Radiation exposure during image-guided endoscopic procedures: The next quality indicator for endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently used image-guided procedures in gastrointestinal endoscopy. Post-ERCP pancreatitis is an important concern, and prophylaxis, cannulation and other related technical procedures have been well documented by endoscopists. In addition, medical radiation exposure is of great concern in the general population because of its rapidly increasing frequency and its potential carcinogenic effects. International organizations and radiological societies have established diagnostic reference levels, which guide proper radiation use and serve as global standards for all procedures that use ionizing radiation. However, data on gastrointestinal fluoroscopic procedures are still lacking because the demand for these procedures has recently increased. In this review, we present the current status of quality indicators for ERCP and the methods for measuring radiation exposure in the clinical setting as the next quality indicator for ERCP. To reduce radiation exposure, knowledge of its adverse effects and the procedures for proper measurement and protection are essential. Additionally, further studies on the factors that affect radiation exposure, exposure management and diagnostic reference levels are necessary. Then, we can discuss how to manage medical radiation use in these complex fluoroscopic procedures. This knowledge will help us to protect not only patients but also endoscopists and medical staff in the fluoroscopy unit.     

Video x-ray progressive scanning: new technique for decreasing x-ray exposure without decreasing image quality during cardiac catheterization

A newly developed video x-ray progressive scanning system improves image quality, decreases radiation exposure, and can be added to any pulsed fluoroscopic x-ray system using a video display without major system modifications. With use of progressive video scanning, the radiation entrance exposure rate measured with a vascular phantom was decreased by 32 to 53% in comparison with a conventional fluoroscopic x-ray system. In addition to this substantial decrease in radiation exposure, the quality of the image was improved because of less motion blur and artifact. Progressive video scanning has the potential for widespread application to all pulsed fluoroscopic x-ray systems. Use of this technique should make cardiac catheterization procedures and all other fluoroscopic procedures safer for the patient and the involved medical and paramedical staff.     

Low-dose cardiac imaging: reducing exposure but not accuracy

Cardiac imaging techniques that use ionizing radiation have become an integral part of current cardiology practice. However, concern has arisen that ionizing radiation exposure, even at the low levels used for medical imaging, is associated with the risk of cancer. From a single diagnostic cardiac imaging procedure, such risks are low. On a population basis, however, malignancies become more likely on account of stochastic effects being more probable as the number of procedures performed increases. In light of this, and owing to professional and industrial commitment to the as low as reasonably achievable (ALARA) principle, over the last decade major strides have been made to reduce radiation dose in cardiac imaging. Dose-reduction strategies have been most pronounced in cardiac computed tomography. This was important since computed tomography has rapidly become a widely used diagnostic alternative to invasive coronary angiography, and initial protocols were associated with relatively high radiation exposures. Advances have also been made in nuclear cardiology and in invasive coronary angiography, and these reductions in patient exposure have all been achieved with maintenance of image quality and accuracy. Improvements in imaging camera technology, image acquisition protocols and image processing have lead to reductions in patient radiation exposure without compromising imaging diagnostic accuracy.     

Radiation Exposure During Radiofrequency Catheter Ablation for Atrial Fibrillation

MACLE, L., et al. : Radiation Exposure During Radiofrequency Catheter Ablation for Atrial Fibrillation. RF catheter ablation of paroxysmal atrial fibrillation (PAF) is associated with prolonged fluoroscopy. The procedural duration and fluoroscopic exposure to patients and medical staff were recorded and compared among 43 ablation procedures for PAF, 20 for common atrial flutter, and 16 for accessory pathways. Patient radiation exposure was measured by dosimeters placed over the xyphoid, while that of physicians and nurses was measured by dosimeters placed outside and inside the lead apron. The mean fluoroscopy time was   57 ± 30   minutes for PAF,   20 ± 10   minutes for common flutter, and   22 ± 21   minutes for accessory pathway ablation. The patient median radiation exposure was 1110μSv for PAF, compared with 500 μSv for common flutter and 560 μSv for accessory pathway ablation (P < 0.01). The median radiation exposure to physician and nurse inside the lead apron were, respectively, 2 μSv and 3 μSv for PAF, 1 μSv and 2 μSv for common flutter, and <0.5 μSv and 3 μSv for accessory pathway ablations. RF catheter ablation for PAF was associated with prolonged fluoroscopy times and a twofold higher radiation exposure to the patient and physician compared with other ablation procedures. Assuming 300 procedures/year, radiation exposure to the medical staff was below the upper recommended annual dose limit. (PACE 2003; 26[Pt. II]:288–291)     

Attitude and Knowledge of Physicians and Nurses About Ionizing Radiation

The purpose of this study was to describe physicians' and nurses' knowledge and attitude about the potential dangers of imaging tests. The study comprised 144 participants; 68 physicians, and 76 nurses. Over 70% of the physicians reported that to complete their diagnosis, they always sent patients for ionized testing. Most of the physicians and nurses indicated that they knew that these tests could cause cancer and genetic changes. Over 80% of the medical staff did not know the amount of environmental radiation that was equal to an x-ray test or computed tomography scan. Thirty percent of the respondents noted that they did not protect the patient's sensitive organs during radiation procedures. As for the physicians and nurses in the invasive unit, they did not follow precise instructions for self-protection from exposure to radiation while working. There is a necessity to follow up on quantity of exposure to x-ray and computed tomography scan radiation for all patients and to promote physicians' and nurses' knowledge about protection from exposure to radiation.     

The hazard of scattered radiation in a trauma intensive care unit

OBJECTIVE: Patients admitted to the trauma intensive care unit (TICU) often require bedside imaging procedures such as radiographs, fluoroscopic placement of enteral feeding tubes, and insertion of vena cava filters. The potential for scattered radiation exposure is a concern to healthcare workers. Our study's purpose was to measure the level of scattered ionizing radiation present in a TICU. DESIGN AND SETTING: This prospective study was conducted over 3 months in an open-design, ten-bed TICU of a Level I trauma center. INTERVENTIONS AND MEASUREMENTS: Fifteen dosimeters were placed in selected areas of the TICU to measure the amount of scattered radiation present. Standard radiation protection precautions were used throughout the study period. At the end of each month, data from the dosimeters were sent to the manufacturer for analysis. MAIN RESULTS: One thousand seventy-four radiologic studies were performed at the bedside during the study period (803 portable chest radiographs, 103 abdominal radiographs, 303 extremity radiographs, 223 spine radiographs, and 15 fluoroscopic procedures). Dosimetry analysis showed <5 mrem (1/1000 roentgen equivalent in man) scattered radiation per month (<60 mrem/year) in each of the monitored areas. All monitored areas measured <2 mrem per week of scattered radiation when adjusted for occupancy. CONCLUSIONS: The level of scattered radiation in our TICU is less than the recommended allowable exposure of <100 mrem/year, indicating that radiation exposure is not a significant occupational hazard in our TICU, even in the setting of frequent use of bedside imaging studies.     

Local Diagnostic Reference Levels in Interventional Radiology

PurposeInterventional cardiology procedures, during which live images are acquired, involve exposure to x-rays. The use of fluoroscopy can cause high radiation doses to patients and operators because of the prolonged duration of x-ray emission. For this reason, special attention and constant vigilance represent challenges for commissions and groups of experts in the field. The purpose of this study is to establish local diagnostic reference levels (DRLs) for these procedures, to improve radiological practice, and to optimize radiation doses.MethodsThis work was carried out in two university hospitals and two private medical facilities in Rabat, the capital of Morocco, during the period 2017–2018. The study concerns 657 interventional cardiology procedures (457 coronary angiography [CA] and 200 percutaneous transluminal coronary angioplasty [PTCA]), performed by 11 cardiologists on different installations in 5 catheterization rooms. The data collected for each procedure were patient age, height and weight, dosimeter indicators in terms of dose area product (P_KA), total air kerma at the reference point (K_ar), fluoroscopy time (FT), and the number of frames, together with the primary beam parameters as kV and total mAs. The proposed DRLs were set from the 75th percentile of the P_KA and FT.ResultsThe mean of P_KA for CA and PTCA procedures were 29.2 Gy1cm² and 70.4 Gy1cm², respectively, the mean of fluoroscopy time were 4.0 min and 12.17 min for 334 and 685 frames, respectively. Results for the local DRLs were 37.3 and 87.1 Gy cm² for P_KA and 4.48 and 16.15 min for FT, corresponding to CA and PTCA procedures.ConclusionThis work focuses on proposing local DRLs in Morocco for CA and PTCA procedures. The results show that the values found conform with those of international studies.     

The use of basic life support skills by hospital staff; what skills should be taught?

Objectives: To assess the frequency of use of basic life support (BLS) skills among hospital staff of all disciplines. Design: Postal survey of 9600 teaching hospital staff. Participants: 3807 respondents from all disciplines. Main outcome measures: Frequency of attendance, and the use of BLS skills, at patients with cardiopulmonary arrest. Results: Most respondents reported having attended BLS training previously: 27.9% in the prior 6 months; 24.5% 6-12 months previously; 17.1% over 1 year ago; and 11.5% over 2 years ago. 17.1% reported never having received BLS training. 1.9% gave no valid response. Nearly half of all respondents had never attended a cardiopulmonary arrest. Among those most likely to have attended, i.e. qualified nursing and medical staff, the median frequency of attendance was less than once per year. Ventilation delivered using a pocket mask or bag-valve-mask was reported by 9.4 and 29.2% of respondents, respectively. Less than 7% reported the use of mouth-to-mouth ventilation. Only among qualified nursing (8.8%) and medical (24.7%) staff did this proportion exceed 5%. The vast majority of non-qualified nursing staff (84.9%), allied health professionals (86%) and administrative and clerical staff (98%) had used neither chest compressions nor mouth-to-mouth ventilation. Conclusions: Some skills taught during BLS training are used infrequently in the in-hospital situation. The likelihood of attendance at arrest events and of the use of BLS skills is extremely low among some identified professional groups. BLS skills teaching should be targeted at those groups most likely to actually use them in order to make best use of the resources available.     

Eye lens dosimetry in anesthesiology: a prospective study

The eye lens is one of the most sensitive organs for radiation injury and exposure might lead to radiation induced cataract. Eye lens dosimetry in anesthesiology has been published in few clinical trials and an active debate about the causality of radiation induced cataract is still ongoing. Recently, the International Commission on Radiological Protection (ICRP) recommended a reduction in the annual dose limit for occupational exposure for the lens of the eye from 150 to 20 mSv, averaged over a period of 5 years, with the dose in a single year not exceeding 50 mSv. This prospective study investigated eye lens dosimetry in anesthesiology practice during a routine year of professional activity. The radiation exposure measured represented the exposure in a normal working schedule of a random anesthesiologist during 1 month and this cumulative eye lens dose was extrapolated to 1 year. Next, eye lens doses were measured in anesthesiology during neuro-embolisation procedures, radiofrequency ablations or vertebroplasty/kyphoplasty procedures. The eye lens doses are measured in terms of the dose equivalent H _p(3) with the Eye-D dosimeter (Radcard, Poland) close to the right eye (on the temple). In 16 anesthesiologists, the estimated annual eye lens doses range from a minimum of 0.4 mSv to a maximum of 3.5 mSv with an average dose of 1.33 mSv. Next, eye lens doses were measured for nine neuro-embolisation procedures, ten radiofrequency ablations and six vertebroplasty/kyphoplasty procedures. Average eye lens doses of 77 ± 76 µSv for neuro-embolisations, 38 ± 34 µSv for cardiac ablations and 40 ± 44 µSv for vertebro-/kyphoplasty procedures were recorded. The maximum doses were respectively 264, 97 and 122 µSv. This study demonstrated that the estimated annual eye lens dose is well below the revised ICRP’s limit of 20 mSv/year. However, we demonstrated high maximum and average doses during neuro-embolisation, cardiac ablation and vertebro-/kyphoplasty procedures. With radiation induced cataract being explained as a possible stochastic effect, without a threshold dose, anesthesiologists who regularly work in a radiological environment should remain vigilant and maintain radiation safety standards at all times. This includes adequately protective equipment (protection shields, apron, thyroid shield and leaded eye wear), keeping distance, routine monitoring and appropriate education.     

A Survey of Radiation Protection Utilization and Accessibility Within Australian Cardiac Angiography Laboratories

Continuing improvements in both catheterization and imaging equipment have resulted in greater numbers and increasingly more complex angiographic cases being performed, which has led to higher patient and staff doses. Occupational radiation exposure to staff within fluoroscopic suites has been demonstrated to elevate the risk of carcinogenesis and radiation-induced cataracts. A survey was undertaken to compare the accessibility and utilization of radiation protective equipment by staff within a selection of cardiovascular suites throughout Australia. A number of Australian cardiovascular suites were invited to complete an online survey comprising 10 questions. The survey questions focused on the availability and use of head, thyroid, and eye radiation protection by doctors and nurses present in the room during cardiac angiography procedures. The study identified that the utilization of ceiling-mounted lead and thyroid shields was adequate within the surveyed departments but has highlighted that there are areas that staff could further reduce their risk of the occupational exposure. There is very strong evidence proving the importance of additional shielding such as lead caps and glasses in minimizing dose, and there needs to be a focus on education to ensure that staff are cognizant of the benefit of wearing them. It is advisable that staff working within angiography suites have access to appropriate radiation protection devices to minimize their exposure to ionizing radiation. In addition, training should be provided to staff regarding the risk of occupational exposure and dose optimization.     

介入放射医护人员的辐射防护现状分析

随着介入放射学的飞快发展,由放射介入操作所导致的辐射损害已引起医学界的广泛关注.本文就介入放射医护人员的辐射危害、暴露水平及国内防护现状进行分析,旨在加强介入诊疗操作中的防护意识,提高医护人员的防护水平.     

急诊科医护人员血源性职业暴露防护知信行调查及其干预对策分析

目的调查急诊科医护人员血源性职业暴露防护知信行现状,分析原因,提出应对策略。方法采用分层抽样的方法,选取本市2018年6月至2019年6月本市3所综合医院共120名急诊科医护人员,问卷调查其资料及血源性职业暴露防护知信行水平,然后对相关数据进行统计学处理。结果本组人员中,1年内发生血源性职业暴露的医护人员比率高达54.17%,其独立影响因素有医护人员学历、工作年限、职称、参加培训情况(P<0.05)。结论急诊科血源性职业暴露防护知信行水平总体较低,与医护人员的学历、工作年限、职称、参加培训情况相关,应采取针对性干预策略,提高其防护知识和水平,从而形成正确的态度和行为,降低血源性职业暴露的发生。     

Brachytherapy for head and neck cancer: a case study

Brachytherapy currently is being used as a treatment modality for head and neck cancer. A case study is presented to illustrate the treatment and safety procedures required when brachytherapy is delivered. A multidisciplinary approach is essential to ensure that family and staff exposure to radiation is minimized. Nursing care considerations include preventing airway impairment, maintaining hydration, developing alternative communication methods, pain management, and bowel preparation. Through intensive patient, family, and staff education, patients with head and neck cancer can be treated with brachytherapy safely and effectively.     

General public's and physicians' perception of health risk associated with radon exposure in the state of Azad Jammu and Kashmir

ABSTRACT Objective: To conduct a radon awareness survey to examine the level of awareness and risk perception of indoor radon exposure among the general public, medical students, and physicians of the state of Azad Jammu and Kashmir, given that long-term exposure to indoor radon increases lifetime risk of lung cancer and may pose a substantial threat to public health.
Design: Cross-sectional survey. Sample: households by telephone (500), interviews with menial laborers (200), questionnaires to shopkeepers and government employees (1,000), undergraduates (200), social science graduates (1,500), science graduates (1,500), medical students (325), and physicians (100). Measures: familiarity with radioactivity and the nature and health hazards of radiation and radon. Analysis: Significance of data trends was measured using the Kruskal-Wallis test.
Results: About 30% people (excluding medical students and physicians) were aware of radon, and about 6% had knowledgeable awareness of radon. About 80% of the medical students and physicians had heard about radon and about 30.5% of them had knowledgeable awareness about radon and its hazards.
Conclusion: The study suggested a positive relationship of awareness of radon and its hazards with the educational level of people.     

Reducing Radiation Exposure from Cardiovascular Imaging Through Implementation of Appropriate Use Criteria

Cardiac imaging is a key instrument in the evaluation of patients with known or suspected coronary artery disease. Although clear benefits accompany the use of nuclear cardiology and cardiac CT techniques, is well-documented in the medical literature, there is growing concern about the risk related to exposure to ionizing radiation. Although the true impact of low-level ionizing radiation is often poorly characterized, clinicians and medical organizations encourage minimization of exposure, with a focus on a balance between benefits and risks of cardiac imaging procedures. The appropriate use criteria (AUC), developed by the American College of Cardiology Foundation, American Heart Association, and multiple other societies, provide guidance regarding test utilization and assist in optimizing an approach involving the right test for the right patient at the right time. By reducing inappropriate use of cardiac CT and radionuclide imaging, exposure to unnecessary ionizing radiation may be minimized. Evaluation of appropriateness allows for practitioners to monitor their performance and serves to provide focus for educational efforts related to inappropriate test indications. Several key areas, including test layering and the use of serial imaging in asymptomatic patients likely contribute to inappropriate use and increased radiation exposure. Therefore, the use of AUC, in conjunction with other radiation dose reduction efforts, promotes significant improvement in patient safety.     

Percutaneous coronary intervention

Symptoms associated with coronary heart disease include chest pain, dyspnoea, palpitations and collapse (Delahaye, 1999). Percutaneous transluminal coronary angioplasty (PTCA) has been found effective for relieving some of these symptoms (RITA-2 trial participants, 1997). The National Service Framework for Coronary Heart Disease (Department of Health, 2000) identified a need to double the number of these procedures carried out per year by 2010 to provide a service comparable with the rest of western Europe.     

外科ICU护士岗位动态调整应用效果

目的：以科室人力资源与工作任务情况为依据,动态调整护士岗位,确保医疗护理安全,提高外科嗌护室护理质量和满意度。方法：根据护士实际工作综合能力与工作量弹性排班,指派临时组长负责,各班次护士各司其职,分工合作,共同完成工作任务。结果：调动了各级护理人员的工作积极性及参与管理的意识,较好地完成了逐年大幅度增长的工作量且保证了质量和安全,有效地激励了护士的专业发展。结论：在工作量分配不均衡,人力资源有限,无法将护士固定分组排班的护理单元实施临时纽长负责制管理模式,能够激发各级护理人员的潜能,有效提高人力资源利用效果和护理质量,是一种可行的护理管理模式。     

Triage nurses order x-rays for patients with isolated distal limb injuries: A 12-month ED study.

OBJECTIVES: To determine whether triage nurses could safely, accurately, and appropriately order x-rays for patients with distal limb injuries. METHODS: All adult patients presenting to the emergency department of a tertiary teaching hospital for 12 months with distal limb injuries were eligible for the study. Patients with severe pain or evidence of acute neurovascular compromise were excluded. Triage nurses who had completed a training workshop offered patients the option of having an x-ray obtained before seeing a physician. Data were collected regarding the number and type of x-rays ordered, the number of positive x-ray findings on radiologic review, and violations of x-ray ordering guidelines. All ED distal limb x-rays ordered during the 12-month study period were analyzed for type, frequency, and abnormality. To determine the impact of the project on practice, all triage nurses were given the opportunity to complete a questionnaire, patient satisfaction surveys were conducted, and structured interviews were conducted with senior ED medical and radiography personnel. RESULTS: During the 12-month study, triage nurses ordered 876 x-rays (49%), whereas physicians ordered 930 x-rays (51%). Medical staff and triage nurses ordered equal proportions of upper and lower limb x-rays. The abnormality rate in the total study group was 699 (39%). The abnormality rate for x-rays when comparing nursing and medical staff was 43% (390) and 33% (309), respectively (x(2) = 23.4; P <.0001). The triage x-ray abnormality rate for the upper limb was 51%, compared with 31% for the lower limb. Data indicated that all staff believed that this new triage practice had increased patient satisfaction and improved patient flow and waiting times. CONCLUSION: With structured education, triage nurses at one institution safely assessed patients and ordered appropriate distal limb x-rays prior to physician assessment.     

Nature of after-hours calls at a tertiary-level rehabilitation center

OBJECTIVES: To determine the incidence and nature of calls for on-call physicians after hours at a tertiary-level rehabilitation center. DESIGN: Prospective survey of on-call physicians during 1 year. SETTING: A tertiary-level rehabilitation center with 66 beds in Nova Scotia. PARTICIPANTS: Residents, clinical associates, and staff physicians covering calls. INTERVENTIONS: Not applicable.Main Outcome Measures: Number of calls during 1 year, types of calls, medical issues dealt with, and time spent in center after hours dealing with calls. RESULTS: The overall response rate by on-call physicians was 75%. In the 274 days for which surveys were returned, 467 calls were received. Of these calls, 53% were for medication orders, 36% for medical issues, 7% for procedures, and 5% for incidents. CONCLUSIONS: For a 65-bed unit, on-call staff were called a median of once per night. The most common call was for medication orders. House staff were required to come in about once in every 9 calls (11%) and stayed less than 1 hour in most cases.     

Cardiac CT for acute chest pain in the emergency department: advantages of prospective triggering

Coronary CT angiography (CCTA) is emerging as a powerful tool for the diagnosis and characterization of coronary artery disease. In the emergency department (ED) setting, the high negative predictive value of CCTA has been shown to reduce the length of stay and the cost of care in the evaluation of patients at low and intermediate risk for an acute coronary syndrome (ACS). In addition, CCTA and triple-rule-out protocol CT examinations which simultaneously evaluate the coronary arteries, aorta and pulmonary arteries, have the potential to diagnose not only significant atherosclerotic coronary artery disease (CAD) and coronary artery anomalies, but noncoronary etiologies of chest pain, including pulmonary embolism, aortic dissection, infection, pleural and pericardial disease. Caution has been raised about the widespread use of CCTA in this setting, particularly given the prevalence of repeat ED visits for chest pain, due to the radiation exposure associated with retrospectively-gated CCTA. However, the recent development of prospectively-triggered coronary artery CTA makes the ED evaluation possible with a substantially lower radiation exposure to the patient. Although most studies of CCTA to date are performed with retrospective ECG gating, early reports on prospectively triggered CCTA demonstrate equivalent image quality and accuracy when compared to studies acquired with retrospective ECG gating.