ASSIGNMENT ON OCCUPATIONAL HEALTH HAZARDS OF EMPLOYEES WORKING IN DIAGNOSTIC RADIOLOGY DEPARTMENT

SUBMITTED BY SR KEERTHANA 24-5-12

SUBMITTED TO MR. SUNDERBUNGA

Introduction Radiology is the branch of medicine that makes diagnostic images of anatomic structures through the use of electromagnetic radiation or sound waves and that treats disease through the use of radioactive compounds. Radiology has been used for medical purposes for over a century and remains a cornerstone of the medical field. Electromagnetic energy produces visible images that are then read and interpreted by radiologists. Physicians use the information gained through radiological imaging to diagnose, treat and monitor injuries and diseases. .Radiological imaging techniques include x-rays, C T scans, PET scans, MRIs, and ultra sonograms Radiology uses medical imaging technology to diagnose and treat medical conditions. Cancer and other medical conditions are also treated with radiological technology through the use of concentrated radiation doses. Radiology began with the invention of the X-ray machine in 1895. Though before this date others had seen x-ray images, Wilhelm Conrad Roentgen of Germany was the first to recognize the importance of the images he saw. Roentgen discovered the x-ray by accident while performing experiments with vacuum tubes. The first x-ray picture ever was taken of his wife's hand just a few weeks later. In 1901, Roentgen won the Noble Prize for Physics for his work on the x-ray machine. Today, he is considered the father of modern diagnostic radiology. EFFECTS/ HAZARDS OF RADIATION 1. Biological Effects of Radiation Energy from ionizing radiation breaks chemical bonds, releasing reactive free radicals and ions that can damage and proteins. Short-term radiation damage includes burns and hair loss; long-term effects of radiation injury include cancer induction and cataract formation. Radiation damage often is described as stochastic or nonstochastic. of stochastic effects include cancer and genetic mutations. Nonstochastic damage is dose dependent and includes cell death caused by

multiple exposures. Examples include erythema, cataracts, sterility, atrophy of internal organs and bone marrow suppression. radiation dose determines the number of radicals and ions released in a given cell, researchers presume that the risk, or probability, of a radiation-induced cancer is proportional to the dose of disruptive energy received. This assumption is the basis of the linear model of risk. When these random processes damage the DNA that controls cell division (mitosis) or programmed cell death (apoptosis), they can set off the unmanaged cell proliferation that characterizes cancer Natural sources of ionizing radiation include ultraviolet and cosmic radiation encountered during air travel or at high elevations. Over time and through natural selection, organisms have developed mechanisms to repair cellular and genetic damage caused by natural, background levels of radiation. Cells routinely use repair enzymes to reverse DNA damage, for example. It is not known if enzyme repair is as efficient at low levels of exposure as at high levels. Although theoretically possible, researchers have not proven a nonlinear relationship exists between enzyme repair activity and radiation damage to DNA, with enzyme production at higher levels of radiation exposure failing to keep pace with resulting genetic damage 2. SOMATIC EFFECT Somatic effects occur when radiation has an impact on the health of the exposed individual, whereas genetic effects are seen in the offspring of the exposed individual and result from irradiation of reproductive organs. This terminology is somewhat confusing because both somatic and genetic effects involve underlying genetic damage due radiation exposure. The distinction between somatic and genetic effects depends on which cells' DNA is damaged. When germ cells (sperm or ova) are involved, damage is likely to be expressed as genetic effects in offspring; when nongerm cells are affected, somatic effects occur. Tissue Radio sensitivities

Some tissues and organs are more vulnerable to radiation damage. Tissue weighting factors allow dose to be adjusted with tissue-specific vulnerabilities in mind. For example, reproductive tissues such as ova and testes are more radiosensitive than bone marrow and lung, which in turn are more radiosensitive than liver and bladder tissue organ or tissue doses. Measuring Exposures Radiation exposure is measured with a film badge containing an x-ray sensitive film chip or a reusable thermo luminescent dosimeter (TLD) badge. TLD badges contain lithium chloride crystals that absorb x-ray energy, forcing the crystals to release energy in light wave lengths proportional to the radiation levels encountered with increasingly sophisticated biomolecular and genetic tools, scientists also have identified several ways to measure the actual biological damage caused by radiation exposure. Biological radiation dosimetry, also known ms biodosimetry, is the study of biomarkers that reflect radiation dose. T A recent European study of DNA strand breaks in lymphocytes revealed that occupational exposure in hospital radiology departments significantly increased levels of DNA damage compared with other hospital occupations. (12) Because cells constantly repair damaged DNA, however, it does not necessarily follow that radiology personnel suffer increased cancer rates. Risk Models The prevailing theory of medical radiation risk is the linear model, which assumes that there is no threshold dose below which radiation exposure is truly safe and that risk increases proportionally with higher dose levels. The risk posed by low-level radiation is therefore calculated using data extrapolated from populations subjected to high-level radiation exposures. Scientists disagree about how these extrapolations are best performed or, indeed, whether they should be calculated. In addition to assuming that the risk of cancer induction is proportional to radiation dose, the linear model presumes that repair enzyme efficiency is constant, regardless of radiation dose. (1) Because the relationship between radiation dose and risk is believed to be linear and to have no minimum threshold, the ALARA principle prevails in diagnostic

radiology: All radiation exposures should be "as low as reasonably achievable." Most epidemiologists see the linear model as a responsibly conservative view of the risks posed by medical irradiation. Many believe that the linear model overestimates the number of cancers induced by diagnostic radiology. A distinct minority of researchers reject the linear model altogether. They point out that epidemiological data do not definitively establish that absorbed radiation doses smaller than 200 mSv increase cancer risk, and risk estimates extrapolated from higher exposure levels may be misleading. (13) Citing these facts, along with anecdotal evidence and results from some animal studies, these authors propose that, as with many toxic chemicals, ionizing radiation does not increase risk below a certain, unknown threshold. They maintain that radiation may even have health benefits below that threshold. This controversial hypothesis, called "radiation hormesis," has received increased attention in the scientific and popular press in recent years. The publicity surrounding the hypothesis may have led the public to discount the potential dangers of radiographic exams. Despite strong support from its advocates, radiation hormesis has yet to be defined precisely in the literature. Currently, there is little compelling evidence for a threshold below which radiation exposure is noncarcinogenic or protective against cancer. No medical organization or authority officially recognizes the hormesis hypothesis. 3. Cancer Risk Radiation is one of the most-studied and still most-controversial carcinogens. Studies of major events, such as Chernobyl and Hiroshima, clearly prove that increased cancer risk is associated with high-dose radiation exposure, but lower levels of radiation exposure have a more ambiguous role in cancer risk. The relatively low doses found in diagnostic radiology and the long latency periods between exposure and ultimate outcome often make the connection between medical imaging and cancer difficult to quantify with traditional epidemiological tools. (16) Nevertheless, some epidemiological studies indicate that even a single medical exposure to radiation may increase lifetime cancer risk. Additionally, the risk of developing leukemia, breast, thyroid and bone marrow cancers from medical exposure is higher than the risk for other cancers

Leukemia appears to be the cancer most often induced by medical irradiation. Prenatal exposure to x-rays is widely considered to be a risk factor for childhood leukemia, but evidence showing an association between low-level diagnostic radiation exposure and adult leukemia is inconclusive. Frequent exposure to xrays, however, does appear to increase the risk of developing multiple myeloma, a hematological malignancy once considered a subtype of leukemia. Age is an important factor as well. For example, among female atomic bomb survivors in Japan and female patients undergoing frequent diagnostic chest radiographs or fluoroscopic examinations, breast cancer risk is most pronounced in girls and women who were younger than 20 at time of radiation exposure. The estimated number of cancers directly attributable to imaging-related radiation exposure varies from nation to nation, reflecting differences in imaging procedures and the frequency with which imaging examinations are ordered. In the United States, where 962 radiologic imaging exams are ordered annually per 1000 residents, nearly 1% of the nation's cumulative cancer risk is credited to diagnostic radiation exposures (ie, more than 2500 cancer cases each year). This imagingrelated cancer rate is almost twice as high as a 1981 estimate for the United States and may reflect, in part, increases in the number of imaging examinations ordered by American clinicians during the 1980s and 1990s. Japan, in contrast, currently has the highest medical radiation exposure rate (more than 1400 imaging exams per 1000 residents annually, representing 3.2% of that nation's cumulative cancer risk. As the number of imaging exams increases, resulting cancer rate estimates change as well. In the United Kingdom, 0.6% of estimated cumulative cancer risk is due to diagnostic x-rays, resulting in approximately 700 cancer cases per year. This figure is considerably higher than the 100 to 250 cases per year estimated just a decade ago. However, it also represents the lowest annual x-ray frequency among 15 nations studied and the second lowest imaging-attributable cancer risk recorded among these nations. When annual diagnostic imaging use is compared with the amount of cancer risk attributable to diagnostic irradiation, the United States appears to have a better record than most other nations. Only Germany and Japan have a higher per capita

x-ray examination rate than the United States; however, 8 developed nations have higher cancer risk rates associated with medical imaging, including Australia, which has the second lowest manual radiographic exam frequency. As the number of radiographic exams per capita rises, it is likely that the percentage of cancers attributable to diagnostic radiology will increase as well, making it important that radiologic technologists minimize radiation exposure whenever possible. Cancer incidence among radiologic technologists has been studied with varying results. A large retrospective study found that after controlling for known cancer risk factors, the risk of breast cancer and risk of all cancers combined were significantly higher among radiologic technologists first employed before 1940 than for those first employed after 1960. The same study found that cancer risk declined significantly over time. Unlike many such studies, this analysis controlled for known cancer risk factors in a substantial subset of the individuals studied. The risk of breast cancer among radiologic technologists has been a particularly complex issue. A recent prospective study of more than 90 000 U.S. technologists from 1983 to 1998 found that female radiologic technologists had a slightly higher risk for all solid tumors and a significantly elevated risk for breast cancer.The authors concluded that the elevated breast cancer risk was a potential result of occupational radiation exposure. However, earlier studies found that after controlling for known risk factors, employment as a radiologic technologist per se did not increase breast cancer risk. 4. Radiation Exposure Management Radiation exposure to patients and radiologic technologists can be reduced using 3 broad approaches: * Duration. Reduce the time of exposure to reduce radiation dose. * Distance. Increase the distance between the radiation source and the patient and medical personnel by employing the inverse square law. Protective measures include the use of lead aprons or gloves (particularly by radiologic technologists assisting with fluoroscopic exams) and lead-lined barriers

around control consoles. Other measures include innovations such as radiographic filters, collimators and image intensification technology. Aluminum filters placed in x-ray tube housings reduce exposure to diagnostically irrelevant low-energy xrays. In addition to improving image contrast, collimators direct the x-ray beam to the target anatomy, reducing exposure to nontarget tissues. And finally, radiographic films now are typically exposed either digitally or with intensification screens that reduce patient radiation doses to less than 5% of what was required before intensification screen technology was developed. Computer enhancement of digital images may further reduce radiation dose in the near future Biological Effects of Imaging Examinations Computed Tomography As computed tomography (CT) is used more frequently for diagnostic imaging, radiation exposure to patients has increased steadily. (3) Particularly for children, the radiation dose from CT examinations often is higher than can be justified in terms of image quality and clinical utility. Additionally, the authors of a dosimetry study of helical CT radiation exposures to radiologists strongly recommended that lead aprons, gloves and thyroid shields be employed routinely by medical personnel during these exams. Pediatric Exposures Children and small adult patients are particularly vulnerable to the effects of radiation exposure. Pediatric CT examinations increase lifetime cancer risk up to nearly an order of magnitude more than the increase for adult CT scans. The need for a certain level of clinical image quality vs radiation dose should be reviewed carefully when these examinations are considered, with the ALARA principle always in mind. In pediatric cranial CT scans, researchers have found that the standard recommended radiation dose can be reduced by 40% without degrading the diagnostic quality and clinical utility of the images. Regularly optimizing radiographic techniques and procedures for children can reduce radiation doses while maintaining image quality. Using TLDs and dose-area product meters, researchers at the Royal Belfast Hospital for Sick Children in Ireland identified infant pelvic anteroposterior (AP) radiography as a "problem

procedure." By increasing tube filtration and tube potential from 50 to 56 kVp, entrance surface dose was reduced by 50% for these examinations. Fluoroscopy Fluoroscopic examinations pose radiation risks for both patients and medical personnel, and historically were a major radiation hazard. Even though recent studies suggest that safety protocols effectively reduce occupational exposure, (38) clinicians and radiologists should closely examine radiographs before fluoroscopy to ensure that they are as familiar as possible with the imaging targets and patient anatomy. Fluoroscopy should be used only when radiographs or magnetic resonance (MR) images are insufficient to evaluate the area of interest. Studying radiographs before fluoroscopy decreases search time during the procedure, thereby reducing radiation dose. In no case should a fluoroscopic examination exceed 5 minutes. Automatic timers often are built into fluoroscopic units to ensure that exams do not go beyond safe exposure times. Using the smallest possible aperture and image intensification tools to improve visualization also can reduce fluoroscopic irradiation of patients. Mobile C-arm units expose medical personnel to significantly increased scatter radiation compared with fixed or stationary dedicated fluoroscopy units. Personnel using mobile fluoroscopy units should take specific precautions, including avoiding the right corner of the unit and positioning vertical lead shields for protection.

Magnetic Resonance Imaging MR imaging is a younger and less extensively studied imaging modality, but the medical community widely accepts that the biological effects of clinical MR are much less serious than those associated with radiography, if they exist at all. MR does not cause genetic mutations like those induced by ionizing radiation. (40) No replicated studies have yet established a human health hazard related to exposure to magnetic fields.

5. Use of advanced diagnostic technologies Most safety concerns associated with MR are related to acute trauma caused by dislocation of medical prostheses such as aneurysm clips, pacemakers, cochlear hearing aid implants and drug infusion pump implants. Hearing loss can be an indirect biological effect of MR examinations because of the noise produced by rapid current alterations within the gradient coils. Reducing image section thickness and field of view increases noise but reduces acquisition time. Most MR examinations now are conducted with proper hearing protection (ear plugs or headphones). More than 40% of patients not given ear protection suffer temporary hearing loss, and cases of permanent hearing loss also have occurred. The 3 MR-related exposures of interest are static magnetic fields, time-varying gradient magnetic fields and radiofrequency pulses. The static magnetic field of MR units typically ranges no higher than 2.0 tesla, compared with the earth's background magnetic field strength of 70 microtesla . The current gold standard for MR imaging is 1.5 T for all regions of the body, but newer 3.0 T imaging and spectography equipment now are used in some neuro radiology units because of their superior resolution and reduced scan times. High-field (up to 3.0 T), very high-field (3.0 to 7.0 T) and even ultra high-field (above 7.0 T) equipment for whole-body MR scans will become more common in the near future. As high-field MR units come into clinical use, biological effects must be carefully evaluated. The hippocampus (the part of the brain associated with body orientation and memory consolidation) contains microscopic accumulations of magnetite. Biogenic magnetite plays a role in body orientation and spatial memory in some animal species; in some cases, the effect is related to the subtle torque exerted on magnetite molecules by variations in the earth's magnetic field. It is not yet known whether biogenic magnetite has a similar function in the human brain, but there is evidence that MR fields can induce neurological effects. Animal studies conducted at very high-field strengths (eg, 7.0 T) resulted in severe neurological impairment, altered gene expression and disorientation. A study conducted by General Electric and Oxford Instruments in 1992 found that humans experience more severe, temporary neurological side effects (metallic taste sensation, vertigo and nausea) when subjected to 4.0 T than when exposed to the

standard 1.5 T field. More recently, Philips Medical Systems and university researchers in the Netherlands reported impaired hand coordination and visual contrast perception among men after prolonged (1 hour) exposures to 1.5 T fields. Although these results have yet to be replicated in other laboratories and the reported effects are subtle and seemingly benign, it should be noted that age and sex have dramatic effects on the amount of magnetite in the hippocampus. Therefore, it is possible that neurological effects of magnetic field exposure may vary among patient populations. In mice, even extremely prolonged (9 hour) prenatal exposures to 4.0 T static magnetic fields caused no significant changes in fetal growth, although prenatal exposure to a combination of ultrasound and MR fields of this strength retarded fetal growth. Though such findings suggest that there are theoretical upper time and field strength safety limits for magnetic field exposures, it is important to remember that these limits are tar above any current clinical exposure level. No research has demonstrated dangerous biological effects from MR in pregnant women or human fetuses, but this reflects a lack of large-scale studies rather than conclusive demonstration of safety. A study of occupational exposure to static, low-level MR fields among pregnant MR technologists found no increased risk of miscarriage, preterm birth or low birth rate in offspring. Time-varying magnetic field gradients create electrical currents. The biological effects of these currents are believed to be limited to peripheral nerve stimulation and temporary rotation of photoreceptor cell arrangement in the eyes, resulting in perceived flashes of light called magnetophosphenes. These effects are rare at standard clinical magnetic field strengths. A recent Australian study indicated that MR-induced electrical currents in the heart may increase the risk of cardiac arrhythmia in patients with heart disease. The study also found that increasing the strength of MR-switching gradients in local chest gradient examinations could increase healthy patients' risk of arrhythmia. As high-field MR units come into clinical use, biological effects must be carefully evaluated. The hippocampus (the part of the brain associated with body orientation and memory consolidation) contains microscopic accumulations of magnetite. Biogenic magnetite plays a role in body orientation and spatial memory in some

animal species; in some cases, the effect is related to the subtle torque exerted on magnetite molecules by variations in the earth's magnetic field. It is not yet known whether biogenic magnetite has a similar function in the human brain, but there is evidence that MR fields can induce neurological effects. Animal studies conducted at very high-field strengths (eg, 7.0 T) resulted in severe neurological impairment, altered gene expression and disorientation. A study conducted by General Electric and Oxford Instruments in 1992 found that humans experience more severe, temporary neurological side effects (metallic taste sensation, vertigo and nausea) when subjected to 4.0 T than when exposed to the standard 1.5 T field. More recently, Philips Medical Systems and university researchers in the Netherlands reported impaired hand coordination and visual contrast perception among men after prolonged (1 hour) exposures to 1.5 T fields. Although these results have yet to be replicated in other laboratories and the reported effects are subtle and seemingly benign, it should be noted that age and sex has dramatic effects on the amount of magnetiTherefore, it is possible that neurological effects of magnetic field exposure may vary among patient populations. In mice, even extremely prolonged (9 hour) prenatal exposures to 4.0 T static magnetic fields caused no significant changes in fetal growth, although prenatal exposure to a combination of ultrasound and MR fields of this strength retarded fetal growth. Though such findings suggest that there are theoretical upper time and field strength safety limits for magnetic field exposures, it is important to remember that these limits are tar above any current clinical exposure level. No research has demonstrated dangerous biological effects from MR in pregnant women or human fetuses, but this reflects a lack of large-scale studies rather than conclusive demonstration of safety. A study of occupational exposure to static, low-level MR fields among pregnant MR technologists found no increased risk of miscarriage, preterm birth or low birth rate in offspring. Time-varying magnetic field gradients create electrical currents. The biological effects of these currents are believed to be limited to peripheral nerve stimulation and temporary rotation of photoreceptor cell arrangement in the eyes, resulting in perceived flashes of light called magnetophosphenes. These effects are rare at

standard clinical magnetic field strengths. A recent Australian study indicated that MR-induced electrical currents in the heart may increase the risk of cardiac arrhythmia in patients with heart disease. The study also found that increasing the strength of MR-switching gradients in local chest gradient examinations could increase healthy patients' risk of arrhythmia. (5 One study reported that radiofrequency pulses released from tissues during an MR scan burned tattooed skin, but the incidence of such burns appears to be extremely low. Radiofrequency fields can cause burns when skin-to-skin contact between hands or feet creates a closed conducting loop. Ultrasound colour doppler Diagnostic ultrasound provides real-time imaging without exposing patients to ionizing radiation. Ultrasound can cause changes in biological tissues and physiological processes through thermal and non thermal effects. Whether these biological effects have serious clinical relevance remains a controversial topic. Standard practice guidelines have been developed to reduce the risk of harm, and diagnostic ultrasound equipment now is designed to display safety information on the screen. Thermal effects occur when local tissue temperature increases rapidly. Animal studies suggest that this may be a biological effect of particular concern when fetal brains are exposed to prolonged ultrasound energy. Most human epidemiological studies of prenatal ultrasound exposure have methodological limitations, such as small study populations, the failure to report equipment or acoustic output used or the absence of appropriate control populations. Several studies that do not suffer from these methodological flaws identified reduced birth weight among babies exposed to repeated ultrasound examinations and increased non right-handedness among male children who were exposed to prenatal ultrasound. Non righthandedness is believed to be an indicator of brain asymmetry resulting from subtle prenatal neuro developmental disruption. Although atypical brain asymmetry is more common among some clinical populations (eg, schizophrenics), there is no evidence of serious neurological outcomes among children subjected to prenatal ultrasound.

Color, pulsed or power Doppler ultrasound should be avoided for prenatal exams, particularly during the first trimester. The proliferation of "imaging boutiques" offering non diagnostic ultrasound services for expectant parents is increasing the incidence of prolonged fetal ultrasound exposures--up to 50 minutes of viewing time in some cases. Given the lack of clinical decision-making benefits associated with this application of ultrasound, the potential biological effects and developmental impact are difficult to justify. Animal studies have shown that ultrasound has non-thermal biological effects such as capillary rupture in lung or intestinal tissue. It is unknown whether this effect occurs in humans. Therefore, a variant of the ALARA principle should be applied to ultrasound examinations involving lung tissue: These examinations should be kept to the absolute minimum duration necessary to obtain the needed clinical data. Use of advanced diagnostic technologies in radiology department helps to reduce the chance of occupational health hazards such as biological and somatic hazards to the employees working in this departments. Conclusion Steady improvements in equipment design and safety procedures have markedly reduced diagnostic radiation exposure during the past century, and continuing improvements such as computer enhancement of digital images promise to further reduce radiation doses in the coming decade. Diagnostic radiology-related illnesses have declined in lockstep with reductions in radiation exposure levels. With the rising per capita use of radiographic examination in the United States, however, the percentage of cancers attributable to diagnostic radiology will continue to climb. Very real concerns exist about the high percentage of clinically useless imaging examinations undertaken each year and the increasingly common use of pediatric CT scans delivering inappropriately high radiation doses. In addition, further research must investigate the biological effects of imaging specialties such as MR and ultrasound. Reference from journals

1.http://findarticles.com/p/articles/mi_kmens/is_200409/ai_n6868542/?lc=int_mb_ 1001

2.http://radiology.rsna.org/search?author1=Kiyohiko+Mabuchi&sortspec=date&su bmit=Submit