Risk and radiation exposure in orthopedic surgery of the spine in Mexico / Risco e exposição à radiação em cirurgia ortopédica da coluna no México / Riesgo y exposición a radiaciones en cirugía ortopédica de columna vertebral en México

OBJECTIVE: To find a biological effect by means of detection of the thyroid profile in research personnel, and a physical effect through radiation detection plates type Durr. METHODS: Five medical residents (four of first year and one of second) were submitted to the study of the basal thyroid profile, and annually after a year of radiation exposure. In two of them five plates of Durr type were placed by surgery at different body parts and 20 separate surgeries, using fluoroscopy, a total of 200 plates exposed. RESULTS: Three residents had decreased thyroid-stimulating hormone and two had a significant increase. Ninety-one plates were exposed, most of which corresponds to the neck (thyroid). CONCLUSION: Biological and physical changes were observed that require us to realize and implement protective measures against radiation, at least in the neck, because the thyroid is susceptible to radiation. .

OBJETIVO: Encontrar um efeito biológico através da detecção do perfil da tireoide dos profissionais de investigação, e um efeito físico através da detecção de radiação com placas tipo Durr. MÉTODOS: Cinco médicos residentes (quatro de primeiro ano e um de segundo) foram submetidos ao estudo do perfil tireoidiano basal, e anualmente após um ano de exposição à radiação. Em dois deles, foram colocadas cinco placas de Durr por cirurgia, em diferentes partes do corpo e em 20 cirurgias distintas, utilizando-se fluoroscopia, perfazendo um total de 200 placas expostas. RESULTADOS: Três residentes tiveram diminuição do hormônio estimulador da tireoide e dois, um aumento significativo. Foram expostas 91 placas, cuja maioria corresponde ao pescoço (tireoide). CONCLUSÃO: Foram verificadas mudanças biológicas e físicas que nos impulsionam à conscientização e implementação de medidas de proteção contra a radiação, pelo menos no pescoço, uma vez que a tireoide é suscetível à radiação. .

OBJETIVO: Encontrar un efecto biológico mediante detección de perfil tiroideo al personal investigador, y un efecto físico mediante detección de radiación con placas tipo Durr. MÉTODOS: Fueron sometidos al estudio, cinco médicos residentes, (cuatro de primer año y uno de segundo) para el perfil tiroideo basal, y anual después de un año de radiación. A dos de ellos les fueron colocadas cinco placas de Durr por cirugía, distribuidas en diferentes partes del cuerpo en 20 cirugías distintas con la utilización de fluoroscopio, dando un total de 200 placas expuestas. RESULTADOS: En tres de los residentes hubo una disminución de la hormona tiroidea estimulante y en dos un aumento significativo. Se expusieron 91 placas siendo la mayoría de estas correspondientes al cuello (tiroides). CONCLUSIÓN: Se encontraron cambios biológicos y físicos que nos impelen a tomar conciencia y medidas necesarias de radioprotección por lo menos a nivel del cuello, ya que la tiroides es susceptible a las radiaciones .

Alopecia rectangular transitoria post embolización de fístula carótido-cavernosa: reporte de caso y revisión de la literatura / Transient alopecia after embolization: case report and literature review

En la actualidad, los procedimientos de radiología intervencional intracraneanos son cada vez más frecuentes. Sin embargo, la exposición a altas dosis de radiación durante la fluoroscopía puede inducir a complicaciones cutáneas como la alopecia transitoria post embolización, forma peculiar de radiodermatitis que afecta a las regiones del cuero cabelludo que reciben dosis más altas de radiación durante el proceso de embolización. El cuadro clínico se caracteriza por alopecia completa, no cicatricial, en parches con bordes bien delimitados y formas peculiares(rectángulos, círculos superpuestos), generalmente de localización occipital o en región temporo-parietal. Ocurre en promedio 2 a 4 semanas después del procedimiento endovascular, con repoblación del área alopécica a partir de las 4 a 5 semanas. Es de buen pronóstico y no requiere tratamiento específico. Es importante conocer este cuadro para poder orientar adecuadamente a los pacientes y alertar respecto a la incidencia de efectos adversos de la radiación terapéutica.

In the present, the neuroradiological procedures are more frequent. However, exposure to radiation can conduce to dermatological complication as transient alopecia after embolization, rare form of radiodermatitis that affect the areas of the scalp that receive highest doses of radiation. The clinical presentation is characterized by a complete alopecia, without any signs of inflammation of the scalp, with sharply defined patches in rare forms (rectangular, overlapped circles), generally located on occipital or temporo-parietal region. This phenomenon starts after 2 or 4 weeks since endovascular procedure, with hair re-growth after 4 or 5 weeks. It has good prognosis and no specific treatment is required. It is important to recognize this condition, in order to give adequate information to patients and warn about the incidence of adverse effects of therapeutic radiation.

Occupational Hazard: Radiation Exposure for the Urologist – Developing a Reference Standard

Introduction To date, there is a paucity of literature offering practicing urologists a reference for the amount of radiation exposure received while surgically managing urolithiasis. This study examines the cumulative radiation exposure of an urologist over 9 months. Materials and Methods We present a case series of fluoroscopic exposures of an experienced stone surgeon operating at an academic comprehensive stone center between April and December 2011. Radiation exposure measurements were determined by a thermoluminescent dosimeter worn on the outside of the surgeon's thyroid shield. Estimations of radiation exposure (mrem) per month were charted with fluoroscopy times, using scatter plots to estimate Spearman's rank correlation coefficients. Results The total 9-month radiation exposure was 87 mrems for deep dose equivalent (DDE), 293 mrem for lens dose equivalent (LDE), and 282 mrem for shallow dose equivalent (SDE). Total fluoroscopy time was 252.44 minutes for 64 ureteroscopies (URSs), 29 percutaneous nephrolithtomies (PNLs), 20 cystoscopies with ureteral stent placements, 9 shock wave lithotripsies (SWLs), 9 retrograde pyelograms (RPGs), 2 endoureterotomies, and 1 ureteral balloon dilation. Spearman's rank correlation coefficients examining the association between fluoroscopy time and radiation exposure were not significant for DDE (p = 0.6, Spearman's rho = 0.2), LDE (p = 0.6, Spearman's rho = 0.2), or SDE (p = 0.6, Spearman's rho = 0.2). Conclusions Over a 9-month period, total radiation exposures were well below annual accepted limits (DDE 5000 mrem, LDE 15,000 mrem and SDE 50,000 mrem). Although fluoroscopy time did not correlate with radiation exposure, future prospective studies can account for co-variates such as patient obesity and urologist distance from radiation source. .

Complication Rate of Transfemoral Endomyocardial Biopsy with Fluoroscopic and Two-dimensional Echocardiographic Guidance: A 10-Year Experience of 228 Consecutive Procedures

Endomyocardial biopsy (EMB) is one of the reliable methods for the diagnosis of various cardiac diseases. However, EMB can cause various complications. The purpose of this study is to evaluate the complication of transfemoral EMB with both fluoroscopic and two-dimensional (2-D) echocardiographic guidance. A total of 228 patients (148 men; 46.0+/-14.6 yr-old) who underwent EMB at Kyungpook National University Hospital from January 2002 to June 2012 were included. EMB was performed via the right femoral approach with the guidance of both echocardiography and fluoroscopy. Overall, EMB-related complications occurred in 21 patients (9.2%) including one case (0.4%) with cardiac tamponade requiring emergent pericardiocentesis, four cases (1.8%) with small pericardial effusion without pericardiocentesis, two cases (0.9%) with hemodynamically unstable ventricular tachycardia (VT), one case (0.4%) with nonsustained VT, one case (0.4%) with tricuspid regurgitation, twelve cases (5.3%) with right bundle branch block. There was no occurrence of either EMB-related death or cardiac surgery. Left ventricular ejection fraction was significantly lower (32.0+/-18.7% vs 42.0+/-19.1%, P=0.023) and left ventricular end-diastolic dimension was larger (60.0+/-10.0 mm vs 54.2+/-10.2 mm, P=0.013) in patients with EMB related complications than in those without. It is concluded that transfemoral EMB with fluoroscopic and 2-D echocardiographic guidance is a safe procedure with low complication rate.

Exposição à radiação ionizante na sala de hemodinâmica / Exposure to ionizing radiation in the cardiac catheterization lab

INTRODUÇÃO: Com a evolução tecnológica e o crescimento da cardiologia intervencionista, os níveis de exposição aos raios X dos pacientes e da equipe técnica assim como o número de procedimentos de cateterismo têm aumentado consideravelmente. Isso tem impacto no inerente risco de exposição à radiação ionizante, ainda subestimado por muitos. Os níveis dessa exposição necessitam de mensuração e correção periódicas. Nosso objetivo foi investigar e aferir os níveis de radiação ionizante emitida por equipamentos de cinefluoroscopia. Método: Foram realizados ensaios técnicos para avaliar a taxa de kerma no ar de 8 equipamentos de hemodinâmica. Resultados: Apenas 2 (25 por cento) dos 8 equipamentos apresentavam dosimetria dentro dos limites máximos de segurança. A média das doses foi 65 por cento maior nos equipamentos com tecnologia flat detector. Após aplicação da manutenção supervisionada, verificou-se diminuição média de 42 por cento nos valores dosimétricos. Todos os equipamentos foram aprovados nos ensaios de resolução espacial de alto e baixo contrastes, e a qualidade da imagem foi corroborada pela equipe médica. Conclusão: A maioria dos equipamentos analisados apresentava dosimetria acima dos limites máximos de segurança, particularmente com a tecnologia flat detector. Essas distorções foram corrigidas com medidas de supervisão simples, sem prejuízo à qualidade da imagem. Nossos resultados ressaltam a necessidade de criação de programas institucionais de auqlidade visando à manutenção regular dos equipamentos e à incorporação criteriosa de novas tecnologias no intuito de minimizar os potenciais efeitos deletérios da radiação ionizante, promovendo maior segurança e economia.

BACKGROUND: With the technological evolution and expansion of interventional cardiology, the levels of X-ray exposure of patients and technical staff as well as the number of catheterization procedures have increased considerably. This has an impact on the inherent risk of exposure to ionizing radiation which is still underestimated by many. The levels of exposure must be routinely measured and adjusted. Our objective was to investigate and measure ionizing radiation levels emitted by cath lab X-ray equipments. METHODS: Technical tests were conducted to evaluate the air kerma of 8 X-ray equipments. RESULTS: Only 2 (25%) of the 8 equipments had dosimetry within maximum safety levels. The mean dose was 65% higher in devices with the flat detector technology. After supervised maintenance, there was a mean decrease of 42% in dosimetry values. All equipments were approved by the high and low contrast spatial resolution tests, and the image quality was approved by the medical team. CONCLUSIONS: Most of the equipments evaluated had dosimetry levels exceeding the maximum safety levels, especially those with the flat detector technology. These distortions were corrected by simple monitoring measures, without losses in image quality. Our results emphasizes the need to create institutional quality programs, to keep regular equipment maintenance and to exercise discretion in the incorporation of new technologies to minimize the potential effects of the deleterious effects of ionizing radiation, promoting greater safety and economy.

Resultados de la litotricia extracorpórea utilizando el litotritor MODULITH SLX-MX (STORZ) para el tratamiento de la litiasis ureteral / Results of the shock waves extracorporeal lithotripsy using the MODULITH SLX-MX (STORZ) lithotriptor for treatment or ureteral lithiasis

INTRODUCCIÓN. La litiasis del uréter constituye una gran preocupación para los médicos debido a que frecuentemente ocasiona una uropatía obstructiva y el deterioro progresivo de la función renal ipsolateral, estado patológico de alta prevalencia, por lo que los hospitales con frecuencia no pueden dar solución quirúrgica con la celeridad necesaria. El objetivo de esta investigación fue conocer los resultados de la litotricia extracorpórea por ondas de choque (LEC) con el litotritor MODULITH SLX-MX (STORZ) para el tratamiento de la litiasis ureteral. MÉTODOS. Se incluyeron 598 pacientes con litiasis radiopaca del uréter, atendidos en el Hospital Hermanos Ameijeiras entre enero de 2007 y diciembre de 2008. Se conformaron 4 grupos según la localización del cálculo: en la unión pieloureteral (UPU) (96), uréter lumbar (UL) (263), iliaco (UI) (40), pelviano (UP) (199) y se analizó su relación con la superficie litiásica, sesiones de tratamiento, maniobras complementarias previas a la litotricia, aplicación de procedimientos auxiliares posteriores, resolución definitiva por otra técnica quirúrgica y eficacia terapéutica. La colimación se realizó por fluoroscopia. RESULTADOS. El mayor número de cálculos se localizó en el uréter lumbar, y en segundo lugar, en el uréter pelviano. El tamaño medio de la litiasis fue de 0,8 ± 0,5233 cm2, en rango de 0,09-4 cm2. La media de sesiones utilizadas fue de 1,24 ± 0,531, rango de 1-4. Se realizaron maniobras complementarias previas en 72 pacientes (12,04 por ciento) y la más utilizada fue la nefrostomía percutánea (40; 6,6 por ciento). Después de la LEC fue necesaria la conversión a otro procedimiento para la solución del 4,68 por ciento de los casos. La LEC fue eficaz en el 95,32 por ciento, con mejores resultados en el UP (96,99 por ciento) y peores en el UI (92,50 por ciento). CONCLUSIONES. Los resultados fueron buenos utilizando el litotritor MODULITH SLX-MX (STORZ). Los mejores resultados se obtuvieron en el uréter pelviano y en general es posible considerar la LEC como la primera opción terapéutica de la litiasis ureteral(AU)

INTRODUCTION. Ureter lithiasis is a concern for physicians because frequently provokes an obstructive uropathy and a progressive deterioration of ipsilateral renal function and a high prevalence of pathological state that is why the hospitals can not give a surgical solution as quickly as possible. The objective of present research was to know the results of the shock waves extracorporeal lithotripsy (SWEL) using the MODULITH SLX-MX (STORZ) lithotriptor for treatment or ureteral lithiasis. METHODS. In present research 598 patients presenting with ureter radiopaque lithiasis, seen in the Hermanos Ameijeiras Clinical Surgical Hospital from January, 2007 to December, 2008, divided into four groups according to the calculus localization: in pyeloureteral joint (PUJ) (96), lumbar ureter (LU) (263), iliac joint (IJ) (40), pelvic joint (PJ) (199) analyzing its relationship with lithiasis surface, treatment sessions, complementary manoeuvres previous to lithotripsy, application of subsequent auxiliary procedures, definite resolution using other surgical technique and therapeutical effectiveness. Collimation was carried out by fluoroscopy. RESULTS. Most of calculi were located in the lumbar ureter and in the second place in pelvic ureter. The mean size of lithiasis was of 0,8 ± 0,5233 cm2 in the rank of 0,09-4 cm2. The mean of sessions used was of 1,24 ± 0,531, in the rank of 0,09-4 cm2. The mean of sessions used was of 1,24 ± 0,531, rank of 1-4. In 72 patients 12,04 percent) previous complementary manoeuvres were carried out and the more used one was the percutaneous nephrostomy (40; 6,6 percent). After SWEL it was necessary the conversion to other procedure for solution of 4,68 percent of the cases. The SWEL was effective in the 95,32 percent with better results in the UP (96,99 percent) and with worse results in the IJ (92,50 percent). CONCLUSIONS. The results were good using the MODULITH SLX-MX (STORZ) lithotriptor. The better results were obtained in the pelvic ureter and in general, it is possible to consider the SWEL as the first therapeutical choice of ureteral lithiasis(AU)

Radiation safety issues in fluoroscopy during percutaneous nephrolithotomy

personnel are important. Patient radiation doses are used for comparison with other centers for achieving the best possible radiation practice. In addition, there are performance checks for the fluoroscopy machines so that x-ray emitting machines should work at the optimum level ie, producing good images at minimum possible radiation doses. This is a review of literature and discussion on radiation dose to patients and personnel, and on basic radiation safety tenets and their application in urological interventions of PCNL procedure. Radiation doses during PCNL have gone down over the time due to advances in technology. However, as radiation is hazardous, there is no room for complacency. A hospitals medical physicist may ensure even further reduction of x-ray dose by carrying out regular dosimetry and quality assurance tests on the fluoroscopy machines. A survey meter may provide an easy and quicker but not-so-accurate method for occupation exposure determination. The practice of PCNL procedures seems to be quite safe with radiation point of view. The quick, easy, and economical method of estimation of radiation dose using survey meter may need further calibration with the standard thermoluminescence dosimetry method. Setting optimum x-ray parameters, incorporation of filters, and quality assurance tests are a few areas where medical physicists may help in further reduction of radiation doses

Blind puncture in comparison with fluoroscopic guidance in percutaneous nephrolithotomy: a randomized controlled trial

Our aim was to evaluate blind puncture in percutaneous nephrolithotomy [PCNL] for decreasing the risk of radiation. One hundred candidates for PCNL were randomly assigned into 2 groups. Blind access was performed for the patients in group 1 and the standard access using fluoroscopy for those in group 2. In group 1, displacement of the targeted calyx in the prone position was estimated by fluoroscopy comparing to the image on intravenous urography. Puncture of the calyx was attempted 3 cm to 4 cm below the marked site of the targeted calyx with a 30 degree sign angle. If the access to the collecting system was felt and urine came out, the site of puncture would be controlled by fluoroscopy. If the access failed, we would repeat puncturing up to 5 times. The mean time to access was 6.6 +/- 2.1 minutes and 5.5 +/- 1.7 minutes in groups 1 and 2, respectively [P=.008]. The mean time of radiation exposure was 0.95 +/- 0.44 minutes in group 2. A successful puncture of the targeted calyx was achieved in 50% and 90% of the patients in groups 1 and 2, respectively [P<.001] and a successful calculus removal in 62% and 100% of the patients in groups 1 and 2 [P<.001]. Although about half of the patients benefited from blind access in our study, this technique can not be solely relied on, and fluoroscopy or ultrasonography should be available for prevention of complications

Ionizing radiation. The question of responsible use: Pandora's box revisited

For over one hundred years, ionizing radiation has assisted in medical diagnostics. Recently, there have been reports of radiation injury in patients undergoing fluoroscopic procedures. It is time to review some of the risks of ionizing radiation as well as some of our practices at the University Hospital of West Indies (UHWI). In this review, we discuss the relative risks associated with common radiological examinations as well as explore the relative merits of various clinical protocols for the radiological investigation of common diseases seen at the UHWI

Extravasation of the contrast in the unused urinary bladder.

Ruptured bladder or extravasation from the bladder is almost always associated with trauma. Spontaneous extravasation is extremely rare with only a few reported cases. All those reported extravasations occurred in the patients diagnosed with end stage renal disease (ESRD) and were self limiting conditions. During the one-year period of 2001, voiding cystourethrography (VCUG) of 115 patients were performed in our institution with various indications. The authors found 3 cases with extravasation of contrast from the bladder during VCUG. All extravasations were occurred in ESRD patients and the VCUG was performed as part of the routine investigation prior to renal transplantation. The presented cases shared a similar observation of 1) no traumatic catheterization, 2) only minimal and self limiting extravasation and 3) no immediate or delayed symptom associated with extravasation. The cause and mechanism of leakage remain uncertain. Hypertonicity and mucosal changes within the unused bladder were purposed as probably the two main causes of extravasation.

Impacto de la radiación secundaria en el operador durante la arteriografía coronaria selectiva / Secondary irradiation of operators during coronary arteriography

Background: The activity over cellular genetic pattern of ionizing radiation can produce stochastic and unspecific damages. Interventional cardiology operators have increasing exposure times to ionizing radiation and there is no information about the real protection conferred by simple radiological protection devices. Aim: To assess the magnitude of secondary ionizing radiation exposure of operators during conventional coronary arteriography, evaluating the radiation exposure during different beam projections and the usefulness of leaded aprons. Material and methods: Ionizing radiation received by operators during coronary arteriography was measured using a Geiger-Müller Victoreen model 490 counter. The device was placed in the ventral region, covered by the leaded apron and in the unprotected dorsal region. Radiation was measured in right and left projections during fluoroscopy and shooting. Results: In right projection, the intensity of ionizing radiation in ventral and dorsal regions was 1.24 ñ 1.1 and 2.9 ñ 4 mR/h respectively (p= 0.08). In left projection, the figures were 2.95 ñ 3 and 7.86 ñ 7.2 mR/h respectively (p= 0.001). During shooting in left projection the radiation exposure in ventral and dorsal regions was 9.66 ñ 6.7 and 32.8 ñ 27 mR/h respectively (p< 0.001). During shooting in right projection that figures were 10.1 ñ 16 and 20.7 ñ 39.8 mR/h respectively (p= 0.09). No correlation between radiation exposure and patients surface area was observed. Conclusions: Secondary radiation received by operators is higher during shooting and in left projections. Leaded apron confers a partial protection for ventral region, and great fluctuations in the magnitude of radiation exposure were recorded. Unprotected dorsal region receives a greater amount of radiation in left projections

Investigación sobre niveles de dosis en exámenes con fluoroscopia gastrointestinal como parte de un programa de control de calidad / An investigation of the levels of radiation exposure in diagnostic examinations involving gastrointestinal tract fluoroscopy

El Servicio de Radiodiagnóstico del Hospital Universitario de la Universidad Federal de Río de Janeiro, juntamente con el Instituto de Radioprotección y Densitometría de la Comisión Nacional de Energía Nuclear, se encuentra desarrolllando programas en el área de garantía de calidad en radiodiagnóstico. Estas actividades contemplan como objetivo importante la optimización de las dosis. Uno de los programas en marcha comprende exámenes de fluoroscopia gastrointestinal. A fin de investigar los niveles de exposición a la radiación fueron realizadas medidas de dosis de entrada en la piel recibidas por pacientes y médicos en exámenes de esofagografía, seriografía y colon, utilizando dosímetros colocados en varias posiciones del cuerpo. En este trabajo se describe la metodología seguida y se muestran los resultados obtenidos hasta el presente. Se hace un análisis del espectro de dosis observadas en pacientes y profesionales, de acuerdo con diversos parámetros tales como ubicación de dosímetros, tiempo de exposición, técnicas empleadas, número de radiografías, etc. También se describen los pasos a seguir con el objeto de concretar la implantación de un programa de control de calidad en los exámenes mencionados

Avaliaçäo de níveis de radiaçäo em diferentes atos cirúrgicos

A quantidade de radiaçäo ionizante a que está exposta a equipe médica durante um ato cirúrgico depende evidentemente da duraçäo e das dificuldades do próprio ato, além da técnica radiológica utilizada. Fizemos um levantamento do simétrico das doses equivalentes médias recebidas pela equipe médica durante dez diferentes cirurgias em um mês. Chegamos a conclusäo de que os resultados obtidos demonstram que os níveis de radiaçäo ionizante a que estäo sujeitos os funcionários durante um ato cirúrgico näo ultrapassam as doses máximas admissíveis estipuladas pelas normas básicas de proteçäo radiológica nas seguintes cirurgias: nefrolitotomía, ureterolitotomia percutânea, ureteroscopia + retirada de cálculo em terço inferior do ureter, osteossíntese de platô tibial + toalete articular + minirreconstruçäo do joelho. Para cirurgias compostas - como osteossíntese de fratura de fêmur + biópsia de fêmur a céu aberto, ou netrolitotomia percutânea (casos mais complexos) - o limite é ultrapassado por ser necessário um tempo maior de fluoroscopia