Radiologists: The Unsuspecting Subject Matter Experts

The social and political climates are changing rapidly in the United States and the world at large. The threat of a chemical, biologic, radiologic, and/or nuclear event is a rising concern to many. The current Ebola crisis has shed light on health care providers’ preparedness for such an event. Radiologists, including radiation oncologists, nuclear medicine specialists, and all radiology subspecialists are considered “subject matter experts” in this area and are likely to be called upon in response to a radiation incident. Although others, such as radiation safety officers, provide important expertise, the clinical leadership will be the responsibility of physicians and other health care providers. However, many radiologists are unaware that they are considered subject matter experts who may be called on to assist, should their local hospital’s emergency department need to take care of casualties from a radiation incident.A mass-casualty situation with hundreds of patients would require the immediate assistance of all available medical providers. Radiologists are primed and positioned to take the lead in ensuring preparedness of their local hospital and community, through emergency planning for a radiologic incident, given their combined medical and radiation physics knowledge. Therefore, increasing the skills of radiologists first is the more prudent approach in such planning. This preparation can be done through understanding of the critical components of such scenarios: the threat, types of radiation incidents, contamination, detection, decontamination, and acute radiation syndrome and its treatment. Once the necessary knowledge supplementation has been completed, radiologists can participate in educating their fellow medical colleagues and health care staff, and assist in the radiation-related aspects of an “all hazards” emergency department response, decreasing “radiophobia” in the process.     

核与辐射事故应急药物储备研究进展

在当前国际形势下,存在核战争和核恐怖发生的可能性,核与辐射事故应急不可懈怠。世界卫生组织(WHO)于2023年1月27日发布出版物,更新了应对辐射和核紧急情况建议储备的药物清单,这是自2007年以来的首次更新。出版物里建议的药物储备清单,包括防止或减少辐射影响的药物,以及在受照后用于治疗损伤的药物。围绕该药物清单,从核与辐射事故应急、应急药物储备概况、一些国家的药物储备和当前的思考等几个方面进行综述,以期为我国核与辐射事故应急医学救援提供参考。     

Reducing hospital emergency department costs through aggressive use of diagnostic imaging

With the current pressure to decrease costs, we in emergency radiology have an advantage that can be useful for our hospitals: by aggressively using diagnostic imaging, we can help the hospital reduce the costs of taking care of emergency department patients. An appropriate response to the pressure to decrease costs in emergency diagnosstic imaging is to analyze the impact of imaging on costs, patient management decisions, and patient outcome. The most convincing type of analysis is a cost-minimization analysis in which costs are defined as resources used by the hospital in taking care of patients. This review discusses the types of analyses that can be performed, perspectives of analyses, definition of costs, and definition of quality.     

What is risk management?

Medical accidents recently have become a social problem as a result of the old-fashioned hospital system in Japan. Therefore, risk management for medical procedures has been considered very important. In the field of radiotherapy, specific characteristics include the management of radiation and the triangular relationship between patients, referred doctors, and radiation oncologists. In future, the difference between incident and accident in radiotherapy should be clearly defined by the Society.     

1894例青藏高原道路交通伤分析

目的探讨青藏高原道路交通伤的流行病学特点，寻求有效的预防高原交通事故的方法和交通伤患者的急救措施。方法回顾性统计分析我院1980年1月-2000年12月救治的有较详细记录的1894例道路交通伤病案和门、急诊室相关登记。结果21年间，青藏高原道路交通伤共1894例；大部分的交通伤发生在青藏公路上，占68．0％(1288／1894)；交通伤患者损伤较重，需要住院治疗者占54．0％(1022／1894)；患者以内地初到高原者居多，占61．1％(1158／1894)；死亡108例，死亡率5．7％；受伤至就诊时间较长，平均后送时间为6h以上；就诊前大多数患者无任何处理措施。结论高原缺氧、道路不明、疲劳驾驶是造成交通事故的主要原因；沿途缺乏医疗卫生机构、严重缺氧、后送时间长和后送人员医疗卫生知识较差是造成交通伤患者死亡率较高的原因。     

Coronary CT angiography with iterative reconstruction in early triage of patients with acute chest pain

Background

Patients who present to the emergency department (ED) complaining of acute chest pain are of clinical concern because a small percentage will have acute coronary syndrome (ACS). The American College of Cardiology (ACC) and the American Heart Association (AHA) recommend hospitalization for patients with a low-to-intermediate risk of ACS who have initial negative ECG and enzyme test results. A negative coronary CT angiography (CCTA) during the triage has a very high negative predictive value for ruling out ACS decreasing the length of hospital stay. Recent techniques e.g. ASiR in CCTA should be used to decrease the radiation dose as low as possible.

Objective

The aim of this study is to evaluate the role of low radiation dose CCTA with ASiR in triage of low-risk patients with acute chest pain in emergency department. A negative CCTA early in the workup may enable a shorter length of stay.

Subjects and methods

We studied 54 selected patients (55.6% men; mean age 48 ± 6 years) with chest pain who were awaiting hospital admission to rule out ACS despite the absence of diagnostic ECG changes and normal cardiac enzymes on ED presentation. Patients underwent CCTA before hospital admission. Afterward, patients received standard clinical care (SCC). ER physicians involved in the patient’s care were blinded to the results of CCTA. An expert panel established the presence or absence of ACS based on AHA guidelines. The CCTA images were evaluated for the presence of significant coronary artery stenosis (diameter reduction >50%) and were used to make a triage decision.

Results

Four patients (7.4%) with chest pain had at least one significant coronary stenosis on CCTA (sensitivity 100%, specificity 96%, accuracy 96.3%, positive predictive value (PPV) 66.7% and negative predictive value (NPV) 100%). Significant coronary stenosis was excluded in 48 of the 54 patients by CCTA (88.9%), potentially saving about 71.6% of unnecessary hospital admission hours.

Conclusion

CCTA based detection of significant coronary stenosis has potential role to decrease the length of hospital stay , without reducing appropriate patient care, in low risk patients with acute chest pain. CCTA should be done with lowest radiation possible using recent techniques.     

Impact of nodal regression on radiation dose for lymphoma patients after radioimmunotherapy.

Radioimmunotherapy for non-Hodgkin's lymphoma often results in surprisingly high response rates compared with those expected from estimated absorbed radiation doses. Several factors, including radiobiologic response, selective targeting, and heterogeneous absorbed radiation within the lymphoma, are likely to contribute to the lack of a dose-response relationship. This article investigates the impact of nodal regression on absorbed radiation dose and applies a correction factor to account for its effect. METHODS: The radioactivity in and regression of 37 superficial lymph nodes were measured in 7 non-Hodgkin's lymphoma patients treated with 775-3,450 MBq/m(2) of (131)I-Lym-1 monoclonal antibody. Nodal dimensions were measured with calipers and radioactivity was quantitated using gamma-camera imaging on multiple days after (131)I-Lym-1 injection. Both nodal regression and radioactivity were fit with monoexponential functions. Formulas were developed to account for simultaneous change in nodal mass and radioactivity. All lymph nodes with size and radioactivity measurements, and exponential-fit coefficients of determination of >0.8, were included in the analysis. RESULTS: A 3 orders-of-magnitude node-to-node variation in initial radiopharmaceutical concentration (MBq/g) was observed, with the highest concentrations in the smallest nodes. Reduction in radioactivity as a function of time (biologic half-life) varied by about a factor of 2. In contrast, the rate of nodal regression varied by orders of magnitude, from a 14-h half-time to no regression at all. Five nodes regressed with a half-time that was shorter than their observed effective radiopharmaceutical half-life. Accounting for the effect of nodal regression resulted in dose corrections ranging from 1 (no correction) to a factor of >10, with 70% of nodes requiring a correction factor of at least 20% and >50% of nodes requiring a correction factor of >2. Corrected for nodal regression, 46% of nodes analyzed had absorbed radiation doses of >10 Gy and 32% had doses of >20 Gy. CONCLUSION: These results highlight the importance of accounting for change in mass, particularly tumor regression, when assessing absorbed radiation dose for tissues whose mass changes during the time the radiation dose is being absorbed. The increase in calculated absorbed dose when this change is considered provides better insight into the high nodal response rates observed in non-Hodgkin's lymphoma patients.     

Occupational exposure to radiation

Since the discovery of X-rays , overexposures and radiation injuries have been reported in both patients and persons exposed in the course of their professional duties. Each year, more than 2,500 million diagnostic radiological examinations, 32 million nuclear medicine examinations or treatment procedures and 5.5 million radiotherapy sessions are performed worldwide. Despite all precautions, avoidable incidents and accidents occur throughout the world every year , albeit with low frequency. Whereas diagnostic radiology is generally safe for patients and staff, interventional procedures (e.g. coronary artery dilatations) involve the risks of occupational overexposure and of skin injuries to patients. In nuclear medicine, radiation protection is focused on the introduction of new procedures with beta-emitters, for example. The increasing frequency of positron emission tomography (PET) requires a special focus on shielding measures. In radiotherapy, occupational overexposure caused by malfunctions and accidents is relatively rare.     

劳力性热射病国内外防治现状

劳力性热射病(EHS)是一种病死率很高的急症,起病急且识别困难.预防EHS发生的重点包括对环境的专业评估、预防措施的提前制订、发病内外风险因子的识别、热适应和耐力训练的事前进行、高风险人员的实时状态监测等.EHS发生后,救治成功的关键在于准确的现场识别及诊断,继而迅速实施有效的降温措施,为EHS患者转入医院治疗赢得时间.本文对目前EHS患者从现场到医院的国内外救治现状进行综述,总结目前EHS识别、诊断、降温措施、医院内外救治的理念与原则,以期为医院内外EHS救治提供参考和借鉴.     

剖宫产术后切口感染危险因素研究

目的：探讨剖宫产术后切口感染的危险因素及预防。方法：将2009-01～2010-01本院行剖宫产的产妇96例随机分为观察组48例（切口感染）和对照组48例（无切口感染）,分析切口感染的危险因素。结果：两组的体质量指数、合并基础疾病、胎膜早破、瘢痕子宫、试产时间、急症手术、未预防应用抗生素、手术时间、住院时间、失血量方面相比差异均具有显著性（P〈0.05）。结论：剖宫产术后切口感染的危险因素是多种的,应采取针对性措施预防剖宫产术后切口感染。     

Physically-based biodosimetry using in vivo EPR of teeth in patients undergoing total body irradiation

Purpose:?The ability to estimate individual exposures to radiation following a large attack or incident has been identified as a necessity for rational and effective emergency medical response. In vivo electron paramagnetic resonance (EPR) spectroscopy of tooth enamel has been developed to meet this need.

Materials and methods:?A novel transportable EPR spectrometer, developed to facilitate tooth dosimetry in an emergency response setting, was used to measure upper incisors in a model system, in unirradiated subjects, and in patients who had received total body doses of 2 Gy.

Results:?A linear dose response was observed in the model system. A statistically significant increase in the intensity of the radiation-induced EPR signal was observed in irradiated versus unirradiated subjects, with an estimated standard error of dose prediction of 0.9?±?0.3 Gy.

Conclusions:?These results demonstrate the current ability of in vivo EPR tooth dosimetry to distinguish between subjects who have not been irradiated and those who have received exposures that place them at risk for acute radiation syndrome. Procedural and technical developments to further increase the precision of dose estimation and ensure reliable operation in the emergency setting are underway. With these developments EPR tooth dosimetry is likely to be a valuable resource for triage following potential radiation exposure of a large population.     

严重创伤院前救治流程:专家共识

随着社会的进步与发展,创伤已成为当今世界各国普遍面临的一个重大卫生问题。在对严重创伤救治过程中,院前急救还存在反应时间过长、救治流程不合理、处置措施不恰当等问题。本文就严重创伤的院前急救流程进行归纳和总结,以便进一步提高院前创伤急救的水平。     

严重创伤急救程序-时间控制模式研究

目的探讨在医院内建立严重创伤的急救程序-时间控制模式对严重创伤的救治效果。方法选取2013年1月~2013年12月期间在中山市人民医院就诊的严重创伤患者80例作为研究组,其中男性60例,女性20例;平均年龄37.8岁。致伤原因:道路交通伤58例,工程事故及高处坠落伤12例,意外伤害10例。2012年类似创伤患者64例作为对照组,其中男性48例,女性16例;平均年龄36.5岁。致伤原因:道路交通伤46例,工程事故及高处坠落10例,意外伤害8例。记录两组患者在急诊抢救室滞留时间、检查检验时间、就诊至手术时间。结果两组在性别、年龄、致伤机制及院前指数(PHI)等指标分布无统计学意义(P0.05)。急救程序-时间控制组死亡4例,死亡率为5%;对照组死亡6例,死亡率为9.37%(P0.05)。急救程序-时间控制组在急诊抢救室滞留时间、检查检验时间、就诊至手术时间较对照组明显缩短(P0.05)。结论建立严重创伤急救程序-时间控制模式可提高严重创伤的院内救治水平,规范院内救治中伤情评估、紧急手术和损害控制各环节流程,建立操作性强、效率较高的严重创伤院内救治管理模式,可显著提高救治成功率,降低死亡率。     

Coronary CT angiography for acute chest pain in the emergency department

Acute chest pain in the emergency department (ED) is a common and costly public health challenge. The traditional strategy of evaluating acute chest pain by hospital or ED observation over a period of several hours, serial electrocardiography and cardiac biomarkers, and subsequent diagnostic testing such as physiologic stress testing is safe and effective. Yet this approach has been criticized for being time intensive and costly. This review evaluates the current medical evidence which has demonstrated the potential for coronary CT angiography (CTA) assessment of acute chest pain to safely reduce ED cost, time to discharge, and rate of hospital admission. These benefits must be weighed against the risk of ionizing radiation exposure and the influence of ED testing on rates of downstream coronary angiography and revascularization. Efforts at radiation minimization have quickly evolved, implementing technology such as prospective electrocardiographic gating and high pitch acquisition to significantly reduce radiation exposure over just a few years. CTA in the ED has demonstrated accuracy, safety, and the ability to reduce ED cost and crowding although its big-picture effect on total hospital and health care system cost extends far beyond the ED. The net effect of CTA is dependent also on the prevalence of coronary artery disease (CAD) in the population where CTA is used, which significantly influences rates of post-CTA invasive procedures such as angiography and coronary revascularization. These potential costs and benefits will warrant careful consideration and prospective monitoring as additional hospitals continue to implement this important technology into their diagnostic regimen.     

Procedures for radioactive I-131

Details of the radioactive I-131 administration and radiation safety considerations are presented. Topics covered include patient survey, radioactive labelling, levels in patients containing radioactivity, hospital discharge of radioactive patients, and nursing procedures.     

State of the art of standard methods used for environmental radioactivity monitoring.

Methods for assessment of radioactivity in the environment are selected by the prevailing circumstances and the objective of the investigations. Examples of the broad range of scenarios to be considered are routine monitoring of large areas for low-activity concentrations and emergency monitoring dealing possibly with high dose rates. For each of these situations the type of monitoring programme to be established is influenced by the source of radioactivity as well as the environment, with different characteristics in terms of time schedule and subject of measurement. Over the past years, the methods of radiation surveys to assess environmental effects have been optimised for low-level detection and quantification of releases. This paper gives a brief overview of various standard monitoring techniques used for assessments of environmental radioactivity, for those sample types, which are most representative.     

新型冠状病毒肺炎放射诊断检查场所的感染控制与辐射安全监测和分析

目的 对新型冠状病毒肺炎放射诊断场所存在的感染控制和辐射安全风险进行调查和监测，为放射技师及相关工作人员的安全防护提供数据支持。方法 根据国家标准（WS 519-2019和GBZ 130-2013）对湖北省4所未启用的应急医院（"小汤山式"甲、乙医院及方舱医院、砖混模式医院）中新安装的8台CT及其场所进行成像性能和放射防护检测并评价。对机房布局等感染控制安全的因素实施了监测与调查。选择定点医院2所（综合医院和传染病专科医院），通过现场调查和对4个CT机房环境生物样本进行新型冠状病毒核酸检测，对放射场所的布局、感染防控和核酸检测结果的分布进行分析，评价其生物安全的可靠性和风险点。结果 应急医院的8台CT设备的成像性能和放射防护指标均能满足国家标准的要求。甲、乙医院各有3个CT机房，面积均为38.8 m²和4 mm Pb当量的屏蔽防护；方舱医院和砖混建筑医院的CT机房面积和屏蔽防护分别为20.0 m²、4 mm Pb当量和35.8 m²、3 mm Pb当量。8个放射诊断场所符合感染防控"三区两通道"的设计要求。新型冠状病毒核酸检测结果显示，CT机房内患者触碰到的多个位点如检查床、机架内侧、地面等多处发现核酸阳性。放射技师通过手部、足底沾染造成操作间内操作台和地面的病毒污染风险。此外，机房内患者未触及的区域如观察窗和排风口等处也出现类似阳性。结论 4所应急医院的8台CT设备和机房基本满足成像性能和放射防护要求。新型冠状病毒肺炎放射诊断检查场所需加强消毒的规范化。     

急诊科流程优化在优质护理服务示范工程中的应用

目的：提高急诊科护理服务质量,做到“以病人为中心”,减少护患纠纷,为急诊病人抢救争取时间,树立医院良好的窗口形象。方法：以护理部制定的优质护理服务标准为指导,通过优化护理服务流程,提升护理工作效率等做法,为病人提供满意服务。结果：实施“优质护理服务”后,护理服务质量提高,患者满意率提高,医生及患者对护士满意度提高。结论：“优质护理服务”活动能整体提升急诊科护理服务水平。     

Subjective perception of radiation risk

Physicians, medical staff, and patients, much like the general population, are becoming increasingly sensitized to the issue of radiation exposure from diagnostic or therapeutic procedures. The attitudes of patients undergoing diagnostic imaging procedures that use ionizing radiation vary widely. Patient perception of radiation dose strongly influences their acceptance of diagnostic examinations or therapies involving radioactivity. Here, we review perceptions and concerns about radiation and radioactivity by laypersons and medical experts. Several studies show that physicians are frequently poorly informed about radiation levels associated with nuclear medicine and radiologic examinations. In addition, patients' decisions against undergoing an imaging procedure are frequently based on partial and sometimes incorrect information. Thus, physicians must take the concerns of their patients seriously. From the literature and our own experience, we conclude that it is extremely important to thoroughly and carefully educate all involved in patient work-up about radiation exposure levels and perceived or actual health risks. Although the choice and timing of imaging examinations should always outweigh the risk that secondary illness will develop, the patients' concerns still must be alleviated.