Three principles for radiation safety: time, distance, and shielding

Trends in Radiation at a Level I Trauma Center

Introduction Following traumatic injury, patients often require imaging modalities that subject them to large amounts of radiation. The current protocol for imaging workup in trauma patients includes plain radiographs and computed tomography (CT). Although these imaging modalities have improved quality and efficiency in trauma interventions, it is essential to understand their potential limitations and adverse effects. The large amounts of radiation from these imaging tests have raised concern for particularly vulnerable populations, including children and adolescents. Objective To evaluate the trends in radiation exposure in trauma assessment and imaging seen at a Level I trauma center. Methods This retrospective analysis used a de-identified dataset from the trauma registry at Desert Regional Medical Center Level I Trauma Center in Palm Springs, CA. Total radiation amounts were calculated based on the type of diagnostic modality. An effective radiation dose was assigned to each examination (radiograph and CT scan) based on the values provided by the American College of Radiology. Results There was a statistically significant positive correlation between injury severity score and effective radiation dose from imaging workup. From 2016 to 2021, radiation amount and year were found to be negatively correlated. There was a larger, statistically significant amount of radiation dosage among adult trauma patients (16.32 mSv) when compared to pediatric (6.32 mSv) and geriatric (12.67 mSv) groups. Conclusion Our Level I trauma center has observed a decline in radiation exposure with our current trauma protocols in place. On average, adult patients received the highest effective radiation dose to pediatric and geriatric patients. CT scans and radiography are essential tools in initial trauma workup and should be used only in appropriate patients.

Interventional bronchoscopy in lung cancer treatment

Interventional bronchoscopy has seen significant advancements in recent decades, particularly in the context of lung cancer. This method has expanded not only diagnostic capabilities but also therapeutic options. In this article, we will outline various therapeutic approaches employed through either a rigid or flexible bronchoscope in multimodal lung cancer treatment. A pivotal focus lies in addressing central airway obstruction resulting from cancer. We will delve into the treatment of initial malignant changes in central airways and explore the rapidly evolving domain of early peripheral malignant lesions, increasingly discovered incidentally or through lung cancer screening programmes. A successful interventional bronchoscopic procedure not only alleviates severe symptoms but also enhances the patient's functional status, paving the way for subsequent multimodal treatments and thereby extending the possibilities for survival. Interventional bronchoscopy proves effective in treating initial cancerous changes in patients unsuitable for surgical or other aggressive treatments due to accompanying diseases. The key advantage of interventional bronchoscopy lies in its minimal invasiveness, effectiveness and favourable safety profile.

The Utility and Feasibility of Smart Glasses in Spine Surgery: Minimizing Radiation Exposure During Percutaneous Pedicle Screw Insertion

OBJECTIVE

Spine surgeons are often at risk of radiation exposure due to intraoperative fluoroscopy, leading to health concerns such as carcinogenesis. This is due to the increasing use of percutaneous pedicle screw (PPS) in spinal surgeries, resulting from the widespread adoption of minimally invasive spine stabilization. This study aimed to elucidate the effectiveness of smart glasses (SG) in PPS insertion under fluoroscopy.

METHODS

SG were used as an alternative screen for fluoroscopic images. Operators A (2-year experience in spine surgery) and B (9-year experience) inserted the PPS into the bilateral L1-5 pedicles of the lumbar model bone under fluoroscopic guidance, repeating this procedure twice with and without SG (groups SG and N-SG, respectively). Each vertebral body's insertion time, radiation dose, and radiation exposure time were measured, and the deviation in screw trajectories was evaluated.

RESULTS

The groups SG and N-SG showed no significant difference in insertion time for the overall procedure and each operator. However, group SG had a significantly shorter radiation exposure time than group N-SG for the overall procedure (109.1 ± 43.5 seconds vs. 150.9 ± 38.7 seconds; p = 0.003) and operator A (100.0 ± 29.0 seconds vs. 157.9 ± 42.8 seconds; p = 0.003). The radiation dose was also significantly lower in group SG than in group N-SG for the overall procedure (1.3 ± 0.6 mGy vs. 1.7 ± 0.5 mGy; p = 0.023) and operator A (1.2 ± 0.4 mGy vs. 1.8 ± 0.5 mGy; p = 0.013). The 2 groups showed no significant difference in screw deviation.

CONCLUSION

The application of SG in fluoroscopic imaging for PPS insertion holds potential as a useful method for reducing radiation exposure.

Sequential radiation exposure: uncovering the potential of low dose ionizing radiation in mitigating high dose effects on immune cells

PURPOSE

The radioadaptive response refers to a phenomenon wherein exposure to a low dose of ionizing radiation (LDIR) can induce a protective response in cells or organisms, reducing the adverse effects of a subsequent higher dose of ionizing radiation (HDIR). However, it is possible to administer the low dose after the challenge dose. This study was conducted to determine the potential mitigating effect of LDIR administered after HDIR on mice immune cells.

MATERIALS AND METHODS

Alongside the conventional adaptive response setting, one group of mice was initially exposed to HDIR and subsequently treated with LDIR. Neutrophil activation was done using DHR-reducing assay and cell proliferation was evaluated through CFSE-dilution assay in helper (CD4+) and cytotoxic (CD8+) T cells. Cytokine production by these T cell subsets was also assessed by intracellular staining using flow cytometry.

RESULTS

The results of this study revealed no change in neutrophil function between any of the mice groups compared to the untreated control group. Although significant changes were not detected in the proliferation of CD4+ T cells, decreased proliferation was observed in stimulated CD8+ T cells in the HDIR group. In contrast to IFN-ɣ, which showed no evident change in either of the T cell subsets after stimulation, IL-4 was rigorously dropped in stimulated CD4+ T cells in the HDIR group.

CONCLUSIONS

In summary, the results of this study indicated that the administration of LDIR to mice before HDIR was not able to reduce the detrimental effects of HDIR in our experimental setting. Instead, we observed a mitigating effect of LDIR when administered after the challenge dose. This suggests that not only the dose and duration but also the order of LDIR relative to HDIR affects its efficacy.

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.

Traumatic Brain Injury Recovery with Photobiomodulation: Cellular Mechanisms, Clinical Evidence, and Future Potential

Traumatic Brain Injury (TBI) remains a significant global health challenge, lacking effective pharmacological treatments. This shortcoming is attributed to TBI's heterogeneous and complex pathophysiology, which includes axonal damage, mitochondrial dysfunction, oxidative stress, and persistent neuroinflammation. The objective of this study is to analyze transcranial photobiomodulation (PBM), which employs specific red to near-infrared light wavelengths to modulate brain functions, as a promising therapy to address TBI's complex pathophysiology in a single intervention. This study reviews the feasibility of this therapy, firstly by synthesizing PBM's cellular mechanisms with each identified TBI's pathophysiological aspect. The outcomes in human clinical studies are then reviewed. The findings support PBM's potential for treating TBI, notwithstanding variations in parameters such as wavelength, power density, dose, light source positioning, and pulse frequencies. Emerging data indicate that each of these parameters plays a role in the outcomes. Additionally, new research into PBM's effects on the electrical properties and polymerization dynamics of neuronal microstructures, like microtubules and tubulins, provides insights for future parameter optimization. In summary, transcranial PBM represents a multifaceted therapeutic intervention for TBI with vast potential which may be fulfilled by optimizing the parameters. Future research should investigate optimizing these parameters, which is possible by incorporating artificial intelligence.

Development of DynamicMC for PHITS Monte Carlo package

Previously, we have developed DynamicMC for modeling relative movement of Oak Ridge National Laboratory phantom in a radiation field for the Monte Carlo N-Particle package (Health Physics. 2023,124(4):301-309). Using this software, three-dimensional dose distributions in a phantom irradiated by a certain mono-energetic (Mono E) source can be deduced through its graphical user interface. In this study, we extended DynamicMC to be used in combination with the Particle and Heavy Ion Transport code System (PHITS) by providing it with a higher flexibility for dynamic movement for an anthropomorphic phantom. For this purpose, we implemented four new functions into the software, which are (1) to generate not only Mono E sources but also those having an energy spectrum of an arbitrary radioisotope (2) to calculate the absorbed doses for several radiologically important organs (3) to automatically average the calculated absorbed doses along the path of the phantom and (4) to generate user-defined slab shielding materials. The first and third items utilize the PHITS-specific modalities named radioisotope-source and sumtally functions, respectively. The computational cost and complexity can be dramatically reduced with these features. We anticipate that the present work and the developed open-source tools will be in the interest of nuclear radiation physics community for research and teaching purposes.

Differing radiation exposure in scrub technicians and rotating staff in Cardiac catheterization laboratory: occupation matters

BACKGROUND

Radiation exposure is a significant hazard associated with invasive Cardiology, with most studies based on primary operator exposure. This prospective, observational study aimed to find out over lead radiation exposure as effective dose acquired by non-physician staff comprising scrub technicians and rotating staff in the cath laboratory. Effective dose (ED) measured per procedure via Raysafe i2®dosimeter badges worn by both rotating staff and scrub technicians over lead aprons along with dose area product (DAP), fluoroscopy time (FT) and procedure time (PT) in minutes was collected prospectively over forty-six invasive Cardiology procedures.

RESULTS

This study shows that rotating staff acquire higher ED in comparison with their scrub technician colleagues in diagnostic, interventional and electrophysiology cases. However, a statistically significant difference in radiation exposure of both staff groups was demonstrated in diagnostic and interventional Cardiology procedures, with p values of 0.04 and 0.01, respectively.

CONCLUSIONS

These findings highlight occupational role and mobility around fluoroscopic sources as major factors in radiation exposure, which should be addressed within current radiation protection practices.

Impact of Growth Temperature of Lead-Oxide Nanostructures on the Attenuation of Gamma Radiation

Chemical bath deposition (CBD) technique is utilized to grow lead-oxide (PbO) nanostructures (NSs) over PbO seed fabricated by physical vapor deposition (PVD) method on glass substrates. The effect of growth temperatures 50 and 70 °C on the surface topography, optical properties, and crystal structure of lead-oxide NSs has been studied. The investigated results suggested that the growth temperature has a huge and very considerable influence on the PbO NS, and the fabricated PbO NS has been indexed as the Pb₃O₄ polycrystalline tetragonal phase. The crystal size for PbO thin films grown at 50 °C was 85.688 nm and increased to 96.61 nm once the growth temperature reached 70 °C. The fabricated PbO nanofilms show a high rate of transmittance, which are ∼70 and 75% in the visible spectrum for the films deposited at 50 and 70 °C, respectively. The obtained E_g was in the range of 2.099-2.288 eV. Also, the linear attenuation coefficient values of gamma-rays for shielding the Cs-137 radioactive source increased at 50 °C. The transmission factor, mean free path, and half-value layer are reduced at a higher attenuation coefficient of PbO grown at 50 °C. This study evaluates the relationship between synthesized lead-oxide NSs and the radiation energy attenuation of gamma-rays. This study provided a suitable, novel, and flexible protective shield of clothes or an apron made of lead or lead oxide to protect against ionizing radiation that meets safety rules and protects medical workers from ionizing radiation.

High-flow nasal cannula (HFNC) oxygenation for sclerotherapy of facial and upper airway vascular malformations in pediatric patients: Case series

We report anesthesia management of sclerotherapy for vascular malformations (VMs) of the upper airway and face of pediatric patients conducted under sedation using a high-flow nasal cannula (HFNC) oxygen delivery system. Sclerotherapy procedures were carried out in six patients (five males, one female; age group: 5-12 years). The patients were sedated with midazolam, fentanyl, ketamine, and graded doses of propofol along with continuous oxygen delivery using HFNC. There were no episodes of oxygen desaturation, tongue fall or obstruction of the airway, interruption of procedure for assisted ventilation, and postoperative nausea and vomiting (PONV). Only two patients showed transient apnea for 10 and 15 s but did not require ventilatory assistance. HFNC provides effective oxygenation in pediatric patients undergoing sclerotherapy of VMs of the upper airway and face under sedation.

Evaluation of Acrylonitrile Butadiene Styrene (ABS) polymer reinforced with Bi and TiO2 nanopowders for gamma and neutron shielding

3D printer technology has recently become easily reachable technology and are used to create simple or complex structures with high-quality. Its superior advantages could also be useful on the production of effective radiation shielding materials. On this purpose, the presented work studies the gamma and neutron shielding effectiveness of Acrylonitrile Butadiene Styrene (ABS) sample, a 3D printing material, reinforced with Bi and TiO2 nanopowders at various gamma and neutron energies. The gamma shielding properties were evaluated using experimental (High Purity Germanium detector system), theoretical (WinXCOM computer program) and simulation techniques (GEANT4 and FLUKA) in a wide gamma energy region ranging from 59.5 to 1332.5 keV. The investigation on neutron attenuation capabilities of the printed composites were performed with help of simulation and theoretical approaches for various sample thickness and neutron energies. The half value layer of ABS-Bi10 sample is found to be as 4.9565 cm, which is much smaller than some commercial polymers: polyvinylidenechloride, polyamide, polyacrylonitrile, polyphenylenesulfide, and unsaturated polyester. With the usage of 3D printing technology, significant enhancements in neutron and gamma shielding were reported.

Potential hazards and mitigation of X-ray radiation generated by laser-induced plasma from research-grade laser systems

A large range of laser-matter applications employ ultrashort pulses and high laser intensity. Such processes can lead to unrequired X-ray generation, which represents a hazardous radiation factor even for common laboratory research-grade laser systems. We present here an analysis of the radiation dose rate and X-ray spectrum emitted during ablation of a rotating copper cylinder with respect to several laser parameters. The results show that focused sub-picosecond pulses with intensity above 10¹³ W/cm² can exceed the annual irradiation limit even in one hour, requiring appropriate shielding for the safety of the researchers.

Mechanical properties, elastic moduli, transmission factors, and gamma-ray-shielding performances of Bi2O3–P2O5–B2O3–V2O5 quaternary glass system

Mechanical properties, elastic moduli, transmission factors (TFs), and gamma-ray shielding performance of quaternary glass systems with chemical composition (0.25−x)Bi2O3–xB2O3−0.75(50%P2O5−50%V2O5), where x = 0.05 (S1), 0.10 (S2), 0.15 (S3), and 0.20 (S4) mol%, were comprehensively studied. The MCNPX code, Phy-X/PSD software, and the Makishima–Mackenzie model were utilized to achieve the mentioned purposes. The values of the packing density (V t) decreased from 0.634432 to 0.600611, while those of the dissociation energy (G t) increased from 51.6125 kJ/cm3 for the S1 glass sample (with Bi2O3 = 5 mol%) to 56.7525 kJ/cm3 for the S4 glass sample (with Bi2O3 = 20 mol%). This means that the mechanical properties were enhanced by increasing the Bi2O3 content in glasses. Linear (µ) and mass attenuation (µ m) coefficients for the S4 glass sample were the greatest compared to those for glass materials investigated, i.e., (µ, µ m)S1 < (µ, µ m)S2 < (µ, µ m)S3 < (µ, µ m)S4. Half- and tenth-value layers (HVL and TVL, respectively) follow the trend: (HVL, TVL)S1 > (HVL, TVL)S2 > (HVL, TVL)S3 > (HVL, TVL)S4. The effective atomic number (Z eff) of investigated glasses has the same trend as of linear and mass attenuation coefficients. Our findings indicate that increasing the amount of Bi2O3 reinforcement decreased the exposure buildup factor and energy absorption buildup factor values for all mean free path values (0.5–40 mfp). All glasses recorded the minimum TF values at a thickness of 3 cm. The findings would benefit the scientific community in determining the most appropriate additive bismuth(iii) oxide/diboron trioxide type and related glass composition to provide the shielding properties previously mentioned in terms of needs and utilization requirements, as well as the most suitable glass composition.

Radiation safety for pain physicians: principles and recommendations

C-arm fluoroscopy is a useful tool for interventional pain management. However, with the increasing use of C-arm fluoroscopy, the risk of accumulated radiation exposure is a significant concern for pain physicians. Therefore, efforts are needed to reduce radiation exposure. There are three types of radiation exposure sources: (1) the primary X-ray beam, (2) scattered radiation, and (3) leakage from the X-ray tube. The major radiation exposure risk for most medical staff members is scattered radiation, the amount of which is affected by many factors. Pain physicians can reduce their radiation exposure by use of several effective methods, which utilize the following main principles: reducing the exposure time, increasing the distance from the radiation source, and radiation shielding. Some methods reduce not only the pain physician's but also the patient's radiation exposure. Taking images with collimation and minimal use of magnification are ways to reduce the intensity of the primary X-ray beam and the amount of scattered radiation. It is also important to carefully select the C-arm fluoroscopy mode, such as pulsed mode or low-dose mode, for ensuring the physician's and patient's radiation safety. Pain physicians should practice these principles and also be aware of the annual permissible radiation dose as well as checking their radiation exposure. This article aimed to review the literature on radiation safety in relation to C-arm fluoroscopy and provide recommendations to pain physicians during C-arm fluoroscopy-guided interventional pain management.

A case report of radiopharmaceutical needlestick injury with scintigraphic imaging and dose quantification

Attention to the implications of common needle stick injuries has focused heavily on the risk of cross-infection from blood-borne pathogens. An additional risk to the nuclear medicine healthcare worker is that of subcutaneous radioactive contamination from radiopharmaceuticals. This case report provides a rare opportunity to examine the clinical and operator causes of one such event during the dispensing of ^99mTc-Tetrofosmin. Contamination monitoring, scintigraphic imaging, and quantification of effective radiation dose provide the level of risk to the operator from the subcutaneous radioactive contamination. Findings demonstrated a very low dose to operator and no deterministic radiobiological effects. Delayed imaging demonstrated negligible biological clearance from the injury site. Implications of the findings for clinical practice are discussed, highlighting the need for a careful and calm approach to radiopharmacy activities.

COVID-19 pandemic and the effect of increased utilisation of mobile X-ray examinations on radiation dose to radiographers

Introduction

The use of ionising radiation results in occupational exposure to medical imaging professionals, requiring routine monitoring. This study aims to assess the effect of increased utilisation of mobile X‐ray units, mobile imaging of non‐routine body regions and radiographer work practice changes for impact on staff radiation dose during the early stages of the COVID‐19 pandemic.

Methods

A retrospective analysis of general radiology departments across two metropolitan hospitals was performed. Personal radiation monitor exposure reports between January 2019 and December 2020 were analysed. Statistical analysis was conducted using a Mann–Whitney U test when comparing each quarter, from 2019 to 2020. Categorical data were compared using a Chi‐squared test.

Results

Mobile X‐ray use during the pandemic increased approximately 1.7‐fold, with the peak usage observed in September 2020. The mobile imaging rate per month of non‐routine body regions increased from approximately 6.0–7.8%. Reported doses marginally increased during Q2, Q3 and Q4 of 2020 (in comparison to 2019 data), though was not statistically significant (Q2: P = 0.13; Q3: P = 0.31 and Q4 P = 0.32). In Q1, doses marginally decreased and were not statistically significant (P = 0.22).

Conclusion

Increased utilisation and work practice changes had no significant effect on reported staff radiation dose. The average reported dose remained significantly lower than the occupational dose limits for radiation workers of 20 mSv.

Development and evaluation of the effectiveness of educational material for radiological protection that uses augmented reality and virtual reality to visualise the behaviour of scattered radiation

Understanding the behaviour of scattered radiation is important for learning appropriate radiation protection methods, but many existing visualisation systems for radiation require special devices, making it difficult to use them in education. The purpose of this study was to develop teaching material for radiation protection that can help visualise the scattered radiation with augmented reality (AR) and virtual reality (VR) on a web browser, develop a method for using it in education and examine its effectiveness. The distribution of radiation during radiography was calculated using Monte Carlo simulation, and teaching material was created. The material was used in a class for department of radiological technology students and its influence on motivation was evaluated using a questionnaire based on the evaluation model for teaching materials. In addition, text mining was used to evaluate impressions objectively. Educational material was developed that can be used in AR and VR for studying the behaviour of scattered radiation. The results of the questionnaire showed that the average value of each item was more than four on a five-point scale, indicating that the teaching material attracted the interest of users. Through text mining, it could be concluded that there was improved understanding of, and confidence in, radiation protection.

Application of a tungsten apron for occupational radiation exposure in nursing care of children with neuroblastoma during 131I-meta-iodo-benzyl-guanidine therapy

The use of effective shielding materials against radiation is important among medical staff in nuclear medicine. Hence, the current study investigated the shielding effects of a commercially available tungsten apron using gamma ray measuring instruments. Further, the occupational radiation exposure of nurses during 131I-meta-iodo-benzyl-guanidine (131I-MIBG) therapy for children with high-risk neuroblastoma was evaluated. Attachable tungsten shields in commercial tungsten aprons were set on a surface-ray source with 131I, which emit gamma rays. The mean shielding rate value was 0.1 ± 0.006 for 131I. The shielding effects of tungsten and lead aprons were evaluated using a scintillation detector. The shielding effect rates of lead and tungsten aprons against 131I was 6.3% ± 0.3% and 42.1% ± 0.2% at 50 cm; 6.1% ± 0.5% and 43.3% ± 0.3% at 1 m; and 6.4% ± 0.9% and 42.6% ± 0.6% at 2 m, respectively. Next, we assessed the occupational radiation exposure during 131I-MIBG therapy (administration dose: 666 MBq/kg, median age: 4 years). The total occupational radiation exposure dose per patient care per 131I-MIBG therapy session among nurses was 0.12 ± 0.07 mSv. The average daily radiation exposure dose per patient care among nurses was 0.03 ± 0.03 mSv. Tungsten aprons had efficient shielding effects against gamma rays and would be beneficial to reduce radiation exposures per patient care per 131I-MIBG therapy session.

Radiation exposure during angiographic interventions in interventional radiology - risk and fate of advanced procedures

PURPOSE

Advanced angiographic procedures in interventional radiology are becoming more important and are more frequently used, especially in the treatment of several acute life-threatening diseases like stroke or aortic injury. In recent years, technical advancement has led to a broader spectrum of interventions and complex procedures with longer fluoroscopy times. This involves the risk of higher dose exposures, which, in rare cases, may cause deterministic radiation effects, e.g. erythema in patients undergoing angiographic procedures. Against this background, these procedures recently also became subject to national and international regulations regarding radiation protection. At the same time, individual risk assessment of possible stochastic radiation effects for each patient must be weighed up against the anticipated benefits of the therapy itself. Harmful effects of the administered dose are not limited to the patient but can also affect the radiologist and the medical staff. In particular, the development of cataracts in interventionalists is a rising matter of concern. Furthermore, long-term effects of repeated and prolonged x-ray exposure have long been neglected by radiologists but have come into focus in the past years.

CONCLUSIONS

With all this in mind, this review discusses different efforts to reduce radiation exposition levels for patients and medical staff by means of technical, personal as well as organizational measures.

Clinical Efficacy of the Transradial Approach in Percutaneous Intervention for a Malfunctioning Arteriovenous Fistula

Purpose

To evaluate the effectiveness of the transradial artery approach (TRA) for treating malfunctioning arteriovenous fistulas (AVFs) in patients on hemodialysis.

Materials and Methods

A retrospective analysis was conducted in this single-center study of TRA endovascular procedures in 73 patients (43 male and 30 female; mean age of 67.4 years (range, 42–92 years) with malfunctioning AVFs, between January 2008 and April 2019. Patients’ baseline and lesion characteristics, technical and clinical success, and complications were evaluated, and functional patency was analyzed using the Kaplan-Meier method.

Results

Radial artery approaches were successful in all patients. Angioplasty performed using the TRA achieved technical and clinical success rates of 98.6%(72/73) and 91.7%(67/73), respectively. The median primary patency time was 18.8 ± 15.9 months. The primary functional patency rates at 3, 6, and 12 months were 82.1%, 68.6%, and 63.9%, respectively. There were no major complications or adverse events, such as hand ischemia, related to the radial artery approach.

Conclusion

In selected cases, the TRA can be used complementary to the transvenous approach to treat malfunctioning AVFs.

RADIATION EXPOSURE TO THE BACK WITH DIFFERENT TYPES OF APRONS

Physicians and nurses stand with their back towards the C-arm fluoroscope when using the computer, taking things out of closets and preparing drugs for injection or instruments for intervention. This study was conducted to investigate the relationship between the type of lead apron and radiation exposure to the backs of physicians and nurses while using C-arm fluoroscopy. We compared radiation exposure to the back in the three groups: no lead apron (group C), front coverage type (group F) and wrap-around type (group W). The other wrap-around type apron was put on the bed instead of on a patient. We ran C-arm fluoroscopy 40 times for each measurement. We collected the air kerma (AK), exposure time (ET) and effective dose (ED) of the bedside table, upper part and lower part of apron. We measured these variables 30 times for each location. In group F, ED of the upper part was the highest (p < 0.001). ED of the lower part in group C and F was higher than that in group W (p = 0.012). The radiation exposure with a front coverage type apron is higher than that of the wrap-around type and even no apron at the neck or thyroid. For reducing radiation exposure to the back of physician or nurse, the wrap-around type apron is recommended. This type of apron can reduce radiation to the back when the physician turns away from the patient or C-arm fluoroscopy.

Pediatric Anesthesia Outside the Operating Room: Safety and Systems

Anesthesia care performed outside the operating room is a growing area of pediatric anesthesia practice. The anesthesiology team expects to care for children in diverse locations, which include diagnostic and interventional radiology, gastroenterology and pulmonary endoscopy suites, radiation oncology sites, and the cardiac catheterization laboratory. To provide safe, high-quality care the anesthesiologist working in these environments must understand the unique environmental, logistical, and perioperative considerations and risks involved with each remote location. This 2-part review provides an overview of safety and system considerations in pediatric nonoperating room anesthesia before describing in more detail considerations for particular remote anesthetizing locations.

Comparison of Nonimage- and Fluoroscopy-Guided Interlaminar Epidural Block: A Matched Paired Analysis in the Same Individuals

Background

Although fluoroscopic guidance is recommended highly for more accurate lumbar interlaminar epidural steroid injection (L-ESI), many physicians still use a nonimage-guided approach for L-ESIs. However, because of its associated risk of radiation and increased medical expense, the cost-effectiveness and safety of fluoroscopy-guided ESI have been called into question. The goal of this retrospective matched paired analysis in the same individuals was to assess the effectiveness and prevalence of complications of nonimage-guided L-ESI compared to those of fluoroscopy-guided L-ESI. Methods. Between 2015 and 2016, 94 patients who received both nonimage- and fluoroscopy-guided L-ESIs were analyzed retrospectively. The changes of the numeric rating scale (NRS) in pain intensity and functional outcome and the differences in the number of complications between blind and fluoroscopy-guided L-ESIs in the same individuals were evaluated by a matched paired analysis.

Results

Of the 94 patients, the differences in NRS before and after the procedure were 1.29 (95% confidence interval (CI) = 0.94–1.65) for the nonimage-guided group and 1.64 (95% CI = 1.28–2.01) for the fluoroscopy-guided group (p=0.16). More subjective functional improvement was observed in fluoroscopy-guided L-ESI (57, 60.6%) than in nonimage-guided L-ESI (47, 50.0%) without statistical significance (p=0.16). Nine (9.6%) patients in the nonimage-guided group experienced complications related to the procedure overall compared to 4 (4.3%) in the fluoroscopy-guided group (p=0.27).

Conclusions

In this study, both blind and image-guided L-ESI techniques included similar extents of postprocedural outcomes and complications. Physicians should consider the risks associated with the two different techniques overall and develop ways to individualize the procedure to decrease the risk of complications and improve the positive outcomes of lumbar epidural steroid injections.