The Risk of Cancer from CT Scans and Other Sources of Low-Dose Radiation: A Critical Appraisal of Methodologic Quality

Sagittal Full-Spine vs. Sectional Cervical Lateral Radiographs: Are the Measurements of Cervical Alignment Interchangeable?

(1) Background: This study assessed the relationship between cervical spine parameters taken on standing full-spine lateral radiographic images compared to sectional lateral cervical radiographs. (2) Methods: Full-spine (FS) and sectional lateral cervical (LC) radiographs from four spine treatment facilities across the USA retrospectively provided data collected on 220 persons to assess the comparison of three sagittal cervical radiographic measurements between the two views. The measures included cervical lordosis using the absolute rotation angle from C2-C7, sagittal cervical translation of C2-C7, and atlas plane angle to horizontal. Linear correlation and R2 models were used for statistical comparison of the measures for the two views. (3) Results: The mean values of the three measurements were statistically different from each other: C2-C7 translation (FS = 19.84 ± 11.98 vs. LC = 21.18 ± 11.8), C2-C7 lordosis (FS = -15.3 ± 14.63 vs. LC = -18.32 ± 13.16), and atlas plane (FS = -19.99 ± 8.88 vs. LC = -22.56 ± 8.93), where all values were p < 0.001. Weak-to-moderate-to-strong correlations existed between the full-spine and sectional lateral cervical radiographic variables. The R2 values varied based on the measurement were R2 = 0.768 (p < 0.001) for sagittal cervical translation of C2-C7 (strong), R2 = 0.613 (p < 0.001) for the absolute rotation angle C2-C7 (moderate), and R2 = 0.406 (p < 0.001) for the atlas plane line (weak). Though a linear correlation was identified, there were consistent intra-person differences between the measurements on the full spine versus sectional lateral cervical radiographic views, where the full-spine view consistently underestimated the magnitude of the variables. (4) Conclusion: Key sagittal cervical radiographic measurements on the full spine versus sectional lateral cervical radiographic views show striking intra-person differences. The findings of this study confirm that full spine versus sectional lateral cervical radiographic views provide different biomechanical magnitudes of cervical sagittal alignment, and caution should be exercised by health care providers as these are not interchangeable. We recommend the LC view for measurement of cervical sagittal alignment variables.

Two Methods of Forward Head Posture Assessment: Radiography vs. Posture and Their Clinical Comparison

Background: Forward head posture (FHP) and altered cervical lordotic curvatures are common spine displacements often associated with neck pain and disability. Two primary categories for determining FHP exist: radiographic and postural measurements. Methods: This study investigated the correlation between the craniovertebral angle (CVA), the radiographically measured C2-C7 sagittal vertical axis (SVA), and cervical lordosis (absolute rotation angle: ARA C2-C7) in a sample of participants with chronic myofascial pain (CMP). In 120 participants, we performed both a postural measurement of the CVA and a lateral cervical radiograph, where the C2-C7 SVA and ARA C2-C7 were measured. A linear-regression R2 value to assess the correlation between the CVA, C2-C7 SVA, and ARA C2-C7 was sought. Results: A statistically significant weak linear fit was identified (Spearman's r = 0.549; R2 = 0.30, p < 0.001) between the CVA and C2-C7 SVA, having considerable variation between the two measures. A statistically significant linear fit (very weak) was identified for the lordosis ARA C2-C7 and the CVA: Spearman's r = 0.524; R2 = 0.275; p < 0.001. A value of 50° for the CVA corresponded to a value of 20 mm for the C2-C7 SVA on an X-ray. Conclusion: While the CVA and radiographic C2-C7 SVA are weakly correlated in an individual, they seem to represent different aspects of sagittal cervical balance. The CVA cannot replace radiographically measured cervical lordosis. We recommend that more emphasis be given to radiographic measures of sagittal cervical alignment than the CVA when considering patient interventions.

COVID-19 and cancer risk arising from ionizing radiation exposure through CT scans: a cross-sectional study

BACKGROUND

The surge in the utilization of CT scans for COVID-19 diagnosis and monitoring during the pandemic is undeniable. This increase has brought to the forefront concerns about the potential long-term health consequences, especially radiation-induced cancer risk. This study aimed to quantify the potential cancer risk associated with CT scans performed for COVID-19 detection.

METHODS

In this cross-sectional study data from a total of 561 patients, who were referred to the radiology center at Imam Hossein Hospital in Shahroud, was collected. CT scan reports were categorized into three groups based on the radiologist's interpretation. The BEIR VII model was employed to estimate the risk of radiation-induced cancer.

RESULTS

Among the 561 patients, 299 (53.3%) were males and the average age of the patients was 49.61 ± 18.73 years. Of the CT scans, 408 (72.7%) were reported as normal. The average age of patients with normal, abnormal, and potentially abnormal CT scans was 47.57 ± 19.06, 54.80 ± 16.70, and 58.14 ± 16.60 years, respectively (p-value < 0.001). The average effective dose was 1.89 ± 0.21 mSv, with 1.76 ± 0.11 mSv for males and 2.05 ± 0.29 mSv for females (p-value < 0.001). The average risk of lung cancer was 3.84 ± 1.19 and 9.73 ± 3.27 cases per 100,000 patients for males and females, respectively. The average LAR for all cancer types was 10.30 ± 6.03 cases per 100,000 patients.

CONCLUSIONS

This study highlights the critical issue of increased CT scan usage for COVID-19 diagnosis and the potential long-term consequences, especially the risk of cancer incidence. Healthcare policies should be prepared to address this potential rise in cancer incidence and the utilization of CT scans should be restricted to cases where laboratory tests are not readily available or when clinical symptoms are severe.

Awareness of Radiation Hazards and Knowledge About Radiation Protection Among Medical Students at the Northern Border University, Arar

Studies have shown that medical students and doctors are not well equipped with knowledge of radiation hazards and their protection. This lack of knowledge may cause harm to patients and healthcare professionals. Objectives To compare the awareness of radiation hazards and knowledge about radiation protection among medical students at Northern Border University, Arar, Saudi Arabia, with and without prior teaching. Methods and materials This cross-sectional study was carried out among medical students from clinical years at Northern Border University, Arar, Saudi Arabia, from May 1st, 2023, to June 30th, 2023. Their consents were taken. Then they were randomly sorted into two groups. One group was given a radiation safety short course, and then they answered a questionnaire. The other group filled out the questionnaire without prior instruction, and analysis was done. The outcome of this study was quantified based on the score calculated after participants filled out the questionnaire. Results The mean score of students who didn't attend the radiology course was 3.38±1.8, while the score of students who attended the radiology course was 7.87±1.4 (p<0.001). Radiology course attendance showed a significant association with knowledge and awareness scores. Conclusions The average knowledge of medical students regarding radiation protection and hazards is quite poor. This lack of understanding could potentially lead to increased risks for both patients and healthcare professionals. The knowledge about radiation hazards and protection is increased in students who attended a short radiology course. We recommend implementing comprehensive educational programs that focus on radiation hazards and protection for medical students.

Evaluating the Necessity and Radiation Risk of Brain CT Scans Requested by the Trauma Emergency Department

Background

Numerous Computed Tomography (CT) scan requests for trauma patients have raised serious concern about the impacts of radiation such as radiation-induced cancers.

Objective

This study aimed to evaluate the necessity rate of requested head CT scans for traumatic patients and to ultimately estimate the risk of radiation-induced brain cancer.

Material and Methods

In this retrospective analytical study, traumatic patients, who had undergone a head CT scan in a two-month period from August 23 to October 22, 2018, were considered as the study population. Two radiologists reviewed each patient individually to evaluate the rate of normal and abnormal cases. Dose length product in milligrays (mGy) was utilized to calculate the effective dose (ED) in millisieverts (mSv), resulting in an assessment of the risk of radiation-induced brain cancer using ICRP 103.

Results

Among 523 scans, 460 patients (88%) received normal reviews, while only 47 patients (9%) had findings related to their current trauma. The mean effective dose value was 1.05±0.36 mSv. Risk of the radiation induced brain cancer was calculated to be 0.037 and 0.030 new cancer cases in 10000 males and females per Gy, respectively.

Conclusion

Final results demonstrated that a significant number of traumatic patients undergoing a CT scan are in fact, healthy. Such reckless usage of CT and consequently the excess exposure could result in a dramatic rise in cancer rates. The need to limit unnecessary CT scan usage and keeping the radiation given to patients as low as reasonably achievable (ALARA) when collecting essential diagnostic data is more critical than ever.

Toddler with giant omental cyst, profound anemia, and shock: case report and review of the literature

Giant greater omental cysts with associated massive hemorrhage are rare. We encountered a 16-month-old boy with a four-day history of acute abdominal pain, distension, and paleness. Physical examination revealed a blood pressure of 74/27 mmHg. No well-defined masses were observed on abdominal palpation. The hemoglobin level on admission was 24 g/L. After initial resuscitation and blood transfusion, a computed tomography (CT) scan was performed, revealing a giant cystic mass with an intracystic hemorrhage. The diagnosis was confirmed via exploratory laparotomy, and the cyst, with the attached partial omentum was removed. Pathological findings revealed a simple cyst originating from the greater omentum. The patient recovered uneventfully and remained well during the two-year follow-up period. We reviewed the literature published over the last 27 years on cases of omental cysts to evaluate demographic characteristics, clinical presentations, complications, diagnostic tool options, and surgical approaches.

Assessment of radiation level and potential risk to public living around major hospitals in central and western Bangladesh

Human beings are continuously bathed in radiation coming from natural and artificial sources. Although the use of radiation in medical applications is beneficial to patients, it also contributes significantly to the health hazard for radiation workers and the public if radiation-generating equipment and radioactive sources are not handled properly. 96% dose contributed from medical uses of ionizing radiation in the US population among man-made sources as per NCRP Report No. 160. There is no extensive study conducted on the large hospitals in Bangladesh following the In-Situ method. We used a real-time digital portable radiation monitor with Garmin eTrex Global Positioning System at 320 monitoring points for radiation monitoring and positioning around the ten largest hospitals in central & western Bangladesh from September to November 2021. The mean radiation dose rates around Bangabandhu Sheikh Mujib Medical University, Dhaka Medical College Hospital, Evercare Hospital, Khulna Medical College Hospital, Mitford Hospital, National Institute of Cancer Research Hospital, Popular Hospital, Rajshahi Medical College Hospital, Shaheed Suhrawardy Medical College Hospital, and Square Hospitals were measured as 0.145 ± 0.012 μSv/h, 0.135 ± 0.009 μSv/h, 0.148 ± 0.008 μSv/h, 0.139 ± 0.01 μSv/h, 0.133 ± 0.007 μSv/h, 0.153 ± 0.011 μSv/h, 0.144 ± 0.012 μSv/h, 0.137 ± 0.008 μSv/h, 0.145 ± 0.01 μSv/h, and 0.153 ± 0.009 μSv/h, respectively. The mean excess lifetime cancer risk (ELCR) of the public who lives nearby the hospital's boundary was estimated at 1.05 × 10-3, 0.983 × 10-3, 1.071 × 10-3, 1.004 × 10-3, 0.964 × 10-3, 1.084 × 10-3, 1.043 × 10-3,0.996 × 10-3, 1.051 × 10-3 & 1.112 × 10-3 respectively. ELCR in most of the locations around the ten largest hospitals in central & western Bangladesh is higher than the global average value. Radiation monitoring is significant for minimizing the public's radiation risk and keeping hospital environments as radiation-free as possible.

Potential Chemopreventive Role of Pterostilbene in Its Modulation of the Apoptosis Pathway

Cancer incidence keeps increasing every year around the world and is one of the leading causes of death worldwide. Cancer has imposed a major burden on the human population, including the deterioration of physical and mental health as well as economic or financial loss among cancer patients. Conventional cancer treatments including chemotherapy, surgery, and radiotherapy have improved the mortality rate. However, conventional treatments have many challenges; for example, drug resistance, side effects, and cancer recurrence. Chemoprevention is one of the promising interventions to reduce the burden of cancer together with cancer treatments and early detection. Pterostilbene is a natural chemopreventive compound with various pharmacological properties such as anti-oxidant, anti-proliferative, and anti-inflammatory properties. Moreover, pterostilbene, due to its potential chemopreventive effect on inducing apoptosis in eliminating the mutated cells or preventing the progression of premalignant cells to cancerous cells, should be explored as a chemopreventive agent. Hence, in the review, we discuss the role of pterostilbene as a chemopreventive agent against various types of cancer via its modulation of the apoptosis pathway at the molecular levels.

Identifying the Potential Role of Regional Bone Mineral Density on the Degree of Malleolar Involvement in Acute Ankle Fractures

Ankle fractures are a common traumatic lower extremity injury and are generally classified and characterized by the rotational mechanism of injury. At each malleolus (i.e., posterior, medial, and lateral) a fracture can occur or a ligamentous injury may be sustained. The purpose of this retrospective study was to determine if bone mineral density is a contributing factor on the number of fractured malleoli versus soft tissue injury in adult ankle fractures. Data was obtained from a registry of ankle fractures that were operatively treated by the foot and ankle team throughout our institutional facilities, from July 2017 to August 2019, and in which a preoperative computerized tomography scan was performed. Regional bone mineral density (BMD) was measured by calculating the average Hounsfield Unit (HU) on axial computerized tomography images of the distal fibula and tibia. The average HU was then compared to the number of fractured malleoli. One hundred eight patients met the study criteria. We identified statistically significant relationships between decreased BMD with increasing age (p < .01) and the male gender (p < .01). After adjusting for the covariates age and gender, no statistically significant relationship was identified between BMD and the number of malleoli involved in a given ankle fracture (p = .11). These findings suggest that while more investigation is required for ankle fracture patterns and BMD evaluation, increased age and biologic female gender is significantly related to decreased BMD as identified via HU.

AIGAN: Attention-encoding Integrated Generative Adversarial Network for the reconstruction of low-dose CT and low-dose PET images

X-ray computed tomography (CT) and positron emission tomography (PET) are two of the most commonly used medical imaging technologies for the evaluation of many diseases. Full-dose imaging for CT and PET ensures the image quality but usually raises concerns about the potential health risks of radiation exposure. The contradiction between reducing the radiation exposure and remaining diagnostic performance can be addressed effectively by reconstructing the low-dose CT (L-CT) and low-dose PET (L-PET) images to the same high-quality ones as full-dose (F-CT and F-PET). In this paper, we propose an Attention-encoding Integrated Generative Adversarial Network (AIGAN) to achieve efficient and universal full-dose reconstruction for L-CT and L-PET images. AIGAN consists of three modules: the cascade generator, the dual-scale discriminator and the multi-scale spatial fusion module (MSFM). A sequence of consecutive L-CT (L-PET) slices is first fed into the cascade generator that integrates with a generation-encoding-generation pipeline. The generator plays the zero-sum game with the dual-scale discriminator for two stages: the coarse and fine stages. In both stages, the generator generates the estimated F-CT (F-PET) images as like the original F-CT (F-PET) images as possible. After the fine stage, the estimated fine full-dose images are then fed into the MSFM, which fully explores the inter- and intra-slice structural information, to output the final generated full-dose images. Experimental results show that the proposed AIGAN achieves the state-of-the-art performances on commonly used metrics and satisfies the reconstruction needs for clinical standards.

The why, who, how, and what of communicating CT radiation risks to patients and healthcare providers

Computed tomography (CT) has witnessed tremendous growth in utilization. Despite its immense benefits, there is a growing concern from the general public and the medical community about the detrimental consequences of ionizing radiation from CT. Anxiety from the perceived risks associated with CT can deter referring physicians from ordering clinically indicated CT scans and patients from undergoing medically necessary exams. This article discusses various strategies for educating patients and healthcare providers on the benefits and risks of CT scanning and salient techniques for effective communication.

Radiation Exposure and Lifetime Attributable Risk of Cancer Incidence and Mortality from Low- and Standard-Dose CT Chest: Implications for COVID-19 Pneumonia Subjects

Since the novel coronavirus disease 2019 (COVID-19) outbreak, there has been an unprecedented increase in the acquisition of chest computed tomography (CT) scans. Nearly 616 million people have been infected by COVID-19 worldwide to date, of whom many were subjected to CT scanning. CT exposes the patients to hazardous ionizing radiation, which can damage the genetic material in the cells, leading to stochastic health effects in the form of heritable genetic mutations and increased cancer risk. These probabilistic, long-term carcinogenic effects of radiation can be seen over a lifetime and may sometimes take several decades to manifest. This review briefly describes what is known about the health effects of radiation, the lowest dose for which there exists compelling evidence about increased radiation-induced cancer risk and the evidence regarding this risk at typical CT doses. The lifetime attributable risk (LAR) of cancer from low- and standard-dose chest CT scans performed in COVID-19 subjects is also discussed along with the projected number of future cancers that could be related to chest CT scans performed during the COVID-19 pandemic. The LAR of cancer Incidence from chest CT has also been compared with those from other radiation sources, daily life risks and lifetime baseline risk.

Prophylactic Splenectomy and Hyposplenism in Spaceflight

BACKGROUND: There is debate whether astronauts traveling to space should undergo a prophylactic splenectomy prior to long duration spaceflight. Risks to the spleen during flight include radiation and trauma. However, splenectomy also carries significant risks.METHODS: Systematic review of data published over the past 5 decades regarding risks associated with splenectomies and risks associated with irradiation to the spleen from long duration spaceflight were analyzed. A total of 41 articles were reviewed.RESULTS: Acute risks of splenectomy include intraoperative mortality rate (from hemorrhage) of 3-5%, mortality rate from postoperative complications of 6%, thromboembolic event rate of 10%, and portal vein thrombosis rate of 5-37%. Delayed risks of splenectomy include overwhelming postsplenectomy infection (OPSI) at 0.5% at 5 yr post splenectomy, mortality rate as high as 60% for pneumococcal infections, and development of malignancy with relative risk of 1.53. The risk of hematologic malignancy increases significantly when individuals reach 40 Gy of exposure, much higher than the 0.6 Gy of radiation experienced from a 12-mo round trip to Mars. Lower doses of radiation increase the risk of hyposplenism more so than hematologic malignancy.CONCLUSION:For protection against hematologic malignancy, the benefits of prophylactic splenectomy do not outweigh the risks. However, there is a possible risk of hyposplenism from long duration spaceflight. It would be beneficial to prophylactically provide vaccines against encapsulated organisms for long duration spaceflight to mitigate the risk of hyposplenism.Siu M, Levin D, Christiansen R, Kelly E, Alouidor R, Kamine TH. Prophylactic splenectomy and hyposplenism in spaceflight. Aerosp Med Hum Perform. 2022; 93(12):877-881.

Dose Descriptors and Assessment of Risk of Exposure-Induced Death in Patients Undergoing COVID-19 Related Chest Computed Tomography

For more than two years, coronavirus disease 19 (COVID-19) has represented a threat to global health and lifestyles. Computed tomography (CT) imaging provides useful information in patients with COVID-19 pneumonia. However, this diagnostic modality is based on exposure to ionizing radiation, which is associated with an increased risk of radiation-induced cancer. In this study, we evaluated the common dose descriptors, CTDI_vol and DLP, for 1180 adult patients. This data was used to estimate the effective dose, and risk of exposure-induced death (REID). Awareness of the extensive use of CT as a diagnostic tool in the management of COVID-19 during the pandemic is vital for the evaluation of radiation exposure parameters, dose reduction methods development and radiation protection.

Potential of a Non-Contrast-Enhanced Abbreviated MRI Screening Protocol (NC-AMRI) in High-Risk Patients under Surveillance for HCC

Purpose: To evaluate NC-AMRI for the detection of HCC in high-risk patients. Methods: Patients who underwent yearly contrast-enhanced MRI (i.e., full MRI protocol) of the liver were included retrospectively. For all patients, the sequences that constitute the NC-AMRI protocol, namely diffusion-weighted imaging (DWI), T2-weighted (T2W) imaging with fat saturation, and T1-weighted (T1W) in-phase and opposed-phase imaging, were extracted, anonymized, and uploaded to a separate research server and reviewed independently by three radiologists with different levels of experience. Reader I and III held a mutual training session. Levels of suspicion of HCC per patient were compared and the sensitivity, specificity, and area under the curve (AUC) using the Mann–Whitney U test were calculated. The reference standard was a final diagnosis based on full liver MRI and clinical follow-up information. Results: Two-hundred-and-fifteen patients were included, 36 (16.7%) had HCC and 179 (83.3%) did not. The level of agreement between readers was reasonable to good and concordant with the level of expertise and participation in a mutual training session. Receiver operating characteristics (ROC) analysis showed relatively high AUC values (range 0.89–0.94). Double reading showed increased sensitivity of 97.2% and specificity of 87.2% compared with individual results (sensitivity 80.1%–91.7%–97.2%; specificity 91.1%–72.1%–82.1%). Only one HCC (2.8%) was missed by all readers. Conclusion: NC-AMRI presents a good potential surveillance imaging tool for the detection of HCC in high-risk patients. The best results are achieved with two observers after a mutual training session.

Neuroimaging of Headache: Indications and Controversies

Headache is a common presenting symptom in the ambulatory setting that often prompts imaging. The increased use and associated health care money spent in the setting of headache have raised questions about the cost-effectiveness of neuroimaging in this setting. Neuroimaging for headache in most cases is unlikely to reveal significant abnormality or impact patient management. In this article, reasons behind an observed increase in neuroimaging and its impact on health care expenditures are discussed. The typical imaging modalities available and various imaging guidelines for common clinical headache scenarios are presented, including recommendations from the American College of Radiology.

Recommendations for reducing exposure to medical X-ray irradiation (Review)

With the increasing frequency of X-ray examinations in clinical medicine, public concern regarding the harm caused by exposure to X-ray radiation is also increasing. However, some physicians are not completely aware of the dangers of exposure to X-ray irradiation. Individuals specialized in this field, including physicians, have a better understanding of these dangers, which limits the use of X-rays in medicine. The present study aimed to address strategies for reducing the harm caused by exposure to medical X-rays and increase public awareness regarding X-ray radiation. Through a literature search and review, combined with the current status of clinical X-ray examination and the authors' professional experience, the present study highlights the importance of reducing X-ray exposure, and proposes several specific recommendations and measures for reducing the frequency or dose of X-ray irradiation. On the whole, the finding discussed in the present review suggest the minimal use of medical X-ray examinations and that alternative tests should be selected whenever possible. When medical X-ray screening and treatments are necessary, the risk-benefit ratio should be assessed, possibly aiming to achieve avoidable exposure. Further attention should be paid to protect sensitive glands and reduce the risks in children.

How should radiation exposure be handled in fluoroscopy-guided endoscopic procedures in the field of gastroenterology?

Fluoroscopy-guided endoscopic procedures (FGEPs) are rapidly gaining popularity in the field of gastroenterology. Radiation is a well-known health hazard. Gastroenterologists who perform FGEPs are required to protect themselves, patients, as well as nurses and radiologists engaged in examinations from radiation exposure. To achieve this, all gastroenterologists must first understand and adhere to the International Commission on Radiological Protection Publication. In particular, it is necessary to understand the three principles of radiation protection (Justification, Optimization, and Dose Limits), the As Low As Reasonably Achievable principle, and the Diagnostic Reference Levels (DRLs) according to them. This review will mainly explain the three principles of radiation exposure protection, DRLs, and occupational radiological protection in interventional procedures while introducing related findings. Gastroenterologists must gain knowledge of radiation exposure protection and keep it updated.

High-performance reconstruction of CT medical images by using out-of-core methods in GPU

BACKGROUND AND OBJECTIVE

Since Computed Tomography (CT) is one of the most widely used medical imaging tests, it is essential to work on methods that reduce the radiation the patient is exposed to. Although there are several possible approaches to achieve this, we focus on reducing the exposure time through sparse sampling. With this approach, efficient algebraic methods are needed to be able to generate the images in real time, and since their computational cost is high, using high-performance computing is essential.

METHODS

In this paper we present a GPU (Graphics Processing Unit) software for solving the CT image reconstruction problem using the QR factorization performed with out-of-core (OOC) techniques. This implementation is optimized to reduce the data transfer times between disk, CPU, and GPU, as well as to overlap input/output operations and computations.

RESULTS

The experimental study shows that a block cache stored on main page-locked memory is more efficient than using a cache on GPU memory or mirroring it in both GPU and CPU memory. Compared to a CPU version, this implementation is up to 6.5 times faster, providing an improved image quality when compared to other reconstruction methods.

CONCLUSIONS

The software developed is an optimized version of the QR factorization for GPU that allows the algebraic reconstruction of CT images with high quality and resolution, with a performance that can be compared with state-of-the-art methods used in clinical practice. This approach allows reducing the exposure time of the patient and thus the radiation dose.

Reduction of lumbar hyperlordosis in a pediatric: a Chiropractic Biophysics^® case report

[Purpose] To demonstrate the reduction of lumbar hyperlordosis, sacral base angle and anterior thoracic translation posture in an 11-year-old female. [Participant and Methods] A pediatric patient presented with lumbar hyperlordosis and underwent Chiropractic BioPhysics^® treatment protocols to reduce her spinal deformity and correlated symptoms. Symptoms included thoracolumbar, hip, knee and ankle pains and lower extremity weakness. Radiographs confirmed lumbar hyperlordosis, increased sacral base angle and a forward translated thoracic posture. Spinal traction as well as corrective exercises and spinal manipulative therapy was performed over an 11-month period. [Results] After 57 treatments, there was a 13.4° reduction in L1-L5 lordosis, an 11.8° reduction in sacral base angle and a 13.8 mm reduction in anterior thoracic translation. The improved structural changes correlated with improved symptoms. [Conclusion] Lumbar hyperlordosis can be reduced in pediatric patients presenting with hyperlordosis and associated symptomatology. Routine radiography may be warranted in the diagnosis of lumbar spine deformities in pediatrics. Further research into the non-surgical reduction of lumbar spine hyperlordosis is needed.

Radiophobia Overreaction: College of Chiropractors of British Columbia Revoke Full X-Ray Rights Based on Flawed Study and Radiation Fear-Mongering

Fears over radiation have created irrational pressures to dissuade radiography use within chiropractic. Recently, the regulatory body for chiropractors practicing in British Columbia, Canada, the College of Chiropractors of British Columbia (CCBC), contracted Pierre Côté to review the clinical use of X-rays within the chiropractic profession. A "rapid review" was performed and published quickly and included only 9 papers, the most recent dating from 2005; they concluded, "Given the inherent risks of radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine." The CCBC then launched an immediate review of the use of X-rays by chiropractors in their jurisdiction. Member and public opinion were gathered but not presented to their members. On February 4, 2021, the College announced amendments to their Professional Conduct Handbook that revoked X-ray rights for routine/repeat assessment and management of patients with spine disorders. Here, we highlight current and historical evidence that substantiates that X-rays are not a public health threat. We also point out critical and insurmountable flaws in the single paper used to support irrational and unscientific policy that discriminates against chiropractors who practice certain forms of evidence-based X-ray-guided methods.

Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective

BACKGROUND

Patients on antithrombotic medications presenting with blunt trauma are at risk for delayed intracranial hemorrhage. We hypothesized that clinically significant delayed intracranial hemorrhage is rare in patients presenting on antithrombotic medications and therefore routine, repeat head computed tomography imaging is not a cost-effective practice to monitor for delayed intracranial hemorrhage.

METHODS

Patients presenting to our institution on antithrombotic (anticoagulant and antiplatelet) medications during a 5-y period from January 2014 through March 2019 who underwent a head computed tomography for blunt trauma were identified in our trauma registry. Patients with an initial negative head computed tomography underwent repeat imaging 6 h after their initial head computed tomography. Patient demographics, antithrombotic medication, international normalized ratio, Glasgow Coma Score, clinical change in neurologic status, and need for neurosurgical intervention were collected.

RESULTS

Our institution evaluated 1,676 patients on antithrombotic therapy with blunt trauma. The initial head computed tomography was negative in 1,377 patients (82.0%). Of those with an initial negative head computed tomography, 12 patients (0.9%) developed an intracranial hemorrhage that was identified on the second head computed tomography. Delayed intracranial hemorrhage included 6 patients with intraventricular hemorrhage, 3 with subdural hematoma, 2 with subarachnoid hemorrhage, and 1 with an intraparenchymal hemorrhage. None of the patients with delayed intracranial hemorrhage developed a change in neurologic status, required an intracranial pressure monitor, or underwent neurosurgical intervention. The estimated total direct cost of the negative head computed tomography scans was $926,247.

CONCLUSION

Clinically significant delayed intracranial hemorrhage is rare in trauma patients on antithrombotic therapy, with an initial negative head computed tomography. Routine repeat head computed tomography imaging in patients with a negative scan on admission is not cost-effective.

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.

Are Continued Efforts to Reduce Radiation Exposures from X-Rays Warranted?

There are pressures to avoid use of radiological imaging throughout all healthcare due to the notion that all radiation is carcinogenic. This perception stems from the long-standing use of the linear no-threshold (LNT) assumption of risk associated with radiation exposures. This societal perception has led to relentless efforts to avoid and reduce radiation exposures to patients at great costs. Many radiation reduction campaigns have been launched to dissuade doctors from using radiation imaging. Lower-dose imaging techniques and practices are being advocated. Alternate imaging procedures are encouraged. Are these efforts warranted? Based on recent evidence, LNT ideology is shown to be defunct for risk assessment at low-dose exposure ranges which includes X-rays and CT scans. In fact, the best evidence that was once used to support LNT ideology, including the Life Span Study data, now indicates thresholds for cancer induction are high; therefore, low-dose X-rays cannot cause harm. Current practices are safe as exposures currently encountered are orders of magnitude below threshold levels shown to be harmful. As long as imaging is medically warranted, it is shown that efforts to reduce exposures that are within background radiation levels and that are also shown to enhance health by upregulating natural adaptive protection systems are definitively wasted resources.

Assessing and coping with the financial burden of computed tomography utilization in Limbe, Cameroon: a sequential explanatory mixed-methods study

BACKGROUND

There has been a significant increase in computed tomography (CT) utilization over the past two decades with the major challenges being a high exposure to ionizing radiation and rising cost. In this study we assess the risk of financial hardship after CT utilization and elaborate on how users adapt and cope in a sub-Saharan context with user fee for services and no national health insurance policy.

METHODS

We carried out a sequential explanatory mixed methods study with a quantitative hospital-based survey of CT users followed by in-depth interviews of some purposively selected participants who reported risk of financial hardship after CT utilization. Data was summarized using frequencies, percentages and 95% confidence intervals. Logistic regression was used in multivariable analysis to determine predictors of risk of financial hardship. Identified themes from in-depth interviews were categorized. Quantitative and qualitative findings were integrated.

RESULTS

A total of 372 participants were surveyed with a male to female sex ratio of 1:1.2. The mean age (standard deviation) was 52(17) years. CT scans of the head and facial bones accounted for 63% (95%CI: 59-68%) and the top three indications were suspected stroke (27% [95%CI: 22-32%]), trauma (14% [95%CI: 10-18%]) and persistent headaches (14% [95%CI: 10-18%]). Seventy-two percent (95%CI: 67-76%) of the respondents reported being at risk of financial hardship after CT utilization and predictors in the multivariable analysis were a low socioeconomic status (aOR: 0.19 [95%CI: 0.10-0.38]; p < 0.001), being unemployed or retired (aOR: 11.75 [95%CI: 2.59-53.18]; p = 0.001) and not having any form of health insurance (aOR: 3.59 [95%CI: 1.31-9.85]; p = 0.013). Coping strategies included getting financial support from family and friends, borrowing money and obtaining discounts from the hospital administration and staff.

CONCLUSION

No health insurance ownership, being unemployed or retired and a low socioeconomic status are associated with financial hardship after CT utilization. Diverse coping strategies are utilized to lessen the financial burden, some with negative consequences. Minimizing out-of-pocket payments and/or the direct cost of CT can reduce this financial burden and improve CT access.

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.

Diagnostic performance between CT and initial real-time RT-PCR for clinically suspected 2019 coronavirus disease (COVID-19) patients outside Wuhan, China

INTRODUCTION

Chest CT is thought to be sensitive but less specific in diagnosing the 2019 coronavirus disease (COVID-19). The diagnostic value of CT is unclear. We aimed to compare the performance of CT and initial RT-PCR for clinically suspected COVID-19 patients outside the epicentre-Wuhan, China.

MATERIALS AND METHODS

Patients clinically suspected of COVID-19 infection who underwent initial RT-PCR and chest CT at the same time were retrospectively enrolled. Two radiologists with specific training reviewed the CT images independently and final diagnoses of the presence or absence of COVID-19 was reached by consensus. With serial RT-PCR as reference standard, the performance of initial RT-PCR and chest CT was analysed. A strategy of combining initial RT-PCR and chest CT was analysed to study the additional benefit.

RESULTS

82 patients admitted to hospital between Jan 10, 2020 to Feb 28, 2020 were enrolled. 34 COVID-19 and 48 non-COVID-19 patients were identified by serial RT-PCR. The sensitivity, specificity was 79% (27/34) and 100% (48/48) for initial RT-PCR and 77% (26/34) and 96% (46/48) for chest CT. The image readers had a good interobserver agreement with Cohen's kappa of 0.69. No statistical difference was found in the diagnostic performance between initial RT-PCR and chest CT. The comprehensive strategy had a higher sensitivity of 94% (32/34).

CONCLUSIONS

Initial RT-PCR and chest CT had comparable diagnostic performance in identification of suspected COVID-19 patients outside the epidemic center. To compensate potential risk of false-negative PCR, chest CT should be applied for clinically suspected patients with negative initial RT-PCR.

Death of the ALARA Radiation Protection Principle as Used in the Medical Sector

ALARA is the acronym for "As Low As Reasonably Achievable." It is a radiation protection concept borne from the linear no-threshold (LNT) hypothesis. There are no valid data today supporting the use of LNT in the low-dose range, so dose as a surrogate for risk in radiological imaging is not appropriate, and therefore, the use of the ALARA concept is obsolete. Continued use of an outdated and erroneous principle unnecessarily constrains medical professionals attempting to deliver high-quality care to patients by leading to a reluctance by doctors to order images, a resistance from patients/parents to receive images, subquality images, repeated imaging, increased radiation exposures, the stifling of low-dose radiation research and treatment, and the propagation of radiophobia and continued endorsement of ALARA by regulatory bodies. All these factors result from the fear of radiogenic cancer, many years in the future, that will not occur. It has been established that the dose threshold for leukemia is higher than previously thought. A low-dose radiation exposure from medical imaging will likely upregulate the body's adaptive protection systems leading to the prevention of future cancers. The ALARA principle, as used as a radiation protection principle throughout medicine, is scientifically defunct and should be abandoned.