Radiographic Practice Research Articles

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post–cardiothoracic surgery patients

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post–cardiothoracic surgery patients

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post-cardiothoracic surgery patients

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post-cardiothoracic surgery patients

Audit of Staff and Patient Doses in a General Vascular Laboratory

The aim of the audit presented here was to confirm in our environment that consistent good practice in interventional radiography results in acceptably low patient and staff doses, as well as a radiation safe environment, even in a high use general vascular laboratory.

Practice radiography: time to go digital?

THREE years ago, an article in In Practice asked whether digital x-ray was a toy or tool (Baxter 2004). For that particular author, who specialised in dental and oral surgery,...

The use of gonadal shielding in singular common diagnostic radiographic procedures

AbstractThe aim of this study was to make recommendations regarding when the use of gonadal shielding is significant in reducing gonad dose for common diagnostic procedures. Two separate literature reviews were conducted and the data compared. The first review proposed to determine average entrance surface doses (ESD) for common diagnostic procedures and the second to determine a threshold for exposure to the gonads below which risk of genetic effects was negligible. By comparing accepted ESD and associated gonad doses with the threshold dose, recommendations for each procedure could be made. This recommendation would be that either gonadal shielding is significant in reducing risk of genetic effects for this examination, or that gonadal shielding would make no difference because the doses involved are negligible. Common procedures were selected as well as common series, based on the fact that these procedures contribute relatively high dose to the gonads. A threshold dose to the gonads was established to be 10 mGy. Below this level of exposure, genetic risk to the gonads is considered negligible. It was found that none of the series or individual exams contributed significant dose to the gonads (dose levels above the 10 mGy threshold). It should be noted, however, that this recommendation applies only to individual patients receiving individual exposures. The effect of repeat examinations or the risk to a population of patients was not considered. It was also found that gonadal shielding may alleviate fears of radiation exposure in patients. It was recommended that for all individual examinations/series included in this study that gonadal shielding was unnecessary because the doses involved present negligible genetic risk to the patient. However, best practice in radiography includes upholding the ‘As low as reasonably achievable’ principle (ALARA) and considering the fears of patients, and it is for this reason that gonadal shielding should be used.

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post–cardiothoracic surgery patients

We sought to determine the effect of elimination of daily routine chest radiographs on chest radiographic practice in cardiothoracic surgery patients in the intensive care unit and the post-intensive care unit ward. We used a prospective, comparative study design with an intervention in a 28-bed intensive care unit/post-intensive care unit ward (including a 4-bed medium-care unit) in a university hospital. Cardiothoracic surgery patients were admitted to the intensive care unit during a period of 6 months (3 months before intervention and 3 months after intervention). Daily routine chest radiographs in the intensive care unit were eliminated; all chest radiographs required a clinical indication. Routine chest radiographs were not performed in the post-intensive care unit ward, both before and after the intervention. Before intervention, in the intensive care unit 353 daily routine chest radiographs and 261 on-demand chest radiographs were obtained in 175 patients; after intervention, 275 on-demand chest radiographs were obtained in 163 patients. Before intervention, in the post-intensive care unit ward 413 on-demand chest radiographs were obtained in 167 patients; after intervention, 445 on-demand chest radiographs were obtained in 161 patients. In the intensive care unit the number of chest radiographs per patient day decreased from 1.8 +/- 0.6 to 1.1 +/- 0.6. In the post-intensive care unit ward the number of chest radiographs per patient per day was 0.4 +/- 0.2, both before and after the intervention. Slightly more unexpected abnormalities were found in the on-demand chest radiographs after the intervention. No negative influence on chest radiography timing, length of stay in the intensive care unit and hospital, and readmission rate was seen. Elimination of daily routine chest radiographs led to a decrease of the total number of chest radiographs obtained per patient per day in the intensive care unit and did not change chest radiography practice in the post-intensive care unit ward.

Preparedness for clinical practice – Perceptions of graduates and their work supervisors

Purpose The standards of performance of healthcare professionals are now well defined and used to determine health professional curricula. Empirical research evidence exists in medicine and nursing which explores how well these curricula prepare their students for clinical practice but not in the radiography profession. This research aims to determine how well prepared newly qualified radiographers were for clinical practice and to identify strengths and weaknesses in their preparedness to inform curriculum development. Methods A postal questionnaire and semi-structured interview were used to obtain data from newly qualified diagnostic radiographers and their work-based supervisors. The questionnaire assessed graduate preparedness against a number of items drawn from published documents which define UK radiographic practice. Statistical analysis, using ANOVA and Wilcoxon, examined differences between the groups’ perception of preparedness. A sample of graduates and their work supervisors were interviewed to explore preparedness. Results There were significant differences ( p ≤ 0.05) between; the preparedness scores of the graduates and supervisors, with supervisors rating the graduates higher than the graduates themselves; subscales of teamwork ( p ≤ 0.05), personal attributes ( p ≤ 0.05) and digital skills ( p ≤ 0.01). No significant differences were found between graduates employed in their training hospital and those employed elsewhere. Interview data revealed perceived areas of graduate strength, weaknesses and areas for curriculum development. Suggestions for improvement to the methodology were identified for exploring preparedness in other health professional programmes. Conclusion The graduates were well prepared for their role as a diagnostic radiographer. Some curriculum development is needed in specific areas and advice on methodological improvement is offered.

Digital Radiography Image Quality: Image Acquisition

This article on digital radiography image acquisition is the first of two articles written as part of an intersociety effort to establish image quality standards for digital and computed radiography. The topic of the other paper is digital radiography image processing and display. The articles were developed collaboratively by the ACR, the American Association of Physicists in Medicine, and the Society for Imaging Informatics in Medicine. Increasingly, medical imaging and patient information are being managed using digital data during acquisition, transmission, storage, display, interpretation, and consultation. Data management during each of these operations has a direct impact on the quality of patient care. These articles describe what is known to improve image quality for digital and computed radiography and make recommendations on optimal acquisition, processing, and display. The practice of digital radiography is a rapidly evolving technology that will require the timely revision of any guidelines and standards. This document provides a basis for the technologies available today in clinical practice and may be useful in guiding the future clinical practice of digital radiography.

SU‐FF‐I‐46: Measuring Kerma‐Area Products (KAP) in CT

Purpose. To determine Kerma‐Area Product (KAP) for head and body CT examinations, and compare these with KAP of common radiographic and fluoroscopy examinations. Method. A single projection in CT is analagous to a conventional radiograph; for both exposures, the average incident air kerma may be multiplied by the corresponding cross‐sectional area that intercepts the patient to obtain the projection KAP. Summing all projections in a CT examination enables CT examination KAP to be determined. Measurements of the absolute intensity of the CT beam was obtained at the scanner isocenter (CTDIair), together with relative intensities on a line perpendicular to the long patient axis (z‐direction). The beam cross‐sectional area was determined using the known geometry of the CT scanner combined with eliptical shaped head and body dimensions of adult patients. Results: CT KAP values for head and body examinations were ∼10 Gy‐cm2 and ∼25 Gy‐cm2, respectively. For comparison, average values in the 2000 UNSCEAR report were: (a) ∼1 Gy‐cm2 for head/chest radiographic examinations; (b) ∼5 Gy‐cm2 for abdominal radiographic examinations; (c) ∼20 Gy‐cm2 for barium studies; (d) ∼100 Gy‐cm2 for interventional procedures. Conclusion: Measurement of the CT output, and the corresponding x‐ray beam profile transmitted through the beam shaping filter, permits the determination of KAP values for CT examinations. Specifying KAP as a measure of the radiation incident on patients undergoing CT examanitions would unify CT dosimetry with current practice in radiography and fluoroscopy.

Digital Radiography Image Quality: Image Processing and Display

This article on digital radiography image processing and display is the second of two articles written as part of an intersociety effort to establish image quality standards for digital and computed radiography. The topic of the other paper is digital radiography image acquisition. The articles were developed collaboratively by the ACR, the American Association of Physicists in Medicine, and the Society for Imaging Informatics in Medicine. Increasingly, medical imaging and patient information are being managed using digital data during acquisition, transmission, storage, display, interpretation, and consultation. The management of data during each of these operations may have an impact on the quality of patient care. These articles describe what is known to improve image quality for digital and computed radiography and to make recommendations on optimal acquisition, processing, and display. The practice of digital radiography is a rapidly evolving technology that will require timely revision of any guidelines and standards.

Is routine portable pelvic X-ray in stable multiple trauma patients always justified in a high technology era?

According to the Advanced Trauma Life Support, portable pelvis radiography (PXR) is mandatory in multiple trauma patients, and is performed following initial clinical evaluation. The purpose of an early PXR is to identify pelvic fractures that may have haemodynamic consequences. Today, ultrafast multi-detector CT scanners (MDCT) are readily available and widely used in the evaluation of stable trauma patients. The objective of this study was to determine the impact of PXR in stable blunt multiple trauma patients, who required CT scan for full evaluation of the abdomen and pelvis. A retrospective review of all stable blunt trauma patients, suffering from pelvic fractures was performed from January 2001 until December 2004 at two high volume Trauma Centres. Patients' demographics and Injury Severity Scores (ISS) were abstracted from our trauma registry. Two certified radiologists and two certified orthopaedic surgeons retrospectively evaluated and compared PXR films and CT angiographies (CTA) of the abdomen and pelvis. We recorded each case when the management policy was altered due to the results of imaging and compared the clinical impact of both modalities. One hundred and twenty-nine stable blunt multiple trauma patients with pelvic fractures underwent CTA of the abdomen and pelvis during their initial evaluation. Mean ISS was 16.5. Average Glasgow Coma Scale on arrival was 13.2 (range 3-15). Compared to CTA, sensitivity and specificity of the PXR was 64.4 and 90.0%, respectively. CTA diagnosed 35.6% more pelvic fractures than PXR (p<0.05). No changes in the therapeutic policy were observed following PXR results. In 19 (14.7%) patients, CTA findings led to pelvic angiography. PXR in stable blunt multiple trauma patients did not change the therapeutic policy in our patients. CTA of the abdomen and pelvis is the imaging modality of choice in blunt multiple trauma, regardless of the findings of PXR. Benefit of routine PXR is questionable in hospitals where MDCT is available. Based on our results, we suggest re-evaluating the current practice of routine mandatory portable pelvis radiography.

Patient doses and image quality in chest radiography: The influence of different beam qualities

A simple method of assessing optimal X-ray beam quality in respect to patient exposure and image quality in chest screen-film radiography is presented here. Different beam qualities were generated by the use of various combinations of tube voltages (70 kV to 110 kV) and Al and Cu filter thick nesses. Patient doses were assessed by kerma-area product measurements. Simultaneously, image quality was evaluated by a twofold method: a clinical study applying European quality criteria for the radiographic technique of image on image of 126 patients and a multifunctional home-made dosimetric phantom with embedded test objects. The quantification of image quality criteria yields a simpler method of optimizing image quality and patient dose relationships. Modifications of radiographic practice, based on image quality assessment and dose measurements, resulted in significant dose reductions and preservation of image quality. Through the use of harder beam quality, dose reduction of up to a value of factor 3 were observed, compared to the doses from previously used radiographic techniques, implying that sufficient image quality does not necessarily imply higher doses. As a result of the optimization process, an optimal radiographic technique was suggested.

Advanced practice for therapy radiographers – A discussion paper

Purpose The purpose of this discussion paper is to explore issues related to advanced practice for therapy radiographers. Key themes The paper will focus on key themes that have impacted on advanced practice for therapy radiographers such as government initiatives and policy, confounding terminology associated with advanced practice such as role extension, role expansion, role development, and expert practice. The theory and development of expert practice is explored and paralleled to existing roles in therapy using the Benner model to define stages of professional development and competence. Evidence for advanced practice, and education and training will also be explored. All of these issues will be considered within the perspective of the current clinical and political environment that therapy radiographers operate in. Conclusions The application of advanced practice can and should incorporate elements of role extension and role development, with some tangible skills ladder to guide and shape the development of potential consultant practitioners. There is a need to identify the current position of advanced practice nationally, and to monitor existing and emerging roles, possibly though a longitudinal study. The skill mix as a whole within departments need to be part of an ongoing evaluation with close collaboration between the professional body, departmental managers and higher education institutes to develop curricula to support existing and emerging roles. There are also key lessons to be learned from other professions with more experience with advanced practitioners if recruitment and retention is not going to continue to be a problem.

Radiographs Associated with One Episode of Orthodontic Therapy

Obtaining lifetime diagnostic radiation histories in head and neck cancer studies is often challenging due to the almost universal lack of centralized registries on X-ray utilization in medicine and dentistry. Both the common nature of orthodontics and the young age at which orthodontics typically occurs make it important to quantify what diagnostic radiographs are typically taken during orthodontic therapy. The aim of this study was to assess the number and type of radiographic films associated with one episode of orthodontic therapy in an educational setting. Charts stored in an orthodontic clinic at one academic setting were randomly sampled, and the type and number of radiographic examinations were tallied for the 325 individuals who were in orthodontic therapy for at least one year. Being under orthodontic therapy for one or more years was associated with a median number of seven extra-oral radiographs and twenty-four intra-oral radiographic films. The extra-oral radiographs included three panoramic radiographs and three cephalometric radiographs. Less than 10 percent of the variability was explained by factors such as age, gender, calendar year, surgical orthodontic therapy, and duration of therapy. Head and neck cancer etiology studies should take into account the ionizing radiation during episodes of orthodontic care. The substantial variability in radiographic practices in orthodontics could be reduced by research into clinical utility and by establishing guidelines.

Practical Radiography: Principles and Applications

Practical Radiography: Principles and Applications

The use of dental radiographs: Update and recommendations

The National Council on Radiation Protection & Measurements updated its recommendations on radiation protection in dentistry in 2003, the Centers for Disease Control and Prevention published its Guidelines for Infection Control in Dental Health-Care Settings in 2003, and the U.S. Food and Drug Administration updated its selection criteria for dental radiographs in 2004. This report summarizes the recommendations presented in these documents and addresses additional topics such as patient selection criteria, film selection for conventional radiographs, collimation, beam filtration, patient protective equipment, film holders, operator protection, film exposure and processing, infection control, quality assurance, image viewing, direct digital radiography and continuing education of dental health care workers who expose radiographs. This report discusses implementation of proper radiographic practices. In addition to these guidelines, dentists should be aware of, and comply with, applicable federal and state regulations. Dentists should weigh the benefits of dental radiographs against the consequences of increasing a patient's exposure to radiation and implement appropriate radiation control procedures.

An audit of follow-up chest radiography after coronary artery bypass graft

To investigate the clinical value and audit chest radiography, which is currently undertaken as part of routine practice, in the follow-up of coronary artery bypass graft (CABG) patients. Six hundred and sixty-six first time CABG patients were identified from the Patient Analysis and Tracking System database representing the work of a single surgeon between February 2001 and September 2005. The data regarding the clinical and radiological findings on follow-up were collected from the follow-up clinic letters and case notes. Any need for re-admission/intervention was also noted. Of the 666 patients, 11 died and a further 10 either refused or failed to arrive for follow-up. Chest radiography was undertaken in 645 patients. Only 13 patients (2%) were found to have an abnormality on chest radiography. In all cases this was a pleural effusion that was confirmed on clinical examination in seven patients (53.9%) patients. Only one patient needed re-admission and intervention. In this case the effusion had been noted on clinical examination. Seven patients were discharged and the remaining five were followed up with repeat chest radiography before discharge. Seventy-four patients had a respiratory complication postoperatively, but only three had any evidence of an effusion on follow-up. The diagnostic yield of a routine chest radiography in a CABG follow-up clinic is low (2%) and the need for intervention is rare and is determined by clinical examination. The practice of routine radiography in this group of patients has now stopped and follow-up audit will be conducted in 12 months.

WE-D-330D-01: Determination and Optimization of DR Receptor Dose

Unlike conventional radiographic receptors (screen-film), digital systems do not generally have a fixed speed, but respond over a wide range of receptor dose. Therefore, specifying and monitoring receptor dose is an important component of quality assurance for digital radiography. Digital radiographs are currently characterized in terms of a variety of incompatible, vendor specific speed or dose metrics, which make it difficult for users to monitor receptor dose or to inter-compare receptor dose from different systems. The lack of a universal vendor-independent measure of receptor dose has prompted the formation of AAPM Task Group 116, which is currently working to “Standardize an Image Receptor Dose Index for Digital Radiography”. This talk will review the currently available vendor-specific measures of receptor dose, describe and illustrate a set of desirable attributes that should characterize a universal receptor dose metric, and explore some of the pitfalls and opportunities that having a universal metric afford. Digital radiography offers a substantial opportunity to optimize and standardize radiographic practice well beyond what could be done with conventional imaging. These along with some of the pitfalls that must be avoided will be illustrated by comparing several specific proposals for measuring receptor dose applied to a large set of clinical images for which body part, projection, thickness, technique factors (kV, mAs and SID) were documented. These alternative approaches will be compared in terms of their conformance to the desirable attributes developed at the outset. A well-designed universal measure of receptor dose enables a vision for digital radiography that encompasses improved patient care through optimized and consistent image quality and dose. The concepts reviewed in this presentation are expected to influence the development of international standards for receptor dose anticipated within the next few years. Research sponsored by the Eastman Kodak Company. Learning Objectives: 1. Understand the translation of screen-film speed and dose concepts into a digital environment. 2. Understand the relationship among the many measures of dose, including the vendor specific measures of receptor dose. 3. Appreciate the need for and the desirable attributes of a universal vendor-independent measure of receptor dose. 4. Understanding the use and interpretation of receptor dose in clinical practice.

The appropriate use of radiography in clinical practice: a report of two cases of biomechanical versus malignant spine pain

BackgroundTo describe the evaluation, treatment, management and referral of two patients with back pain with an eventual malignant etiology, who were first thought to have a non-organic biomechanical disorder.Clinical featuresThe study was a retrospective review of the clinical course of two patients seen by a chiropractor in a multi-disciplinary outpatient facility, who presented with what was thought to be non-organic biomechanical spine pain. Clinical examination by both medical and chiropractic physicians did not indicate the need for radiography in the early course of management of either patient. Upon subsequent re-evaluation, it was decided that certain clinical factors required investigation with advanced imaging.In one instance, the patient responded to conservative care of low back pain for nine weeks, after which she developed severe pain in the pelvis. In the second case, the patient presented with signs and symptoms consistent with uncomplicated musculoskeletal pain that failed to respond to a course of conservative care. He was referred for medical therapy which also failed to relieve his pain. In both patients, malignancy was eventually discovered with magnetic resonance imaging and both patients are now deceased, resulting in an inability to obtain informed consent for the publication of this manuscript.ConclusionIn these two cases, the prudent use of diagnostic plain film radiography did not significantly alter the appropriate long-term management of patients with neuromusculoskeletal signs and symptoms. The judicious use of magnetic resonance imaging was an effective procedure when investigating recalcitrant neuromusculoskeletal pain in these two patients.

Chest radiography practice in critically ill patients: a postal survey in the Netherlands

BackgroundTo ascertain current chest radiography practice in intensive care units (ICUs) in the Netherlands.MethodsPostal survey: a questionnaire was sent to all ICUs with > 5 beds suitable for mechanical ventilation; pediatric ICUs were excluded. When an ICU performed daily-routine chest radiographs in any group of patients it was considered to be a "daily-routine chest radiography" ICU.ResultsFrom the number of ICUs responding, 63% practice a daily-routine strategy, in which chest radiographs are obtained on a daily basis without any specific reason. A daily-routine chest radiography strategy is practiced less frequently in university-affiliated ICUs (50%) as compared to other ICUs (68%), as well as in larger ICUs (> 20 beds, 50%) as compared to smaller ICUs (< 20 beds, 65%) (P > 0.05). Remarkably, physicians that practice a daily-routine strategy consider daily-routine radiographs helpful in guiding daily practice in less than 30% of all performed radiographs. Chest radiographs are considered essential for verification of the position of invasive devices (81%) and for diagnosing pneumothorax, pneumonia or acute respiratory distress syndrome (82%, 74% and 69%, respectively). On demand chest radiographs are obtained after introduction of thoracic drains, central venous lines and endotracheal tubes in 98%, 84% and 75% of responding ICUs, respectively. Chest films are also obtained in case of ventilatory deterioration (49% of responding ICUs), and after cardiopulmonary resuscitation (59%), tracheotomy (58%) and mini-tracheotomy (23%).ConclusionThere is notable lack of consensus on chest radiography practice in the Netherlands. This survey suggests that a large number of intensivists may doubt the value of daily-routine chest radiography, but still practice a daily-routine strategy.