociety Task Force on Colorectal Cancer,other entities,such as the US Preventive Services Task Force,have considered the evidence insuff icient to justify its use as a mass screening method.Medicare has also recently denied reimbursement for CTC as a screening test.Nevertheless,multiple advantages exist for using CTC as a CRC screening test:high accuracy,full evaluation of the colon in virtually all patients,non-invasiveness,safety,patient comfort,detection of extracolonic findings and cost-effectiveness.The main potential drawback of a CTC screening is the exposure to ionizing radiation.However,this is not a major issue,since low-dose protocols are now routinely implemented,delivering a dose comparable or slightly superior to the annual radiation exposure of any individual.Indirect evidence exists that such a radiation exposure does not induce additional cancers.

Male-mediated developmental toxicity

Male-mediated developmental toxicity has been of concern for many years. The public became aware of male-mediated developmental toxicity in the early 1990s when it was reported that men working at Sellafield might be causing leukemia in their children. Human and animal studies have contributed to our current understanding of male-mediated effects. Animal studies in the 1980s and 1990s suggested that genetic damage after radiation and chemical exposure might be transmitted to offspring. With the increasing understanding that there is histone retention and modification, protamine incorporation into the chromatin and DNA methylation in mature sperm and that spermatozoal RNA transcripts can play important roles in the epigenetic state of sperm, heritable studies began to be viewed differently. Recent reports using molecular approaches have demonstrated that DNA damage can be transmitted to babies from smoking fathers, and expanded simple tandem repeats minisatellite mutations were found in the germline of fathers who were exposed to radiation from the Chernobyl nuclear power plant disaster. In epidemiological studies, it is possible to clarify whether damage is transmitted to the sons after exposure of the fathers. Paternally transmitted damage to the offspring is now recognized as a complex issue with genetic as well as epigenetic components.

Error rate of multi-level rapid prototyping trajectories for pedicle screw placement in lumbar and sacral spine

Objective：Free-hand pedicle screw placement has a high incidence of pedicle perforation which can be reduced with fluoroscopy,navigation or an alternative rapid prototyping drill guide template.In our study the error rate of multi-level templates for pedicle screw placement in lumbar and sacral regions was evaluated.Methods：A case series study was performed on 11 patients.Seventy-two screws were implanted using multilevel drill guide templates manufactured with selective laser sintering.According to the optimal screw direction preoperatively defined,an analysis of screw misplacement was performed.Displacement,deviation and screw length difference were measured.The learning curve was also estimated.Results：Twelve screws （17％） were placed more than 3.125 mm out of its optimal position in the centre of pedicle.The tip of the 16 screws （22％） was misplaced more than 6.25 mm out of the predicted optimal position.According to our predefined goal,19 screws （26％） were implanted inaccurately.In 10 cases the screw length was selected incorrectly：1 （1％） screw was too long and 9 （13％） were too short.No clinical signs of neurovascular lesion were observed.Learning curve was insignificantly noticeable （P=0.129）.Conclusion：In our study,the procedure of manufacturing and applying multi-level drill guide templates has a 26％ chance of screw misplacement.However,that rate does not coincide with pedicle perforation incidence and neurovascular injury.These facts along with a comparison to compatible studies make it possible to summarize that multi-level templates are satisfactorily accurate and allow precise screw placement with a clinically irrelevant mistake factor.Therefore templates could potentially represent a useful tool for routine pedicle screw placement.

Risk of cataract of different morphological types in Urals population chronically exposed at low doses

Objective To assess the risk of lens opacity depending on the dose in the population exposed to external and internal radiation for a long time,based on a long-term clinical follow-up of the cohorts of people exposed to radiation as a result of two radiation accidents in the South Urals.Methods A layer-by-layer morphological study of the lens of 1,377 exposed individuals was conducted according to a special program in the Clinical Department of the Urals Research Center for Radiation Medicine(URCRM)68 years after the onset of exposure.Lens changes were classified in accordance with the lens opacities classification(LOCS)III and included images of lens.To calculate the doses to lens,the data were taken into account,including the person's residence history in the radioactively contaminated territory,age and sex that affected their lifestyle and diet,radionuclide distribution in organs and tissues.Individualized lens doses were calculated using Techa River Dosimetry System(TRDS)-2016.Case-control method was used for statistical analysis.Results Individual values of absorbed dose to lens ranged from 0 to 600mGy.A dose-dependent increased risk of posterior subcapsular cataract(PSC)(OR1.54,95%CI:1.04–2.27)and nuclear cataract(OR1.84,95%CI:1.14–2.95)was found among chronically exposed individuals by a case-control method.No evidence of dose effect was found for cortical cataracts.Conclusions The results showed that population exposed to long-term chronic low-dose radiation was subjected to an increased risk of PSC and nuclear cataract development.