On the justification of justification in radiation protection - legal and sociological considerations

ObjectivesThe objectives of the review were to investigate the legal and sociological basis of justification in society in order to fully assess its relevance to radiation protection. The difference between the justification of practices as distinct from the justification of reasons for the justification of individual activities within a practice and the relevance of cost–benefit analysis to this process are key elements.Key findingsJustification of practices as a principle of radiation protection is automatically enshrined within the appropriate legislation once it has been enacted. However, the justification of reasons for justification of activities within a practice are subject to many sociological factors, which are often conflicting and indeterminate and can be subject to political, economic and environmental factors that may change over time. This applies especially to new developments where the primary reason for justification is based upon potential but possibly ill-defined future benefits.ConclusionThe primary mechanism whereby society develops a collective consensus on the justification of practices lies within a legal framework. This represents the mechanism by which society defines the accepted standards that must be applied for acceptance of a practice. The justification of reasons for justifying activities that form part of a practice has largely been ignored within the framework of radiation protection.Implications for practiceThe employment of justification of practices as a fundamental principle of radiation protection should be eliminated since it is already enshrined within the legal framework applicable to applications of ionising radiation. Justification of reasons for pursuing new or modified practices is based upon their perceived benefits to society, which underpins most developments in society.     

放射诊断检查频次变化趋势及其影响因素分析

目的 探讨某综合医院近四年放射诊断检查频次的变化趋势及其相关影响因素。方法 利用医院信息系统和放射信息系统收集2019—2022年门急诊、住院人数和放射诊断检查信息。使用数据透视表对各种影像设备的检查频次和占比进行统计,并计算各检查项目频次及其占比。统计放射诊断检查的阳性率、患者性别和年龄分布情况;对放射检查人次数与门急诊、住院人数的关系采用Spearman相关分析。结果 2019—2022年放射诊断检查每年的频次分别为 307 306、 245 418、317 250、325 625人次,累计1 195 599人次;其中CT、X射线摄影、床旁X射线摄影、骨密度、消化道造影、乳腺X射线摄影的占比分别为59.74%、38.04%、1.39%、0.42%、0.21%、0.19%。各年度中,CT在所有放射诊断检查中的占比依次为49.58%、63.40%、60.40%、65.20%。急诊CT和急诊胸部CT检查频次与急诊就诊人次数具有相关性(r=0.63、0.61,P<0.05),非急诊CT检查频次与门诊、住院人次数有相关性(r=0.61、0.66,P<0.05)。CT检查阳性率除2021年最低为79.95%外均高于80%。结论 放射检查尤其是CT检查显著增加,在疾病诊断中发挥着重要的作用,但应重视CT检查正当性的判断。及时统计分析放射检查信息,可为放射检查科学管理提供数据支持和参考。     

A Summary and Critical Assessment of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: Filling the Gaps

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines has recently released the new cholesterol treatment guideline. This update was based on a systematic review of the evidence and replaces the previous guidelines from 2002 that were widely accepted and implemented in clinical practice. The new cholesterol treatment guideline emphasizes matching the intensity of statin treatment to the level of atherosclerotic cardiovascular disease (ASCVD) risk and replaces the old paradigm of pursuing low-density lipoprotein cholesterol targets. The new guideline also emphasizes the primacy of the evidence base for statin therapy for ASCVD risk reduction and lists several patient groups that will not benefit from statin treatment despite their high cardiovascular risk, such as those with heart failure (New York Heart Association class II-IV) and patients undergoing hemodialysis. The guideline has been received with mixed reviews and significant controversy. Because of the evidence-based nature of the guideline, there is room for several questions and uncertainties on when and how to use lipid-lowering therapy in clinical practice. The goal of the Mayo Clinic Task Force in the assessment, interpretation, and expansion of the ACC/AHA cholesterol treatment guideline is to address gaps in information and some of the controversial aspects of the newly released cholesterol management guideline using additional sources of evidence and expert opinion as needed to guide clinicians on key aspects of ASCVD risk reduction.     

High-sensitivity C-reactive protein and atherosclerotic disease: From improved risk prediction to risk-guided therapy

There is compelling experimental and clinical evidence suggesting a crucial role for inflammation in the initiation and also the progression of atherosclerosis. Numerous biomarkers involved at various levels of the inflammation cascade have been shown to be associated with adverse cardiovascular outcomes. Yet, to date, it is not clear whether inflammation simply accompanies the atherosclerotic process or represents a major driver. Among all blood biomarkers, C-reactive protein (CRP), the classical acute phase reactant that can be measured with high-sensitivity (hs) assays seems to be the most promising candidate. It has already found its way into the guidelines in primary prevention. Hs-CRP can also be used to identify a high-risk group for recurrent events in patients with manifest atherosclerosis. Several post hoc analyses of large-scale randomized clinical trials testing various statins have indicated that, besides low density lipoprotein (LDL) cholesterol, hs-CRP levels might also further aid in tailoring statin treatment. The large JUPITER trial has prospectively confirmed these findings in primary prevention in patients with elevated hs-CRP but normal LDL cholesterol levels. Still, statin therapy is not a specific anti-inflammatory regime acting on the inflammation cascade. Thus, to directly test the inflammation hypothesis, a novel, more proximally located cytokine-based approach is needed. Canakinumab, a fully human monoclonal antibody against interleukin-1β, might represent a promising compound in this regard and provide a proof of concept. If successful, this may become a novel strategy to treat high-risk patients with stable atherosclerotic disease to prevent recurrent events on top of standard medical care.     

CT head in children

The advances in computerized technology (CT) technique over the last few decades have greatly modified imaging protocols in children. The range of pathologies that can now be demonstrated has broadened with the advent of newer techniques such as CT perfusion and the ability to perform complex reconstructions. Increasing speed of scanning and reduction in scan time have influenced the need for sedation and general anaesthetic as well as impacting on motion artefact. Additionally, concerns about radiation safety and avoidance of unnecessary radiation have further impacted on the inclusion of CT in the imaging armamentarium. Justification and image optimisation are essential. It is important to familiarize oneself with the appearances of normal variants or age related developmental changes. CT does however remain an appropriate investigation in a number of conditions.     

Unjustified CT examinations in young patients

The doses of radiation from computed tomography (CT) are relatively high, yet CT is being increasingly utilized. Furthermore, the radiation-induced lifetime risk of cancer mortality is higher at younger age. The purpose of this study was to find out whether previous CT examinations done on patients aged under 35 years were justified, and if not, whether there would have been other, more justifiable imaging modalities available. Fifty CT examinations of the head and 30 CT examinations each of the lumbar spine, cervical spine, abdomen, nasal sinuses and trauma were evaluated consecutively since the beginning of the year 2005 by using electronic patient files, the referral guidelines for imaging recommended by the European Commission and certain principles of classification. Seventy-seven per cent of the CT examinations of the lumbar spine, 36% of the head, 37% of the abdomen, 20% of the nasal sinuses and 3% of the cervical spine were unjustified. Most of these unjustified examinations could have been replaced by magnetic resonance imaging. In order to reduce utilization of ionizing radiation, both the referring practitioner and the radiologist responsible for the examination should carefully consider the justification for CT examinations and the possibility of using other imaging modalities.     

Service evaluation of radiographer-led vetting and protocoling of Computed Tomography (CT) scan requests in a Singapore public healthcare institution

IntroductionA service improvement project involving the vetting and protocoling of Computed Tomography (CT) scan requests by qualified CT radiographers was initiated in 2018.AimThis study provides a comprehensive evaluation of how a radiographer-led initiative aims to ensure that the CT scan requests received by the Radiology department are clinically appropriate, which in turn will reduce interruptions to the interpretation and reporting of imaging examinations by radiologists, who might otherwise be required to attend to clinically inappropriate and wrongly protocolled CT scan requests.MethodOutpatient CT scan requests received from July to October 2021 were vetted and protocolled by a qualified CT-trained radiographer for parameters which included the appropriateness of the clinical indication, adequacy of patient preparation for the scan, as well as the suitability of the requested examination protocol pertaining to the need for contrast media, multiple contrast-enhanced imaging phases, and the appropriateness of the scan range.ResultsPoor patient preparation and insufficient or inaccurate clinical indications were the most common findings during the vetting process (71%). Out of the 64 CT scan requests with protocol errors, 77% were attributed to contrast media type errors. The odds of incorrect CT scan requests increased with the requesting clinician’s rank, while there was no such significant correlation with the clinical specialty of the requesting clinician or the CT scan type.ConclusionThe meticulous vetting of imaging requests helps to ensure that limited imaging hardware resources are allocated to more clinically appropriate cases, correct protocols are applied to requested imaging scans, and that patients undergoing imaging are adequately prepared, thereby enhancing overall patient care.Implications for practiceVetting of imaging requests by radiographers, who are capable to make appropriate clinical decisions related to their enhanced level of practice ensures patient safety and optimisation of Radiology resources.     

Rationale for unequal randomization in clinical trials is rarely reported: a systematic review

ObjectivesTo assess the reporting of the unequal randomization ratio in reports of trials with this design and to identify the justification for the design.Study Design and SettingSystematic review of reports of trials with unequal randomization. We selected all original reports of two parallel-group randomized controlled trials with unequal randomization, which were published in 2009 and 2010 in core clinical journals in MEDLINE on the basis of the abstract (and full text, if necessary). Additional information was collected by an author survey.ResultsWe retrieved 106 reports (prevalence, 4.7%). The randomization ratio was not stated in 8.5% of reports and 51.9% of abstracts. Sample size calculation was reported in 70 reports, with unequal randomization not taken into account in 25.7% (n = 18). Justification for unequal randomization was not reported in 77.4% (n = 82) of reports. Combining information from reports and author surveys, we had justification for 41 trials. The main justification was safety issues for 20 trials. In 11 of those latter 20 reports, adverse events were not fully reported.ConclusionA better reporting of the randomization ratio, sample size calculation, and justification to unequal randomization could help readers appraise the quality and risk of bias of such trials.