Breast compression and radiation dose in two different mammographic oblique projections: 45 and 60 degrees.

INTRODUCTION: Standard mammography includes two views, craniocaudal and medio-lateral oblique. Depending on patient's body constitution, central beam angle in mediolateral oblique projection may vary, with 45 degrees being suitable for the majority of patients in routine daily practice. With continuous improvement in X-ray technology and radiographers' training, the risk of radiation induced cancerogenesis is considerably reduced and acceptable when compared to benefit. However, the risk still exists, being cumulative and directly related to absorbed glandular dose. There is no minimal dose of radiation which is absolutely harmless, and every effort to reduce the dose is welcome. In this retrospective study two different angles (45 vs. 60 degrees) of mediolateral oblique view were compared according to radiation dose and efficacy of breast compression. PATIENTS AND METHODS: In 52 women, additional 60 degrees oblique films were done after craniocaudal and mediolateral oblique 45 degrees-films, with the same kVp and positioning technique. Breast thickness, time-current products (mA s) and absorbed doses were compared between 45 degrees- and 60 degrees-films. Subgroups of women with large, small, prominent and pendulous breasts were analyzed separately, following the same methodology as for the whole group. RESULTS: mA s were 11.5% lower and compression 7% better with an angle of 60 degrees than with 45 degrees. In the subgroup of women with small breasts, mA s values were 13% lower and compression 9% better with 60 degrees than with 45 degrees, while in the subgroup with large breasts, mA s were 9% lower and compression 5% better. In the subgroup of patients with pendulous breasts, mA s values were 12% lower and compression 10% better with 60 degrees than with 45 degrees, while in the subgroup with prominent breasts, mA s values were 4% lower and compression 3% better. Absorbed glandular dose was estimated to be approximately 20% lower when an oblique mammogram was done with 60 degrees instead of 45 degrees. The compression with 15 kp was well tolerated by the majority of patients. DISCUSSION AND CONCLUSION: Mammograms of excellent quality should be done with as low a radiation dose as possible. Adequate breast compression is fundamental in mammography due to immobilization of the breast, shortening of the exposure times, reduction of motion and geometric blur and prevention of overpenetration by means of equalizing breast thickness. As the absorbed glandular dose cannot be accurately measured, it is convenient to estimate the dose approximately, on the basis of its linear proportionality with exposure dose. With constant technical properties of X-ray machines, exposure dose is determined only by mA s. Hence, the absorbed glandular dose in our study was influenced only by changes of mA s and breast thickness. As the absorbed dose reduction is proportional to the product of the reduction of mA s and thickness, we estimated that absorbed dose was 7-22% lower if 60 degrees is applied instead of 45 degrees. Breast compression and mA s were more favourable in women with pendulous breasts, possibly because of elongation of the glandular disc in the lateroascending direction, with its longer axis directed more perpendicularly. Fibroglandular tissue in the 60 degrees-view is thus projected onto a larger film area, with less effect of superimposition. In conclusion, because of lower mA s values and better compression, which finally result in a 25% lower absorbed dose, we recommend the oblique view be done with an angle of 60 degrees, especially for small and pendulous breasts.

[Selective ambulatory transbrachial intra-arterial DSA of supra-aortic arteries with atypical origins]. / Selektive ambulante transbrachiale intraarterielle DSA der supraaortalen Arterien bei atypischen Abgängen der supraaortalen Arterien.

We have already published the technique of SATISDA of supra-aortic arteries using the Tomac 1-3 catheter. In this group of 500 patients, selective demonstration of individual supra-aortic arteries was unsuccessful in 77 patients (15.4%). Demonstration was unsuccessful of three left vertebral arteries (0.6%), 45 left carotid arteries (9%), right carotid in nine (1.8%) and right vertebral artery in 20 (4%). In most cases the failure was due to an atypical origin of the vessel. To increase the success rate we used a 4-French newly developed straight Tomac 4-5 catheter. Using a combination of both catheters, selective demonstration of the left carotid was successful in 41 patients (91.1%), the right carotid in 8 (88.8%) and the right vertebral in 18 (90%). In three patients, a left-sided catheterisation had to be performed to demonstrate the left vertebral artery. Complications consisted of 17 local haematomas (3%) and reversible spasm at the puncture site in one patient (0.2%).

[Selective ambulant transbrachial intra-arterial DSA of the supra-aortic arteries]. / Selektive ambulante transbrachiale intraarterielle DSA der supraaortalen Arterien.

The improved Tomac 1, 2 and 3 (T1, T2, T3) catheters for selective transbrachial intra-arterial DSA of supra-aortic arteries are described. 1,100 patients have been examined. Using the T1 or T2 catheters, selective demonstration of the left subclavian artery was possible in 98% of 880 patients and the left common carotid artery in 88%. Semiselective demonstration of the right cerebral vessels was successful in all patients. In 220 patients a combination of T1, T2 and T3 catheters was used, resulting in 100% demonstration of the left subclavian artery, 97% demonstration of the right carotid artery, 88% demonstration of the right vertebral artery and 95% demonstration of the left common carotid artery. The only serious complication was thrombosis at the site of puncture in 0.18% of patients. These results have encouraged us to use the new catheters for outpatients.

Asymptomatic carotid stenosis: selective or routine use of intraluminal shunt.

BACKGROUND: To evaluate the use of temporary intraluminal shunt (IS) during operations in our patients for asymptomatic carotid stenosis (ACS) of the internal carotid artery (ICA). METHODS: Complications of ICA endarterectomy were reviewed in two groups of asymptomatic patients. In group A (144 patients, operation 1972-1985) temporary IS was used in 43 patients with the intraoperatively measured ICA back pressure <50 mmHg. In group B (170 patients, operation 1986-1998) shunt was used in all cases. RESULTS: The incidence of neurologic deficit was higher ia group A than in group B (5.6% vs 1.2%, p<0.05). Within group A, the incidence of neurologic deficit was significantly higher in the subgroup with back pressure >50 mmHg, and thus without shunt, than in group B with routine use of shunt (6.0% vs 1.2%, p<0.05). There were no differences in the incidence of shunt-related complications between the groups (3.0% vs 4.0%, p>0.05). We had no mortality after operations of asymptomatic patients. CONCLUSIONS: The routine use of IS reduced the rate of intraoperative and early postoperative neurologic complications of asymptomatic carotid endarterectomy, and it was not associated with a higher incidence of complications.

Organization and activity of the health service in the Croatian province of Lika in the first year of the war.

The aim of this report is to present the various aspects of the reorganization of the health service in the Croatian province of Lika during the first year, 1991-1992, of the war in Croatia. In the former Socialist Republic of Yugoslavia, the health service was completely in the hands of the state, and Croatia was not able to transform it in the first year of its independence. The paper documents the personnel, supplies, and equipment that the health service of Lika had at its disposal in the first year of the war, the division of the health service into the stationary and front-line medical corps, and the evacuation protocols developed to transfer surgical patients to the rear-area hospital. The response of the health service allowed for rapid and successful patient treatment, emphasized by the fact that the usual time elapsed between wounding and delivery of the patient to the operating table was less than 30 minutes. All surgeries, with the exception of those involving severe craniocerebral injuries, were performed in the war hospitals of Lika. After stabilization of their postoperative condition, generally within 30 minutes, patients were evacuated to the rear-area hospital in Rijeka, with artificial respiration. The distance by road from the war hospitals in Otocac and Gospic to the reararea hospital in Rijeka was 120 and 170 km, respectively. Collectively, the results of our work demonstrate that a nonmilitary health service can be transformed successfully and efficiently into a war medical service. Yet, we believe that this is possible only under the extreme conditions of a defensive war.

Transformation of health services from civilian to wartime medical corps--example from Bosnia and Herzegovina.

In the multiethnic Bosnia and Herzegovina, Croats and Muslims, attacked by the Yugoslav army and Serbs, had to employ rationally their poorly provisioned civilian health services so that they could respond to the extremely numerous and prompt needs of war conditions. The health services in the areas controlled by Croats and Muslims had to be reorganized twice because of sudden changes of wartime conditions. With further development of the situation, when all three sides participated in the conflict, the number of wounded increased rapidly. In the meantime, a large-scale population shift on an ethnic basis occurred in all parts of Bosnia and Herzegovina, thus giving rise, along with a greater number of the wounded, to a severe humanitarian crisis. Civilians were therefore another heavy burden to the wartime health services. This created enormous problems for the inadequately provisioned health services of Bosnia and Herzegovina in the area under the control of Croats and Muslims. However, poorly equipped with personnel as well as everything else, the health services in the area controlled by Croats and Muslims, through appropriate reorganization, successfully accomplished their task in the wartime medical corps. Besides this correctly executed transformation from civilian health services into a wartime medical corps, high motivation of medical staff also greatly contributed to successful operation of the medical corps in the war zone despite the long duration of the war. In the majority of cases, the wounded were within 30-40 minutes from the moment of injury in the hands of a surgical team and within the next ten minutes were already in the operating theater. After primary wound dressing, the wounded were sent to one of the well-organized main war hospitals for further treatment. This resulted, along with secure evacuation routes, in a minimum number of lifelong invalidity among the wounded.

[The direction of Croatian health care in the post-war period]. / Smjernice hrvatskoga zdravstva u poslijeratnom razdoblju.

A radical transformation of the health-care system in Croatia has begun after the first free and democratic elections in the country. Changes were initiated along the lines suggested by the World Health Organization experts and in accordance with the positive experiences of the earlier health-care organization and practice. The newly introduced changes involved the introduction of market mechanisms in health care (private medical practice and contracting for medical services), establishment of health insurance funds, formulation of rules and standards for the provision of medical services, and reorganization of management in medical institutions. With the start of the armed aggression against the Republic of Croatia, all of these activities ceased and the health-care system switched very quickly from peace-time to war-time operation. At the same time, preparatory work continued on the definitive reorganization of the health-care and health insurance systems. The present paper discusses the underlying principles for the three basic pieces of legislation: Health Care Act, Professional Chambers Act, and Health Insurance Act. The Health Care Act will be based on new patterns of property relations in health-care organizations. Three types of ownership are envisaged - state, private and mixed. Most of the existing health-care institutions will be state-owned, and the owner (government, district or municipal authority) will appoint a governing board in each case, which, in turn, will appoint the director or manager. A separate piece of legislation will regulate the status of health workers.(ABSTRACT TRUNCATED AT 250 WORDS)

[The integral civil and military health care system]. / Integralni civilni i vojni zdravstveni sustav.

The problem of the organization of the army health care system in the Republic of Croatia is very actual. At the beginning of the war, the all fighting formations were covered by the civil health organization. After the Croatian army was organized, the differentiation between civil and army health system has been established. The characteristic of that differentiation was integral system with primary health care and transporting of the wounded persons organized by the army, while the specialistic and hospital care were organized by the civil institutions. In the peaceful future the integral health system must be kept. There is no need for the army hospitals, because only one hundred beds for a year will be enough for the army consisted of about 50,000 persons. The civil hospitals can provide the high quality service with a short-term transporting of the patients. The Government of the Republic of Croatia has decided to establish such integral system which includes the civil hospital care and the civil specialistic out-patient care, while the primary and specific health care are in the organization of the army. This system is less expensive than the full army health system, but is of better quality and includes an easy approach to all health institutions.

[Analysis of the frequency, types and justification for radiographic examination based on a sample of a community population]. / Analiza ucestalosti, vrsta i opravdanosti rendgenskih pregleda na primjeru stanovnika jedne opcine.

According to the patient's general practitioner files of the Health centre "Josip Adamic" Ivanic-Grad, all x-ray diagnostic examinations carried out in health insured persons of the Ivanic-Grad community were analyzed between 1983 and 1987. During the period, a total of 22,615 x-ray examinations were done. An average number of 0.761 radiographs was performed and the average x-ray dose to which patients were exposed was 126.62 mrads (1.26 mGy). The site of most usual examination was the thorax (44.1%). Males underwent more x-ray examinations than females (53.2% versus 46.8%). X-rays of thorax, head and neck, arms and legs were more frequent in males, while abdomen and pelvis x-ray examinations and diascopies were more usual in females. The greatest number of x-ray examinations was performed between the ages of 0 to 20 years of age, and patients were exposed to the highest x-ray dose between the ages of 41 to 60 years of age. The average gonadal dose was 58.78 mrads (0.58 mGy) per year. Clinical examinations preceded radiologic examinations in 81.3% of cases, laboratory investigations in 9.7% and other non-radiologic examinations in 1.4% of cases. The working diagnosis existed before x-ray examination in 77% of cases and pathological findings were discovered in 32.7% of cases.

[The role of intravenous digital subtraction angiography in the detection of the cause of cerebral ischemia]. / Uloga intravenske digitalne suptrakcijske angiografije u otkrivanju uzroka ishemije mozga.

A comparative analysis of two angiography methods applied in two unrelated groups of patients with brain ischemia symptoms is described. The first group of 452 patients suffering from extracranial cerebral artery disease was analyzed by an intravenous digital subtraction angiography (DSA); the second group of 500 patients was subjected to a conventional aortic arch angiography. Research was based on comparative analysis of angiograms as per type and location of morbid changes. In the area of common carotid artery and internal carotid artery the stenosis was considerably more frequently detected by the conventional angiography than by the intravenous DSA, i.e. in 105 (20.0%) as compared to 40 (8.8%) patients, respectively. Similar difference is indicated in a total number of morbid changes in these arteries detected in 248 patients (49.6%) by aortic arch angiography and in 154 (34.1%) patients by intravenous DSA. The dissimilarity is noticed with minor atherosclerotic changes, while medium and major stenoses are detected with equal frequency by both methods. The intravenous DSA more often indicated flexion of carotid artery, and considerably more often the vertebral artery flexion as found in 53 (11.7%) patients analyzed by intravenous DSA compared to 33 (6.6%) patients analyzed by conventional angiography. Advantage of intravenous DSA is less complications and ambulatory performance. The conventional angiography better indicates morbid changes in common carotid artery bifurcation and vertebral artery origin.

[Diagnostic approach in patients with kidney tumors]. / Racionalizacija dijagnostickih postupaka u bolesnika s tumorima bubrega.

The basic reason for the rationalization of diagnostic procedure is the cost benefit relation and making of the diagnostic course algorithms. On the basis of the Receiver Operating Characteristic (ROC) analysis of the diagnostic procedure (excretory urography, ultrasonography, computed tomography, digital subtraction angiography) the significance ranking has been established for certain kidney tumor diagnostic procedures. Angiography has been determined to be the most precise method, but the high degree of sensitivity (98%) and accurate diagnosis probability (98%), as well as noninvasiveness and relative inexpensiveness of ultrasonographic examination procedure, all argue for ultrasonography as the cornerstone, of renal tumor diagnosis. Using conditional probabilities and the Bayes analysis the advantage of the newly suggested over the standard diagnostic course has been calculated. The study has shown a significant decrease in the number of examinations: in 60 patients 16 excretory urographies, 10 computed tomographies, and 22 digital subtraction angiographies can be spared.

[The age of diagnostic radiologic equipment in Croatia]. / Starost radioloske dijagnosticke opreme u Republici Hrvatskoj.

The quality of health care also depends partly on technological equipment. Among the devices which diminish the quality of services if they are old, increasing at the same time the danger when used, are certainly those in radiodiagnostics. Besides, their age controls the dose of radiation to which patients and professional staff are exposed. The knowledge of the age of this equipment is the basis of the plans for further development. The aim of the study is to determine the age of each individual radiodiagnostic device in Croatian institutions. The assessment of each device was made by a qualified professional. The method of data collection was based on the uniform questionnaire which comprised radiodiagnostic devices older than ten years, classified according to type and location (primary health care center or hospital, in total 655 devices). Determination of the age index of generators and x-ray tubes older than seven years (according to the World Bank recommendation), included also mobile units (55 for fluoroscopy and 68 for radiography), devices for dental radiography, devices in private sector (118) and devices which are out of use but not officially blocked (88), which means in total 859 generators and 1111 x-ray tubes. In addition, the availability of image intensifiers for fluoroscopy and manufactures of all devices were determined. The results of the study reveal that in primary health care centers, out of 248 radiodiagnostic devices, 193 are older than ten years (77.8%), while 4 are of unknown age. In hospitals, out of 407 devices, there are 261 older than ten years (64.1%), while 46 are of unknown age (11.3%). Among devices for fluoroscopy, 97 out of totally 206 have no image intensifier (32%). These devices should be immediately excluded from utilization. The index of age above seven years, which is according to the recommendation of the World Bank the lifetime of devices, reveals that 859 generators out of totally 984 (91%) are too old to be used, while there are 1111 x-ray tubes out of totally 1206 (92%) which are in the same condition. Regarding the manufacturers, the ratio is also unfavourable, since 49.3% of devices have been manufactured by comparies whose technology and spare parts are now inaccessible (Elektronska industrija). Such unacceptable obsoleteness of the radiological equipment requires urgent renewal.