Rheumatoid arthritis: a novel radiographic projection for hand assessment.

Rheumatoid arthritis (RA) is the most common form of inflammatory disease, affecting 1-2% of the population. Posteroanterior (PA) and Brewerton projections are well established in radiographic practice for scoring and monitoring RA, but there is little evidence to demonstrate the diagnostic efficacy of these techniques. This work, by varying the positioning of a cadaveric hand, investigates whether an alternative radiographic projection could yield greater diagnostic information than the traditional techniques. Phase I of the study evaluated moving the hand 15 degrees from the anteroposterior position and then in 5 degrees increments in four directions: medial rotation, lateral rotation, flexion of the wrist and extension of the wrist. Phase II of the study took the optimum projections from Phase I and further manipulated these positions in a direction at right angles to the original position. Images were scored based on joint space visualisation in 29 joints. Results demonstrated that significantly higher diagnostic efficacy was evident with 15 degrees lateral rotation of the hand or 15 degrees flexion at the wrist compared to the Brewerton projection. Either projection is recommended, but on the basis of patient comfort, the latter of these novel positions, now known as the UCD projection, was chosen as the optimum procedure to replace the Brewerton projection. The value of using cadavers for the establishment of optimum radiographic procedures is highlighted.

Potential Irish dose reference levels for cardiac interventional examinations.

Collective dose for cardio-angiography studies is the highest of all non-CT radiological investigations. Deterministic effects such as erythema, epilation and ulceration being reported on patients who have undergone these procedures emphasise the importance of optimising radiation dose, whilst not compromising diagnostic efficacy. This study investigated radiation doses delivered to patients for four common types of cardiac radiological examinations: coronary angiography (CA), percutaneous coronary intervention (PCI), coronary angiograms (which were followed by an interventional procedure (CA-PCI)) and permanent pacemaker insertions (PPIs). 21 cardiac imaging suites participated in the study in 14 hospitals, representing 90% of relevant centres within Ireland. Radiation dose was monitored for 1804 adult patients using dose-area product meters. Operational and examination details, such as cardiologist grade, patient details, examination complexity and exposure factors, were recorded for each examination. Variation factors in dose between centres ranged from 2.7 to 11.1, but these factors were not higher than intrahospital variations previously recorded for other examinations within Ireland, such as chest X-ray. High-dose centres were often associated with long screening times, a high patient body mass index and complexity of the procedure. Preliminary dose reference levels (DRLs) were established using rounded third quartile values at 4200 cGy cm(2), 8400 cGy cm(2), 10,700 cGy cm(2) and 2100 cGy cm(2) for CA, PCI, CA-PCI and PPI, respectively. With these commonly performed relatively high-dose procedures, it is important that some guideline values are available to encourage optimised strategies. These proposed DRLs offer such guidance.

Proposed preliminary diagnostic reference levels for three common interventional cardiology procedures in Ireland.

This study has gathered data across Ireland to determine the range of radiation doses received during interventional cardiology (IC) investigations. Radiation doses for three common types of IC examinations where investigated: coronary angiography (CA), percutaneous coronary intervention (PCI) and pacemaker insertions (PPI). A total of 22 cardiac imaging suites participated in the study. Radiation dose was monitored for 1804 adult patients using dose area product (DAP) meters. Individual patient DAP values ranged from 136-23,101 cGy cm2, 475-41,038 cGy cm2 and 45-17,192 cGy cm2 for CA, PCI and PPI respectively, with third quartile values of 4654 cGy cm2, 10,650 cGy cm2 and 1686 cGy cm2. The importance of optimising radiation dose, while not compromising diagnostic efficacy is clear. Although setting reference levels for these complex procedures has some difficulties, it is important that some guideline values are available as a benchmark to guide the operators during these potentially high dose procedures. The third quartile values as described by this paper may offer such guidance.