Fluoroscopy-guided placement of nasoenteral tubes in children using intermittent digital pulse fluoroscopy and last image save/grab technique.

AIM: To document the radiation exposure metrics, including fluoroscopic radiation time and radiation dose-area product, in children <18 years of age who undergo nasoenteral tube placement using fluoroscopic guidance with maximal dose-reduction techniques. MATERIALS AND METHODS: Following institutional review board approval, the age, gender, anatomical information, immediate procedure-related complications if any, fluoroscopy time, and radiation dose-area product were collected retrospectively in all paediatric patients who underwent fluoroscopically guided nasoenteral tube placement during a 5-year period. Three paediatric radiology faculty members, a radiologist assistant, and trainee residents during their paediatric radiology rotation performed the procedures on two different digital fluoroscopic machines using radiation-minimising techniques. Median values of the fluoroscopy time and radiation dose-area product were calculated and compared to values reported in the literature using the Wilcoxon procedure. RESULTS: There were 41 male and 33 female patients with a median age of 4 years and 6 months. Median fluoroscopy time used for placing a nasoenteral tube was 1.25 minutes with a median radiation exposure dose-area product of 0.245 Gy·cm(2). All patients had successful placement of nasoenteral tube without immediate procedure-related complications. CONCLUSION: Fluoroscopy-guided nasoenteral feeding tube placement can be performed successfully with minimal radiation exposure without compromising procedural success.

Changes in growth rate of an experimental solid tumor following increasing doses of cyclophosphamide.

Well-defined times for minimum and maximum growth rates of rat hepatoma 3924A were found when cyclophosphamide doses were increased from 50 to 250 mg/kg. Minimum growth rates occurred 8 to 10 days after treatment and maximum growth rates occurred 13 to 16 days after treatment in 5 groups of 10 animals each that received 50, 100, 150, 200, and 250 mg of cyclophosphamide per kg. Tumor growth delay increased from 6 to 18 days when the dose was increased from 50 to 250 mg/kg. The accelerated growth rate of treated tumors on Day 14 after cyclophosphamide (150 mg/kg) was more than twice that of controls on the same day, 0.349 +/- 0.030 (S.E.) (day-1) and 0.156 +/- 0.011 (day-1), respectively. In addition, the accelerated growth rate of treated tumors on Day 14 was greater than that of controls at initiation of treatment, 0.298 +/- 0.026 (day-1) on Day 2. Increased DNA synthetic rate precedes increased tumor cell proliferation, which, in turn, increases tumor volume. Thus, biochemical studies demonstrating increased cellular proliferation confirm accelerated tumor growth following treatment.

A survey of radiation oncologists regarding their radiation physics instruction.

The American Association of Physicists in Medicine, Committee on Training of Radiologists conducted a survey of radiation oncologists requesting information regarding their radiation oncology physics training. General questions were asked of the oncologist regarding their radiation oncology practice such as number of oncologists, number of new patients treated, and the size and type of facility in which the practice is located. The oncologist also responded to questions regarding their educational background. The survey requested the radiation oncologists to answer questions regarding the adequacy and importance of their training in specific areas of radiation physics. The responders indicated that the importance of most physics topics in their clinical practice corresponded to the level of their understanding. The survey indicated that for most radiation oncologists their physics instruction was an important and interesting part of their residency program.

Health effects of low level radiation: carcinogenesis, teratogenesis, and mutagenesis.

The carcinogenic effects of radiation have been demonstrated at high dose levels. At low dose levels, such as those encountered in medical diagnosis, the magnitude of the effect is more difficult to quantify. Three reasons for this difficulty are (1) the effects in human populations are small compared with the natural incidence of cancer in the populations; (2) it is difficult to transfer results obtained in animal studies to the human experience; and (3) the effects of latency period and plateau increase the complexity of population studies. In spite of these difficulties, epidemiologic studies of human populations exposed to low levels of radiation still play a valuable role in the determination of radiation carcinogenecity. They serve to provide upper estimates of risk and to rule out the appearance of new effects that may be masked by the effects of high doses. While there is evidence for mutagenic effects of radiation in experimental animals, no conclusive human data exist at the present. It is not possible to rule out the presence of genetic effects of radiation in humans, however, because many problems exist with regard to the epidemiologic detection of small effects when the natural incidence is relatively large. In animals, subtle effects (eg, a decrease in the probability of survival from egg to adult) may occur with greater frequency than more dramatic disorders in irradiated populations. However, these types of genetic abnormalities are difficult to quantitate. Current risk estimates are based primarily upon data pertaining to dominant mutations in rodents. Some specific locus studies also permit identification of recessive mutation rates. The embryo and fetus are considered to be at greater risk for adverse effects of radiation than is the adult. This sensitivity was predicted in 1906 by the law of Bergonie and Tribondeau and has been demonstrated in human and animal populations. At high dose levels (above 15 rem), the effects of radiation depend upon the gestational stage at which irradiation occurs. Prior to the second week, the predominant effect is preimplantation death, while during the period of major organogenesis (second to sixth week), growth retardation and CNS abnormalities may be produced. These effects have not been demonstrated with a high degree of statistical significance at low dose levels (below 15 rem) and are not considered to present a serious hazard for patients undergoing radiologic exams.

Screening mammography. A risk versus risk decision.

The potential risk of a radiologic procedure often is compared with the potential benefit of the procedure. While risk vs. benefit analysis has been useful as a step toward increased communication and understanding among radiologists, referring physicians, and the general public, it has the disadvantage that risk and benefit are fundamentally different quantities. Hence, their juxtaposition for purposes of comparison presents contextual difficulties. In this article, the concept is presented of comparing the risk of doing a procedure with the risk of choosing not to do the procedure. An example of risk vs. risk analysis of screening mammography for women over the age of 50 is given, with the conclusion that the risk of having yearly mammograms is less than 1/10 the risk of early death caused by failure to diagnose breast cancer by x-ray mammography. This approach to risk analysis would yield interesting data for examinations that are part of more complicated diagnostic pathways.

Gray-scale sonographic characterization of aminoglycoside-induced nephrotoxicosis in a canine model.

RATIONALE AND OBJECTIVES: The diagnostic usefulness of gray-scale sonography was evaluated in a canine model of aminoglycoside-induced nephrotoxicosis. METHODS: Sonography was performed before and during the onset and progression of nephrotoxicosis induced by administration of a toxic dosage of gentamicin. Subjective visualization of increased renal cortex echogenicity (IRCE) was objectified with digital image analysis methods. Results of both subjective and objective evaluation were correlated with clinicopathologic tests and renal cortex biopsy obtained concurrently. RESULTS: Subjective visualization of IRCE was associated with significant nephrotoxicosis and was superior to serum creatinine elevation in nephrotoxicity detection. Objective detection of IRCE improved nephrotoxicity detection sensitivity to that of increased urine enzymuria. CONCLUSIONS: Based on the above results, subjective visualization of IRCE in patients with aminoglycoside-induced nephrotoxicity may occur before azotemia and is suggestive of significant renal dysfunction; application of digital image analysis methods may lead to earlier sonographic recognition of nephrotoxicity.

Lossy compression should not be used in certain imaging applications such as chest radiography. For the proposition.

Computational techniques are frequently used to compress image data so that transmission and storage requirements are reduced. If the computational techniques result in no loss in image resolution, the technique is referred to as lossless compression. Greater compression of data may yield some loss in spatial or temporal resolution, and is referred to as lossy compression. In some radiologic examinations [e.g., gastrointestinal (GI) studies], some resolution loss may be tolerable, whereas in others (chest examinations and mammography) it conceivably could result in missed pathology. Without lossy compression, however, data requirements can be overwhelming for transmission, storage and retrieval of images such as chest films. The unanswered question, addressed in this Point/Counterpoint issue, is whether some degree of lossy compression can be tolerated in chest radiography.

The potential for radiation-induced skin damage in interventional neuroradiological procedures: a review of 522 cases using automated dosimetry.

The Food and Drug Administration (FDA) has recommended the monitoring of radiation skin dose to patients during procedures having the potential for radiation damage. Radiologists need information about typical radiation doses during interventional procedures. The skin doses to patients during 522 interventional neuroradiological procedures have been monitored using an automated dosimetry system. Estimated entrance skin doses (ESD) were binned into 0.5 Gy increments and compared to FDA recommended thresholds for inclusion in the patient record. Percentages of procedures exceeding the above mentioned thresholds are presented. In addition, the percentage of dose in each view and the percentage of dose in fluoroscopic and digital angiographic modes are shown. Six percent of embolization procedures and one percent of cerebral angiograms are estimated to have potential for main erythema (ESD>6 Gy). All types of procedures have potential for temporary erythema and exceed the threshold for inclusion in the patient record (ESD> 1 Gy) at the 95% percentile. The types of procedures with most potential for skin damage also have significant percentages of dose in the digital angiographic mode. Thus, monitoring fluoroscopic time alone underestimates the potential for skin injury. On the other hand, combining the doses in the posterior-anterior and lateral views, tends to overestimate the potential for radiation injury.

Ionization produced by electron beams beneath curved surfaces.

Ionization produced by high-energy (6-18 MeV) electrons beneath cylindrical surfaces has been measured and compared to ionization at corresponding locations under a flat surface. Results are reported as ionization ratios over a range of depths, off-axis distances, radii of curvature, and electron energies. Phantoms with cylindrical entrance surfaces (radii 6-15 cm) were utilized to simulate patient contours. Measurements reveal that ionization ratios may depart from unity by as much as 50% and that a simple shifting of isodose curves may be insufficient to compensate for perturbation in electron dose distribution introduced by curved surfaces.

Solid tumor models for the assessment of different treatment modalities. XIX. Tumor cure rates and tumor control following sequential administration of radiation and cyclophosphamide.

Tumor cure rates greater than 50% have been realized by the administration of three and four series of 1500 rads radiation and 150 mg/kg (0.9 g/m2) cyclophosphamide which were separated by 1, 7. or 11 days. Increasing the time between treatment modalities from 1 to 7 and 11 days provided a 2- to 3-week recovery period for each treatment modality without a reduction in cure rates. However, the mean time for complete response increased from 24.8 +/- 17 days for 1 day, 30.7 +/- 3.0 days for 7 days, and 38.3 +/- 4.8 days for 11 days between treatment modalities. Giving the second series of radiation and cyclophosphamide on days 16 and 17 resulted in a cure rate of 50%. Increasing this interval to 21-22 days resulted in no cures. The results of giving each modality alone at 11-day intervals have been compared with results of altering administration of the two modalities at 11-day intervals. Comparing the three regimens where a treatment was given every 11 days, the numbers of animals with cures were 0 of 10 for cyclophosphamide alone, 2 of 10 for radiation alone, and 5 of 9 for alternation of the two treatments every 11 days. Well-defined periods of accelerated growth occur between 10 and 20 days after administration of single doses of either radiation or cyclophosphamide. The increased effectiveness of alternate utilization of the two modalities suggests that prior treatment by one modality increases tumor sensitivity to the second modality.

Absence of mutagenic effects of continuous and pulsed ultrasound in cultured (AL) human-hamster hybrid cells.

Mutagenic effects of continuous and pulsed ultrasound were looked for using an in vitro assay system, the AL hybrid, that is up to 100 times more sensitive for mutagens such as x-rays and neutrons than the assays used previously to evaluate ultrasound. Cells in suspension in rotated plastic test tubes were insonated with continuous wave ultrasound at 1 MHz, ISPTP = 0.62-40 W/cm2 for 0-40 min. Cells attached in the central region of culture flasks received pulsed exposures at fc = 2.5 MHz, PRF = 1 kHz, 2 and 8 cycles per pulse, with p- = 1.2 MPa (ISPTA = 31-180 mW/cm2) for 0-30 min. Although these exposures were cytotoxic (the plating efficiency was decreased to approximately 65% by the highest doses), induction of mutation, if any occurred, was less than would be expected in this test system from 10-30 cGy of x-ray.

Estimation of arcuate artery resistive index as a diagnostic tool for aminoglycoside-induced acute renal failure in dogs.

OBJECTIVE: To determine the potential clinical usefulness of duplex Doppler estimation of arcuate artery resistive index (a measure of intrarenal blood flow impedance) for diagnosis of aminoglycoside-induced nephrotoxicosis. ANIMALS: 30 adult, female, mixed-breed dogs, allotted to 3 groups of 10 dogs each as: toxic dosage of gentamicin, therapeutic dosage of gentamicin, and saline solution sham equivalent in volume to that of the toxic dosage of gentamicin. PROCEDURE: After baseline screening to establish normalcy (serum biochemical analysis, endogenous creatinine clearance determination, urinalysis, urine protein-to-creatinine ratio, urine culture, gray-scale sonography, and percutaneous ultrasound-guided renal biopsy), results of arcuate artery resistive index determination were compared with serum creatinine and urine specific gravity values on a Monday-Wednesday-Friday data collection schedule for 10 days. Endogenous creatinine clearance determination, ultrasound-guided renal biopsy, and urine culture were repeated at the end of data collection in all 3 groups. RESULTS: Significant differences in resistive index measurements were not observed, despite clinicopathologic and renal biopsy results compatible with severe acute tubular necrosis in dogs of the toxic dosage group. CONCLUSIONS: Duplex Doppler sonography of arcuate artery blood flow impedance, expressed as the resistive index, appears to have poor clinical usefulness as a diagnostic tool in this disorder. CLINICAL RELEVANCE: Normal arcuate artery resistive index values obtained in dogs for which aminoglycoside-induced nephrotoxicosis is suspected do not exclude the disorder. If abnormal arcuate artery resistive index values are obtained for such dogs, further evaluation for nephropathies other than aminoglycoside-induced nephrotoxicosis may be considered.

A survey of films for use as dosimeters in interventional radiology.

Analysis of radiation doses in interventional radiological procedures that can lead to deterministic radiation effects such as erythema and epilation would assist physicians in planning patients care after exposure and in reducing doses. Photographic films used to measure skin exposure in the past are too sensitive for the high doses involved in interventional procedures. Seventeen different types of films, many of which are generally available in hospitals, were surveyed to see if any would meet the demands of interventional radiology. Sensitometric curves obtained demonstrate that most films are inappropriate for high dose procedures. Using Kodak Fine Grain Positive and Dupont duplicating films and automatic processing, doses as high as 2.8 Gy could be measured with reasonable accuracy. Similar results can be obtained by manually processing Kodak XV-2 verification film at room temperature.

Magnetic resonance imaging: the basic physical and clinical concepts. Part II.

Noninvasive evaluation of the human body has become an essential tool in the diagnosis of disease processes. Recent developments in nuclear magnetic resonance imaging (MRI) have extended a powerful chemical analytic technique to the medical imaging field. This article presents the fundamental principles of MRI in terms of the concept of transmission and reception of energy. The physical principles of spin resonance were discussed in Part I. Spin relaxation and pulse sequences will be examined in Part II and III. A selected bibliography directs the reader to a more detailed discussion of the pertinent physics.

Magnetic resonance imaging: the basic physical and clinical concepts. Part I.

Noninvasive evaluation of the human body has become an essential tool in the diagnosis of disease processes. Recent developments in nuclear magnetic resonance imaging (MRI) have extended a powerful chemical analytic technique to the medical imaging field. This article presents the fundamental principles of MRI in terms of the concept of transmission and reception of energy. The physical principles of spin resonance are discussed in Part I. Spin relaxation and pulse sequences will be examined in Part II and III. A selected bibliography directs the reader to a more detailed discussion of the pertinent physics.

Magnetic resonance imaging: the basic physical and clinical concepts. Part III.

Noninvasive evaluation of the human body has become an essential tool in the diagnosis of disease processes. Recent developments in nuclear magnetic resonance imaging (MRI) have extended a powerful chemical analytic technique to the medical imaging field. This article presents the fundamental principles of MRI in terms of the concept of transmission and reception of energy. A selected bibliography directs the reader to a more detailed discussion of the pertinent physics.