Inter-rater and Intra-rater Reliability of the Videofluoroscopic Dysphagia Scale with the Standardized Protocol.

This study aimed to develop a standardized protocol for the assessment of videofluoroscopic dysphagia scale (VDS) and to demonstrate the inter-rater and intra-rater reliability of the VDS by applying the new standard protocol. A standardized protocol for the VDS was developed by dysphagia experts, including the original developer. To identify the reliability of the VDS using the protocol, 60 patients who underwent videofluoroscopic swallowing study (VFSS) for various etiologies were recruited retrospectively from three tertiary medical centers. Ten randomly selected cases were duplicated to evaluate the intra-rater reliability. Six physicians evaluated the VFSS data sets. Intraclass correlation coefficients were calculated for inter-rater and intra-rater reliability of the VDS score, and Gwet's kappa values for each VDS item were calculated. The inter-rater and intra-rater reliability of the total VDS score was 0.966 and 0.896, respectively. Notably, the evaluators' experience did not appear to have a significant impact on the reliability (physiatrists: 0.933/0.869, residents: 0.922/0.922). The reliability was consistent across different centers and dysphagia etiologies. The inter-rater and intra-rater reliability of the oral and pharyngeal sub-scores were 0.953/0.861 and 0.958/0.907, respectively. The inter-rater agreement of individual items ranged from 0.456 to 0.929, and nine items demonstrated good to very good level of agreement. Assessment of dysphagia using the VDS with the standard protocol showed excellent inter-rater and intra-rater reliabilities regardless of the evaluator's experience, VFSS equipment, and dysphagia etiologies. The VDS can be a useful assessment scale in the quantitative analysis of dysphagia based on VFSS findings.

Relationship Between Pharyngeal Residues Assessed by Bolus Residue Scale or Normalized Residue Ratio SCALE and Risk of Aspiration in Head and Neck Cancer Who Underwent Videofluoroscopy.

Dysphagia affects 60-75% of patients treated for head and neck cancer (HNC). We aimed to evaluate the association between residue severity and airway invasion severity using a videofluoroscopic swallowing study and identify risk factors for poor penetration-aspiration outcomes in patients with dysphagia treated for HNC. Penetration-Aspiration Scale (PAS) was used to assess airway invasion severity, while residue severity was assessed using both the Bolus Residue Scale (BRS) for residue location and the Normalized Residue Ratio Scale (NRRS) for residue amount. Relevant covariates were adjusted in the logistic regression models to account for potential confounding. Significantly higher abnormal PAS was reported for increased piriform sinus NRRS (NRRSp) [odds ratio (OR), 4.81; p = 0.042] with liquid swallowing and increased BRS value (OR, 1.52; p = 0.014) for semi-liquid swallowing in multivariate analysis. Tumor location, older age, and poorer Functional Oral Intake Scale (FOIS) were significant factors for abnormal PAS in both texture swallowings. After adjusting for confounding factors (sex, age, and FOIS score), NRRS model in liquid swallowing (area under the curve [AUC], 0.83; standard error = 0.04, 95% confidence interval [CI]: 0.75, 0.91) and BRS in semi-liquid swallowing (AUC, 0.83; SE = 0.04; 95% CI: 0.76, 0.91) predicted abnormal PAS. The results indicate that while assessing residue and swallowing aspiration in patients with HNC, it is important to consider age, tumor location, and functional swallowing status. The good predictability of abnormal PAS with BRS and NRRS indicated that residue location and amount were both related to the aspiration event in patients with HNC.

Radiation Dose During Videofluoroscopic Swallowing Studies and Associated Factors in Pediatric Patients.

Although children are more radio-sensitive than adults, few studies have evaluated radiation dosage during videofluoroscopic swallowing study (VFSS) in children. The aim of the study was to investigate the radiation dosage using dose-area product (DAP) for VFSS in pediatric cases and to identify factors affecting the radiation dose. Patients aged 0-17 years who had undergone VFSS were included. The following data were collected retrospectively: DAP; fluoroscopic time; number of tried diets; and clinical characteristics including sex, age, etiology of dysphagia, and recommended feeding type. In the videofluoroscopic field, use of collimation and appearance of metal object, such as a lead apron or a wheel chair, was checked. A total of 290 VFSSs were included. The mean DAP was 5.78 ± 4.34 Gy cm2 with a mean screening time of 2.69 ± 1.30 min. The factors associated with the DAP included screening time, appearance of metal objects in the field, and use of collimation. In 98 cases with no metal object in the field and with collimation, the mean DAP was decreased to 2.96 ± 2.53 Gy cm2. This study evaluated the radiation dosage during VFSS in children according to age groups and the influencing factors such as screening time, appearance of metal objects in the field, and use of collimation in VFSS. To reduce radiation risk, it is important to identify and control modifiable factors.

Radiation Exposure to Staff and Patient During Videofluoroscopic Swallowing Studies and Recommended Protection Strategies.

Videofluoroscopic swallowing studies expose both the patients and the staff to ionising radiation. Although the radiation exposure is considered low compared to other diagnostic procedures, it is still prudent to keep the radiation dose as low as reasonably achievable. This review aims to summarise the latest literature pertaining to staff and patient radiation dose, as well as to make evidence-based recommendations on dose optimisation strategies. The evidence shows that patient radiation dose is low; nonetheless, care must be taken for patients that require multiple examinations. There are limited studies measuring the staff dose during videofluoroscopic swallowing procedures. However, the operator may receive radiation doses approaching 1 mSv per year. Recommendations for radiation protection strategies are summarised.

Incidence of Pneumonia After Videofluoroscopic Swallowing Study and Associated Factors.

Pneumonia after videofluoroscopic swallow study (VFSS) is sometimes considered to be caused by aspiration during VFSS; however, to our knowledge, a relationship between these events has not been clearly investigated. The aim of this study was to assess the incidence of VFSS-related pneumonia and related factors. Overall, 696 VFSS cases were retrospectively reviewed. Cases in which blood culture was performed within 3 days after VFSS due to newly developed infectious signs were considered as post-VFSS infection cases. Pneumonia was suspected when there was some evidence of respiratory infectious signs in clinical, radiological, and laboratory findings. The underlying disease, clinical signs, and VFSS findings of the pneumonia group were assessed. Among 696 cases, pneumonia was diagnosed in 15 patients. The patients in the pneumonia group tended to be older and had higher aspiration rate on VFSS than those in the non-pneumonia group. In the pneumonia group, 2 patients showed no aspiration during VFSS. In 6 patients, pneumonia developed after massive aspiration of gastric content in 5 patients and inappropriate oral feeding with risk of aspiration before VFSS in 1 patient. Only 7 patients (1.0 %) were finally determined as having VFSS-related pneumonia. In conclusion, the 72-h incidence of VFSS-related pneumonia was 1.0 %. Old age and severity of swallowing difficulty are associated with occurrence of pneumonia.

Fluoroscopy-induced chronic radiation skin injury: a disease perhaps often overlooked.

BACKGROUND: Fluoroscopy-induced chronic radiation dermatitis (FICRD) resulting from prolonged exposure to ionizing radiation during interventional procedures has been documented in the radiology and cardiology literature. However, the phenomenon has been rarely reported in the dermatologic literature. Since patients with FICRD often see a dermatologist or a primary care physician to treat their injuries, the diagnosis of FICRD is perhaps often overlooked. OBSERVATIONS: A 62-year-old man with type 2 diabetes mellitus and severe coronary artery disease was seen with a 2-year history of a pruritic, tender, telangiectatic patch lesion over his left scapula. Over the next 2 years, the lesion became indurated and eventually ulcerated. A skin biopsy specimen demonstrated changes consistent with a chronic radiation dermatitis. The patient was unaware of radiation exposure, but persistent questioning from his dermatologists revealed that he had undergone multiple fluoroscopy-guided cardiac procedures. This was confirmed by a review of his medical records. CONCLUSION: The diagnosis of FICRD should be considered for any patient who is seen with an acquired vascular lesion, a morphealike lesion, or an unexplained ulcer localized over the scapula, the back, or lateral trunk below the axilla.

High-dose fluoroscopy: the administrator's responsibilities.

During the past 15 years, developments in x-ray technologies have substantially improved the ability of practitioners to treat patients using fluoroscopically guided interventional techniques. Many of these procedures require a greater use of fluoroscopy and serial imaging (cine). This has increased the potential for radiation-induced dermatitis, epilation and severe radiation-induced burns to patients. Radiology administrators must realize that these high-dose procedures increase the risk for radiation injury and radiation-induced cancer in personnel as well as in patients. This article discusses particular clinical cases and describes positive, pro-active steps that practitioners and administrators can take to help prevent such injuries in their facilities. Unfortunately, with the exception of radiologists, a large proportion of physicians who use fluoroscopy have effectively no training or credentials in management of radiation or the biological effects associated with its use. In 1994, an FDA advisory warned that training of physicians for modern-day use of the fluoroscope was for the most part insufficient and needed to be expanded. Many prominent medical organizations such as the American College of Cardiology (14) and the American Heart Association (15) have published strongly worded position papers agreeing that there is an urgent need for such training. The consensus is that "rubber-stamp" privileges (16,17) to perform fluoroscopic procedures should no longer be granted. At present, the JCAHO is considering the implementation of a statement regarding JCAHO standards and privileges for practitioners to use fluoroscopic x-ray equipment. Whether or not the JCAHO becomes involved, it is becoming increasingly clear that all practitioners who use fluoroscopic radiation should be required to complete focused training in radiation physics, radiation biology and radiation safety. Training should include the pertinent aspects of radiation management in the clinical setting so that these physicians will be able to acceptably control risks to patients and personnel. The task of securing these materials and lecturers and documenting everything may fall on the shoulders of the radiology administrator or radiation safety staff. Completion of an approved educational program (with appropriate testing) provides the evidence needed by the facility to approve the practitioner's qualifications. In summary, it will take a concerted effort on the part of professional medical organizations and regulatory agencies to insure that the wealth of preventative information now available is disseminated to and put to use by these physicians who may fail to fully appreciate the potential for imparting serious injury to their patients. Even one radiation injury caused by lack of education is unacceptable.

Evaluation of radiation dose and risk to the patient from coronary angiography.

BACKGROUND: Coronary angiography is a commonly performed diagnostic procedure with life saving benefits for the patient. However, because of its potential to deliver a high radiation dose, caution is warranted. AIM: The purpose of this study was to determine the effective dose to an average patient from coronary angiography, to estimate the associated radiation risk in terms of fatal malignancy, and to examine ways effective dose may be reduced. METHOD: The dose-area product data from 210 examinations was used to determine the effective dose to the average patient by means of a commercially available software programme. Subsequently, the effective dose was used to estimate radiation risk based on the population averaged probability coefficients given in ICRP 60 and contrasted against age-related risk coefficients from the NRPB. The components of effective dose and radiation risk were examined to identify the organs most at risk. RESULTS: The average effective dose was found to be 3.4 +/- 1.3 mSv. The risk of fatal malignancy was estimated as 170 per million cases, or around one in 6000. The average lung dose was 14.7 mSv, with the risk of fatal lung cancer estimated as 125 per million cases or one in 8000. CONCLUSIONS: The average effective dose in this study was less than half that of most other studies. The lung was identified as the critical organ and the estimated risk of fatal cancer amounted to an increase of 0.017% above the normal incidence for the general population. The study affirmed that using a reduced cine frame rate, low dose pulsed fluoroscopy, added copper filtration and a conscious effort to reduce screening time can significantly reduce patient dose.

Radiation risk to patients from percutaneous transluminal coronary angioplasty.

OBJECTIVES: This retrospective study sought to estimate patient radiation exposure during percutaneous transluminal coronary angioplasty, the corresponding organ doses and the resulting cancer mortality risk. Patient demographic data were also examined. BACKGROUND: Coronary angioplasty is commonly used as an intervention for coronary atherosclerosis, and repeated application in the same patient is now common. The combined use of fluoroscopy and cineradiography in this complicated, delicate and, hence, lengthy procedure induced us to investigate the patient radiation exposures and resulting risks. METHODS: All complete records for angioplasty procedures performed over a 3-year period were entered into a data base. The data comprised 1,893 procedures performed in a total of 1,503 patients, of whom 21% had two or more procedures in the 3-year period. Fluoroscopy time was converted to entrance exposures, assuming a rate of 520 muC kg-1 min-1 (2.0 R min-1). Cineradiographic film lengths were determined for a smaller number of procedures (200) and converted to exposures at 7.7 muC kg-1 frame-1 (30 mR frame-1). In addition, fluoroscopy and cineradiographic times and, hence, exposures for 91 diagnostic angiograms performed in these patients were obtained. Exposures were converted to organ doses using the Monte Carlo results of the Rosenstein group and then to cancer mortality risks using the latest rates of the International Commission on Radiological Protection. RESULTS: The mean age was 56.0 years; men constituted 77.5% of the patients. Radiation doses varied considerably owing to a large spread in exposure times (e.g., fluoroscopy time per angioplasty case averaged 19 min but for some cases exceeded 1 h). The average patient skin entrance exposure per angioplasty procedure was 32.0 mC kg-1 (124 R), of which 69.7% was from cineradiography. The resulting cancer mortality risk per angioplasty procedure is approximately 8 x 10(-4). CONCLUSIONS: The skin exposures estimated for angioplasty are on average higher than for other X-ray procedures. The cancer mortality risk does not exceed the mortality risk of bypass surgery. Good professional practice requires maximization of the benefit/risk ratio through quality assurance in all aspects of the procedure.

Dissection of the left main coronary artery: diagnosis by angioscopy.

A 58-year-old woman with mitral valve disease was investigated with cardiac catheterization. At catheterization, a suspected dissection of the left main coronary artery occurred. This diagnosis was confirmed at urgent operation by intraoperative angioscopy. The patient underwent mitral valve replacement and coronary artery bypass grafting and made a good postoperative recovery. Coronary angioscopy at operation provides a useful means of diagnosing pathology in the left main coronary artery.

Irradiation to the thyroid gland at cardiac catheterization and angiocardiography in children.

Irradiation to the thyroid gland was measured during cardiac catheterization in 16 infants and 30 children aged 1 to 13 years. The doses from fluoroscopy, full-scale angiocardiography, and cineradiography were measured separately with thermoluminescent dosimeters and, in addition, the exposure-area product was assessed during fluoroscopy with a transparent ionization chamber. Median value of the absorbed dose to the thyroid from the complete heart investigation was 370 mrad in infants and 260 mrad in children. The highest values and also the greatest range in dosage were observed in infants. The quotient of the thyroid-absorbed dose divided by the integral dose or the dose per exposed film area was also highest in infants, due to anatomical conditions. The absorbed dose to the thyroid during heart catheterization comes almost exclusively from scattered radiation. By appropriate examination technique this dose can be kept within acceptable limits.