Epidemiology Without Biology: False Paradigms, Unfounded Assumptions, and Specious Statistics in Radiation Science (with Commentaries by Inge Schmitz-Feuerhake and Christopher Busby and a Reply by the Authors)

Society and Nuclear Energy: What Is the Role for Radiological Protection?

ABSTRACT

The harm that society expects from ionizing radiation does not match experience. Evidently there is some basic error in this assumption. A reconsideration based on scientific principles shows how simple misunderstandings have exaggerated dangers. The consequences for society are far-reaching. The immediate impact of ionizing radiation on living tissue is destructive. However, this oxidative damage is similar to that produced during normal metabolic activity where the subsequent biological reaction is not only protective but also stimulates enhanced protection. This adaptation means that the response to oxidative damage depends on past experience. Similarly, social reaction to a radiological accident depends on the regulations and attitudes generated by the perception of previous instances. These shape whether nuclear technology and ionizing radiation are viewed as beneficial or as matters to avoid. Evidence of the spurious damage to society caused by such persistent fear in the second half of the 20 th century suggests that these laws and attitudes should be rebased on evidence. The three stages of radiological impact-the initial physical damage, the subsequent biological response, and the personal and social reaction-call on quite different logic and understanding. When these are confused, they lead to regulations and public policy decisions that are often inept, dangerous, and expensive. One example is when the mathematical rigor of physics, appropriate to the immediate impact, is misapplied to the adaptive behavior of biology. Another, the tortured historical reputation of nuclear technology, is misinterpreted as justifying a radiological protection policy of extreme caution.Specialized education and closed groups of experts tend to lock in interdisciplinary misperceptions. In the case of nuclear technology, the resulting lack of independent political confidence endangers the adoption of nuclear power as the replacement for fossil fuels. In the long term, nuclear energy is the only viable source of large-scale primary energy, but this requires a re-working of public understanding.

Multicenter Quantification of Radiation Exposure and Associated Risks for Prostatic Artery Embolization in 1476 Patients

Background Prostatic artery embolization (PAE) is a safe, minimally invasive angiographic procedure that effectively treats benign prostatic hyperplasia; however, PAE-related patient radiation exposure and associated risks are not completely understood. Purpose To quantify radiation dose and assess radiation-related adverse events in patients who underwent PAE at multiple centers. Materials and Methods This retrospective study included patients undergoing PAE for any indication performed by experienced operators at 10 high-volume international centers from January 2014 to May 2021. Patient characteristics, procedural and radiation dose data, and radiation-related adverse events were collected. Procedural radiation effective doses were calculated by multiplying kerma-area product values by an established conversion factor for abdominopelvic fluoroscopy-guided procedures. Relationships between cumulative air kerma (CAK) or effective dose and patient body mass index (BMI), fluoroscopy time, or radiation field area were assessed with linear regression. Differences in radiation dose stemming from radiopaque prostheses or fluoroscopy unit type were assessed using two-sample t tests and Wilcoxon rank sum tests. Results A total of 1476 patients (mean age, 69.9 years ± 9.0 [SD]) were included, of whom 1345 (91.1%) and 131 (8.9%) underwent the procedure with fixed interventional or mobile fluoroscopy units, respectively. Median procedure effective dose was 17.8 mSv for fixed interventional units and 12.3 mSv for mobile units. CAK and effective dose both correlated positively with BMI (R2 = 0.15 and 0.17; P < .001) and fluoroscopy time (R2 = 0.16 and 0.08; P < .001). No radiation-related 90-day adverse events were reported. Patients with radiopaque implants versus those without implants had higher median CAK (1452 mGy [range, 900-2685 mGy] vs 1177 mGy [range, 700-1959 mGy], respectively; P = .01). Median effective dose was lower for mobile than for fixed interventional systems (12.3 mSv [range, 8.5-22.0 mSv] vs 20.4 mSv [range, 13.8-30.6 mSv], respectively; P < .001). Conclusion Patients who underwent PAE performed with fixed interventional or mobile fluoroscopy units were exposed to a median effective radiation dose of 17.8 mSv or 12.3 mSv, respectively. No radiation-related adverse events at 90 days were reported. © RSNA, 2024 See also the editorial by Mahesh in this issue.

The challenges of defining hormesis in epidemiological studies: The case of radiation hormesis

In the current radiation protection system, preventive measures and occupational exposure limits for controlling occupational exposure to ionizing radiation are based on the linear no-threshold extrapolation model. However, currently an increasing body of evidence indicates that this paradigm predicts very poorly biological responses in the low-dose exposure region. In addition, several in vitro and in vivo studies demonstrated the presence of hormetic dose response curves correlated to ionizing radiation low exposure. In this regard, it is noteworthy that also the findings of different epidemiological studies, conducted in different categories of occupationally exposed workers (e.g., healthcare, nuclear industrial and aircrew workers), observed lower rates of mortality and/or morbidity from cancer and/or other diseases in exposed workers than in unexposed ones or in the general population, then suggesting the possible occurrence of hormesis. Nevertheless, these results should be considered with caution since the identification of hormetic response in epidemiological studies is rather challenging because of a number of major limitations. In this regard, some of the most remarkable shortcomings found in epidemiological studies performed in workers exposed to ionizing radiation are represented by lack or inadequate definition of exposure doses, use of surrogates of exposure, narrow dose ranges, lack of proper control groups and poor evaluation of confounding factors. Therefore, considering the valuable role and contribution that epidemiological studies might provide to the complex risk assessment and management process, there is a clear and urgent need to overcome the aforementioned limits in order to achieve an adequate, useful and more real-life risk assessment that should also include the key concept of hormesis. Thus, in the present conceptual article we also discuss and provide possible approaches to improve the capacity of epidemiological studies to identify/define the hormetic response and consequently improve the complex process of risk assessment of ionizing radiation at low exposure doses.

Entrance Skin Dose (ESD) and Bucky Table Induced Backscattered Dose (BTI-BSD) in Abdominal Radiography With nanoDot Optically Stimulated Luminescence Dosimeter (OSLD)

In radiography, inconsistencies in patients' measured entrance skin dose (ESD) exist. There is no published research on the bucky table induced backscattered radiation dose (BTI-BSD). Thus, we aimed to ascertain ESD, calculate the BTI-BSD in abdominal radiography with a nanoDot OSLD, and compare the ESD results with the published data. A Kyoto Kagaku PBU-50 phantom (Kyoto, Japan) in an antero-posterior supine position was exposed, selecting a protocol used for abdominal radiography. The central ray of x-ray beam was pointed at the surface of abdomen at the navel, where a nanoDot dosimeter was placed to measure ESD. For the BTI-BSD, exit dose (ED) was determined by placing a second dosimeter on the exact opposite side (backside) of the phantom from the dosimeter used to determine (ESD) with and without bucky table at identical exposure parameters. The BTI-BSD was calculated as the difference between ED with and without bucky table. The ESD, ED, and BTI-BSD were measured in milligray (mGy). ESD mean values with and without bucky table were 1.97 mGy and 1.84 mGy, whereas ED values were 0.062 mGy and 0.052 mGy, respectively. Results show 2-26% lower ESD values with nanoDot OSLD. The BTI-BSD mean value was found to be approximately 0.01 mGy. A local dose reference level (LDRL) can be established using ESD data to safeguard patients from unnecessary radiation. In addition, to minimize the risk of BTI-BSD in patients in radiography, the search for the use or fabrication of a new, lower atomic number material for the bucky table is suggested.

Can Low-Level Ionizing Radiation Do Us Any Harm?

The current system of radiological protection relies on the linear no-threshold (LNT) hypothesis of cancer risk due to humans being exposed to ionizing radiation (IR). Under this tenet, effects of low doses (i.e. of those not exceeding 100 mGy or 0.1 mGy/min. of X- or γ-rays for acute and chronic exposures, respectively) are evaluated by downward linear extrapolation from regions of higher doses and dose rates where harmful effects are actually observed. However, evidence accumulated over many years clearly indicates that exposure of humans to low doses of radiation does not cause any harm and often promotes health. In this review, we discuss results of some epidemiological analyses, clinical trials and controlled experimental animal studies. Epidemiological data indicate the presence of a threshold and departure from linearity at the lowest dose ranges. Experimental studies clearly demonstrate the qualitative difference between biological mechanisms and effects at low and at higher doses of IR. We also discuss the genesis and the likely reasons for the persistence of the LNT tenet, despite its scientific implausibility and deleterious social consequences. It is high time to replace the LNT paradigm by a scientifically based dose-effect relationship where realistic quantitative hormetic or threshold models are exploited.

Ionizing radiation protection and the linear No-threshold controversy: Extent of support or counter to the prevailing paradigm

This study has developed a relationship that categorized radiation protection and allows for a proper, clear, and concise review of the different classifications in terms of principles of protection, dose criteria, categories, fundamental tools, exposure situations, applications and control measures. With the groundwork laid, advances of the linear no-threshold (LNT) model which has attracted attention in the field of radiobiology and epidemiology were examined in detail. Various plausible dose-response relationship scenarios were x-rayed under low-dose extrapolation. Intensive review of factors opposing the LNT model involving radiophobia (including misdiagnosis, alternative surgery/imaging, suppression of ionizing radiation (IR) research); radiobiology (including DNA damage repair, apoptosis/necrosis, senescence protection) and cost issues (including-high operating cost of LNT, incorrect prioritization, exaggeration of LNT impact, risk-to-benefit analysis) were performed. On the other hand, factors supporting the use of LNT were equally examined, they include regulatory bodies' endorsement, insufficient statistical significance, partial DNA repair, variability of irradiated bodies, different latency periods for cancer, dynamic nature of threshold and conflicting interests. After considering the gaps in the scientific investigations that either support or counter the scientific paradigm on the use of LNT model, further research and advocacy is recommended that will ultimately lead to the acceptance of an alternative paradigm by the international regulators.

Biological and cellular responses of humans to high-level natural radiation: A clarion call for a fresh perspective on the linear no-threshold paradigm

There remains considerable uncertainty in obtaining risk estimates of adverse health outcomes of chronic low-dose radiation. In the absence of reliable direct data, extrapolation through the linear no-threshold (LNT) hypothesis forms the cardinal tenet of all risk assessments for low doses (≤ 100 mGy) and for the radiation protection principle of As Low As Reasonably Achievable (ALARA). However, as recent evidences demonstrate, LNT assumptions do not appropriately reflect the biology of the cell at the low-dose end of the dose-response curve. In this regard, human populations living in high-level natural radiation areas (HLNRA) of the world can provide valuable insights into the biological and cellular effects of chronic radiation to facilitate improved precision of the dose-response relationship at low doses. Here, data obtained over decades of epidemiological and radiobiological studies on HLNRA populations is summarized. These studies do not show any evidence of unfavourable health effects or adverse cellular effects that can be correlated with high-level natural radiation. Contrary to the assumptions of LNT, no excess cancer risks or untoward pregnancy outcomes have been found to be associated with cumulative radiation dose or in-utero exposures. Molecular biology-driven studies demonstrate that chronic low-dose activates several cellular defence mechanisms that help cells to sense, recover, survive, and adapt to radiation stress. These mechanisms include stress-response signaling, DNA repair, immune alterations and most importantly, the radiation-induced adaptive response. The HLNRA data is consistent with the new evolving paradigms of low-dose radiobiology and can help develop the theoretical framework of an alternate dose-response model. A rational integration of radiobiology with epidemiology data is imperative to reduce uncertainties in predicting the potential health risks of chronic low doses of radiation.

Ionizing radiation and cancer: The failure of the risk model

This review presents evidence that the methodology that supports the current radiation risk model for cancer is insecure. As a consequence, the legal limits on internal exposures to certain common radionuclides are incorrect by several orders of magnitude. Because of this, hundreds of millions of people will have developed cancer due to internal exposures from atmospheric testing fallout, nuclear accidents, Depleted Uranium and releases from nuclear sites. There are fatal errors in both the mechanistic and epidemiological bases of the Linear No Threshold (LNT) Absorbed Dose model. The review discusses the history of the model and refers to published studies that clearly demonstrate these errors. It argues that the ways in which the models were constructed were arbitrary, capricious and unscientific.

Reflections on effects of low doses and risk inference based on the UNSCEAR 2021 report on 'biological mechanisms relevant for the inference of cancer risks from low-dose and low-dose-rate radiation'

The 2021 United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) report summarises the knowledge on biological mechanisms of radiation action at low doses where, due to low statistical power of epidemiological investigations, the level of cancer risk must be inferred. It is the fourth UNSCEAR report since 1994 that looks into biological effects following low dose exposure with the aim of examining whether they support the assumption of the linear non-threshold (LNT) dose response for radiation-induced cancers. The conclusions of all four reports are affirmative. The new aspect of the 2021 report is that it focuses on the process of cancer risk inference. The aim of this article is to discuss the consequences of the conclusions regarding LNT and the possibilities of inferring risks from biological studies.

Thresholds for carcinogens

Current regulatory cancer risk assessment principles and practices assume a linear dose-response relationship-the linear no-threshold (LNT) model-that theoretically estimates cancer risks occurring following low doses of carcinogens by linearly extrapolating downward from experimentally determined risks at high doses. The two-year rodent bioassays serve as experimental vehicles to determine the high-dose cancer risks in animals and then to predict, by extrapolation, the number of carcinogen-induced tumors (tumor incidence) that will arise during the lifespans of humans who are exposed to environmental carcinogens at doses typically orders of magnitude below those applied in the rodent assays. An integrated toxicological analysis is conducted herein to reconsider an alternative and once-promising approach, tumor latency, for estimating carcinogen-induced cancer risks at low doses. Tumor latency measures time-to-tumor following exposure to a carcinogen, instead of tumor incidence. Evidence for and against the concept of carcinogen-induced tumor latency is presented, discussed, and then examined with respect to its relationship to dose, dose rates, and the dose-related concepts of initiation, tumor promotion, tumor regression, tumor incidence, and hormesis. Considerable experimental evidence indicates: (1) tumor latency (time-to-tumor) is inversely related to the dose of carcinogens and (2) lower doses of carcinogens display quantifiably discrete latency thresholds below which the promotion and, consequently, the progression and growth of tumors are delayed or prevented during a normal lifespan. Besides reconciling well with the concept of tumor promotion, such latency thresholds also reconcile favorably with the existence of thresholds for tumor incidence, the stochastic processes of tumor initiation, and the compensatory repair mechanisms of hormesis. Most importantly, this analysis and the arguments presented herein provide sound theoretical, experimental, and mechanistic rationales for rethinking the foundational premises of low-dose linearity and updating the current practices of cancer risk assessment to include the concept of carcinogen thresholds.

Radiophobic Fear-Mongering, Misappropriation of Medical References and Dismissing Relevant Data Forms the False Stance for Advocating Against the Use of Routine and Repeat Radiography in Chiropractic and Manual Therapy

There is a faction within the chiropractic profession passionately advocating against the routine use of X-rays in the diagnosis, treatment and management of patients with spinal disorders (aka subluxation). These activists reiterate common false statements such as "there is no evidence" for biomechanical spine assessment by X-ray, "there are no guidelines" supporting routine imaging, and also promulgate the reiterating narrative that "X-rays are dangerous." These arguments come in the form of recycled allopathic "red flag only" medical guidelines for spine care, opinion pieces and consensus statements. Herein, we review these common arguments and present compelling data refuting such claims. It quickly becomes evident that these statements are false. They are based on cherry-picked medical references and, most importantly, expansive evidence against this narrative continues to be ignored. Factually, there is considerable evidential support for routine use of radiological imaging in chiropractic and manual therapies for 3 main purposes: 1. To assess spinopelvic biomechanical parameters; 2. To screen for relative and absolute contraindications; 3. To reassess a patient's progress from some forms of spine altering treatments. Finally, and most importantly, we summarize why the long-held notion of carcinogenicity from X-rays is not a valid argument.

Adaptation to ionizing radiation of higher plants: From environmental radioactivity to chernobyl disaster

The purpose of this work is to highlight the effects of ionizing radiation on the genetic material in higher plants by assessing both adaptive processes as well as the evolution of plant species. The effects that the ionizing radiation has on greenery following a nuclear accident, was examined by taking the Chernobyl Nuclear Power Plant disaster as a case study. The genetic and evolutionary effects that ionizing radiation had on plants after the Chernobyl accident were highlighted. The response of biota to Chernobyl irradiation was a complex interaction among radiation dose, dose rate, temporal and spatial variation, varying radiation sensitivities of the different plants' species, and indirect effects from other events. Ionizing radiation causes water radiolysis, generating highly reactive oxygen species (ROS). ROS induce the rapid activation of detoxifying enzymes. DeoxyriboNucleic Acid (DNA) is the object of an attack by both, the hydroxyl ions and the radiation itself, thus triggering a mechanism both direct and indirect. The effects on DNA are harmful to the organism and the long-term development of the species. Dose-dependent aberrations in chromosomes are often observed after irradiation. Although multiple DNA repair mechanisms exist, double-strand breaks (DSBs or DNA-DSBs) are often subject to errors. Plants DSBs repair mechanisms mainly involve homologous and non-homologous dependent systems, the latter especially causing a loss of genetic information. Repeated ionizing radiation (acute or chronic) ensures that plants adapt, demonstrating radioresistance. An adaptive response has been suggested for this phenomenon. As a result, ionizing radiation influences the genetic structure, especially during chronic irradiation, reducing genetic variability. This reduction may be associated with the fact that particular plant species are more subject to chronic stress, confirming the adaptive theory. Therefore, the genomic effects of ionizing radiation demonstrate their likely involvement in the evolution of plant species.

5 Reasons Why Scoliosis X-Rays Are Not Harmful

Radiographic imaging for scoliosis screening, diagnosis, treatment, and management is the gold standard assessment tool. Scoliosis patients receive many repeat radiographs, typically 10-25 and as many as 40-50, equating to a maximum 50 mGy of cumulative exposure. It is argued this amount of radiation exposure is not carcinogenic to scoliosis patients for 5 main reasons: 1. Estimated theoretical cumulative effective doses remain below the carcinogenic dose threshold; 2. Scoliosis patient x-rays are delivered in serial exposures and therefore, mitigate any potential cumulative effect; 3. Linear no-threshold cancer risk estimates from scoliosis patient cohorts are flawed due to faulty science; 4. Standardized incidence/mortality ratios demonstrating increased cancers from aged scoliosis cohorts are confounded by the effects of the disease entity itself making it impossible to claim cause and effect resulting from low-dose radiation exposures from spinal imaging; 5. Children are not more susceptible to radiation damage than adults. Radiophobia concerns from patients, parents, and doctors over repeat imaging for scoliosis treatment and management is not justified; it adds unnecessary anxiety to the patient (and their parents) and interferes with optimal medical management. X-rays taken in the evidence-based management of scoliosis should be taken without hesitation or concern about negligible radiation exposures.

X-Ray Hesitancy: Patients' Radiophobic Concerns Over Medical X-rays

All too often the family physician, orthopedic surgeon, dentist or chiropractor is met with radiophobic concerns about X-ray imaging in the clinical setting. These concerns, however, are unwarranted fears based on common but ill-informed and perpetuated ideology versus current understanding of the effects of low-dose radiation exposures. Themes of X-ray hesitancy come in 3 forms: 1. All radiation exposures are harmful (i.e. carcinogenic); 2. Radiation exposures are cumulative; 3. Children are more susceptible to radiation. Herein we address these concerns and find that low-dose radiation activates the body's adaptive responses and leads to reduced cancers. Low-dose radiation is not cumulative as long as enough time (e.g. 24 hrs) passes prior to a repeated exposure, and any damage is repaired, removed, or eliminated. Children have more active immune systems; the literature shows children are no more affected than adults by radiation exposures. Medical X-rays present a small, insignificant addition to background radiation exposure that is not likely to cause harm. Doctors and patients alike should be better informed of the lack of risks from diagnostic radiation and the decision to image should rely on the best evidence, unique needs of the patient, and the expertise of the physician-not radiophobia.

Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) Science and the CBRNE Science Medical Operations Science Support Expert (CMOSSE)

A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.

Are Restrictive Medical Radiation Imaging Campaigns Misguided? It Seems So: A Case Example of the American Chiropractic Association's Adoption of "Choosing Wisely"

Since the 1980s, increased utilization of medical radiology, primarily computed tomography, has doubled medically sourced radiation exposures. Ensuing fear-mongering media headlines of iatrogenic cancers from these essential medical diagnostic tools has led the public and medical professionals alike to display escalating radiophobia. Problematically, several campaigns including Image Gently, Image Wisely, and facets of Choosing Wisely propagate fears of all medical radiation, which is necessary for the delivery of effective and efficient health care. Since there are no sound data supporting the alleged risks from low-dose radiation and since there is abundant evidence of health benefits from low-doses, these imaging campaigns seem misguided. Further, thresholds for cancer are 100 to 1000-fold greater than X-rays, which are within the realm of natural background radiation where no harm has ever been validated. Here, we focus on radiographic imaging for use in spinal rehabilitation by manual therapists, chiropractors, and physiotherapists as spinal X-rays represent the lowest levels of radiation imaging and are critical in the diagnosis and management of spine-related disorders. Using a case example of a chiropractic association adopting "Choosing Wisely," we argue that these campaigns only fuel the pervasive radiophobia and continue to constrain medical professionals, attempting to deliver quality care to patients.

Quantification of DNA Double Strand Breaks and Oxidation Response in Children and Adults Undergoing Dental CBCT Scan

Assessing the possible biological effects of exposure to low doses of ionizing radiation (IR) is one of the prime challenges in radiation protection, especially in medical imaging. Today, radiobiological data on cone beam CT (CBCT) related biological effects are scarce. In children and adults, the induction of DNA double strand breaks (DSBs) in buccal mucosa cells and 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxo-dG) and antioxidant capacity in saliva samples after CBCT examination were examined. No DNA DSBs induction was observed in children nor adults. In children only, an increase in 8-oxo-dG levels was observed 30 minutes after CBCT. At the same time an increase in antioxidant capacity was observed in children, whereas a decrease was observed in adults. Our data indicate that children and adults react differently to IR doses associated with CBCT. Fully understanding these differences could lead to an optimal use of CBCT in different age categories as well as improved radiation protection guidelines.

Manifestations of allostatic load in residents of radiation contaminated areas aged 18–24 years

We studied the features of allostatic load (AL) in 100 students aged 18–24 years old who, from birth to adulthood, lived in the territories assigned to the IV radiation zone after the Chornobyl accident (density of soil contamination by isotopes 137Cs 3.7–18.5∙104 Bq/m2) and underwent prolonged exposure to small doses of ionizing radiation. The examined students did not have any clinical signs of the immune-neuroendocrine system dysfunction. 50 people had signs of vegetative-vascular dystonia syndrome (VVD), 48 had signs of moderate hyperthyroidism and 21 had signs of moderate hypothyroidism. During the examination session, as a factor of additional psycho-emotional load, in 66 of the examined the immunoregulatory index CD4+/CD8+ went below the lower limit of the homeostatic norm, in 62 of the examined low density lipoprotein cholesterol (LDL-C) exceeded the upper level. The relative risk (RR) and attributable risk (AR) of the participation of potential secondary factors of allostatic load formation in CD4+/CD8+ immunoregulatory index going below the lower limit were calculated. The presence of statistically significant relative risk of participation in the formation of suppression of the index CD4+/CD8+: the state of hyperthyroidism, state of hypothyroidism, vegetative-vascular dystonia syndrome, higher than normal LDL-C. When the examined students combined the signs of hyperthyroidism, vegetative-vascular dystonia syndrome and higher level of LDL-C; with combination of signs of hypothyroidism, vegetative-vascular dystonia syndrome and higher level of LDL-C. The attributable risk in all cases exceeded 0.10, which confirmed the importance of some of these factors and their complexes in the formation of the effect of reduced immunoregulatory index. The CD4+/CD8+ index can be considered an important biomarker of AL and premature age-related changes in the immune system in residents of radiation-contaminated areas. The risk of AL formation in the case of occurrence of a complex of mediated secondary biomarkers (vegetative-vascular dystonia syndrome, thyroid dysfunction, hypercholesterolemia) is higher compared to their individual significance.

Repeat Radiography in Monitoring Structural Changes in the Treatment of Spinal Disorders in Chiropractic and Manual Medicine Practice: Evidence and Safety

There is substantial evidence for normal relationships between spine and postural parameters, as measured from radiographs of standing patients. Sagittal balance, cervical lordosis, thoracic kyphosis, lumbar lordosis, pelvic tilt, and the more complex understanding of the interrelations between these essential components of normal stance have evolved to where there are known, established thresholds for normalcy. These spinal parameters are reliably measured from X-ray images and serve as goals of care in the treatment of spine and postural disorders. Initial and follow-up spinal imaging by X-ray is thus crucial for the practice of contemporary and evidence-based structural rehabilitation. Recent studies have demonstrated that improvement in the spine and posture by nonsurgical methods offers superior long-term patient outcomes versus conventional methods that only temporarily treat pain/dysfunction. Low-dose radiation from repeated X-ray imaging in treating subluxated patients is substantially below the known threshold for harm and is within background radiation exposures. Since alternative imaging methods are not clinically practical at this time, plain radiography remains the standard for spinal imaging. It is safe when used in a repeated fashion for quantifying pre-post spine and postural subluxation and deformity patterns in the practice of structural correction methods by chiropractic and other manual medicine practices.

A Critical Assessment of the Linear No-Threshold Hypothesis: Its Validity and Applicability for Use in Risk Assessment and Radiation Protection

The Society of Nuclear Medicine and Molecular Imaging convened a task group to examine the evidence for the risk of carcinogenesis from low-dose radiation exposure and to assess evidence in the scientific literature related to the overall validity of the linear no-threshold (LNT) hypothesis and its applicability for use in risk assessment and radiation protection. In the low-dose and dose-rate region, the group concluded that the LNT hypothesis is invalid as it is not supported by the available scientific evidence and, instead, is actually refuted by published epidemiology and radiation biology. The task group concluded that the evidence does not support the use of LNT either for risk assessment or radiation protection in the low-dose and dose-rate region.

Linear No-threshold (LNT) vs. Hormesis: Paradigms, Assumptions, and Mathematical Conventions that Bias the Conclusions in Favor of LNT and Against hormesis

The linear no-threshold assumption misunderstands the complex multiphasic biological response to ionizing radiation, focusing solely on the initial physical radiogenic damage. This misunderstanding is enabled (masked and amplified) by a number of mathematical approaches that bias results in favor of linear no-threshold and away from alternatives, like hormesis, that take biological response into account. Here we explore a number of these mathematical approaches in some detail, including the use of frequentist rather than Bayesian statistical rules and methods. We argue that a Bayesian approach cuts through an epidemiological stalemate, in part because it enables a better understanding of the concept of plausibility, which in turn properly rests on empirical evidence of actual physical and biological mechanisms. Misuse of the concept of plausibility has sometimes been used to justify the mathematically simple and convenient linearity-without-a-threshold assumption, in particular with the everywhere-positive slope that is central to linear no-threshold and its variants. Linear no-threshold's dominance in the area of dose regulation further rests on a misapplication of the precautionary principle, which only holds when a putative caution has positive effects that outweigh the negative unintended consequences. In this case the negative consequences far outweigh the presumed hazards.

Educating about radiation risks in high schools: towards improved public understanding of the complexity of low-dose radiation health effects

The levels of stochastic health effects following exposure to low doses of ionising radiation are not well known. A consequence of the uncertainty is that any radiation exposure is met with deep concern-both by the public and by scientists who disagree about how the partly conflicting results from low-dose studies should be interpreted. The concern is not limited to ionising radiation but is inherent to other areas of modern technologies such as biotechnology or electromagnetic fields. The everyday presence of advanced technologies confronts people with the necessity to take decisions and there is an ongoing debate regarding both the nature and magnitude of potential risks and how education efforts may empower peoples´ decision-making. In the field of radiation research there are different opinions regarding the optimal education methods, spanning from the idea that peoples' fears will be eliminated by introducing dose thresholds below which the risk is assumed to be zero, to suggestions of concentrating research efforts in an attempt to eliminate all uncertainties regarding the effects of low doses. The aim of this paper was to present our approach which is based on developing an education program at the secondary school level where students learn to understand the role of science in society. Teaching about radiation risk as a socio-scientific issue is not based on presenting facts but on showing risks in a broader perspective aiming at developing students' competency in making decisions based on informed assessment. We hope to stimulate and encourage other researchers to pursue similar approaches.

The Linear No-Threshold Model of Low-Dose Radiogenic Cancer: A Failed Fiction

The linear no-threshold (LNT) model for low-dose, radiogenic cancer has been a fixture of radiation protection and regulatory requirements for decades, but its validity has long been contested. This article finds, yet again, more questionable data and analyses purporting to support the model, this within the “gold-standard” data set for estimating radiation effects in humans. Herein is addressed a number of significant uncertainties in the Radiation Effects Research Foundation’s Life Span Study (LSS) cohort of atomic bomb survivors, especially in its latest update of 2017, showing that the study’s support of the LNT model is not evidence based. We find that its latest 2 analyses of solid cancer incidence ignore biology and do not support the LNT model. Additionally, we identify data inconsistencies and missing causalities in the LSS data and analyses that place reliance on uncertain, imputed data and apparently flawed modeling, further invalidating the LNT model. These observations lead to a most credible conclusion, one supporting a threshold model for the dose–response relationship between low-dose radiation exposure and radiogenic cancer in humans. Based upon these findings and those cited from others, it becomes apparent that the LNT model cannot be scientifically valid.

Low-dose radiation from A-bombs elongated lifespan and reduced cancer mortality relative to un-irradiated individuals

The US National Academy of Sciences (NAS) presented the linear no-threshold hypothesis (LNT) in 1956, which indicates that the lowest doses of ionizing radiation are hazardous in proportion to the dose. This spurious hypothesis was not based on solid data. NAS put forward the BEIR VII report in 2006 as evidence supporting LNT. The study described in the report used data of the Life Span Study (LSS) of A-bomb survivors. Estimation of exposure doses was based on initial radiation (5%) and neglected residual radiation (10%), leading to underestimation of the doses. Residual radiation mainly consisted of fallout that poured down onto the ground along with black rain. The black-rain-affected areas were wide. Not only A-bomb survivors but also not-in-the-city control subjects (NIC) must have been exposed to residual radiation to a greater or lesser degree. Use of NIC as negative controls constitutes a major failure in analyses of LSS. Another failure of LSS is its neglect of radiation adaptive responses which include low-dose stimulation of DNA damage repair, removal of aberrant cells via stimulated apoptosis, and elimination of cancer cells via stimulated anticancer immunity. LSS never incorporates consideration of this possibility. When LSS data of longevity are examined, a clear J-shaped dose-response, a hallmark of radiation hormesis, is apparent. Both A-bomb survivors and NIC showed longer than average lifespans. Average solid cancer death ratios of both A-bomb survivors and NIC were lower than the average for Japanese people, which is consistent with the occurrence of radiation adaptive responses (the bases for radiation hormesis), essentially invalidating the LNT model. Nevertheless, LNT has served as the basis of radiation regulation policy. If it were not for LNT, tremendous human, social, and economic losses would not have occurred in the aftermath of the Fukushima Daiichi nuclear plant accident. For many reasons, LNT must be revised or abolished, with changes based not on policy but on science.

Increasing the cervical and lumbar lordosis is possible despite overt osteoarthritis and spinal stenosis using extension traction to relieve low back and leg pain in a 66-year-old surgical candidate: a CBP® case report

[Purpose] To present the case of the dramatic relief of low back pain, leg pain and disability in an older female with osteoarthritis, lumbar spinal stenosis and hypolordosis of the cervical and lumbar spine. [Participant and Methods] A 66-year-old female presented with chronic low back pain, right leg pain, numbness and weakness. Despite being recommended for surgery, the patient sought alternative treatment. The patient was treated with Chiropractic BioPhysics^® rehabilitation of the spine with the objective to increase the lumbar and cervical lordoses. Cervical and lumbar extension exercises and traction were performed as well as spinal manipulation. Treatment was performed approximately three times per week for 6.5 months. [Results] Re-assessment after treatment demonstrated significant reduction of low back pain, leg pain and other health improvements. X-rays showed structural improvements in the cervical and lumbar spine despite advanced osteoarthritis. [Conclusion] Lumbar and cervical hypolordosis subluxation may be increased in those with spinal deformity caused symptoms, despite the presence of osteoarthritis and degenerative stenosis of the spine. Spinal x-rays as used in the assessment and monitoring of patients being treated with contemporary spinal rehabilitation methods are not harmful and should be used for routine screening purposes.

A critical evaluation of the NCRP COMMENTARY 27 endorsement of the linear no-threshold model of radiation effects

Regulatory policy to protect the public and the environment from radiation is universally based on the linear, no-threshold model (LNT) of radiation effects. This model has been controversial since its inception over nine decades ago, and remains so to this day, but it has proved remarkably resistant to challenge from the scientific community. The LNT model has been repeatedly endorsed by expert advisory bodies, and regulatory agencies in turn adopt policies that reflect this advice. Unfortunately, these endorsements rest on a foundation of institutional inertia and numerous logical fallacies. These include most significantly setting the LNT as the null hypothesis, and shifting the burden of proof onto LNT skeptics. Other examples include arbitrary exclusion of alternative hypotheses, ignoring criticisms of the LNT, cherry-picking evidence, and making policy judgements without foundation. This paper presents an evaluation of the National Council on Radiation Protection and Measurements' (NCRP) Commentary 27, which concluded that recent epidemiological studies are compatible with the continued use of the LNT model for radiation protection. While this report will likely provide political cover for regulators' continued reliance on the LNT, it is a missed opportunity to advance the scientific discussion of the effects of low dose, low dose-rate radiation exposure. Due to its Congressionally chartered mission, no organization is better positioned than the NCRP to move this debate forward, and recommendations for doing so in future reviews are provided.

Collaborative study of thresholds for mutagens: proposal of a typical protocol for detection of hormetic responses in cytotoxicity tests

BACKGROUND

According to the linear no-threshold model (LNT), even the smallest amount of radiation is hazardous. Although the LNT is not based on solid data, this hypothesis has been applied to mutagens and carcinogens. As a result, it has been postulated that there are no thresholds for these chemicals. To demonstrate negativity by experiments is practically impossible, because negative data may leave behind the possibility that additional data might make the resolution power high enough to change negativity to positivity. Furthermore, additional data collection may be endless and we may be trapped in agnosticism. When hormesis is established, in which biological responses are higher at low-doses and lower at high-doses than the control, thresholds could be established between the low- and high-doses. Before examination of thresholds in chemical mutagenesis, hormetic responses in cytotoxicity were tested using cultured mammalian cells.

METHOD

Human cells (HeLa S3 and TK6) or Chinese hamster cells (CHL/IU) were cultured in 96-well plates and treated with mitomycin C (MMC) or ethyl methanesulfonate (EMS) at various dose levels and optical density was measured after addition of a reagent to detect cellular activity. In hormetic responses, data might fluctuate to and fro; therefore, experimental conditions were examined from various aspects to eliminate confounding factors including cell numbers, detection time, the edge effect of 96-well plates, and measurement time after addition of the reagent for detection.

RESULTS

The dose response relationship was never linear. Cellular activities after treatment with MMC or EMS were generally higher at lower doses levels and lower at higher doses than the control, showing hormesis and allowing the establishment of thresholds. Dose response curves sometimes showed two or three peaks, probably reflecting different cellular responses.

CONCLUSION

Hormetic responses in cytotoxicity tests were observed and thresholds could be established. Based on the results of this investigation, we put forward a tentative protocol to detect chemical hormesis in cytotoxicity tests, i.e., inoculate 2000 cells per well, add various doses of a test chemical 48 h after inoculation, add a detection dye 10 h after treatment, and measure optical density 2 h after addition of the reagent for detection.

Are We Approaching the End of the Linear No-Threshold Era?

The linear no-threshold (LNT) model for radiation-induced cancer was adopted by national and international advisory bodies in the 1950s and has guided radiation protection policies worldwide since then. The resulting strict regulations have increased the compliance costs for the various uses of radiation, including nuclear medicine. The concerns about low levels of radiation due to the absence of a threshold have also resulted in adverse consequences. Justification of the LNT model was based on the concept that low levels of radiation increase mutations and that increased mutations imply increased cancers. This concept may not be valid. Low-dose radiation boosts defenses such as antioxidants and DNA repair enzymes. The boosted defenses would reduce the endogenous DNA damage that would have occurred in the subsequent period, and so the result would be reduced DNA damage and mutations. Whereas mutations are necessary for causing cancer, they are not sufficient since the immune system eliminates cancer cells or keeps them under control. The immune system plays an extremely important role in preventing cancer, as indicated by the substantially increased cancer risk in immune-suppressed patients. Hence, since low-dose radiation enhances the immune system, it would reduce cancers, resulting in a phenomenon known as radiation hormesis. There is considerable evidence for radiation hormesis and against the LNT model, including studies of atomic bomb survivors, background radiation, environmental radiation, cancer patients, medical radiation, and occupational exposures. Though Commentary 27 published by the National Council on Radiation Protection and Measurements concluded that recent epidemiologic studies broadly support the LNT model, a critical examination of the studies has shown that they do not. Another deficiency of Commentary 27 is that it did not consider the vast available evidence for radiation hormesis. Other advisory body reports that have supported the LNT model have similar deficiencies. Advisory bodies are urged to critically evaluate the evidence supporting both sides and arrive at an objective conclusion on the validity of the LNT model. Considering the strength of the evidence against the LNT model and the weakness of the evidence for it, the present analysis indicates that advisory bodies would be compelled to reject the LNT model. Hence, we may be approaching the end of the LNT model era.

Risk factors for human cutaneous anthrax outbreaks in the hotspot districts of Northern Tanzania: an unmatched case-control study

Bacillus anthracis is an aerobic, Gram-positive and spore-forming bacterium, which causes anthrax in herbivores. Humans get infected after coming into contact with infected animals' products. An unmatched case-control study was conducted to identify the importance of demographic, biological and/or behavioural factors associated with human cutaneous anthrax outbreaks in the hotspot areas of Northern Tanzania. A semi-structured questionnaire was administered to both cases and controls. The age range of participants was 1-80 years with a median age of 32 years. In the younger group (1-20 years), the odds of being infected were 25 times higher in the exposed group compared to the unexposed group (OR= 25, 95% CI = 1.5-410). By contrast, the odds of exposure in the old group (≥20 years) were three times lower in the exposed group compared to the unexposed group (OR = 3.2, 95% CI = 1.28-8.00). Demographic characteristics, sleeping on animal's skins, contacting with infected carcasses through skinning and butchering, and not having formal education were linked to exposure for anthrax infection. Hence, a One Health approach is inevitable for the prevention and control of anthrax outbreaks in the hotspot areas of Northern Tanzania.

Overview of Biological, Epidemiological, and Clinical Evidence of Radiation Hormesis

The effects of low-dose radiation are being increasingly investigated in biological, epidemiological, and clinical studies. Many recent studies have indicated the beneficial effects of low doses of radiation, whereas some studies have suggested harmful effects even at low doses. This review article introduces various studies reporting both the beneficial and harmful effects of low-dose radiation, with a critique on the extent to which respective studies are reliable. Epidemiological studies are inherently associated with large biases, and it should be evaluated whether the observed differences are due to radiation or other confounding factors. On the other hand, well-controlled laboratory studies may be more appropriate to evaluate the effects of low-dose radiation. Since the number of such laboratory studies is steadily increasing, it will be concluded in the near future whether low-dose radiation is harmful or beneficial and whether the linear-no-threshold (LNT) theory is appropriate. Many recent biological studies have suggested the induction of biopositive responses such as increases in immunity and antioxidants by low-dose radiation. Based on recent as well as classical studies, the LNT theory may be out of date, and low-dose radiation may have beneficial effects depending on the conditions; otherwise, it may have no effects.

Alleviation of chronic spine pain and headaches by reducing forward head posture and thoracic hyperkyphosis: a CBP® case report

[Purpose] This case presents the reduction of both forward head posture and thoracic hyperkyphosis in a young male with chronic back pain and headaches by a comprehensive posture rehabilitation program as a part of Chiropractic BioPhysics^® methods. [Participant and Methods] A 32 year old male presented with constant pain and headaches for seven years since he was involved in a work related injury. He had seen five different MDs, undergone multiple imaging tests, and received multiple prescriptions, thirteen steroid injections and was recommended for a spine surgery that he had denied. He was on long-term disability. Upon comprehensive posture and spine assessment, the patient had exaggerated forward head translation and thoracic hyperkyphosis. The patient was treated 36 times over 13-weeks with cervical and thoracic extension exercises, traction, and manipulation. [Results] After treatment the patient reported dramatic improvement in symptoms as indicated on valid disability questionnaires and substantial improvements in posture. [Conclusion] Posture-related pain and disability is not often addressed in allopathic medicine but substantial posture improvements are achievable in short time periods as this case illustrates. Poor postures in young patients should be corrected to avoid long-term consequences. Radiography as used in spinal rehabilitation is safe and reliable.

Non-operative correction of flat back syndrome using lumbar extension traction: a CBP® case series of two

[Purpose] To document the non-operative rehabilitation of lumbar lordosis in two cases with chronic low back pain and flexible flat back syndrome. [Participants and Methods] Two young adult males reported suffering from chronic low back pain associated with anterior sagittal balance and severe loss of lumbar lordosis, aka ‘flat back syndrome.’ Lumbar extension traction was applied 3–5 times per week for 16.5–20 weeks. A torsion type lumbar spinal manipulative therapy was provided in the initial 3 weeks for short-term pain relief. [Results] Both patients had dramatic improvement in lumbar lordosis with simultaneous reduction in pain levels. One patient had a 50° lordosis improvement in 100 treatments over 20 weeks; the other had a 26° lordosis improvement in 70 treatments over 16.5 weeks. There were also improvements in sacral base angle, pelvic tilt and sagittal balance. One patient demonstrated stability of health status and further improvements in radiographic measures including lordosis angle nearly 10-months post-treatment. [Conclusion] This is the first successful non-operative correction of flat back syndrome. This approach seems highly effective, is a fraction of the cost of spinal surgery typically used to treat this condition, and offers no health risks including those assumed from radiography necessary for screening and follow-up.

It Is Time to Move Beyond the Linear No-Threshold Theory for Low-Dose Radiation Protection

The US Environmental Protection Agency (USEPA) is the primary federal agency responsible for promulgating regulations and policies to protect people and the environment from ionizing radiation. Currently, the USEPA uses the linear no-threshold (LNT) model to estimate cancer risks and determine cleanup levels in radiologically contaminated environments. The LNT model implies that there is no safe dose of ionizing radiation; however, adverse effects from low dose, low-dose rate (LDDR) exposures are not detectable. This article (1) provides the scientific basis for discontinuing use of the LNT model in LDDR radiation environments, (2) shows that there is no scientific consensus for using the LNT model, (3) identifies USEPA reliance on outdated scientific information, and (4) identifies regulatory reliance on incomplete evaluations of recent data contradicting the LNT. It is the time to reconsider the use of the LNT model in LDDR radiation environments. Incorporating the latest science into the regulatory process for risk assessment will (1) ensure science remains the foundation for decision making, (2) reduce unnecessary burdens of costly cleanups, (3) educate the public on the real effects of LDDR radiation exposures, and (4) harmonize government policies with the rest of the radiation scientific community.

Old Data-New Concepts: Integrating "Indirect Effects" Into Radiation Protection

PURPOSE

To address the following key question, what are the consequences of nontargeted and delayed effects for linear nonthreshold models of radiation risk? This paper considers low-dose "indirect" or nontargeted effects and how they might impact radiation protection, particularly at the level of the environment. Nontargeted effects refer to effects in cells, tissues, or organisms that were not targeted by irradiation and that did not receive direct energy deposition. They include genomic instability and lethal mutations in progeny of irradiated cells and bystander effects in neighboring cells, tissues, or organisms. Low-dose hypersensitivity and adaptive responses are sometimes included under the nontargeted effects umbrella, but these are not considered in this paper. Some concepts emerging in the nontargeted effects field that could be important include historic dose. This suggests that the initial exposure to radiation initiates the instability phenotype which is passed to progeny leading to a transgenerational radiation-response phenotype, which suggests that the system response rather than the individual response is critical in determining outcome.

CONCLUSION

Nontargeted effects need to be considered, and modeling, experimental, and epidemiological approaches could all be used to determine the impact of nontargeted effects on the currently used linear nonthreshold model in radiation protection.

Urology mythbusters: Radiation and radiophobia

In this episode of Mythbusters we critically examine the premise that there is strong biological and epidemiologic evidence that radiation exposure at levels associated with modern genitourinary diagnostic imaging increases the risk of subsequent malignancy, especially in children.

Saving Lives and Preventing Injuries From Unjustified Protective Actions-Method for Developing a Comprehensive Public Protective Action Strategy for a Severe NPP Emergency

During the response to the Fukushima Daiichi nuclear power plant (FDNPP) emergency, about 50 patients died during or shortly after an evacuation when they were not provided with the needed medical support. In addition, it has been shown that during the FDNPP emergency there were increases in mortality rates among the elderly due to long-term dislocation as a result of evacuation and relocation orders and an inability to stay in areas where residents were advised to shelter for extended periods. These deaths occurred even though the possible radiation exposure to the public was too low to result in radiation-induced deaths, injuries, or a meaningful increase in the cancer rate, even if no protective actions had been taken. These problems are not unique to the FDNPP emergency and would be expected if the recommendations of many organizations were followed. Neither the International Commission on Radiological Protection (ICRP), the U.S. Nuclear Regulatory Commission (NRC) nor the U.S Environmental Protection Agency (EPA) adequately take into consideration in their recommendations and analysis the non-radiological health impacts, such as deaths and injuries, that could result from protective actions. Furthermore, ICRP, NRC, EPA, and the U.S. Department of Homeland Security (DHS) call for taking protective actions at doses lower than those resulting in meaningful adverse radiation-induced health effects and do not state the doses at which such effects would be seen. Consequently, it would be impossible for decision makers and the public to balance all the hazards both from radiation exposure and protective actions when deciding whether a protective action is justified. What is needed, as is presented in this paper, is a method for developing a comprehensive protective action strategy that allows the public, decision makers, and others who must work together to balance the radiological with the non-radiological health hazards posed by protective actions, and to counter the exaggerated fear of radiation exposure that could lead to taking unjustified protective actions and adverse psychological, sociological, and other effects.

Hormesis and radiation safety norms: Comments for an update

Hormesis can be explained by evolutionary adaptation to the current level of a factor present in the natural environment or to some average from the past. This pertains also to ionizing radiation as the natural background has been decreasing during the time of the life existence. DNA damage and repair are normally in a dynamic balance. The conservative nature of the DNA repair suggests that cells may have retained some capability to repair damage from higher radiation levels than that existing today. According to this concept, the harm caused by radioactive contamination would tend to zero with a dose rate tending to a wide range level of the natural radiation background. Existing evidence in favor of hormesis is substantial, experimental data being partly at variance with results of epidemiological studies. Potential bias, systematic errors, and motives to exaggerate risks from low-dose low-rate ionizing radiation are discussed here. In conclusion, current radiation safety norms are exceedingly restrictive and should be revised on the basis of scientific evidence. Elevation of the limits must be accompanied by measures guaranteeing their observance.

Radiophobia: 7 Reasons Why Radiography Used in Spine and Posture Rehabilitation Should Not Be Feared or Avoided

Evidence-based contemporary spinal rehabilitation often requires radiography. Use of radiography (X-rays or computed tomography scans) should not be feared, avoided, or have their exposures lessened to decrease patient dose possibly jeopardizing image quality. This is because all fears of radiation exposures from medical diagnostic imaging are based on complete fabrication of health risks based on an outdated, invalid linear model that has simply been propagated for decades. We present 7 main arguments for continued use of radiography for routine use in spinal rehabilitation: (1) the linear no-threshold model for radiation risk estimates is invalid for low-dose exposures; (2) low-dose radiation enhances health via the body's adaptive response mechanisms (ie, radiation hormesis); (3) an X-ray with low-dose radiation only induces 1 one-millionth the amount of cellular damage as compared to breathing air for a day; (4) radiography is below inescapable natural annual background radiation levels; (5) radiophobia stems from unwarranted fears and false beliefs; (6) radiography use leads to better patient outcomes; (7) the risk to benefit ratio is always beneficial for routine radiography. Radiography is a safe imaging method for routine use in patient assessment, screening, diagnosis, and biomechanical analysis and for monitoring treatment progress in daily clinical practice.